GROUP 1

DEABETES MELLITUS

A woman with Diabetes Mellitus

● An endocrine disorder in which the pancreas cannot produce adequate insulin to

regulate body glucose levels.
● The disorder affects 3% to 5% of all pregnancies and is the most frequently seen
medical condition in pregnancy (Bradley, Duprey, & Castorino, 2016)

Three new difficulties for diabetes mellitus have emerged:

1. How to manage both type 1 and type 2 diabetes during pregnancy to achieve a
healthy glucose/insulin balance during pregnancy
2. How to protect an infant in utero from the adverse effects of increased glucose levels
3. How to care for the infant in the first 24 hours after birth until the infant’s
insulin–glucose regulatory mechanism stabilizes

Pathophysiology and clinical manifestation

Key points.
Glucose - is the main type of sugar in the blood and is the major source of energy for the
body's cells.
Insulin - a hormone that lowers the level of glucose (a type of sugar) in the blood. It's made
by the beta cells of the pancreas and released into the blood when the glucose level goes
up, such as after eating. Insulin helps glucose enter the body's cells, where it can be used
for energy or stored for future use.
Glucagon - a natural hormone your body makes that works with other hormones and bodily
functions to control glucose (sugar) levels in your blood. Glucagon prevents your blood
sugar from dropping too low.
Liver - both stores and manufactures glucose depending upon the body's need. The need to
store or release glucose is primarily signaled by the hormones insulin and glucagon. During
a meal, your liver will store sugar, or glucose, as glycogen for a later time when your body
needs it.

● The primary concern for any woman with this disorder is controlling the balance
between insulin and blood glucose levels to prevent hyperglycemia or hypoglycemia.
● Infants of women with unregulated diabetes are five times more apt to be born larger
for gestational age or with birth anomalies.
● As dehydration begins to occur, the blood serum becomes concentrated and the
total blood volume decreases.
● Long-term effects are vascular narrowing that leads to kidney, heart, and retinal
dysfunction.

Diabetes During pregnancy

● Patients with type 1 and type 2 diabetes who have successful regulation of glucose
and insulin metabolism before pregnancy, opt to develop less-than-optimal control
during pregnancy.
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● All patients appear to develop an insulin resistance as pregnancy, a phenomenon

probably caused by the presence of hormone human placental lactogen and high
levels or cortisol, estrogen, progesterone, and catecholamines
● They must then increase their insulin dosage at about week 24 of pregnancy to
prevent hyperglycemia

What are the different Classification of diabetes?

● Type 1 - A state characterized by the destruction of the beta cells in the pancreas
that usually leads to absolute insulin deficiency.
● Type 2 - A state that usually arises because of insulin resistance combined with a
relative deficiency in the production of insulin
● Gestational Diabetes - A condition of abnormal glucose metabolism that arises
during pregnancy. Possible signal for an increase risk of type 2 diabetes later in life
may be as high as 50 to 60%
● Impaired Glucose Hemostasis - A state between “normal” and “diabetes” in which
the body is no longer using and/or secreting insulin properly.
Risk factors for developing gestational diabetes include:

• Obesity
• Age over 25 years
• History of large babies (10 lb or more)
• History of unexplained fetal or perinatal loss
• History of congenital anomalies in previous pregnancies
• History of polycystic ovary syndrome
• Family history of diabetes
• Member of a population with a high risk for diabetes

Symptoms

3 P’s of Hyperglycemia

Polyphagia
Polydipsia
Polyuria
S = sugar in urine (Glycosuria)

Complications

● Macrosomic baby
● Cephalopelvic disproportion
● Shoulder dystocia
● Spontaneous miscarriage
● Spontaneous miscarriage
● Stillbirth

Fetal Complications
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● Hypoglycemia
● Respiratory distress syndrome
● Hypocalcemia
● Hyperbilirunemia
● High incidence of congenital anomaly especially caudal regression syndrome

ASSESSMENT

In the context of diabetes and pregnancy, it is crucial to emphasize the importance of

screening for gestational diabetes in all pregnant women. Gestational diabetes can have
serious implications for both the mother and the baby if left undiagnosed and untreated.

1. Screening Process
- All pregnant women should undergo screening for gestational diabetes.
- Fasting plasma glucose ≥126 mg/dl or nonfasting plasma glucose ≥200 mg/dl indicates
diabetes and does not require confirmation.
- A 50-g glucose challenge test between 24-28 weeks gestation helps identify those at risk
for gestational diabetes.

2. Diagnostic Tests
- If the glucose challenge test result is 140 mg/dl (some may use 130 mg/dl as the cutoff),
a three-hour glucose tolerance test is recommended.
- The three-hour test involves fasting glucose measurement followed by ingestion of a
100-g glucose solution and subsequent blood glucose measurements at 1, 2, and 3 hours.
- Diagnosis of diabetes is considered if two out of the four samples are abnormal or if the
fasting value exceeds 95 mg/dl.

3. Confirmation of Diabetes
- Specific values that confirm the diagnosis of diabetes are outlined in Table 20.3.

MONITORING WOMEN WITH DIABETES

In monitoring a woman with diabetes during pregnancy, several important considerations

come into play. Pregnant women and healthcare professionals will comprehend the need of
treating diabetes throughout pregnancy.

