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

IrritabilityHunger

SweatingNervousness

DizzinessWeaknessFatigue

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/dlCauses: Insufficient insulin, excess or wrong

kinds of food, infection, illness, injuries, emotional stress or insufficient exercise

SIGN & SYMPTOMS OF HYPERGLYCEMIA

ThirstNausea/VomitingAbdominal pain

ConstipationDrowsinessDim vision

Increased urinationFruity breath

Rapid, weak pulseRapid 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 malformations

Macrosomia: infant weight of 4,000-4,500 grams

Intrauterine 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

Questions1. 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?

DiscussionThis 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.