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Diabetes

Maternal Child Test 4 PHCC

QuestionAnswer
Type 3 diabetes gestational
Type IV diabetes abnormality in glucose tolerance caused by trauma or drugs
White's Classification B maturity onset (TypeII), age 20 or older increased risk for hyperrtension, PIH, fetal anomalies and macrosomia
White's Classification C Onset age 10-19 yrs and duration 10-19 yrs. Increased risk HTN, PIH, fetal anomalies and macrosomia
White's Classification D Onset before age 10, duration > 20yrs, chronic HTN, benign retinopathy, and calcified leg vessels. Increased risk HTN, PIH, fetal anomalies and IUGR possible
White's Classification F Kidneys. Diabetic nephropathy and proteinuria. Anemia, HTN, PIH, Preterm labor common, fetal anomalies and IUGR possible
White's Classification H CAD, Congenital anomalies, and risk of fetal death
White's Classification R Proliferative Retinopathy. Spontaneous abortion, intruterine and neonaltal loss, and congenital anomalies
Gestational Diabetes Classification A1 glucose intolerance diagnosed during pregnancy amd managed by diet alone. Least risk of complications
Gestational Diabetes Classification A2 glucose intolerance diagnosed during pregnancy managed by diet and insulin. Higher liklihood of macrosomia
White's Diabetic Classifications are for pregestational diabetets
Effects of Diabetes on Insulin Requirements 1st 20 weeks. High estrogen and progesterone levels cause metabolic alterations hypertrophy of pancreas and inc in beta cells. Suppressed gluconeogenesis Inc in insulin action in muscles and adipose tissue. The action of insulin is facilitated as a result of thses changes Lower amounts of insulin required N/V also contributes
Effects of Pregnancy on Inuslin Requirements 2nd Trimester Food intake improves. Maternal glycogen stores increase. Increasein glycogen synthesis so more insulin is needed
Effects of Pregnancy on Insulin Requirements 2nd half of Pregnancy Increase resistance to Insulin r/t inc levels of hPL r/t size of placenta.As placenta enlarges hPL inc
Effects of Insulin Requirements 2nd half of pregnancy part2 insulinase breaks down maternal insulin. Free cortisols overide estrogen and progesterone resulting in metabolic catabolism of greater quantities of simple sugar that cross the placenta.
Maternal insulin does not cross placenta But maternal glucose does. Baby makes its own insulin but cannot keep up with mothers glucose causing macrosomia
hPL human placenta lactogen. Is in insulin antagonist and causes peripheral insulin resistance
Ketoacidosis insulin does not increae to compensate for hPL, hyperglycemia results. Ketogenic fat increases and protein is broken down for maternal energy needs
Ketones Increase ='s sodium decrease
Insulin requirements in Pregnancy 1st trimester it decreases 2nd trimester increases third trimester increases again can be almost 4X pre pregnancy insulin needs. After birth quickly returns to prepregnancy levels in non breastfeeding mothers
N/V cause metabolic acidosis shift from carb metabolism to fat metabolism causing an increase in ketoacids and subsequent decrease in sodium. Loss of sodium bicarb from vommiting decreases alkali reserves
S/S Diabetes in Pregnancy subtle or asymptomatic 3 P's are also present in normal pregnancy. There can also be retinol changes that can lead to blindness
Dx of Gestational DM Routine blood screening at 24-28 wks
Sullivan Test 1 hour glucose screening test with 50g oral glusose. > 140 Glucose Tolerance Test Needed
Skip Sullivan Test and go straight to 3 hr GTT if the 3 cardnal signs are present, obesity, family hx, An OB hx of LGA neonate, unexpalined stillborn, congenital anomalies, hydraminos, habitual abortions
3 hr GTT Client eats high carb diet (200g) for 2 days followed by fasting at midnight. In the morning 100g oral glucose. Blood levels drawn If two or more of the following are met or exceeded, GDM is dx
Blood Glucose Levels 3 hr GTT fasting >105, 1 hr >190, 2hr > 165 3 hr >145
Hemoglobin A1c glycosylated hemoglobin good <9 Poor >12
Recommended Weght Gain 2-4 lbs/mo 1st trimester, 3-4 lbs/mo 2nd an d3rd trimester
Caloric Requirements 30-40 Kcal/kg of IDEAL body wgt approx 2000 kcal 1st tri and 2500 2nd and 3rd. But calories should never be restricted during pregnancy
Protein Requirements 1.5g/kg of IDEAL body wgt as compared to 0.8 non pregnant
Carb Intake Complex carbs 50% of total calories no refined simple sugars
Oral Hypoglycemics NEVER given during pregnancy. They cross the placenta and we have no way of testing fetus blood sugar
Insulin Regulation regulated so FBS maintained between 60-90 and BG 30 minutes before meals and HS is 60-105
Sample Insulin Dosing Morning 2:1 NPH to regular (2/3 of total insulin)Evening: 1:1 NPH to regular (1/3 of total insulin)
Monitor Fetal Well Being Ultrasound to estimate EDD and monitor growth, External Fetal Monitoring for placental functioning,
Amnio 36 wks L/S (lung maturity) normalis 2:1 diabetics need to be slightly higher 2.5:3.1
Maternal Estriol Levels At 28-32 weeks a 24 hr urine for estriol shold be taken. should inc as pregnancy progresses drops='s placental insuffieciencyMothers with DM may have small placentas and levels may be low
AFP 16-18 wks Diabetic mothers have higher risk of NTD
DM Pretnatal Care Assess Blood Glucose, S/S hypo~hyperglycemia and FHT. Educate Mom how to monitor glucose and adminsiter insulin. Teach Mom an dfamily s/s hyper~hypoglycemia, perform external fetal monitoring, nutrition counseling
DM INtrapartum Care Frequently deliver early, side lying vaginal delivery or c sect, maintain maternal glucose 80-100 with IV insulin
DM Postpartum Care Assess Blood glucose, monitor hor Hemorrhage, infectin and PIH. Assist with breastfeeding,
Contraceptive Teaching DM No oral contraceptives or IUD
Created by: margaretptz