Concurrent disorders in pregnancy

type 1 diabetes

Insulin dependent
◦ Caused from the destruction of insulin secreting beta cells

• Decrease in beta cells = Decrease in insulin

• Body unable to maintain normal glucose levels

Type 2 diabetes

noninsulin dependent
◦ 90% of DM cases
◦ Caused by a combination of peripheral insulin resistance AND inadequate
insulin secretion by beta cells
◦ Typically diagnosed in those over the age of 40 (although there has been an
increase in younger presentation)

neonatal risk with those with preexisting diabetes and pregnancy

◦ Neonatal hypoglycemia
◦ Neonatal hypocalcemia
◦ Neonatal Hyperbilirubinemia
◦ Respiratory distress syndrome
◦ Type 2 DM for baby later in life

maternal risks with those with preexisting diabetes and pregnancy

◦ Preterm delivery
◦ Preeclampsia
◦ Macrosomia
◦ Shoulder dystocia
◦ Intrauterine fetal demise (IUFD)
◦ *Neural tube defects; Cardiac, renal or other congenital malformations (particularly if DM is uncontrolled)
◦ Urinary tract infections
◦ Premature rupture of membranes

Who manages a patients with preexisting DM

OB or Maternal fetal medicine specialist

nursing roles for those with preexisting diabetes

◦ Education

◦ Diabetes management (RNs working in Diabetes clinics)

◦ Inpatient care

fetal surveillance for those with preexisting diabetes

◦ Ultrasound and Fetal echocardiography at 20-22 weeks to evaluate fetal body and cardiac structure
◦ 3rd trimester:
- Fetal kick counting, BPP, and/or non-stress tests
- Monitoring amniotic fluid volume and fetal growth

gestational diabetes mellitus

Onset is during pregnancy, typically considered to develop after 20 weeks gestation

patho of GDM

Pregnancy is naturally a diabetogenic state characterized by:
 Hyperinsulinemia
 Hyperglycemia
 Mild fasting hypoglycemia
Early pregnancy (<20 weeks): cells more responsive to insulin
Late pregnancy: placenta grows and increase in hormones (particularly estrogen,
progesterone, and human placental lactogen) which creates resistance to insulin in
maternal cells to provide an abundant supply of glucose for the fetus
 Diabetogenic effect
 If the pancreas is unable to respond and increase insulin production  hyperglycemia  GDM

GDM risk factors

Overweight (BMI 25-29.9), obese (BMI >30)
Pregnant person age over 25
Previous birth outcome with GDM association
 Macrosomia, HTN, unexplained congenital anomalies, ..
GDM in previous pregnancy
H/o abnormal glucose intolerance
fHx of diabetes in close relative
Part of high risk ethnic group
 Hispanic, African, Native American, South or East Asian, Pacific
Island ancenstry

When does screening for GDM occur?

at 1st OB with serum test (HgbA1c) or glucose challenge test if at increased risk

Standard of care screening

• between 24-28 weeks

• Two step process: screening test followed by a diagnostic test

   GCT (glucose challenge test)  Then GTT (glucose tolerance test

Glucose challenge test

 Oral 50 gram glucose load

 Blood draw 1 hour post oral consumption

 If BG is 130-140mg/dl or greater, pt has failed the test and a 3 hr GTT is recommended

 Cut-off is based on accepted institutional threshold

 No dietary restrictions PRIOR to consuming 50 gram glucose load

When is GDM diagnosed?

if the fasting blood glucose level is abnormal OR if 2 + other values are elevated

Prep for GDM diagnostic

Dietary restrictions 3 days prior to test
 Daily intake of carbohydrates must exceed >150 grams
 No eating (except water) for 8-14 hours before the test- so fasting prior to test is needed

DIAGNOSTIC test for GDM

OGTT-oral glucose tolerance test

Oral 100 gram glucose load (there is a 75g two hour alternative, only need 1 level abnormal for 75g GTT

GDM complications for pregnant persons

• Higher risk of preeclampsia

• Higher risk of cesarean delivery

• Increased risk of type 2 diabetes in later life

GDM complications for fetus/neonate

• Macrosomia

• Neonatal hypoglycemia

• Hyperbilirubinemia

• Shoulder dystocia

• Birth trauma

GDM management

◦ Modifications to diet and increasing exercise
◦ What kind of modifications?
◦ Diabetic Education (nutrition counseling)
◦ Glucose monitoring (fasting and 1 or 2 hr post-prandial)
◦ Insulin is first line pharmacologic therapy (not all patients will need insulin!

