Diabetes care before, during and after pregnancy
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Transcript of Diabetes care before, during and after pregnancy
Diabetes care before, during and after pregnancy
Jo M. Kendrick, APN-BC, CDE Introduction For nurses, diabetes
mellitus, whether gestational or pregestational, represents one of
the most challenging medical complications encountered during
pregnancy. A comprehensive and multidisciplinary approach is
required to improve maternal and neonatal outcomes. Incidence and
significance: United States
29.1 million people (21 million diagnosed and 8.1 million
undiagnosed) have diabetes (CDC, 2014). Women older than 20 account
for 13.4 million individuals with diabetes; this represents 10.8
percent of all women in America (CDC, 2014). An estimated 79
million adults 20 years or older have prediabetes (NIDDK, 2011).
Factors contributing to the prevalence of diabetes are obesity, an
aging population, urbanization, physical inactivity and stress
(Veeraswamy, Vijayam, Gupta & Kapur, 2012). Maternal diabetes
impacts the lifelong prevalence of obesity, diabetes, and
cardiovascular disease in the offspring. Pregnancies complicated by
diabetes are at increased risk of perinatal morbidity and
mortality. Definition and classification
Diabetes mellitus is a metabolic disorder caused by defects in
insulin secretion or action, which lead to abnormalities in the
metabolism of carbohydrates, lipids and protein (ADA, 2014a).
Chronic hyperglycemia associated with diabetes causes tissue damage
in all organ systems. Type 1 diabetes An immune-mediated disorder
characterized by destruction of the beta cells of the pancreas,
which leads to an absolute insulin deficiency. Accounts for 5 to 10
percent of all diabetes cases and 1 percent of diabetes cases in
pregnancy (ADA, 2014a). Definition and classification
(continued)
Type 2 diabetes Accounts for 90 to 95 percent of diabetes cases
(CDC, 2012) A disease of insulin resistance and relative insulin
deficiency. Can be controlled initially with lifestyle modification
and oral medications Gestational diabetes mellitus (GDM) Prevalence
ranges from 1 to 14 percent of pregnant women, depending on the
population (ADA, 2014a) Accounts for 90 percent of all pregnancies
complicated by diabetes Metabolic alterations of pregnancy
During the first trimester, insulin requirements significantly
decrease. By the end of the first trimester, insulin sensitivity
decreases with a responding increase in insulin production.
Increased insulin production occurs in response to rising insulin
antagonistic hormones in the latter half of pregnancy, causing the
diabetogenic state of pregnancy. Exogenous insulin requirements
increase dramatically in the second and third trimesters in women
with preexisting diabetes who are on insulin. The risk of
ketoacidosis is increased in women with pregestational diabetes.
Perinatal implications of diabetes
In pregnancies complicated by preexisting diabetes,
congenitalmalformations and spontaneous abortion account for most
perinatalmortality (Mathiesen & Damm 2010). Fetal growth
alterations most frequently seen in women withpregestational or
gestational diabetes are macrosomia andintrauterine growth
restriction (IUGR) (Landon et al., 2012). Poorly controlled
diabetes, whether pregestational or gestational,increases the risk
of respiratory distress syndrome (RDS) in theinfant (Landon et al.,
2012). The risk of neonatal hypoglycemia,
hyperbilirubinemia,hypocalcemia, hypomagnesemia and polycythermia
is increased ininfants born to women with diabetes who have
suboptimal glycemiccontrol during the third trimester (Hawdon,
2010). Screening and diagnosis of GDM
When pancreatic beta cells fail to produce enough insulin to
maintain euglycemia, hyperglycemia results, and the diagnosis of
GDM can be made. ACOG (2013a) recommends universal screening for
GDM. Guidelines for screening and diagnosing GDM are controversial
and conflicting. ADA (2014c) recommends both one-step and two-step
approaches for identifying GDM but ACOG recommends the two-step
approach. ACOG (2014c) and ADA (2014c) recommend testing for overt
diabetes 6 to 12 weeks postpartum in women with GDM using standard
diagnostic criteria. Antepartum care Providers ideally assess women
with pregestational diabetes before conception so that glycemic
control can be attained before pregnancy. Evaluation includes: A
complete health, obstetric, gynecologic and diabetes history A
physical examination focused on detecting vascular complications
and other diabetes-related abnormalities Laboratory tests
Self-management The burden of diabetes management falls on the
woman.
