Running head: DIABETES IN PREGNANCY

Diabetes in Pregnancy Doris Sanchez Professor Joan Garcia RNSG-2308 Maternal Newborn Nursing and Womens Health February 10, 2012

DIABETES IN PREGNANCY

Diabetes in Pregnancy

Diabetes mellitus is a group of diseases characterized by high blood glucose levels that result from defects in the body's ability to produce or use insulin. Gestational diabetes develops during pregnancy (gestation). Like other types of diabetes, gestational diabetes affects how your cells use sugar (glucose) your body's main fuel. Gestational diabetes causes high blood sugar that can affect your pregnancy and your baby's health. According to the A.D.A.M. Medical Encyclopedia in the Pubmed Health website in pregnancy, abnormal maternal glucose regulation occurs in 3-10% of pregnancies, and gestational diabetes mellitus, which is defined as glucose intolerance in pregnant women who have never had diabetes before but who have high blood glucose levels during pregnancy. Hormones from the placenta help the baby develop. But these hormones also block the action of the mother's insulin in her body. This problem is called insulin resistance. Insulin resistance makes it hard for the mother's body to use insulin. She may need up to three times as much insulin. Gestational diabetes starts when your body is not able to make and use all the insulin it needs for pregnancy. Without enough insulin, glucose cannot leave the blood and be changed to energy. Glucose builds up in the blood to high levels. This is called hyperglycemia. Gestational diabetes affects the mother in late pregnancy, after the baby's body has been formed, but while the baby is busy growing. Because of this, gestational diabetes does not cause the kinds of birth defects sometimes seen in babies whose mothers had diabetes before pregnancy. Untreated or poorly controlled gestational diabetes can hurt the baby. To understand how gestational diabetes occurs, it can help to understand how pregnancy

DIABETES IN PREGNANCY affects your body's normal processing of glucose.

Your body digests the food you eat to produce sugar (glucose) that enters your bloodstream. In response, your pancreas produces insulin. Insulin is a hormone that helps glucose move from your bloodstream into your body's cells, where it's used as energy. During pregnancy, the placenta that connects your growing baby to your blood supply produces high levels of various other hormones. Almost all of them impair the action of insulin in your cells, raising your blood sugar. Modest elevation of blood sugar after meals is normal during pregnancy. As your baby grows, the placenta produces more and more insulin-blocking hormones. In gestational diabetes, the placental hormones provoke a rise in blood sugar to a level that can affect the growth and welfare of your baby. Gestational diabetes usually develops during the last half of pregnancy sometimes as early as the 20th week, but usually not until later. When gestational diabetes occurs, the pancreas works overtime to produce insulin, but the insulin does not lower blood glucose levels. Although insulin does not cross the placenta, glucose and other nutrients do, so extra blood glucose goes through the placenta, giving the baby high blood glucose levels. This causes the baby's pancreas to make extra insulin to get rid of the blood glucose. Since the baby is getting more energy than it needs to grow and develop, the extra energy is stored as fat. This can lead to macrosomia, or a "fat" baby. Babies with macrosomia face health problems of their own, including damage to their shoulders during birth. Because of the extra insulin made by the baby's pancreas, newborns may have very low blood glucose levels at birth and are also at higher risk for breathing problems. Babies with excess insulin become children who are at risk for obesity and adults who are at risk for type 2 diabetes.

DIABETES IN PREGNANCY

The excessive fetal and neonatal morbidity attributable to diabetes in pregnancy should be considered preventable with early diagnosis and effective treatment therapies. Guidelines have been established for the screening of pregnant women. The prevalence of gestational diabetes is strongly related to the patient's race and culture. Prevalence rates are higher in black, Hispanic, Native American, and Asian women than in white women. For example, it is stated in the A.D.A.M. Medical Encyclopedia in the Pubmed Health website that typically, only 1.5-2% of white women develop gestational diabetes mellitus, whereas Native Americans from the southwestern United States may have rates as high as 15%. In Hispanic, black, and Asian populations, the incidence is 58%. According to the American Diabetes Association, you're considered at high risk for this condition and should be screened early if you are obese (your body mass index is over 30), are older than 25 when you are pregnant, you have had gestational diabetes in a previous pregnancy, have a strong family history of diabetes, gave birth to a baby that weighed more than 9 pounds or had a birth defect, have high blood pressure, have too much amniotic fluid, have had an unexplained miscarriage or stillbirth or you have sugar in your urine. For most women, gestational diabetes doesn't cause noticeable signs or symptoms, or the symptoms are mild and not life threatening to the pregnant woman. . Rarely, gestational diabetes may cause excessive thirst, increased urination, blurred vision, fatigue, frequent infections, including those of the bladder, vagina, and skin, nausea and vomiting, and weight loss despite increased appetite. The blood glucose level usually returns to normal after delivery. (Lowdermilk, Perry & Cashion, 2010)

