Clinical Aspect of Maternal and Child Nursing NUR 363 Lecture 3 Complication during pregnancy and its nursing management: - D.M.

Diabetes and pregnancy Outline Normal metabolism in pregnancy Pre existing diabetes and pregnancy Gestational diabetes Antenatal management Postnatal follow up Diabetes during pregnancy requires a multidisciplinary approach. This session is an introduction to pre-existing type 1, type 2 and pregnancy, and gestational diabetes.

Normal metabolism in pregnancy Increased fat metabolism Increased ketone production Decreased glucose production in the liver

Normal fetal metabolism Fetal pancreas develops between 4 and 6 weeks after conception. Insulin is produced at 10-12 weeks. Fetus obtains glucose via the placenta and can not produce its own glucose supply even during maternal hypoglycaemia. 3rd trimester glycogen storage in the liver and triglyceride production increases.

Type 1 diabetes and pregnancy Preconception normoglycaemia (normal blood glucose level) is important. Peri-natal mortality (death in the womb) is 2 and 3%. Insulin requirements initially fall, then increase by 2nd and 3rd trimester. Will need intensive insulin therapy and close monitoring. Gestational diabetes characterized by an abnormal glucose tolerance test-GTT-and elevated fasting glucose.

Type 2 diabetes in pregnancy Pre conception normoglycaemia is important. If on oral medication, may need to switch to insulin. Controlled with diet and exercise. Gestational diabetes characterized by an abnormal glucose tolerance test-GTT-without other symptoms. Fasting glucose is normal. Chan A, Scott J, Nguyen A & Keane R (2005) Pregnancy outcomes in South Australia, Pregnancy Outcomes Unit, Epidemiology Branch, Dept Human Services, Adelaide

Risks To mother: Hypoglycaemia Ketoacidosis (type 1 only) Retinopathy Nephropathy Pre eclampsia Urinary tract infections

Risks To baby: Congenial abnormalities Macrosomia Spontaneous abortion Intrauterine growth retardation Fetal death in uterus

Post natal Risks to baby: Risks to mother: Prematurity Respiratory distress Birth trauma Hypoglycaemia Risks to mother: Hypoglycaemia (if on insulin therapy)

Gestational diabetes (GDM) Risk factors: Family history of diabetes GDM in previous pregnancy Older maternal age (over 30 yrs) Previous large babies (over 4kgs) Obesity High risk ethnic groups (eg South East Asian) Complicated obstetric history Chan A, Scott J, Nguyen A & Keane R (2005) Pregnancy outcomes in South Australia, Pregnancy Outcomes Unit, Epidemiology Branch, Dept Human Services, Adelaide

Antenatal management Management aims are the same for type1, type 2 and gestational. Aim is to maintain BGL’s between 3.5 and 7.0 mmol/L. Regular home blood glucose monitoring Dietary education. Daily activity recommended. Review by the obstetric physician, diabetes educator and dietitian.

Postnatal management gestational diabetes Stop insulin as soon as baby is delivered. Recommence normal diet as tolerated. Regular home blood glucose monitoring Screening prior to planning next pregnancy. GDM Working Party (1999) Based on Hoffman L, Nolan C, Wilson JD, Oats JJ, Simons D, (1998), Gestational diabetes mellitus management guidelines, The Australiasian Diabetes in Pegnancy Ssociety, Med J Aust 169:93-97