Self-monitoring of blood glucose, urine ketone testing and
recordkeeping are the basis for evaluation and adjustment of
therapy. Patient education topics Effect of pregnancy on diabetes
control Potential outcomes of uncontrolled blood glucose Medical
nutrition therapy and exercise Insulin administration and
management Sick day management Significance of GDM on future
pregnancies Use of glucose meter Recording blood glucose results
Urine ketone testing Self-monitoring of blood glucose (SMBG)
SMBG, urine ketone testing and recordkeeping provide the basis for
evaluation and adjustment of therapy. Professional organizations do
not agree on glycemic thresholds, timing or frequency for SMBG
testing. To determine effectiveness of diet in controlling blood
glucose, women with GDM or diet-controlled type 2 diabetes that is
managed by MNT initially test when fasting and 1 or 2 hours
postprandially (ACOG 2013a; ADA, 2011). For women on insulin,
frequent SMBG is critical to obtain glycemic goals without
significant hypoglycemia. Continuous glucose monitoring (CGM)
A temporary sensor implanted subcutaneously makes it possible to
measure glucose in the interstitial fluid every 5 minutes. This
device provides more information on the diurnal variation in blood
glucose than SMBG alone because providers can see variations in
minute-to-minute changes. Further study is needed on the
effectiveness and cost-effectiveness of CGM in pregnancy before
wide implementation into clinical practice (Voormolen, DeVries,
Evers, Mol & Franx, 2013). Urine ketone testing Pregnant women
with type 1 or 2 diabetes need to test urine ketones during nausea
and vomiting, illness, weight loss and reduction in calorie intake
(Reader & Thomas, 2011). Testing urine ketones when blood
glucose values are 180 mg/dl is necessary because diabetic
ketoacidosis can develop at lower levels in pregnancy.
Recordkeeping Accurate records of blood glucose values, urine
ketone testing, dietary intake, activity level and timing and
dosage of insulin allow for appropriate adjustment of the diabetes
regimen. A womans health care provider reviews her records at each
office visit and identifies areas requiring adjustment. Medical
nutrition therapy (MNT)
MNT by a registered dietitian provides the cornerstone for diabetes
management in women with pregestational and gestational diabetes.
Nutritional management of women with preexisting and gestational
diabetes does not differ and has the same goals: adequate nutrition
and weight gain with prevention of ketosis and postprandial
hyperglycemia. The dietitian and the woman develop an
individualized meal plan that provides adequate nutrients and
energy requirements for both mother and baby. IOM recommendations
for weight gain in pregnancy have changed recognizing that a
significant number of women begin pregnancy overweight or obese
(Rassmussen, Yaktine & IOM, 2009). IOM guidelines do not
include recommendations for morbidly obese women (BMI >40). MNT
(continued) The diet for pregnant women with diabetes includes
(Reader & Thomas, 2011): At least 175 g of carbohydrate divided
into three meals and three to four snacks 1.1 g/kg per day of
protein or 25 g extra 28 g of fiber and adequate intake of calcium,
iron, folate, vitamin D and magnesium Recommended weight gain for
pregnant women Exercise Exercise can improve well-being and glucose
control, reduce cardiovascular risk factors and contribute to
weight loss in individuals with diabetes before pregnancy (ADA,
2014c). Before beginning or continuing an exercise program, the
pregnant woman with diabetes needs a thorough evaluation for
vascular disease and other diabetes-associated complications.
Pregnant women with diabetes need to check their urine ketones
before exercise if their blood glucose is >200 mg/dl. Exercise
can worsen hyperglycemia and ketosis; in their presence, women
shouldnt exercise. Women with preexisting diabetes on insulin are
at increased risk for post-exercise hypoglycemia. Pharmacologic
therapy: Pregestational diabetes
Insulin requirements during pregnancy change dramatically due to
the effect of insulin antagonistic placental hormones. Intensive
insulin regimens during pregnancy are most often comprised of
multiple daily injections (MDI) to attempt attainment of glycemic
thresholds. Basal insulins approved for use in pregnancy are
neutral protamine Hagedorn (NPH) and detemir (ADA, 2013). Bolus
insulins approved for use during pregnancy include regular insulin
(short-acting) and aspart and lispro (rapid-acting) insulin
analogues. GDM Most women can control GDM with diet and
exercise.
