2. DEFINITION
an endocrine disorder in which the
pancreas cannot produce adequate
insulin to regulate body glucose levels
Affects 3% to 5% of all pregnancies and is
the most frequently seen medical
condition in pregnancy
3. classification
TYPE I TYPE II
insulin-dependent diabetes
mellitus
Characterized by the
destruction of the beta cells in
the pancreas that usually leads
to absolute insulin deficiency
a. Immune-mediated DM results
from autoimmune destruction
of the beta cells
b. Idiopathic type 1 refers to
forms that have no known
cause
Non-insulin-dependent
diabetes mellitus
Usually arises because of
insulin resistance combined
with a relative deficiency in the
production of insulin
4. classification
GESTATIONAL
Condition of abnormal
glucose metabolism that
arises during pregnancy
Possible signal of an
increased risk for type 2
diabetes later in life
IMPAIRED GLUCOSE
HOMEOSTASIS
State between “normal”
&“diabetes” in which the
body is no longer using
&/or secreting insulin
properly
a. Impaired fasting
glucose: A state when
fasting plasma glucose
is at least 110 but under
126 mg/dL
b. Impaired glucose
tolerance: A state when
results of the oral
glucose tolerance test
are at least 140 but
under 200 mg/dL in the
2-hour sample
5. Clinical
characteristics &
implications
TYPE I
– Onset any age, usually <30
years
– Usually thin at diagnosis with
recent weight loss
– Etiology includes genetic,
immunologic, or environmental
factors (e.g., virus)
– Often have islet cell antibodies
– Little or no endogenous insulin
– Need insulin to preserve life
– Ketosis-prone when insulin is
absent
– Acute complications of
hyperglycemia: diabetic
ketoacidosis
TYPE II
– Onset at any age, usually >30
years
– Usually obese at diagnosis
– Causes include obesity,
heredity & environmental
factors
– No islet cell antibodies
– Decrease in endogenous
insulin, or increased with
insulin resistance
– May need insulin on a short or
long term basis to prevent
hyperglycemia
– Ketosis rare, except in stress
or infection
– Acute complication:
hyperglycemic, hyperosmolar,
non-ketotic syndrome
6. Clinical
characteristics &
implications
GESTATIONAL
– Onset during pregnancy, usually in the second or third trimester
– Due to hormones secreted by the placenta w/c inhibit the action
of insulin
– Above normal risk for perinatal complications, especially
macrosomia (abnormally large babies)
– Treated with diet and if need, insulin to stricly maintain normal
blood glucose levels
– Occurs in about 2% to 5% of all pregnancies
– Screening test (glucose challenge test) should be performed
onALL pregnant women between 24 and 28 week’s gestation
– Glucose intolerance transitory but may recur:
• In subsequent pregnancies
• 30% to 40% will develop overt diabetes (usually type 2) w/in 10 years
(especially if obese)
7. (SYMPTOMS)
TYPE I
– Frequent urination
(polyuria/nocturia)
– Thirst
– Fatigue
– Ketones(acetone on
breath)
– Weight loss-can be
dramatic
– Other minor
symptoms-skin
infections, muscle
cramps,blurred
vision, puritis
– Excessive thirst
– Frequent urination
– Fatigue
– Blurred vision
– Recurrent
infections
– Sometimes weight
loss
– Sometimes
ketones
– Some, all or none
of the above!!
Generally, gestational
diabetes may not
cause any symptoms,
however, the woman
may experience
excessive weight
gain,
excessive hunger or
thirst,
excessive urination
recurrent vaginal
infections.
TYPE II GESTATIONAL
10. Random blood glucose test
Fasting blood glucose test
Hemoglobin A1C test (A1C)
Oral glucose tolerance test
Diagnostic test
(type 1&2)
11. RANDOM BLOOD
GLUCOSE TEST
• blood can be drawn at any
time throughout the day,
regardless of when the
person last ate
• glucose level of 200 mg/dL
(11.1 mmol/L) or higher in
persons who have
symptoms of high blood
glucose suggests a
diagnosis of diabetes
12. FASTING BLOOD
GLUCOSE
• testing involves measuring blood
glucose after not eating or drinking for
8 to 12 hours (usually overnight)
• A normal fasting blood glucose level
is less than 100 mg/dL.
• A fasting blood glucose of 126 mg/dL
(7.0 mmol/L) or higher indicates
diabetes.
• The test is done by taking a small
sample of blood from a vein or
fingertip.
• It must be repeated on another day to
confirm that it remains abnormally
high
13. HEMOGLOBIN A1C
TEST
• measures the average blood
glucose level during the past
two to three months
• used to monitor blood
glucose control in people with
known diabetes, but is not
normally used to diagnose
diabetes
• Normal values for A1C are 4
to 6 percent.The test is done
by taking a small sample of
blood from a vein or fingertip.
