hypoglycemia and hyperglycemia in the pregnanat patient
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Presented by: Excalibur Group
Daphney Jacques, Bridgette Jenkins, Opal Jobson-Cudjoe , Kelly Miller
Objectives
Distinguish between normal and abnormal blood glucose levels based on patient population
Classify the different diagnosis associated with hypoglycemia/hyperglycemia based on patient age
Compare the common causes of hypoglycemia/hyperglycemia based on patient population
ObjectivesFormulate the appropriate interventions for
hypoglycemia/hyperglycemia management based on patient population
Differentiate between the different medications used to manage the hypoglycemic/hyperglycemic patient.
Predict immediate complications of hypoglycemia/hyperglycemia
Objectives State potential long term complications of uncontrolled
blood sugar levels Determine the appropriate educational strategies to
prevent hypoglycemia/hyperglycemia
NORMAL BLOOD GLUCOSE for PREGNANT WOMEN
65mg/dl (fasting)<140 mg/dl (2 hr pp)
CLASSIFICATION OF DIABETES IN PREGNANT WOMEN (cdc.gov)
Pregestational DiabetesType I: primarily due to pancreatic islet beta cell destruction.Type II: most common type of diabetes that is a result of
insulin resistance or insufficiency.
Gestational DiabetesAny degree of glucose intolerance with the onset or first
recognition occurring during pregnancy.
SCREENING FOR GESTATIONAL DIABETES (Lowdermilk, Perry, & Bobak) Screening should be done between 24-
28 weeks gestation. Glucose Tolerance Test (GTT): 50
grams of glucose is consumed, blood is taken after 1 hour and sent to a laboratory for evaluation.
140mg/dl or greater is considered as positive
Oral Glucose Tolerance Test (OGTT) is done if the GTT is positive.
After a overnight fast, a fasting blood glucose level is drawn. Then 100 grams of glucose is consumed and blood is drawn at 1, 2 and 3 hour intervals.
The patient is diagnosed with gestational diabetes if 2 or more values are met or exceeded:
Fasting 105mg/dl 1 hr 190mg/dl 2 hr 165mg/dl 3 hr 145mg/dl
HYPOGLYCEMIA IN PREGNACYBlood glucose: < 60mg/dlCauses: excess insulin, insufficient food, excessive exercise or
work, vomiting or diarrhea.
SIGNS & SYMPTOMS OF HYPOGLYCEMIA
Irritability
Hunger
Sweating
Nervousness
Dizziness
Weakness
Fatigue
Headache
MANAGEMENT OF HYPOGLYCEMIACheck blood sugar when symptoms first appear (fingerstick)Eat 10-15 grams of simple carbsRecheck blood glucose 15 minutes after intakeNotify healthcare provider if blood glucose remains lowIf patient is unconscious call 911If in hospital administer 50% dextrose or glucagon as ordered. Recheck blood sugar, send urine/blood to lab
HYPERGLYCEMIA IN PREGNACYBlood glucose > 200 mg/dl
Causes: Insufficient insulin, excess or wrong kinds of food, infection, illness, injuries, emotional stress or insufficient exercise
SIGN & SYMPTOMS OF HYPERGLYCEMIA
Thirst
Nausea/Vomiting
Abdominal pain
Constipation
Drowsiness
Dim vision
Increased urination
Fruity breath
Rapid, weak pulse
Rapid breathing
MANAGEMENT OF HYPERGLYCEMIANotify healthcare providerAdminister insulin in
accordance with blood glucose level (sliding scale)
Give IV fluids (NS or 0.45 NS)
Monitor blood & urine laboratory testing
MANAGEMENT OF DIABETES IN PREGNACY
Diet2000-2500 daily, less if overweight or morbidly obeseExerciseActive women are encouraged to continue physical activity,
sedentary are encouraged to get active. Walking is recommended
Monitoring of blood glucose levelsFindersticks are done at home. Usually done upon waking
(fasting) and after meals (postprandial)Insulin therapy: done on a individual basis to maintain normal
blood glucose levelsClose monitoring of fetus after 40 weeks until delivery
COMPLICATIONS OF DIABETES IN PREGNACY
Congenital malformationsMacrosomia: infant weight
of 4,000-4,500 gramsIntrauterine growth
retardation (IUGR)StillbirthRespiratory Distress
Syndrome (RDS)
Spontaneous abortion in early pregnancy
Shoulder DystociaPregnancy induced
hypertension (PIH)Infections (UTI’s, yeast
infection)Ketoacidosis
PREVENTIONSeek counseling before getting pregnancyMaintain a healthy weightExercise regularlyEat healthy and balanced mealsSeek prenatal care early in pregnancyKeep all prenatal appointmentsFollow regime prescribed by physician
REFERENCESCDC.GOV (2009). Information on gestational diabetes.
Retrieved July 9, 2009, from: http://diabetes.niddk.nih.gov/dm/pubs/gestational/
Lowdermilk, D., Perry, S., & Bobak, I. (1999). Maternity Nursing (5th. Ed). St. Louis: Mosby.
CASE STUDYMaria, a 40 y/o G4P3 at 29 weeks present to Labor &
Delivery with c/o dizziness, headache, nausea and vomiting for 3 days. After interviewing Maria, you note that she has not had any prenatal care, has a h/o diabetes Her past obstetrical history includes delivery of a 4500 gram male complicated by shoulder dystocia. She weighs 312 pound. Her Bp 129/83, HR 82, RR 26 and Temp 98.8. A UA shows 3+ glucose, and negative ketones. Her accucheck is 179mg/dl.
CASE STUDY DISCISSION
Questions 1. What tests, if any, should be done to evaluate the Maria’s glucose
tolerance? 2. How is the diagnosis of gestational diabetes mellitus (GDM) established?
3. What would be the best treatment and follow-up strategy for Maria?Discussion
This patient has several risk factors for GDM. She is over the age of 30, has a history of GDM and is obese. All these place her at a greater risk for developing GDM. She needs to be referred to a dietician or diabetic counselor. She needs to continue prenatal care and started on insulin therapy. Maria should be followed closely for the remainder of the pregnancy. Birthing options (vaginal vs caesarean section) should be discussed with the patient. Maria should also be followed closely after delivering to assess for the development of Type II diabetes.