GDM antepartum management

◦ Biophysical Profiles, Non-Stress Tests

◦ Growth ultrasounds

◦ Consider IOL depending on level of control over BG

GDM intrapartum management

• During the labor and birth process, blood glucose is monitored hourly to maintain levels at 80 to 110 mg/dL

• Maintain IV access at all times in case need for insulin during labor

• Continuous fetal monitoring

GDM Postpartum management

• Most patients with GDM return to normal glucose levels after birth

◦ Screen for Diabetes between 6-12 weeks postpartum and every 1-3 years thereafter

◦ Patients who have had GDM have up to a 70% chance of developing type 2 later in life!

GDM nurse role

Education on testing and results

Diabetes clinics are often nurse-led

Education on diet, activity, medication, etc

 See examples in textbook/ATI readings!

 How would you counsel a patient on recommended diet changes?

Intrapartum management of insulin drip, preparation for baby needs (blood sugar

checks, temperature regulation)

Resource for organizations if lack of social/economic support

Communication: Addressing anxiety, fear, denial, anger or other feelings

◦ Actively listen

◦ Ask open ended questions

Long term implications of GDM

• pts with GDM have increased risk of type II DM

• fetus increased risk of childhood/adult obesity

• children exposed in utero increase risk of obesity and DM than their unexposed sibs

Ana is a 35-year-old Hispanic-American woman, G2P1001 at 26w0d.

During her first pregnancy, 2 years ago, she had elevated blood glucose levels that she was able to control with diet. The baby weighed 4200 kg (9 pounds 2 ounces). Ana did not lose the weight she gained during her first pregnancy and now is approximately 30 pounds over her ideal weight.

She had a two-step screening for gestational diabetes last week. Her initial 1-h glucose result was elevated. This was followed 4 days later by a 3-h (100 g) oral glucose tolerance test (OGTT), based on the results of her OGTT she was diagnosed with GDM.

What history and assessment findings indicate an increased risk of gestational diabetes?

History: person of color, age, hx of elevated glucose

Assessment: 30 lbs over, OGTT results

Ana is placed on a treatment plan to manage her GDM. The nurse first assesses Ana’s knowledge about GDM, its management and potential complications. She instructs Ana about the treatment plan which includes diet, self-monitoring of blood glucose levels, and medication.

Which of the following recommendations for the management of GDM are correct? Select all that apply.

A. Fasting blood glucose levels less than 80 mg/dL are recommended.

B. Two-hour postmeal glucose levels less than 120 mg/dL are recommended.

C. Dietary modification is the mainstay of treatment for GDM.

D. Overweight or obese women do not need to reduce their caloric intake.

E. A moderate exercise program is recommended

F. Insulin is the recommended medication to maintain blood glucose levels.

B. Two-hour postmeal glucose levels less than 120 mg/dL are recommended.

C. Dietary modification is the mainstay of treatment for GDM.

E. A moderate exercise program is recommended

F. Insulin is the recommended medication to maintain blood glucose levels

Patient has a GCT of 155mg/dL at 25 weeks gestation. What is the best thing to tell her?

A. You have gestational diabetes; please schedule an appointment with diabetes education to learn about dietary modifications and how to monitor your glucose.

B. This is a normal result; no further testing is indicated.

C. This is an abnormal screening test result; please schedule a 3 hr GTT

C. This is an abnormal screening test result; please schedule a 3 hr GTT

Anemia

a condition in which blood lacks adequate healthy red blood cells. Red blood cells carry oxygen to the body's tissues.

Types of anemia

 Iron-deficiency anemia

 Sickle cell disease

 Thalassemias

What is anemia commonly due to ?

 Iron-deficiency

 Acute blood loss

Iron - deficiency anemia

a blood disorder that occurs when the body doesn't have enough iron to produce healthy red blood cells

what does the cdc reccomend with Iron - deficiency anemia during pregnancy?

iron supplements

lab values of those one have IDA

if hemoglobin is <11 g/dL

risk factors Iron - deficiency anemia

 Poor diet

 GI disease

 Short interval btwn pregnancies

Management of low iron with:

Supplements – ferrous sulfate 325 mg BID

 Side effects? green stool