1. Diabetes Mellitus in
Pregnancy
Presentation by
Prativa Dhakal
M.sc. Nursing
Batch 2011

2. Contents

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Define diabetes in pregnancy
State the incidence of diabetes in pregnancy
Define overt diabetes mellitus
Enlist the risk factors diabetes in pregnancy
List out the screening criteria of diabetes in pregnancy
Explain the effects of pregnancy on diabetes
List the maternal and fetal effects of diabetes during
pregnancy.
Explain the management diabetes in pregnancy
List the nursing diagnoses of diabetes in pregnancy
Research evidence
References

3. Diabetes Mellitus

Diabetes is a chronic and progressive disorder.

The term ‘diabetes mellitus’ (DM) describes a
metabolic disorder that affects the normal
metabolism of carbohydrates, fats and protein.

It is characterized by hyperglycemia and
glycosuria resulting from defects in insulin
secretion, or insulin action or both.

Diabetes is the most
complication of pregnancy.
common
medical

4. Etiological Classification of Diabetes Mellitus
I. Type 1:
Cell destruction, usually absolute insulin
A. Immune-mediated
deficiency
B. Idiopathic
II. Type 2:
Ranges from predominantly insulin
resistance to predominantly an insulin
secretory defect with insulin resistance
III. Other types
A. Genetic mutations of β-cell function
B. Genetic defects in insulin action
C. Genetic syndromes- e.g., Down,
Klinefelter, Turner
D. Diseases of the exocrine pancreas- e.g.,
pancreatitis, cystic fibrosis
E. Endocrinopathies- e.g., Cushing
syndrome, pheochromocytoma, others
F. Drug or chemical induced- e.g.,
glucocorticosteroids, thiazides,
adrenergic agonists, others
G. Infections- congenital rubella,
cytomegalovirus, coxsackievirus
IV. Gestational diabetes (GDM)

5. Diagnosis of Diabetes during Pregnancy
Overt Diabetes
 Women with a random plasma glucose level greater than
200 mg/dL plus classic signs and symptoms such as
polydipsia, polyuria, and unexplained weight loss or a
fasting glucose exceeding 125 mg/dL are considered by the
American Diabetes Association (2004) to have overt
diabetes.

The diagnostic cutoff value for overt diabetes is a fasting
plasma glucose of 126 mg/dL or higher.

6. Diagnosis of Diabetes during Pregnancy
Gestational Diabetes
 This is defined as carbohydrate intolerance of
variable severity with onset or first recognition
during pregnancy.

The entity usually presents late in the second or
during the third trimester.

7. Incidence

GDM affects ~ 7% of all pregnancies, resulting in
> 200,000 cases per year.

Depending on the population sample and
diagnostic criteria, the prevalence may range
from1 to 14%.
[Source: Setji TL, BrownAJ, Feinglos MN. Gestational Diabetes Mellitus.
CLINICAL DIABETES 2005;23(1)]

8. The potential candidates for GDM

Strong familial history of diabetes

Have given birth to large infants (4 kg or more)

Demonstrate persistent glucosuria,

Have unexplained fetal losses

Presence of polyhydramnios
candidiasis in present pregnancy.

Over the age of 30

Obesity

Ethnic group (East Asian, pacific island ancestry)
or
recurrent
vaginal

9. Screening

Plasma glucose level after a 50-g glucose test threshold is
best to identify women at risk for gestational diabetes.

Performed between 24 and 28 weeks in those women not
known to have glucose intolerance earlier in pregnancy.

Evaluation is usually done in two steps.
 50-g oral GCT is followed by a diagnostic
 100-g
oral glucose tolerance test (OGTT) if initial
results exceed a predetermined plasma glucose
concentration.

