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Diabetes in Pregnancy

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Diabetes in Pregnancy DIABETES IN PREGNANCY COURSE DESCRIPTION Diabetes during pregnancy can provide a special challenge to the patient and her healthcare providers. The effects of poorly controlled blood glucose levels can result in life-threatening effects for both the mother and the fetus. The outcome of this course is for the learner to describe the types of diabetes, the metabolic changes that occur during diabetic pregnancies, and treatment options (including diet, exercise, and medication). COURSE OBJECTIVES Upon completion of this course, you will be able to do the following: 1. Define diabetes. 2. Identify the major health impacts of diabetes. 3. Explain the role of hormones and other body chemicals on insulin production. 4. Briefly describe the pathophysiology of diabetes. 5. Identify the five main types of diabetes and describe their major characteristics. 6. Describe the metabolic changes that occur in a normal pregnancy. 7. Identify maternal complications from diabetes. 8. Identify fetal and neonatal effects of diabetes. 9. Describe the major characteristics of pregestational diabetes. 10. Identify White’s main classifications of diabetes in pregnancy. 11. Identify key components of screening and treatment for the patient with GDM. 12. Describe general management techniques for the pregnant woman with diabetes, including diet, exercise, and medication therapies. 13. Identify tests used to assess placental function and fetal well-being. 14. Describe major management issues for the pregnant woman during the intrapartum, labor and delivery, and postpartum periods. 15. Describe new therapies for the pregnant woman with diabetes, including oral hypoglycemic agents, insulin pump therapy, and islet cell transplantation. © ALLEGRA Learning Solutions, LLC All Rights Reserved INTRODUCTION Most of the food we eat is converted by our bodies into glucose—fuel for our cells. If that glucose cannot be utilized, as in untreated or uncontrolled diabetes, the cells “starve.” Glucose and fats remain in the bloodstream and, over time, cause damage to vital organs such as the heart, eyes, and kidneys (Centers for Disease Control and Prevention [CDC], 2017). In pregnancy, diabetes can result in serious complications to the mother and/or the fetus and neonate. • Diabetes in pregnancy complicates 2% to 10% of all pregnancies, but these statistics are probably understated. • Although maternal and fetal complications can be life threatening, early and proper intervention can be powerful (Buchanan, 2016). Gestational diabetes mellitus (GDM) can often be controlled through eating a proper diet and exercising regularly, although insulin injections may be necessary. GDM usually goes away after pregnancy but not always, and many women who have GDM develop Type 2 diabetes later in life (CDC, 2017). WHAT IS DIABETES? Pillitteri (2013) defines diabetes mellitus as an endocrine disorder in which the pancreas cannot produce adequate insulin to regulate body glucose. According to the CDC (2017), diabetes is a group of diseases marked by high levels of blood glucose resulting from defects in insulin production, insulin action, or both. The Scope of the Problem Diabetes mellitus is a growing public health problem both nationally and internationally (CDC, 2017; International Diabetes Federation, 2017; World Health Organization [WHO], 2017). • Approximately 8.3% of the population of the United States and the world have diagnosed or undiagnosed diabetes. This is probably an underreported number since almost half of the people with diabetes do not know they have it. • As of 2045, there are expected to be more than 629 million people worldwide living with diabetes. © ALLEGRA Learning Solutions, LLC All Rights Reserved • Diabetes causes 4 million deaths every year and is the 7th leading cause of death in the United States (CDC, 2017), and by 2030 it is expected to be the 7th leading cause of death worldwide. All types of diabetes are now being found in younger and younger individuals. One type, type 2 diabetes, is especially linked to obesity and physical inactivity. Yet most Americans lead sedentary lives with little or no physical exertion. Roughly 27% of adults do not engage in any physical activity while another 28% do not regularly exercise (CDC, 2017; Flood & Constance, 2002). The health impact of diabetes is tremendous. Studies have found the following (American Diabetes Association, 2018; CDC, 2017; WHO, 2017): • The death rate among middle-aged people with diabetes is twice that of middle-aged people without diabetes. • Adults with diabetes have heart disease death rates two to four times higher than adults without diabetes. Heart disease is the leading cause of diabetes- related deaths. • The risk of stroke