ACOG (2013) lists metformin and glyburide as oral medications that
can be used as first-line therapy for GDM, although they are not
approved by the FDA for use during pregnancy. Insulin dosing and
timing in women with GDM is based on the results of SMBG and
calculated on the womans weight and gestational age. Physiologic
administration of insulin requires three to four injections, with
50 to 60 percent of the total daily dose (TDD) as the basal
insulin. Continuous subcutaneous insulin infusion (CSII)
CSII (or insulin pump) consists of a syringe or cartridge filled
with rapid-acting insulin or U-500 regular insulin when large
quantities of insulin are needed. The pump is programmed to
dispense a continuous infusion of basal insulin, plus bolus insulin
for meals, snacks or correction, thus mimicking pancreatic
secretion. Women who become pregnant while using CSII may continue
to use the pump, but they need education regarding the risks of
pump use in general and during pregnancy. Pregnancy alone is not an
indication for CSII; providers consider CSII only for women who
want to use the pump during and after pregnancy. CSII (continued)
Indications for CSII: Difficult-to-control diabetes
History of recurrent hypoglycemia Lifestyle or work schedule that
warrants flexible insulin therapy Desire for pump therapy
Hypoglycemia Intensive metabolic management during pregnancy
carries an increased risk of hypoglycemia. Hypoglycemia has not
been found to adversely affect the fetus, although it can be
hazardous for the mother (Kitzmiller, Jovanovic, Brown, Coustan
& Reader, 2008). Hypoglycemia is classified as mild, moderate
or severe based on symptomatology requiring different levels of
treatment. Hypoglycemia can be the result of too much insulin,
inadequate food intake, vomiting or increased activity. Frequent
testing of blood glucose allows early detection and appropriate
treatment. If the woman is hypoglycemia-unaware, the provider helps
determine the blood glucose level at which symptomatology occurs.
Acute complications: Preterm labor
The incidence of preterm birth is increased in women with GDM and
significantly increased in women with preexisting diabetes (Kock,
Kock, Klein, Bancher-Todesca & Helmer, 2010). Vascular disease,
hypertensive disorders and obesity contribute to the increased risk
of preterm birth in women with diabetes. Management may include 17P
Intravenous hydration Tocolytics Antenatal glucocorticoids Acute
complications: Diabetic ketoacidosis (DKA)
Diabetic ketoacidosis is an uncommon but life-threatening
complication associated with pregestational diabetesall Occurs as a
result of insulin deficiency leading to hyperglycemia,
hyperketonemia and acidosis Most frequently seen in women with type
1 diabetes but also in women with type 2 diabetes; is rare in women
with GDM Can develop in pregnancy at glucose levels 200 mg/dl
(Inturrisi, Lintner & Sorem, 2013) Managed in a critical care
unit with obstetric involvement. Treatment includes (Young, 2010):
Aggressive hydration and insulin therapy Correction of electrolyte
imbalances Identification and treatment of an underlying cause
Continuous fetal and maternal monitoring Acute complications:
Diabetic retinopathy
Diabetic retinopathy is the leading cause of blindness between ages
20 and 74 and the most common vascular complication in pregnancy
(ADA, 2014c). Chronic hyperglycemia contributes to development of
retinopathy as well as other microvascular complications of
diabetes (Meyerle & Chew, 2010). Rapid normalization of blood
glucose that occurs with pregnancy increases development and
progression of retinopathy (ADA, 2014c). Risk factors for
progression during pregnancy include (Rahman, Rahman, Yassin,
Al-Suleiman & Rahman, 2007): Retinal status at conception
(presence or absence of retinal changes) Duration and early onset
of diabetes Elevated first-trimester A1C, persistent poor glycemic
control Rapid normalization of blood glucose Hypertension Acute
complications: Nephropathy
Kidney disease develops in 25 to 30 percent of women with diabetes
(Landon et al., 2012). Diagnostic criteria for overt nephropathy is
albuminuria of >300 mg/24 hours or total urinary protein
excretion of >500 mg/24 hours in the absence of infection.
Diagnosis can be made if criteria is met before 20 weeks gestation
in more than two specimens (ADA, 2014c). Interventions to slow
progression of renal disease include optimization of blood glucose
and blood pressure control (ADA, 2014c). Aggressive management of
blood pressure improves perinatal outcome. Women with overt
nephropathy have increased risks for cesarean birth, preeclampsia,
preterm birth, fetal growth restriction and perinatal mortality
(Sibai, 2010). Providers may consider dietary protein restriction
for women with progressing nephropathy in spite of glycemic and
blood pressure control. Acute complications: Neuropathy
Diabetic neuropathy is a common complication of diabetes;
individuals with type 1 and type 2 diabetes are affected. Chronic
distal symmetric polyneuropathy (DPN) and cardiac autonomic
neuropathy (CAN) are the most common neuropathies (Myers, 2010).