10. GDM Risk Assessment

1.
Should be ascertained at the first prenatal visit
Low Risk: Blood glucose testing not routinely required if
all the following are present:
 Member of an ethnic group with a low prevalence of
GDM
 No
known diabetes in first-degree relatives
 Age
< 25 years
 Weight
normal before pregnancy
 Weight
normal at birth
 No
history of abnormal glucose metabolism
 No
history of poor obstetrical outcome

11. GDM Risk Assessment cont…
2.
Average Risk: Perform blood glucose testing at 24 to 28
weeks using either:
 Two-step procedure: 50-g GCT, followed by a
diagnostic 100-g OGTT
 One–step
procedure: Diagnostic 100-g OGTT

12. GDM Risk Assessment cont…
3.
High Risk: Perform blood glucose testing as soon as
feasible, if one or more of these are present:
 Severe obesity
 Strong
family history of type 2 diabetes
 Previous
history of GDM,
metabolism, or glucosuria.
 If
impaired
glucose
GDM is not diagnosed, blood glucose testing should
be repeated at 24 to 28 weeks or at any time there are
symptoms or signs suggestive of hyperglycemia.

13. GDM Risk Assessment cont…

The test should be performed in the morning after an
overnight fast of at least 8 h but not more than 14 h and
after at least 3 days of unrestricted diet (≥150 g
carbohydrate/d) and physical activity.

The subject should remain seated and should not smoke
during the test.
Time
Oral Glucose Load
100g Glucose
Fasting
95 mg/dL
1 hour
180 mg/dL
2 hour
155 mg/dL
3 hour
140 mg/dL

14. Effects of pregnancy on diabetes

Very difficult to stabilize blood glucose level during
pregnancy.

The insulin antagonism is probably due to the combined
effect of HPL, oestrogen, progesterone, free cortisol and
degeneration of insulin by the placenta.

Insulin requirement during pregnancy increases as
pregnancy advances.

As more glucose leaks out in urine due to renal glycosuria ,
control of insulin dose cannot be made by urine test and
repeated blood glucose estimation becomes mandatory.

15. Effects of pregnancy on diabetes cont…

Ketoacidosis can be precipitated during hyperemesis in
early pregnancy, infection and fasting of labour.

It can be iatrogenically increased by β sympathomimmetic
and corticosteroids used in the management of preterm
labour.

Insulin requirements falls significantly in puerperium.

Vascular changes, specially retinopathy, nephropathy,
coronary artery disease and neuropathy may be worsened
during pregnancy.

16. Maternal and Fetal Effects
Maternal
a. During Pregnancy:
 Abortion
 Preterm
labour (20%)
 UTI
 Increased
incidence of preeclampsia (25%)
 Polyhydramnios
 Maternal
distress
 Diabetic
retinopathy, microaneurysms, hemorrhages and
proliferative retinopathy
 Diabetic
nephropathy
 Ketoacidosis

17. Maternal and Fetal Effects cont…
b. During labour:
 Prolongation of labour due to big baby
 Shoulder
 Perineal
dystocia
injuries
 Postpartum
 Operative
hemorrhages
interferences
c. Puerperium:
 Puerperal sepsis
 Lactation
failure

18. Maternal and Fetal Effects cont…
Fetal hazards
 Fetal macrosomia (30-40%): Results from:
 Maternal
hyperglycemia—hypertrophy
and
hyperplasia of fetal islets of Langerhans—increased
secretion of fetal insulin—stimulates carbohydrate
utilization and accumulation of fat.
 Elevation
of maternal free fatty acids (FFA) in diabetes
leads to increase transfer to the fetus—acceleration of
triglyceride synthesis—adiposity.

Congenital malformation (6-10%) due to severity of
diabetes affecting organogenesis.

