DIABETES MELLITUS
- develops during pregnancy and spontaneously
- An endocrine disorder in which the pancreas
cannot produce adequate insulin to regulate
body glucose levels
- Disorder in CHO, CHON and fat metabolism
- Pregnancy is a diabetogenic state due to the
profound effect of hormones (HPL), which
increases insulin-resistance
> Human placental lactogen - to facilitate the
energy supply of the fetus
Most frequently seen medical conditions
Risk factors of DM:
 Family history
 Rapid hormonal changes in pregnancy
 Tumor/infection of the pancreas
 Obesity
 Stress
Normal Metabolic changes in Pregnancy that
Affect DM:
 Increase insulin antagonistic hormones:
cortisol, E, P and HPL
 Lowered renal threshold for sugar,
increased GFR lt GLYCOSURIA
 Excess glucose crosses placenta lt LGA
 Vomiting decreases CHO intake is link to
metabolic acidosis
 Labor activity requires increased CHO
intake
 Hypoglycemia postpartum due to
involution & lactation
Goal
 Management of glucose/insulin levels
during pregnancy
 Management of adverse effect of
increase glucose with the infant in the
utero
 Management of first 24hours after
birth(infant’s insulin-glucose
mechanism)
> Glycosuria - a condition
characterized by an excess of sugar in
the urine, typically associated with
diabetes or kidney disease.
* High glucose of mother --> brings
extra glucose to baby --> baby gain
extra weight
Gestational Diabetes
resolves after delivery
MATERNAL COMPLICATIONS OF GDM:
 Predisposes to PIH, UTI,
 Infections: candidiasis, UTI
 Uteroplacental insufficiency
 Dystocia due to large infant CS delivery
 PTL, CPD
 PP hemorrhage due to uterine atony
 More difficult to control DM-
hypo/hyperglycemia
 Maternal mortality
 Diabetic retinopathy
 Diabetic nephropathy
> Ptl-pre term labor
> Uteroplacental insufficiency
- complication of pregnancy when the
placenta is unable to deliver an
adequate supply of nutrients and
oxygen to the fetus, and, thus, cannot
fully support the developing baby.
> Diabetic retinopathy / Diabetic eye
disease
- is a medical condition in which
damage occurs to the retina due to
diabetes mellitus.
- leading cause of blindness.
> Diabetic nephropathy
- is kidney damage that results from
having diabetes.
- Having high blood glucose levels due
to diabetes can damage the part of the
kidneys that filters your blood.
- The damaged filter becomes 'leaky'
and lets protein into your urine.
FETAL COMPLICATIONS:
 Macrosomia---birth injuries
 IUGR dt placental insufficiency
 Fetal hypoxia, IUFD, stillbirths
 1st trimester: spontaneous abortion or
fetal anomalies
 Hydramnios
 Prematurity
 Neonatal hypoglycemia as soon as 1 hr
postpartum (common metabolic disorder)
 RDS
 Hyperbilirubinemia
 Hypocalcemia SCREENING TEST
 Birth defects: heart, brain & spine, kidney, At 26-28 wks for high-risk women
GIT 50g oral glucose challenge (if >140 mg/dl, needs
3-hr GTT)

ASSESSMENT FINDINGS GLUCOSE TOLERANCE TEST(GTT)

100 g GTT bw wk 28-34
HISTORY Glucose levels at 1,2 & 3 hrs
 Family hx of DM, previous GDM *Results:GDM if FBS>95 or 2 results are high
 Previous LGA (4k or more) *Normal: FBS(95 mg/dl)
 Previous infant with congenital defects, 1h (180 mg/dl)
hydramnios 2h (155 mg/dl)
 Spontaneous abortion, fetal deaths, 3h (140 mg/dl)
stillbirth
 Obesity 2-hr Postprandial Blood Sugar(PPBS)
 Frequent candidiasis Abn Result: >120 mg/dL
 Marked abdominal enlargement *Goals: FBS <105 mg/dL, PPBS <120
(hydramnios & LGA) mg/dL

Signs of hyperglycemia: Glycosylated Hemoglobin(HgbA1c)(maternal hb

- Polyphagia irreversibly bound to glucose)
- Polyuria Measures long-term(3 mos) compliance to
- Polydipsia treatment
 Weight loss fat and CHON stores used for N: 4%-8%
energy
 Increased blood and urine glucose Urine Glucose monitoring is inaccurate

Signs of Hypoglycemia:
 Sweating with cold, clammy skin TREATMENT OF HYPOGLYCEMIA
 Pallor
 Tremors, shakiness  Consume 15-20 g glucose or simple CHO
 Hunger & nausea - Glucose tabs, 2 tbsp raisins, 4 oz(1/2 c juice or
 Irritability or impatience, anger soda), 8 oz nonfat milk, 1 Tbsp sugar, honey or
 Confusion, indicating delirium corn syrup, hard candies, jellybeans or
 Tachycardia gumdrops
 Nervousness, anxiety
 Sleepiness  Recheck blood glucose after 15 mins.
 Blurred vision
 Seizures  *emergency drug: GLUCAGON IM into
 unconsciousness buttock, arm or thigh to stimulate liver to
release stored glucose into the
SIGNS & SYMPTOMS bloodstream