1. Pre-pregnancy Preparation
- Women with diabetes should meet with their primary healthcare provider before
becoming pregnant.
- Well-regulated diabetes prior to pregnancy helps prevent hyperglycemia during early
pregnancy, reducing the risk of congenital anomalies in the fetus.

2. Glycosylated Homeglobin (HbA1c)

- Measurement of glycosylated hemoglobin (HbA1c) is essential for assessing the
degree of hyperglycemia present.
- HbA1c provides an average blood glucose level over the past 4 to 6 weeks, with an
upper normal level of 6% of total hemoglobin.
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3. Urine Culture and Infection Prevention

- Urine culture may be performed each trimester to detect asymptomatic urinary tract
infections (UTIs) due to increased glucose concentration in the urine, which may lead to
increased infection.

4. Ophthalmic Examination
- A single ophthalmic examination is recommended for women with gestational diabetes
during pregnancy.
- For women with known diabetes, ophthalmic examinations should be conducted at each
trimester to monitor for common background retinal changes associated with diabetes.

Therapeutic Management:

1. INSULIN therapy
Description
Needed by pregestational and gestational diabetics who are uncontrolled with diet or oral
therapy. Necessary for the cells to take glucose from the bloodstream.
Methods
Short-acting insulin may be used alone or with an intermediate type. Two thirds of daily
insulin needs are given before breakfast and one third before dinner. Insulin should be given
subcutaneously and at a 90-degree angle to the skin. The injection site should generally be
the same each injection (arms OR legs OR abdomen).
Precautions
Early in pregnancy, insulin needs may be less. Later in pregnancy, increased insulin may be
needed. Women should eat immediately after injecting insulin to avoid hypoglycemia.
Different body areas take up insulin at different rates. Rotate within the same type of
injection site.

2. Blood glucose monitoring

Description
Completed four times a day by the patient. The patient pricks her finger and uses a
glucometer to determine her blood glucose. She should track these numbers with a chart
and bring it to her OB visits. Her provider will determine if any adjustments in her insulin or
oral diabetic regimen are needed.
Methods
The patient should obtain fasting and 1-hour postprandial values. Her goals include fasting
numbers that are 90 and below and postprandial values that are less than 140.
Precautions
If the patient is hypoglycemic, she should have some carbohydrate rich food, like crackers,
and a protein, like milk. Simple sugars can create hyperglycemia and rebound
hypoglycemia.

3. Insulin pump therapy

Description
An insulin pump is an automatic pump with thin tubing, which is placed subcutaneously,
most often on the woman’s abdomen. Insulin is given through this tube and injection of
insulin is therefore eliminated.
Methods
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A continuous rate (basal) of insulin is given to the patient through the pump, and the patient
can program the pump to give extra doses as boluses prior to meals or correctional doses
related to her blood glucose values after meals.
Precautions
The patient should clean the site daily and cover it with a dressing to keep it clean. The site
also needs to be changed every 24– 48 hr to ensure optimal absorption and decrease
infection.

Test for Placental Function and Fetal Well-Being

● To detect gross abnormalities, a woman will have a-fetoprotein level obtained at

15-17 weeks to assess for neural tube defects and an ultrasound examination
performed at approximately 18-20 weeks.
● Creatinine test may be ordered each trimester.
● A woman may be asked to self-monitoring the fetal well-being recording how many
movements occur an hour (usually about 10 fetal kicks).
● Ultrasound examination may be taken at week 28 then again at 36-38 to
determine the fetal growth, amniotic fluid volume, placental location and biparietal
diameter.

Oligohydramnios – small amount of amniotic fluid

Polyhydramnios – excessive amount of amniotic fluid

● A lecithin/sphingomyelin ratio by amniocentesis is usually performed by week 36

of pregnancy to assess fetal well-being.

Timing for Birth

Among the most hazardous times for a fetus during a diabetes-involved pregnancy are
weeks 36-40 of pregnancy, when the fetus is drawing large stores of maternal nutrients
because of his or her large size. In the past, many infants were birthed early by routine
cesarean birth at 37 weeks gestation to prevent fetal loss from placental insufficiency.
Cesarean birth is chosen because it is difficult to induce labor this early in pregnancy
as the cervix is not yet ripe or responsive to labor contractions. Babies of women with
diabetes are large, making vaginal birth difficult, and a fetus suffering placental
dysfunction or insufficiency did not do well in labor.
If at all possible, vaginal birth is preferred. Labor may be induced by rupture of the
membranes or an oxytocin infusion after measures to induce cervical ripening. Both labor
contractions and fetal heart sounds need to be conscientiously monitored during labor to
ensure early detection of placental dysfunction.

Postpartum adjustment

1. Postpartum Adjustment for Women with Diabetes

- Insulin Regulation Readjustment
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- Temporary diminishment of insulin resistance

- Return to pre-pregnancy insulin requirements within a few days

2. Blood Glucose Monitoring

- Importance of postprandial blood glucose determinations
- Regulating insulin dosage during adjustment period

3. Postpartum Management for Gestational Diabetes

- Normalization of glucose values within 24 hours post-birth
- Potential risks of postpartum hemorrhage for those with polyhydramnios during pregnancy

4. Breastfeeding Considerations
- Insulin's non-transference into breast milk

5. Long-term Disease Monitoring

- Regular glucose testing for the risk of developing type 2 diabetes

6. Contraceptive and Preconception Counseling

- Addressing the need for contraceptive information
- Disease stabilization and management before planning a second pregnancy