19. Fetal Effects cont…
Major birth defects in infants of diabetes mellitus
CNS &
Skeletal
Cardiac
Renal
Neural tube
defects
Anencephaly
Microcephaly
Sacral agenesis
VSD, ASD
Coarctation of
aorta
Transposition
of great
vessels
Cardiomegaly
Renal
agenesis
Hydronephro
sis
Ureteral
duplication
Gastroint
estinal
Others
Duodenal Single
atresia
umbilical
Anorectal artery
atresia

20. Fetal Effects cont…




Birth injuries (brachial plexus)
Growth restriction (less common)
Unexplained fetal death
Neonatal complications:
Hypoglycemia,
 Respiratory distress syndrome,
 Hyperbilirubinemia,
 Polycythemia,
 Hypocalcemia,
 Hypomagnesemia,
 Cardiomyopathy


Perinatal mortality: Increased 2-3 times due
hypoglycemia, RDS, polycythemia and jaundice.
to

21. Management

Diet
 30 kcal/kg/d based on prepregnant body
weight for non-obese women.
women with a BMI > 30 kg/m2 may benefit from a
30 % caloric restriction.
 Obese
 Weekly
tests for ketonuria, because maternal ketonemia
has been linked with impaired psychomotor development
in offspring.

22. Management cont…

Caloric allotment is based on ideal body weight.

Recommendations are 30 kcal/kg for women with a BMI of
22 to 25, 24 kcal/kg for women with a BMI of 26 to 29, and
12 to 15 kcal/kg for women with a BMI above 30.

The recommended overall dietary ratio is 33% to 40%
complex carbohydrates, 35% to 40% fat, and 20% protein.

This calorie distribution will help 75% to 80% of GDM
women become normoglycemic.
[Source: Gilmartin AH, Ural SH, Repke JT. Gestational Diabetes Mellitus.
REVIEWS IN OBSTETRICS & GYNECOLOGY 2008;1(3)]

23. Management cont…

Exercise

Glucose Monitoring
 Daily self blood-glucose monitoring had fewer
macrosomic infants and gained less weight after
diagnosis.
 Glycosylated
hemoglobin should be determined at the
end of first trimester and three months thereafter.
HBA1C level of 5-6% is desirable.

24. Management cont…

Insulin Therapy
 Recommended when standard dietary management does not
consistently maintain fasting plasma glucose at <95 mg/dL or the
2hour postprandial plasma glucose < 120 mg/dL (ACOG, 2001).


Alternatively, weight-based split-dose insulin is administered
twice daily.


Total dose of 20 to 30 units OD, before breakfast, is commonly
used to initiate therapy which is divided into two-thirds
intermediate-acting insulin and a third short-acting insulin.
During the stabilization process of insulin dose, frequent blood
sugar estimation especially at night may be necessary
Oral Hypoglycemic Agents: Avoided during pregnancy.

25. Admission

In uncomplicated cases, the patient is admitted at 3436weeks.

Early hospitalization facilities:
 Stabilization of diabetes
 Minimizes
incidence of preeclampsia, polyhydramnios
and preterm labour.
 To
select out the appropriate time and method of
delivery.

26. Termination of pregnancy

Should be done at 37 weeks as majority of intrauterine
death occurs in last two weeks of pregnancy.

Early delivery may be considered when there is vascular
complication (hypertension) or evidences of fetal
compromise on antenatal monitoring.

27. Induction of labour
The indications are:
 Multipara with good obstetric history

Young primigravida without any obstetric complications

Presence of congenital malformation of fetus.

28. Management cont…

Prior to the day of induction of labour, the usual bedtime
dose of insulin is administered.

No breakfast and no morning dose of insulin is given on
the day of induction.

Normal saline infusion is begun.

Induction is done by low rupture of membrane.

Simultaneously oxytocin drip is started, if not contracted.

An intravenous drip of one liter of 5% dextrose is set up
with 10 units of soluble insulin.

29. Management cont…

An infusion rate of 100-125ml/hr, will be maintain a good
glucose control to approximately 100 mg/dl.

Insulin may also be infused from syringe pump.

Blood glucose level are estimated hourly with a glucose
meter and the soluble insulin dose is adjusted accordingly.