DIABETES IN PREGNANCY

Education is the first step to effective management of the patient with diabetes during pregnancy. The American Diabetes Association offers educational information and materials specific to each type of diabetes encountered during pregnancy and is organized around each phase of the pregnancy. This information can be provided to the patient by office staff and/or labor and delivery nurses. There are also specially trained and certified nurses and dietitians such as certified diabetes educators which are even more effective in providing detailed diabetes management and education. To screen for gestational diabetes, you will take a test called the oral glucose tolerance test. This test involves quickly drinking a sweetened liquid, which contains 50g of sugar. The body absorbs this sugar rapidly, causing blood sugar levels to rise within 3060 minutes. A blood sample will be taken from a vein in your arm 1 hour after drinking the solution. The blood test measures how the sugar solution was metabolized. A blood sugar level greater than or equal to 140mg/dL is recognized as abnormal. If your results are abnormal based on the oral glucose tolerance test, another test will be given after fasting for several hours. In women at high risk of developing gestational diabetes, a normal screening test result is followed up with another screening test at 24-28 weeks for confirmation of the diagnosis. Gestational diabetes usually starts halfway through the pregnancy. All pregnant women should receive another oral glucose tolerance test between the 24th and 28th week of pregnancy to screen for the condition. Women who have risk factors for gestational diabetes may have this test earlier in the pregnancy. Once diagnosed with gestational diabetes, you can see how well you are doing by testing your glucose level at home. The most common way involves pricking your finger and putting a drop of your blood on a machine that will give you a glucose reading. The goals of treatment are to keep

DIABETES IN PREGNANCY

blood glucose levels within normal limits during the pregnancy, and to make sure that the growing baby is healthy. (John A. Seibel, MD, 2012) If you have gestational diabetes, your doctor will likely recommend frequent checkups, especially during your last three months of pregnancy. During these exams, your doctor will carefully monitor your blood sugar. Your doctor may also ask you to monitor your own blood sugar daily as part of your treatment plan.

If you're having trouble controlling your blood sugar, or you need to take insulin, or you have other pregnancy complications, you may need additional tests to evaluate your baby's general health. These tests assess the function of the placenta, the organ that delivers oxygen and nutrients to your baby by connecting the baby's blood supply to yours. If your gestational diabetes is difficult to control, it may affect the placenta and endanger the delivery of oxygen and nutrients to the baby. Tests to monitor your baby's well-being include the Nonstress test, in which sensors are placed on your stomach and connected to a monitor to measure your baby's heart rate, which should increase when the baby moves. If your baby's heart doesn't beat faster during movement, the baby may not be getting enough oxygen. Another test is the Biophysical profile (BPP); this test combines a nonstress test with an ultrasound study of your baby. There's a scoring system that enables your doctor to evaluate your baby's heartbeat, movements, breathing and overall muscle tone, and determine whether your baby is surrounded by a normal amount of amniotic fluid. Your baby's scores on heartbeat, breathing and movement help your doctor tell if the baby's getting enough oxygen. When the amniotic fluid is low, it may mean that your baby hasn't

