1. N323: Parent-Child Nursing
Diabetes in Pregnancy
N323: Parent-Child Nursing
Source: AADE Core, 2001
DM = common complication of IUP
Affects > 150K pregnancies annually
No more steel magnolias? Outlook better = perinatal mort dropped from 25% (1960’s) to 2% (1980’s)
S. Burke, PhD, RN, CDE

2. Pre-Gestational Diabetes
Definition
& Diagnostic Criteria
Pre-conception counseling
Mother/Baby Risks
Testing:
Diabetes in Pregnancy
Management:
At Risk Populations:
Diabetes diagnosed during pregnancy
Pre-existing Diabetes, either type 1 or type 2
Use the tool to take notes

3. A Little Background
Prevalence of diabetes is increasing at a rapid rate
As of 2006
20.8 million Americans with Diabetes
90% Type 2
~ 1/3 undiagnosed
~ 16% children and teens w/T2DM
As diabetes increases in prevalence, the frequency of GDM will continue to increase.

4. Essential Physiology

5. Definitions Pre-gestational diabetes Gestational Diabetes (GDM)
Diabetes that is present prior to a pregnancy
Type 1 or Type 2
Gestational Diabetes (GDM)
Carbohydrate intolerance of variable severity with the onset or first recognition during pregnancy
0.2 – 0.3% all pregnancies = pre-gestational; ~2% women of childbearing age with T2DM
AADE Core Curriculum 4th ed., (2001), p. 34

6. Prevanlence of Obesity, Diabetes and other obesity
related risk factors
Mokdad AH, Ford ES, Bowman BA, et al. Prevalence of obesity, diabetes, and other obesity-related health risk factors, JAMA 2003 Jan 1;289(1):76-9.

7. High Risk Populations Low Risk Women Medium Risk Women High Risk Women
< age 25
BMI 19 – 25
Low risk ethnicity
Negative FH
Negative personal history
No h/o poor OB outcomes
Neither high nor low risk
BMI > 25
+FHx of T2 DM
+ glucosuria
Hx/O GDM
Hx/O baby w/bw over 9#
Member of high risk ethnic group
Early screening for high risk women
Screening between weeks for medium risk women
No routine screening for low risk women.

8. Maternal Risks Pre-existing DM Type 1 DM Type 2 DM Both GDM
Ketoacidosis
Frequent hypoglycemia
Type 2 DM
Obesity
Hypertension
Both
Worsening
Kidney disease
Eye disease
Coronary heart disease
GDM
Hypertensive disorders
PIH
Toxemia
Development of Type 2 diabetes following IUP
2 risk groups: women with and those without chronic complications; In general, higher risk with the latter.

9. Fetal/Newborn Risks Difficult birth Neonatal hypoglycemia
Pre-gestational DM
Early Risks
Birth Defects
Spontaneous AB
Later Risks
Hyperinsulinemia
Overgrowth
Stillbirth
Polycythemia
RDS
Intrauterine growth retardation (a/w nephropathy)
GDM
Hyperinsulinemia
Macrosomia
(>4,000 G)
Possibility of stillbirth
Newborn Risks
Difficult birth
Shoulder Dystocia
Neonatal hypoglycemia
hyperbilirubinemia
risk of perinatal mortality & congenital malformation
20 – 30% of macrosomia in GDM

10. 2 Step Testing (GDM) Step 1 = 1 hour test Step 2 = 3 hour test
50 Gram Glucose Load followed by plasma glucose at 1 hour
if > 140 mg/dL, go to Step 2
Step 2 = 3 hour test
100 Gram Glucose Load
No fast is required before the 1 hour challenge

11. Diagnostic Criteria 100 Gram Glucose Load Plasma Glucose Levels
Fasting
105 mg/dL
95 mg/dL
1 hour
190 mg/dL
180 mg/dL
2 hour
165 mg/dL
155 mg/dL
3 hour
145 mg/dL
140 mg/dL
National Diabetes Data Group vs. Carpenter and Coustan.
Abnormal 1 hour results need to be followed by a 3 hour GTT (unrestricted diet x 3 days followed by an overnight fast then the OGTT)
If FBG >125 on two or more occasions, diabetes is diagnosed and OGTT is not needed.

12. Treatment Meal Planning Exercise Blood Glucose Monitoring Insulin
All patients
Exercise
Physical Activity that does not  fetal risk
Blood Glucose Monitoring
Insulin
All pre-gestational
Some GDM

13. Glycemic Goals During Pregnancy
Fasting Glucose
Less than or equal to 105 mg/dL
Pre-meal Glucose
1 hour after eating
Less than or equal to 155 mg/dL
2 hours after eating
Less than or equal to 130 mg/dL

14. Insulin Preparation
Onset
Peak
Duration
Rapid
5 – 15 min.
90 min.
hours
Regular
30 min.
2 – 4 hrs
6 - 8 hours
Intermediate
(NPH)
~ 2 hours
4 – 10 hrs
12 – 20 hrs
Long acting
~ 4 hours
Flat peak
Up to 24 hrs

17. Meal Planning Diet should be Nutritional Goals Individualized
Culturally appropriate
Nutritional Goals
Provide sufficient calories for normal fetal growth and development
Avoid hyperglycemia

18. General Nutritional Guidelines
Spread carbohydrates throughout the day
3 meals, 3 small snacks
Fewer carbs during periods of higher insulin resistance, e.g., AM hours
Avoid high glycemic index foods
Sugary foods or fluids between meals
Use of sugar substitutes is OK

19. Exercise is important Exercises reduces insulin resistance
Walking is generally well tolerated, cheap, and easy.
AM time frame is when insulin resistance is greatest, but… consistent exercise has a lasting impact.
Goal: patient directed, provider approved, consistent activity at least every other day.

20. Monitoring for Ketones