Gestational Diabetes Mellitus and Nursing Management

Inservice education on GDM by Heera KC. BPKIHS Dharan Nepal

1. CONTINUED NURSING EDUCATION
Presented By
Mrs. Heera KC Parajuli, BN
Staff Nurse
Post-natal ward, BPKIHS
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DIABETES MELLITUS AND
PREGNANCY

2. •About1-14%ofallpregnanciesarecomplicatedby
Diabetesmellitusand90%ofthemaregestational
DiabetesMellitus.
•Nearly50%ofwomenwithGDMwillbecomeovert
Diabetesoveraperiodof5to20years.
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Background
Prevalence

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4. BRAINSTMORMING
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•Mrs,SabitaDeviShah,37yearsold,G8P7AoL6Still
birth1IUFD1,SVDwithEpisiotomydoneat37
completedweeks.
Herhistoryrevealsthatat20weeksshehadher
fastingBloodglucose200mg/dlandPP233mg/dl.
Onsubsequentcheckupalsoherbloodsugarwere
foundabovenormalthatisFBS150mg/dlandPP
287mg/dl.Urinetestshowsglycosuria.Shehada
positivehistoryofDmbeforepregnancyforwhich
shetookayurvedicmedicinesaswell.
a)Whatwouldbeherdiagnosis?

5. You got a handover from OT about a case.
•MrsSushmaBastolaage24years,Emergency
LSCSdoneat38weeksofgestationfor
prolongedlaborwithGestationalDm.Shegave
abirthofamalebabyweighing4kg.Babywas
bornnormalwithnodefects.ONmedicines
alongwiththeantibioticsprotocalInj.GIK
shouldbestartedaswell.RBSshouldbe
monitoredevery2hourlyandalsoofBabys’
RBSat0.2.4,6,8,12,tothen48hoursoflife.
a)What do you mean by GDM?
b)Why the RBS is monitored frequently for
both the baby’s and mother?
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6. Diabetes Mellitus
•Diabetesmellitusisachronicmetabolicdisorder
duetoeitherinsulindeficiency(relativeor
absolute)orduetoperipheraltissueresistance
(decreasesensitivity)totheactionofinsulin.
•Thepathophysiologyinvolvedare:
Insulin resistance and
Inadequate secretion of insulin(B cell
dysfunction)
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Diabetes in
pregnancy
Pre-existing
diabetes
IDDM
(Type1)
NIDDM
(Type2)
Gestational
diabetes
Pre-existing
diabetes
True GDM

8. ICD 10 (Chapter I-XXII)
Chapter XV: Pregnancy, child birth and the puerperium (O00-O99)
O 24 : DM In Pregnancy
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Type Number
O24.0= preexisting DM, Insulin dependent 2
O24.1= Preexisting DM Non insulin dependent 1
O24.2= Preexisting malnutrition -related DM 1
O24.3= Preexisting DM unspecified 2
O24.4= DM arising in pregnancy (GDM) 1
O24.9= DM in pregnancy, unspecified 87
Total 94
Title: Client attending BPKIHS in the Year 2014 Source: MRC, BPKIHS