Pregnant women face additional risks when neuropathy is directed at
the gastrointestinal and cardiovascular systems due to stress from
metabolic, hematologic and vascular changes associated with
pregnancy. Pregnancy does not seem to accelerate progression of
neuropathy. Painful symptoms can be relieved with a combination of
glycemic control and medication. Acute complications:
Gastroparesis
Gastroparesis involves autonomic neuropathy of the viscera, causing
decreased innervation of the stomach and intestines. Prevalence
rates of 30 to 50 percent have been reported in type 1 and 2
diabetes (Myers, 2010). Maternal and fetal morbidity is high
because of difficulty in maintaining adequate nutrition;
hospitalization and total parenteral nutrition may be required
(Myers, 2010). Diagnosis requires referral to a gastroenterologist;
however, providers may suspect it in women with severe nausea and
vomiting and erratic blood glucose control (Myers, 2010). Treatment
may be empiric addressing only the symptoms until after pregnancy
when a more thorough work-up can be done. Acute complications:
Cardiovascular autonomic neuropathy (CAN)
Women with diabetes who have resting tachycardia may have CAN.
Three major syndromes associated with CAN (Vinik & Vinik,
2011): Cardiac denervation syndrome Abnormal cardiovascular
response to exercise Orthostatic hypotension Limited data exists on
CAN in pregnancy. Wearing pressure hose, changing positions slowly,
getting adequate hydration and sleeping with the head of the bed
elevated may minimize symptoms of postural hypotension. Improving
glycemic control usually results in an improvement in hypoglycemia
unawareness. Continuous subcutaneous insulin infusion may decrease
the incidence of hypoglycemia. Acute complications: Cardiovascular
disease (CVD)
Coronary artery disease (CAD), CAN, cerebrovascular disease and
peripheral arterial disease (PAD) make up macrovascular
complications of diabetes; they carry significant risks for
maternal morbidity and mortality (Lorber, 2011). Preconception
evaluation and control of vascular disease can help reduce adverse
outcomes. Treatment for CAD or myocardial infarction (MI) during
pregnancy follows the same principles as for non-pregnancy. Acute
therapy consists of rapid coronary reperfusion by angioplasty,
stenting and thrombolytic therapy (Easterling & Stout, 2012).
Maternal death may occur if delivery happens within 2 weeks of MI;
this timing should be avoided (Easterling & Stout, 2012).
Cesarean birth does not reduce cardiac risk and is reserved for
obstetric indications. Providers use standard cardiac care during
labor with early and carefully administered regional anesthesia
with little to no maternal exertion atdelivery. Maternal
surveillance: Pregestational diabetes
A comprehensive antepartum assessment includes a history, physical
exam and laboratory evaluation at the first prenatal visit. In the
following weeks, visit frequency is based on the level of glycemic
control and the presence of vascular disease or other
comorbidities. Nursing surveillance of women with pregestational or
gestational diabetes: Take vital signs Check weight Test urine for
protein, glucose and ketones Review the self-management log Inspect
injection sites for bruising, infection or atrophy. Pregnant women
with nephropathy require a 24-hour urine for protein and creatinine
clearance and electrolyte assessment at least once each trimester
(Mathiesen, Nielsen & Damm, 2010). Maternal surveillance:
GDM
If GDM is diagnosed in the first trimester, monitoring is similar
to that of women with preexisting diabetes. When women present with
previously undetected profound hyperglycemia, providers obtain
laboratory testing for type 2 diabetes, including A1C, fasting
plasma blood glucose or random blood glucose (Landon et al., 2012).
If a diagnosis of type 2 diabetes is made, providers do a vascular
disease workup and educate the woman about type 2 diabetes,
including emotional and social support. Women who have an A1C
>7.0 percent need an ultrasound to evaluate for birth defects.