14. ORAL GLUCOSE
TOLERANCE
• most sensitive test for diagnosing diabetes and
pre-diabetes
• includes a fasting blood glucose test
• person then drinks a 75 gram liquid glucose
solution
• Two hours later, a second blood glucose level is
measured
• routinely performed at 24 to 28 weeks of
pregnancy to screen for gestational diabetes
• this requires drinking a 50 gram glucose solution
with a blood glucose level drawn one hour later
• For women who have an abnormally elevated
blood glucose level, a 2nd OGTT is performed on
another day after drinking a 100 gram glucose
solution. The blood glucose level is measured
before, and at one, two, and three hours after
drinking the solution.
15. 1. Symptoms of diabetes plus casual plasma glucose concentration
≥200 mg/dL (11.1 mmol/L).Casual is defined as any time of day
without regard to timesince last meal. The classic symptoms of
diabetes include polyuria, polydipsia, and unexplained weight
loss or
2. Fasting plasma glucose ≥126 mg/dL (7.0 mmol/L). Fasting is
defined as no caloric intake for at least 8 hours or
3. 2-hour postload glucose ≥200 mg/dL (11.1 mmol/L) during an oral
glucose tolerance test. The test should be performed as described
by the World Health Organization, using a glucose load containing
the equivalent of 75 g anhydrous glucose dissolved in water. In
the absence of unequivocal hyperglycemia with acute metabolic
decompensation, these criteria should be confirmed by repeat
testing on a different day. The third measure is not recommended
for routine clinical use.
Criteria for
diagnosis of dm
16. • Test for the mother
• Oral glucose tolerance test
• Tests for the baby
• Physical exam – skin, pelvic and
digital rectal exam
• Ultrasound- visualize the woman's
reproductive organs (ovaries,
cervix, vagina, uterus), used to
assess the fetus and the fetal
heart rate; may be taken @ week
28 & then again @ week 36-38
• Fetal movement records- healthy
fetus makes approx. 10
movements/hour
• Fetal monitoring- Physiologic or
biochemical monitoring of the fetus
Diagnostic test
(gestational)
17. • Non-stress test - demonstrates at
least two accelerations in the fetal
heart rate at least 15 beats above
the baseline heart rate and lasting
at least 15 seconds
• Stress test (oxytocin challenge
test)- used to identify fetuses who
are only marginally compromised
by assessing their reserve when
subjected to uterine contractions
induced through an oxytocin
infusion
• Amniocentesis - the presence of
phosphatidylglycerol is used to
indicate lung maturity
Diagnostic test
(gestational)
18. Being overweight,
Sedentary lifestyle
Abnormal cholesterol
& blood fats,
High blood pressure
Smoking
RISK FACTORS
YOU CAN CONTROL YOU CAN’T CONTROL
Race or ethnicity
Family history of
diabetes
Age
19. RISK FACTORS
(gestational)
Obesity
Age over 25 years
HISTORY OF:
1. Large babies(10lbs or more)
2. Unexplained fetal loss
3. Congenital anomalies in
previous pregnancies
4. Polycystic ovary syndrome
Member of a population
with a high risk for
diabetes
(Native American, Asian
Hispanic)
27. management
1. NUTRITIONAL MGT.
Avoid simple sugars, have complex CHO
instead
Don’t skip or delay meals
Eat more fiber-rich foods like vegetables
Cut down on salt
Avoid alcohol
During pregnancy: 1800-2400 calorie diet;
20%-CHON, 40&-50%-CHO, 30%-Fats
N/V→ temporary IV supplementation
2. EXERCISE
It lowers blood glucose by increasing the uptake of glucose
by the body muscles and by improving insulin utilization
Improves circulation & muscle tone
if the insulin-injected arm is actively exercised, the insulin
is released so quickly→hypoglycemia
She should not do aerobic exercises one day & then none
the next day but rather 30 min. of walking everyday
28. 3.MONITORING
Self-monitoring of blood glucose
enables the diabetic to adjust treatment
regimen to obtain optimal blood glucose control
Possible detection and prevention of
hypoglycemia & hyperglycemia
Woman typically uses a fingerstick technique,
using one of her fingertips as the site of lancet
puncture, she places a drop of blood on a test
strip and then inserted into a glucose meter that determines the glucose
level
If hypoglycemic → glass of milk & some crackers
If hyperglycemic → assess urine for ketones → inform health care provider
Acidosis should be prevented during pregnancy because it can lead to
fetal anoxia.
management
29. 4. PHARMACOLOGIC THERAPY
Exogenous insulin must be administered on a
long-term basis to type 1 diabetes because in
this type, the body loses its ability to produce
insulin
Type 2 diabetic patients may temporarily
require insulin during illness, infection,
pregnancy, surgery, or stressful events
These should not be used during pregnancy:
1. Sulfonylureas- Glibenclamide, Gliclazide, Glipizide, Glimepiride
2. Biguanide- Metformin
3. Alpha-glucosidase inhibitors- Acarbose
4. Thiazolidinedione- Troglitazone, Rosiglitazone, Proglitazone
5. Meglitinides
management
31. • Sulfonylurea drugs- stimulate your pancreas to produce
and release more insulin; common side effect of is low blood
sugar, especially during the first 4 months of therapy
• Meglitinides- effects similar to sulfonylureas, but you’re not
as likely to develop low blood sugar. Meglitinides work quickly,
and the results fade rapidly.