Epidural analgesia is ideal for pain relief. If the labour fails
to start within 6-8 hours of if labour progresses
unsatisfactorily, caesarean section should be performed.

30. Management cont…
Caesarean section: indications are
 Early primigravida

Multigravida with bad obstetric history

Diabetes with complications or difficult to control

Obstetric
complications
like
polyhydramnios, malpresentation

Fetal macrosomia (>4 kg)
preeclampsia,

31. Management cont…
Place of awaiting spontaneous onset of labour at term:

Young primigravida or multipara with good obstetric
history

Diabetes well controlled either by diet or insulin and
without any obstetric complications

32. Management cont…
Fetal monitoring
 Constant watch to note fetal condition is mandatory,
preferably continuous electronic fetal monitoring.
 CTG
using a scalp electrode is maintained.
 Fetal
scalp pH sampling
 Labour
should not exceed more than 12 hours and should
be augmented by low rupture of membrane and oxytocin
or delivered by Caesarean section.

33. Management cont…
Examination of cord and placenta and cord
 Placenta is large, the cord is thick and there is increased
incidence of a single umbilical artery.
 Features
of placentosis is present.

34. Management of Acidosis

IV insulin: 0.2-0.4 units/kg (loading dose)—2.0-10.0units/h
(maintenance with frequent capillary glucose measurement)

Fluids: Isotonic NaCl 4-6 L in first 12 hours. 5% dextrose in
normal saline when blood glucose is 200 mg/dl.

Potassium: If reduced or normal—infusion 15-20 mEq/h

Bicarbonate

35. Management cont….

Puerperium
 Antibiotics should be given prophylactically.
 Insulin
requirement
falls
dramatically
following
delivery.
 Fresh
blood glucose after 24 hours of delivery.
 Women
who breastfed should have additional 500 Kcal
daily in diet
 In
lactating women insulin dose is lower.
 Contraceptive
devices should be used.

36. Care of baby
 Neonatologist
should attend at the time of delivery.
 Baby
should be kept in NICU and to remain vigilant for at
least 48 hours.
 Asphyxia
 To
is anticipated and be treated effectively.
look for any congenital malformation
 All
babies should have blood glucose checked within 2
hours of birth.
 All
babies should receive 1 mg vitamin K IM.
 Early
breastfeeding and to be repeated at three to four
hourly intervals.

37. Nursing assessment

Determine immediate and previous 8 week diabetic
control.

Evaluate ongoing client and fetal well being.

Achieve and maintain normoglycemia.

Provide client/couple with appropriate information.

38. Nursing Diagnosis

Risk for imbalanced nutrition related to inability to ingest
sufficient quantity of nutrients/inability to utilize nutrients
appropriately/lack
of
information
about
eating
appropriately.

Risk for fetal injury related to elevated maternal serum
glucose levels.

Risk for maternal injury related to tissue hypoxia/increased
maternal serum glucose level/altered immune response.

Deficient knowledge regarding diabetic condition,
treatment, prognosis and self care related to lack of
information/unfamiliarity with information resources.

39. References
1.
Fraser DM, Cooper MA. Myles Textbook for Midwives.15th
edition. Philadelphia:Churchill livingstone elsevier;2009
2.
Dutta DC. Textbook of obstetrics. 6th edition. Calcutta:New
central book agency;2004
3.
Pillitteri A. Maternal and child health nursing. Care of the
childbearing and childrearing family. Sixth edition.
Philadelphia; Lippincott Williams & Wilkins: 2010.
4.
Integrated management of pregnancy and childbirth. Managing
complications in pregnancy and childbirth: A guide for
midwives and doctors. World Health Organization, Unicef,
UNFPA, The World Bank Group. 2005.
5.
Cunningham, Leveno, Bloom. William’s obstetrics. 23rd
edition. United states of America; Mcgraw Hill companies:
2010.