Women diagnosed with GDM between 24 and 28 weeks require weekly
visits or phone contact to evaluate the level of glycemic control;
women who initiate insulin may need more frequent visits (Landon et
al., 2012). Maternal surveillance: Emotional support
Comprehensive management of diabetes in pregnancy involves ongoing
assessment of the emotional impact of diabetes on pregnancy and
pregnancy on diabetes. Depression, insulin resistance and
hyperglycemia have been established in individuals with type 2
diabetes but have not been documented in women with gestational
diabetes (Byrn & Penckofer, 2013). A pregnant womans emotional
state during pregnancy has long-term effects on the
neurodevelopmental outcome of her children (Glover, 2014).
Recognition of emotional problems is the first step for
intervention, so exploration for anxiety, depression and/or stress
happen at each office visit. Fetal surveillance Perinatal morbidity
and mortality in diabetic pregnancy have declined because of
improved glycemic control and development of fetal surveillance
techniques that identify fetal compromise and allow for timely
intervention (Landon et al., 2012). ACOG (2005) recommends
initiation of fetal testing in women with pregestational diabetes
between 32 and 34 weeks. Method and timing are based on gestational
age, level of glycemic control, obstetric history and the presence
of vascular disease and other comorbid conditions. Each perinatal
center determines the combination of tests it uses. There is no
agreement on a single approach (ADA, 2013). Fetal surveillance:
Ultrasound
An elevated A1C in the first trimester in women with preexisting
diabetes alerts the sonographer to the increased possibility of the
presence of a fetal birth defect that may involve any system. Fetal
echocardiography is obtained when fetal heart defects are suspected
or in women with uncontrolled glucose in the first trimester. Women
who present with GDM either early in the pregnancy or who have A1C
results that indicate the presence of undiagnosed type 2 diabetes
need a detailed ultrasonographic fetal evaluation for defects.
Serial ultrasound evaluation provides growth assessment to detect
macrosomia or IUGR. IUGR occurs more frequently in women with
preexisting diabetes complicated by vascular disease or
hypertension than in unaffected women. Fetal surveillance: Maternal
serum screening
Chromosomal abnormalities are not increased in diabetic pregnancy,
although the incidence of open neural tube defects is. Late in a
womans first trimester (11 to 13 weeks), providers may screen for
aneuploidy by measuring fetal nuchal translucency (NT) using
ultrasound combined with serum screening of pregnancy-associated
plasma protein A (PAPP-A) and beta human chorionic gonadotripin
(hCG). Multiple marker screening of alpha-fetoprotein, unconjugated
estriol, inhibin-A and beta HCG obtained at 16 weeks combined with
first-trimester screening provide a single risk assessment
(Simpson, Holzgreve & Driscoll, 2012). Providers can offer
second-trimester maternal serum screening for chromosomal
abnormalities between 15 and 20 weeks. Fetal surveillance: Fetal
movement count (FMC)
FMC is a noninvasive and valuable tool to evaluate fetal well-being
in high-risk pregnancies. It can begin in the late-second or
early-third trimester. The woman counts fetal movements after meals
for a specific period of time. A decrease in perceived fetal
activity warrants further exploration by NST or BPP. Fetal
surveillance: Nonstress test, biophysical profile, contraction
stress test
Nonstress test (NST) Many provider use NST after 26 to 28 weeks to
evaluate fetal well-being in pregnancies complicated by diabetes.
NST uses an electronic fetal monitor to record fetal heart rate
(FHR) and uterine activity. A nonreactive pattern or lack of
acceleration may indicate fetal compromise and requires further
testing by biophysical profile (BPP) or contraction stress test
(CST) (Landon et al., 2012). Biophysical profile (BPP) BPP is an
ultrasound that measures fetal breathing, gross body movement,
fetal tone and amniotic fluid. Contraction stress test (CST) CST
carries some risk of initiating labor; provider do not use CST in
women for whom labor timing is inappropriate. Delivery With
favorable antepartum testing and well-controlled diabetes, women
with GDM and preexisting diabetes may safely continue pregnancy
until full term (Landon et al., 2012). Indications for delivery in
diabetic pregnancy include: (Landon et al., 2012) Poor glycemic
control Vascular disease with worsening hypertension Significant
growth restriction Abnormal biophysical testing If preterm birth is
expected but not urgent, providers may give antenatal
corticosteroids to enhance fetal lung maturity; insulin adjustments
are required for at least 5 days due to steroid-induced
hyperglycemia; women who are diet-controlled may require insulin
(Landon et al., 2010). ACOG (2005) recommends c-section when EFW
exceeds 4,500 g to reduce the risk of traumatic birth injuries.