 Hyperglycemia(N=80-120mg/dL) DO NOT:
 Glycosuria-bld glucose>150mg/dL Inject insulin
 Polyuria provide food or fluid if unconscious
 Polydipsia put hands in mouth
 Polyphagia
 Weight loss: CHON & Fat stores are used
for energy NURSING IMPLEMENTATION
 Ketoacidosis
 Participate in early detection.
 Encourage early prenatal mgt. &
supervision
-Regular prenatal check-up
-Record dietary intake & monitor
glucose levels
-Insulin when FBS is not consistent at <
105 mg/dL or 2-hr PPBS is not <120mg/dL
-Serial UTZ- from 28-34 wks if DM
poorly-controlled or with complications
-Hospitalization- if DM is poorly-
controlled, with HPN and infection
 Provide teaching:
-Nature, effects of DM
 Signs & symptoms of hypo/hyperglycemia
-Exercise to regulate glucose levels
-Insulin regulation/self-administration
-Prompt reporting of danger signs and
signs of infection
 Promote control of DM
Diet: 1800 to 2,200 cal/day or 35 kcal/kg BW
12%-20& CHON, 40%-45% CHO, 40%
from PUFAs
Use Diabetic food exchange list
Wt gain not > 24 lbs.
 Exercise: decreases need for insulin but
may cause hypoglycemia if excessive
- No exercise when glucose levels are
low or stomach is empty
- Don’t administer insulin in extremity
used in exercise
- Don’t exercise alone always carry
diabetic ID
 Insulin Therapy
- No OHA
- Insulin req drops during 1st trimester,
- increased in 2nd & 3rd tri(tripled);
increased chance of ketoacidosis
- Regular & NPH(Isophane) insulin; only
regular insulin IV during labor to
prevent ketoacidosis
- Humulin (DOC)- least allergenic
- Split-dose therapy: regular &
intermediate combi; 2/3 daily dose
before breakfast at 2:1 ratio(interm to
reg);1/3 30 mins before dinner(1:1)
> DIABETIC KETOACIDOSIS
-diagnosed when
glucose >300 mg/dL, (+) serum ketones
are at level 1:4 & metabolic acidosis is
present
-Causes: poor compliance,
infection, HG, use of drugs like
corticosteroids,+ acetone breath
-Fetal effects: 20% perinatal
mortality
 Prevention of infection, stress, which leads
to hyperglycemia, which increases the
need for insulin
 Encourage assessment of fetal well-being:
ultrasound, amniocentesis(L/S ratio),
phosphatidyl glycerol( fetal lung maturity),
NST, CST, BPP
 Early labor induction or CS in the presence
of fetal distress( 36-37 wks)
MANAGEMENT
 Maintain normal FBS, Hba1c(N=6%)
- Glycosylated hemoglobin measures
the amount of glucose attached to the
- RBC & reflects average measurement
of the glucose levels over the past 4-6
wks
- Good test to assess effectiveness of
treatment
- Abnormal: >7% of total hemoglobin
 Clinic visit every 2 wks up to 36 wks
- Exercise lowers glucose levels
 Ingest protein or complex CHO prior to
exercise
 Diet:
- 1800 to 2,200 cal/day or 35 kcal/kg
BW
- 12%-20& CHON, 40%-45% CHO, 40%
from PUFAs
- Use Diabetic food exchange list
- Wt gain not > 24 lbs.
 Instruct on signs of hypoglycemia(dt
excessive insulin, exercise or insufficient
dietary intake):
 - Pallor  Observe respiration since hydramnios
- Weakness, numbness inflates stomach and may interfere with
- Headache lung expansion
- Confusion or irritability  Observe for hypoglycemia(shrill cry, tetany,
- Blurred vision tremors), BF or give glucose water
- Perspiration  Observe for hypocalcemia (tetany,
- Hunger tremors), give Calcium gluconate
- Convulsions, coma  Observe for congenital anomalies:
esophageal atresia, NTD
“cold and clammy, need some candy”
Mgt: Give CHO foods like fruit juice,
cola, sugar, candy CONTRACEPTION

 Self-monitoring of Blood glucose at least  No IUD- high incidence of PID

TID
Desired values:
 before meal: 95 mg/d
 1 hr after meal: <140 mg/d
 2 hrs after meal <120 mg/dl
 No COCs- P interferes with insulin and E
raises lipid, cholesterol levels & affect
blood coagulation
 Norplant or progestin only pills(mini pills)
may be used safely by diabetic women

 Fetal Well-being Monitor

- Alphafetoprotein level at 15-17 wks
- Ultrasound at 18-20 weeks and
monthly to rule out deformities,
hydramnios,
- NST starting at 34 wks(if abnormal,
CST, BPP)
- Daily kick counts from wk
28(N=10/hr); report if less
L/S Ratio starting 34-36 weeks (N=2.5-
3:1)
- Creatinine clearance to monitor
perfusion

CARE DURING LABOR & DELIVERY

 Plan to deliver bw 36-40 wks when fetus is

mature enough but not too large to cause
CPD
- L/S ratio should be 2.5-3.5:1
- Vaginal delivery is preferred
- Regular insulin on labor day bec need
for insulin drops immediately pp and
may not need insulin in the 1st 24 hrs
pp. Monitor glucose levels.

NEWBORN CARE

 Keep warm.