is two to four times higher in individuals with diabetes. • Diabetes is the leading cause of new cases of blindness in adults 20 to 74 years of age. Each year, more than 12,000 to 24,000 people become blind because of diabetic eye disease. • Diabetes is the leading cause of end-stage renal disease, accounting for 44% of new cases annually. • About 60% to 70% of people with diabetes have mild to severe forms of nervous system damage (including impaired sensation or pain in their hands or feet, slowed digestion, and carpal tunnel syndrome). • The majority of lower-limb amputations throughout the world occur in individuals with diabetes. • Diabetics are more likely than those without the disease to suffer from many other illnesses and infections such as flu and pneumonia. • Women with diabetes are two to three times more likely to experience a newborn death than those women without diabetes. © ALLEGRA Learning Solutions, LLC All Rights Reserved Diabetes costs the U. S. healthcare system more than $245 billion annually related to disability, loss of work, and premature mortality. The full extent of the disease is hard to measure, since death records often do not reflect the role of diabetes in the cause of death (CDC, 2017). Etiology and Pathophysiology of Diabetes Mattson and Smith (2015) define diabetes as a chronic, systemic endocrine disorder of insulin production or of the body’s response to insulin, which is a water-soluble, anabolic hormone secreted by the beta cells of the islets of Langerhans in the pancreas. Insulin is a protein whose primary function is to promote the metabolism of carbohydrates, proteins, lipids, and nucleic acids (Pillitteri, 2013). Insulin acts as a “key” to unlock the cell membrane, allowing glucose, amino acids, and electrolytes into the cells of cardiac, skeletal, and adipose tissues. Brain cells, erythrocytes, leukocytes, intestinal mucosa, and the epithelium of the kidney need glucose to survive but they can survive in an insulin-deficient environment (Pillitteri, 2013). The exact etiology of diabetes is not known but the current belief is that an autoimmune destruction of the islet cells occurs in individuals who are predisposed to the disease (Pillitteri, 2013). The actual amount of insulin secreted by the pancreas is regulated by serum (blood) glucose levels. When serum glucose levels are greater than 100 mg/dL, beta cells increase their production of insulin. When serum glucose levels are lowered, the production of insulin decreases (Pillitteri, 2013). In diabetes, the pancreas cannot produce adequate insulin to regulate body glucose. While the pancreas is primarily responsible for the production of insulin, the following additional hormones are also necessary for its secretion (Pillitteri, 2013): • Gastrin—a gastrointestinal hormone that increases when the stomach is full, stimulating the pancreas to produce more insulin • Glucagon • Cortisol • Progesterone • Estrogen Epinephrine and norepinephrine inhibit the secretion of insulin (Pillitteri, 2013). When the amount of insulin in the body is insufficient, glucose cannot be used by the cells. • The cells continue to demand glucose, and the liver responds by converting glycogen to glucose to increase the serum glucose levels. • However, that glucose cannot be utilized because of the lack of adequate insulin. © ALLEGRA Learning Solutions, LLC All Rights Reserved • Blood glucose levels continue to rise as the cells continue to “request” glucose and the liver continues to try to meet that need. • When serum glucose levels reach 150 mg/100 dL (normal serum glucose levels are 80 to 120 mg/dL), the kidneys attempt to lower the serum glucose levels by excreting glucose in the urine (glycosuria). • Because of the osmotic action of glucose, the kidneys are unable to absorb the normal amount of fluid and large quantities of fluid are lost in the urine (polyuria) (Pillitteri, 2013). As this process continues, dehydration occurs and the blood serum becomes concentrated. • Blood volume may decrease, blood flow decreases, and the body cells become oxygen starved. • Anaerobic metabolism results as large stores of lactic acid pour out of the muscles and into the bloodstream. • The body begins to utilize fat stores as an energy source, a metabolic process that results in the release of ketone bodies into the bloodstream. • Because they are acidic, lactic acid and ketone bodies lower the blood pH and the individual develops metabolic acidosis (Pillitteri, 2013). Next, the body utilizes its protein stores in an attempt to obtain any available energy source for its cells. • Protein destruction (catabolism) reduces the amount of protein available to the cells, the cells can be destroyed, and sodium and potassium are excreted from the body. • In the long term, these processes cause vascular narrowing
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