Intrapartum care The nurse takes a comprehensive and detailed
diabetes history for women with pregestational or gestational
diabetes being admitted for labor and birth. Providers use
continuous electronic fetal monitoring for laboring women with
diabetes (ADA, 2013). No pain relief methods are contraindicated in
women with diabetes unless there are medical complications.
Providers and women thoroughly discuss pain relief options, ideally
before the onset of labor. When labor pain is poorly controlled,
counter-regulatory hormones that antagonize insulin are released,
leading to hyperglycemia and the need for increased doses of
insulin. Admission history of pregnant women with diabetes
Diabetes type and classification Microvascular complications
(retinopathy, nephropathy, autonomic neuropathy) Antenatal diabetes
complications of DKA and hypoglycemia with last hospitalization for
pregnancy or diabetes management Glucose level that precipitates
symptoms of hypoglycemia Glucose log and self-management diary
Results of most recent A1C and A1C in the first trimester Meter
type and frequency of testing Insulin regimen Last food intake
Ultrasound findings Obstetric history Indications for increased
surveillance during labor and delivery
Abnormal (low or high) amniotic fluid Elevated A1C Frequent
hospital admissions during pregnancy Growth restriction Limited or
no prenatal care Macrosomia Uncontrolled blood glucose Monitoring
blood glucose
During labor, blood glucose levels are maintained between 70 and 90
mg/dl to reduce the risk of maternal and fetal hyperglycemia, which
can lead to neonatal hypoglycemia (ADA, 2013). Nurses obtain a
blood glucose reading hourly in women with pregestational diabetes
and every 1 to 2 hours in women with GDM. The nurse assesses urine
ketones with each void when blood glucose is >200 mg/dl, or
every 4 hours if blood glucose is in target range. Intravenous
fluid therapy
The nurse establishes intravenous access soon after a womans
admission to allow for hydration and insulin administration.
Glucose requirements are low during the early stage of labor, so
normal saline may be used initially unless the capillary glucose is
low (Landon et al., 2012). Glucose is required once active labor
begins and can be administered at 100 to 125 ml/hour by a
controlled infusion device to prevent inadvertent administration of
excessive amounts of glucose (ADA, 2013). Insulin management Women
with type 2 diabetes or GDM may not require insulin in labor, even
if they were insulin-dependent during pregnancy. Most have
sufficient pancreatic function to supply the basal insulin required
for labor. All women with type 1 diabetes require insulin in labor.
Insulin is administered subcutaneously or by injection or insulin
pump, or intravenously per institutional protocol or physician
preference. The blood glucose result taken on admission determines
the need for insulin or glucose for cesarean birth, spontaneous
labor or induction. Because insulin requirements plummet after
delivery, the total daily dose is decreased by 50 to 60 percent (70
percent with twins), regardless of the route of administration
(ADA, 2013). CSII Continuous subcutaneous insulin infusion (CSII)
is rarely used for women with GDM, but many women with
pregestational diabetes use CSII during pregnancy. CSII is safe for
use during hospitalization for vaginal and cesarean birth. A
physician capable of managing the pump during hospitalization is
necessary. A certified diabetes educator (CDE) familiar with pump
management can be a valuable resource for nurses. Infusion sites
for CSII are changed every 48 hours to 72 hours to prevent
infection (Hood, 2012). The upper abdomen is the safest site during
the intrapartum period. The site for tubeless pumps is usually the
upper arm. The lower abdomen is avoided due to the risk for
cesarean birth. Placement in the hip is avoided because it may
expose the infusion site to blood and amniotic fluid that may
contribute to infection. Neonatal considerations
Most infants of mothers with diabetes have an uncomplicated
perinatal course, but the risk for adverse outcome is higher than
for infants born to mothers who do not have diabetes. Risks for
offspring include: (Pettitt, 2012) RDS Metabolic derangements
Neonatal hypoglycemia Congenital defects Birth injury Metabolic
syndrome Type 2 diabetes Obesity, abnormal glucose tolerance and
cardiovascular disease Neonatal considerations (continued)
Assessment of infants of diabetic mothers Observe for birth
defects. Observe for birth injury. Inspect the head for
cephalohematoma or caput succedaneum. Measure and document the
occipital and frontal circumferences. Examine for clavicular
fracture, brachial plexus injury, known shoulder dystocia or weight
>4,000 g. Breastfeeding appears to modify the risk of the baby
developing type 2 diabetes and obesity later in life. Nurses play a
pivotal role in educating women with diabetes about lifelong risks
of diabetes and obesity in their offspring. Goals of postpartum
care for women with diabetes (Gilbert, 2011)
Prevention of hypoglycemia and severe hyperglycemia Encouragement
and support of breastfeeding Education Reduction of risk of type 2
diabetes for women with GDM Reduction of risk of diabetes
complications for women with overt diabetes Encouragement of family
planning and interconception care Postpartum and interconception
care
Because many women achieve glycemic control during pregnancy to
improve the health of their infant, the postpartum period is an
ideal time for the nurse to stress the importance of continued
control. During pregnancy, many women realize they can manage their
diabetes and attain a better quality of life for long-term health
benefits. Immediately after birth, insulin resistance improves for
all women with diabetes. Oral medications can be resumed if they
are compatible with breastfeeding. Before discharge from the
hospital, women with diabetes need further education regarding
lifestyle modifications and dietary interventions. Postpartum and
interconception care: Women with GDM
Monitoring of blood glucose continues until normoglycemic.