9. Types
•Type 1 (IDDM)
Young onset(juvenile) and absolute insulinopenia.
Genetic predisposition with presence of autoantibodies.
•Type 2 (NIDDM)
Late age onset
Overweight women
Peripheral tissue insulin resistance(hyperinsulinaemia)
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12. GESTATIONAL DIABETES MELLITUS
•GestationalDiabetesMellitusiscarbohydrates
intoleranceofvariableseveritywithonsetorfirst
recognitionduringthepresentpregnancy.
•Theentityusuallypresentsinthesecondor
duringthethirdtrimester.
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13. OVERT DIABETES
•ApatientwithsymptomsofDiabetesMellitus
(polyuria,Polydipsia,weightloss)andrandom
plasmaglucoseconcentrationof200mg/dlor
moreisovertdiabetes.
•Itmaybedetectedforthefirsttimeinpregnancy.
•AccordingtoADA,FBS>126mg/dland
PP(75gm)>200mg/dl.
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14. EFFECT OF PREGNANCY ON DIABETES
Duringpregnancy,duetoalteredcarbohydrate
metabolismandanimpairedinsulinaction,itis
difficulttostabilisethebloodglucose.
Theinsulinantagonismisduetothecombined
effectofHPL,estrogen,progesterone,freecortisol
anddegradationoftheinsulinbytheplacenta.
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15. •Theinsulinrequirementduringpregnancyincreases
aspregnancyadvances.
•Duringpregnancy,renalthresholdisdiminished,
duetothecombinedeffectofincreasedglomerular
filtrationandimpairedtubularreabsorptionof
glucose.Glucoseleaksoutintheurineeventhough
thebloodsugarleveliswellbelow180mg/100ml.
•Hence,repeatedbloodglucosetestbecomes
mandatory.
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16. •Withtheacceleratedstarvation,thereisrapid
activationoflypolysiswithshortperiodoffasting.
•Ketoacidosiscanbeprecipitatedduring
hyperemesisinearlypregnancy,infectionsand
fastingoflabor.
•Itcanbeiatrogenicallyinducedbycertaindrugs
likecorticosteroidsusedinmanagementofpreterm
labor.
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17. •Insulinrequirementsfallsignificantlyin
puerperium.
•Vascularchanges,especiallyretinopathy,
nephropathy,CADandneuropathymaybe
worsenedduringpregnancy.
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18. Effect of diabetes on pregnancy
To the Mother
During pregnancy:
Abortion:recurrentspontaneousabortionmaybe
associatedwithuncontrolledDM.
Pretermlabor(20%)-infectionorpolyhydramnious
Infection-UTIandvulvovaginitis
Increasedincidenceofpre-eclampsia
Polyhydramnios(25-50%)
Maternaldistress
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19. •Diabetic retinopathy
•Diabetic nephropathy
•ketoacidosis
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20. During Labor
Increase incidence of:
•Prolong labor due to big baby
•Shoulder dystocia
•Perinealinjuries
•Postpartum haemorrhage
•Operative interferences
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21. Puerperium
•Puerperialsepsis
•Lactation failure
•PPH
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22. Fetal and Neonatal Hazards
FETAL MACROSOMIA:(30-40%)
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Elevation of
maternal
free fatty
acids
Maternal
hyperglycemia

23. •Congenital malformation(6-10%)
•Neonatal hypoglycaemia(<37mg/dl)
•Respiratory distress syndrome
•Hyperbillirubinaemia
•Polycythemia
•Hypocalcemia(<7mg/dl)
•cardiomyopathy
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24. Longtermeffects:
•Childhood obesity
•Neuropsychological effects and diabetes
•Stillbirth
Perinatalmortality(2-3 times)
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25. GDM
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26. WHO ARE THE POTENTIAL CANDIDATES ?
•Positivefamilyhistoryofdiabetes(parentsor
siblings).
•Previousbirthofanoverweightbabyof4kgor
more
•Previousstillbirthwithpancreaticdisease..
•Unexplainedperinatalloss.
•Presenceofpolyhydramniosorrecurrentvaginal
candidiasisinpresentpregnancy.
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27. •Persistent glycosuria
•Age over 30 years
•Obesity
•Ethnic group (East Asian, Pacific Island
Ancestry)
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WHO ARE THE POTENTIAL CANDIDATES ?

28. Whom should you plan for screening for
GDM??
•Low risk-absence of any risk factors mentioned
above.
•Average risk-some risk factors
•High risk-blood glucose test as soon as feasible.
•(50gm oral glucose challenge test without regard to
time of day or last meal, between 24-28 weeks of
pregnancy.)
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29. Hazards of GDM
•Increased perinatalloss associated with fasting
hyperglycaemia.
•Increased incidence of macrosomia
•Polyhydramnios
•Birth trauma
•Reoccurenceof GDM in subsequent pregnancy is
about 50 %.
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30. Management
Aim
Achievematernalnearnormoglycemic
leveltopreventadverseperinatal
outcomes

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34. Management
•Close antenatal supervision.
•Periodic FBS/PP . FBS < than 90mg/dl.
•Maintenance of mean plasma blood glucose
between 105 and 110 mg/dl.
•Diet, exercise with or without insulin.
•Human Insulin should be started if FBS exceeds
90mg/dl and 2 hours postprandial value is
greater than 120 mg/dl(repetitive) even on diet
control.
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35. •Diet-normalwoman(2000-2500kcal/day)and
restrictionto1200-1800kcal/dayforoverweight
womanisrecommended.
•Exercise(aerobic,briskwalking)programmes
aresafeinpregnancy.
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Management con….

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38. Obstetric management
Spontaneous labor for good glycaemiccontrol.
Elective delivery for uncontrolled GDM, requiring
insulin or with complications (macrosomia) at
around 38 weeks.
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40. Thank You
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