DIABETES IN PREGNANCY

been urinating enough. This could indicate that over time the placenta has not been working as well as it should. There is also Fetal movement counting. You may perform this simple test at the same time as the nonstress test or the biophysical profile. You simply count how often your baby kicks over a set time. Infrequent movement may mean your baby isn't getting enough oxygen. Diet and exercise is the best way to improve your chances. A healthy diet often focuses on fruits, vegetables and whole grains, foods that are high in nutrition and fiber and low in fat and calories and limits highly refined carbohydrates, including sweets. Eating a variety of healthy foods and you should learn how to read food labels, and check them when making food decisions. A registered dietitian or a diabetes educator can be consulted to create a meal plan based on your current weight, pregnancy weight gain goals, blood sugar level, exercise habits, food preferences and budget even if you are a vegetarian or on some other special diet. In general, your diet should be moderate in fat and protein and provide controlled levels of carbohydrates through foods that include fruits, vegetables, and complex carbohydrates such as bread, cereal, pasta, and rice. You will also be asked to cut back on foods that contain a lot of sugar, such as soft drinks, fruit juices, and pastries. You will be asked to eat three small- to moderate-sized meals and one or more snacks each day. You should not skip meals and snacks and try to keep the amount and types of food such as the carbohydrates, fats, and proteins the same from day to day. Your doctor or nurse will prescribe a daily prenatal vitamin. They may suggest that you take extra iron or calcium. Talk to your doctor or nurse if you're a vegetarian or are on some other special diet. Remember that "eating for two" does not mean you need to eat twice as many calories. You usually need just 300 extra calories a day (such as a glass of milk, a banana, and 10

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crackers). (Association, Nutrition Recommendations and Interventions for Diabetes, 2008) If managing your diet does not control blood glucose levels, you may be prescribed diabetes medicine by mouth or insulin therapy. You will need to monitor your blood glucose levels during treatment. Most women who develop gestational diabetes will not need diabetes medicines or insulin, but some will. Most women with gestational diabetes are able to control their blood sugar and avoid harm to themselves or their baby. Pregnant women with gestational diabetes tend to have larger babies at birth. This can increase the chance of problems at the time of delivery, including birth injury or trauma because of the baby's large size or Delivery by c-section. The baby is more likely to have periods of hypoglycemia during the first few days of life. Mothers with gestational diabetes have an increased risk for high blood pressure during pregnancy. There is also a slightly increased risk of the baby dying when the mother has untreated gestational diabetes. Controlling blood sugar levels reduces this risk. High blood glucose levels often go back to normal after delivery. However, women with gestational diabetes should be watched closely after giving birth and at regular doctor's appointments to screen for signs of diabetes. Many women with gestational diabetes develop diabetes within 5 - 10 years after delivery. (A.D.A.M. Medical

Encyclopedia., 2012) The risk may be increased in obese women. Complications include delivery-related complications due to the infant's large size, development of diabetes later in life, increased risk of newborn death and stillbirth and low blood glucose or illness in the newborn. Beginning prenatal care early and having regular prenatal visits helps improve your health and the health of your baby. Knowing the risk factors for gestational diabetes and

DIABETES IN PREGNANCY

having prenatal screening at 24 - 28 weeks into the pregnancy will help detect gestational diabetes early. (A.D.A.M. Medical Encyclopedia., 2012) If you are overweight,

decreasing your BMI to a normal range before you get pregnant will decrease your risk of developing gestational diabetes.

References Gestational diabetes Glucose intlerance during pregnancy. (2012). Retrieved February 8, 2012, from http://www.ncbi.nlm.nih.gov/pubmedhealth Lowdermilk, D. L., Perry, S. E., & Cashion, K. (2010). Maternity nursing. (8th ed. ed.).

DIABETES IN PREGNANCY Maryland Heights, MO: Mosby.

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Moore, T.R.(2012, January 25). Diabetes Melleitus and Pregnancy. Retrieved February 19, 2012, from http://emedicine.medscape.com/article/127547-overview

Pereira, R.F., & Franz M.J. (2008). Prevention and treatment of cardiovascular disease in people with diabetes through lifestyle modification: Current evidence-based recommendations. [Electronic version].Diabetes Spectrum, 21, 61-78. Pregnancy and Gestational Diabetes. (2012). Retrieved February 18, 2012, from http://diabetes.webmd.com/guide/gestational_diabetes

What is Gestational Diabetes. (2012). Retrieved Feb. 12, 2012, from http://www.diabetes.org/diabetes-basics/gestational/what-is-gestationaldiabetes.html