A PREGNANT WOMAN WITH DIABETES MELLITUS

Diabetes mellitus a group of metabolic Type 1 diabetes a metabolic disorder characterized

diseases characterized by hyperglycemia
resulting from defects in insulin secretion,
insulin action, or both
hyperglycemia elevated blood glucose
level—fasting level greater than
110 mg/dL (6.1 mmol/L); 2-hour postprandial
level greater than 140 mg/dL
(7.8 mmol/L)
hypoglycemia low blood glucose level (less
than 60 mg/dL [less than 2.7 mmol/L])
by an absence of insulin production
and secretion from autoimmune
destruction of the beta cells of the islets of
Langerhans in the pancreas. Formerly
called insulin-dependent, juvenile or
type I diabetes.
Type 2 diabetes a metabolic disorder characterized
by the relative deficiency of insulin
production and a decreased insulin
action and
ketone a highly acidic substance formed
when the liver breaks down free fatty acids
in the absence of insulin. The result is diabetic
ketoacidosis.

Anatomy and Physiology

The Pancreas Has both endocrine (ductless) and exocrine (with duct) types of
tissue.

Islets of langerhans Form the endocrine portion

These are cells scattered in-between the exocrine cells like
small islets

Alpha islet cells Secretes glucagon

Beta islet cells Secretes insulin

Insulin Secreted by beta islet cells Essential for carbohydrate metabolism

Formed by two amino acids chains from a precursor, Important for the metabolism of fats and protein
proinsulin, at a rate of 35 to 50 U/day in adults and
proportionally less in children.

The amount of insulin is regulated by serum glucose levels

When serum glucose that passes through the pancreas exceed

 100 mg/dL, beta cells immediately increase insulin
production.

PROBLEM DESCRIPTION FACTOR NURSING PROCESS MANAGEMENT

(ADPIE) MEDICAL AND NURSING
Assessment:  Glycosylated hemoglobin (normal HbA is 6% of total hgb)
Diabetes mellitus An endocrine
disorder in Fasting plasma  Instruct a woman who is diabetic to meet her OB before she becomes
which the glucose of 126 mg/dL pregnant.
pancreas cannot or above or nonfasting
produce
plasma glucose of 200  Ophthalmic examination
adequate insulin
mg/dL (done using
Types:
50-g oral glucose  Urine culture each trimester
1. DM type 1 - often occurs in Genetic challenge test)
childhood and Nutrition
represents Immunologic  Advise stricter diabetic diet before a woman gets pregnant.
 Dizziness (if
failure of the
pancreas to Environmental hypoglycemic)  1800- to 2400-calorie diet (or one calculated at 30 Kcal per kg of ideal
produce factors (e.g.
 Confusion, if
virus) weight), divided into three meals and three snacks.
hyperglycemic
 Reduced amount of saturated fats and cholesterol
 Congenital
2. DM type 2 Gradual failure Obesity anomalies  Increased amount of dietary fiber
of insulin
 Macrosomia
production Heredity  Urge final snack of the day one of protein and complex carbohydrate to allow
 Poor FHT variability
Environmental slow digestion during the night
and rate from poor
factors
tissue perfusion  No woman should reduce her intake to below 1800 calories during
 Glycosuria
pregnancy
A condition of Obesity  Polyuria
Gestational abnormal
 Hyperglycemia
diabetes glucose Age over 25 yrs
metabolism that  Increased risk of Exercise
arises during History of large
pregnancy babies (10 lb or PIH
 Exercise must begin before pregnancy.
more)  Hydramnios  If the arm in which a woman injected insulin is actively exercised, the insulin is
 Possibility of
History of released so quickly that it can cause hypoglycemia.
unexplained fetal increased monilial
or perinatal loss  Discourage extreme exercise in a woman with poor blood glucose control.
infection
History of Therapeutic Management
congenital
anomalies in 1. INSULIN
previous
Diagnosis
pregnancies
- Explain re-regulation of insulin.
 Risk for ineffective
History of
tissue perfusion
polycystic ovary
syndrome
 Imbalanced
nutrition, less than - Short-acting insulin (regular) combine with an intermediate type
Family history of
body
diabetes (one
requirements,
close relative or  2/3 of total amount of day’s insulin is given in the morning (30
two distant ones)
 Risk for ineffective minutes before breakfast in ratio of 2:1 {intermediate to regular})
coping
Member of a
population with a
 Risk for infection  Remaining 1/3 (1:1 ratio) just before dinner
high risk for
diabetes (Native
 Deficient fluid
American,
volume - Human insulin is recommended than pork or beef insulin
Hispanic, Asian)
 Deficient
knowledge - Instruct to eat almost immediately after injecting short-acting insulins

 Health-seeking
behavior - Oral hypoglycemia agents are not used during pregnancy.

- Help a woman plan her day based on the time interval her insulin takes to
reach its peak.

- Stretch the skin taut and inject at 90 degrees

- Rotate injection sites in the thighs and upper arms

Blood Glucose Monitoring
- Fingerstick technique
- Acceptable well-adjusted values
FBS 95 to 100 mg/dL
<120 mg/dL
- If hypoglycemic, instruct the woman to ingest some form of sustained
carbohydrate such as a glass of milk and some crackers
- Complex carbohydrate prevents phenomenon in which a high glucose level
is created that produces even more pronounced hypoglycemia.
- Monitor for urine ketones. Report if positive in two specimens. Acidosis
during pregnancy must be prevented because maternal acidosis leads to
fetal anoxia because of fetal inability to use oxygen when body cells are
acidotic.

Insulin Pump Therapy

- Continuous pump of insulin to effectively keep serum glucose constant.
- A syringe of regular insulin is palced in the pump chamber and a small
gauge needle is attached to a length of thin polyethylene tubing and
implaned into the subcutaneous tissue of a woman’s abdomen or thigh.
- Continuous rate of about 1 U per hour.
- Clean site daily and cover with sterile gauze
- Injection site is changed every 24 to 48 hours

Tests for Placental Function and Fetal Well-Being

- Serum alpha-fetoprotein level at 15 to 17 weeks
- Ultrasound at approximately 18 to 20 weeks
- Creatinine test each trimester
- Placental functioning assessed by a weekly nonstress test or biophysical
profile during the last trimester
- Instruct the woman to self-monitor fetal well being by recording how many
movements occur an hour
- Ultrasound at weeks 28, 36 and 38 to determine fetal growth, amniotic
fluid volume, placental location, and biparietal diameter.

Timing for Birth

- Vaginal birth is preferred if at all possible
- May be induced by rupture of the membranes or an oxytocin infusion after
measures to induce cervical ripening
 - Monitor labor contractions
- Monitor fetal heart sounds
- Regulate woman’s glucose by IV infusion of regular insulin
- Regulate glucose to reduce the possibility of rebound hypoglycemia in the
newborn
- Avoid IV glucose solution as plasma expander if on epidural anesthetic

Postpartum Management