• Biguanides- works by inhibiting the production and release
of glucose from your liver, which means you need less insulin to
transport blood sugar into your cells; tends to cause less weight
gain than do other diabetes medications; side effects include a
metallic taste in your mouth, loss of appetite, nausea or vomiting,
abdominal bloating, or pain, gas and diarrhea
medication
32. • Alpha-glucosidase inhibitors- block the action of
enzymes in your digestive tract that break down carbohydrates.
That means sugar is absorbed into your bloodstream more
slowly, which helps prevent the rapid rise in blood sugar that
usually occurs right after a meal; inhibitors can cause abdominal
bloating, gas and diarrhea. If taken in high doses, they may also
cause reversible liver damage.
• Thiazolidinediones- make your body tissues more
sensitive to insulin and keep your liver from overproducing
glucose; side effects include swelling, weight gain and fatigue. A
far more serious potential side effect is liver damage
medication
33. 5. EDUCATION
Client should be educated on
nutrition
medication
effects and side effects
exercise
disease progression
prevention strategies
monitoring techniques
and medication adjustment
as part of their
self-management behavior
management
34. management
• Most hazardous times for a fetus
are weeks 36-40 of pregnancy
• To accomplish early births,
cesarean birth was routinely
performed in pregnant diabetic
women at 37 weeks gestation
• Labor may be induced by rupture
of the membranes or an oxytocin
infusion after measures to induce
cervical ripening
TIMING FOR BIRTH
• Pregnant woman w/ diabetes must
undergo yet another readjustment
to insulin regulation
• Often she needs no insulin during
immediate postpartum
• 1 or 2-hour posprandial blood
glucose determinations help to
regulate how much insulin she
needs
• Women w/ DM may breastfeed
because insulin does not pass into
breast milk from the bloodstream
• Woman who had gestational
diabetes is at risk for developing
type 2 diabetes later in life
POSTPARTUM
ADJUSTMENT
35. Nursing
diagnosis
Risk for ineffective tissue
perfusion r/t reduced vascular
flow.
Imbalanced nutrition, less than
body requirements, r/t inability to
use glucose.
Risk for ineffective coping r/t
required change in lifestyle.
Deficient fluid volume r/t polyuria
accompanying disorder.
Deficient knowledge r/t complex
health problem.
Health-seeking behaviors r/t
voiced need to learn home
glucose monitoring.
36. PROGNOSIS (type 1)
Type 1 DM is associated with a high morbidity and premature
mortality. More than 60% of patients with type 1 DM fare
reasonably well over the long term.
Many of the rest develop blindness, end-stage renal disease,
and, in some cases, early death. The risk of end stage renal
disease and proliferative retinopathy (PR) in men compared
with women doubles when age at onset of diabetes was less
than 15 years.
If a patient w/ type 1 DM survives the period 10-20 years after
onset of disease w/o fulminant complications, he or she has a
high probability of good health. The 2011 ADA standard of
care emphasizes the importance of long-term, coordinated
care management for improved outcomes and suggests
structural changes to existing systems of chronic care delivery
37. PROGNOSIS (type 1)
complications include hypoglycemia and hyperglycemia,
increased risk of infections, microvascular complications
(eg, retinopathy, nephropathy), neuropathic
complications, and macrovascular disease.
As a result of these complications, people with diabetes
have an increased risk of developing ischemic heart
disease, cerebral vascular disease, peripheral vascular
disease with gangrene of lower limbs, chronic renal
disease, reduced visual acuity and blindness, and
autonomic and peripheral neuropathy.
38. After many years, diabetes can lead to serious problems with
your eyes, kidneys, nerves, heart, blood vessels, or other areas in
your body.
If you have diabetes, your risk of a heart attack is the same as
that of someone who has already had a heart attack. Both women
and men with diabetes are at risk. You may not even have the
normal signs of a heart attack.
If you control your blood sugar and blood pressure, you can
reduce your risk of death, stroke, heart failure, and other diabetes
problems.
Some people with type 2 diabetes no longer need medicine if they
lose weight and become more active. When they reach their ideal
weight, their body's own insulin and a healthy diet can control their
blood sugar levels.
PROGNOSIS (type 2)
39. Gestational diabetes usually goes away after
pregnancy, but, once a woman has had
gestational
diabetes, the chances are 75% that it will
return in future pregnancies.
In a few women, however, pregnancy
uncovers
insulin-dependent (Type I) or non-insulin
dependent (Type II) diabetes. In other women,
gestational diabetes increases their chances of
developing Type II diabetes within eight years.
PROGNOSIS
(gestational)