Postpartum testing for overt type 2 diabetes is recommended (ACOG,
2013a; ADA, 2014c), but few obtain it (Keely, 2012). Women need
testing at the 6-week postpartum visit or shortly after they stop
breastfeeding (Gilbert, 2011). Because recurrence risk of GDM is
high, postpartum women need diabetes prevention education and
interconceptional evaluation. Because the lifetime risk of
developing type 2 diabetes after GDM ranges from 35 to 60 percent,
annual testing for diabetes is recommended in women with a history
of GDM who are prediabetic (ADA, 2014a; CDC, 2011). Previous GDM
also carries a lifetime risk for metabolic syndrome and
cardiovascular disease (Retnakaren, Qi, Connelly, Sermer, Zinman
& Hanley, 2010). Strategies to delay/prevent type 2 diabetes in
women with GDM (National Diabetes Education Program, 2014) Get
tested for diabetes 6 to 12 weeks postpartum. Breastfeed. Get
tested for diabetes before your next pregnancy. Try to reach your
pre-pregnancy weight 6 to 12 months postpartum. If overweight, lose
5 to 7 percent of body weight slowly after attainment of
pre-pregnancy weight. Get at least 30 minutes of physical activity
each day 5 days a week. Eat healthy foods, including fruits,
vegetables, fish, lean meats, dry beans, peas, lentils, whole-grain
bread and pasta, and low-fat or skim milk and cheese. Eat smaller
portions. Drink water. Breastfeeding Breastfeeding poses an
additional challenge for women with preexisting diabetes due to the
increased risk of hypoglycemia. Women with diabetes need frequent
snacks before or during breastfeeding that consist of carbohydrate
and protein or fat. A schedule for snacking and meals as well as
adequate intake of liquids is important to support the increased
caloric demands of breastfeeding. Women who breastfeed need 500 to
800 additional calories per day (Gilbert, 2011). Insulin
requirements for breastfeeding women usually are lower than for
non-breastfeeding women. Contraception Ideally, a woman and her
provider talk about contraception before she gives birth. When the
woman breastfeeds exclusively without supplementation,
breastfeeding can be used as birth control, called the lactation
amenorrhea method (LAM). When lactation is well established and
thrombogenic risk is minimal, women with pregestational diabetes
may begin progestin-only oral contraceptives at 21 days postpartum
or combined oral contraceptives (COC) at the lowest estrogen dose
at 6 weeks postpartum (Segall-Gutierrez & Kjos, 2010). COC use
in women with diabetes is controversial because thromboembolic
disease and myocardial infarction may be increased (Landon et al.,
2012). Using oral contraceptives may result in increased insulin
resistance because of decreased insulin receptors in women with
diabetes (Landon et al., 2012). Contraception (continued)
For women with diabetes, limited data exists on the use of the
progestin intrauterine device (IUD), progestin implants or
injectable depot medroxyprogesterone acetate (DMPA). However, with
adequate monitoring the use of these methods is acceptable in these
women. Barrier methods produce no metabolic effects and have no
contraindications, although failure rate without perfect use is
around 10 percent (Landon et al., 2012). Summary By providing care
and education that empowers women to achieve glycemic thresholds,
nurses and diabetes educators can profoundly influence treatment
and prevention of diabetes-related complications in pregnancy. With
combined knowledge of diabetes and obstetrics, nurses can provide
interventions and support that help ensure healthy outcomes for
women with diabetes and their infants.