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Postpartum Complications: First let’s go over some Diabetes definitions Maternal Newborn Fellowship 2018

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Gestational Diabetes Mellitus (GDM) Types of Diabetes • Gestational Diabetes Mellitus (GDM) • Any degree of carbohydrate intolerance that is first recognized or onset is during • Type 1 Diabetes Mellitus (ACOG, 2013) • Type 2 Diabetes Mellitus (DM) • Then categorized into A1 and A2 – Type 1 & Type 2 are Pregestational Diabetes – A1 is stated as controlled with diet and exercise – A2 is stated as controlled with diet, exercise, and requiring oral medications and/or insulin

Gestational Diabetes Mellitus Type 1 Diabetes Mellitus (GDM)

• There is a destruction of pancreatic beta • This occurs in about 6-7% of all cells resulting in an absolute deficiency in the United States of insulin secretion • • Accounts for about 90% of diabetic About 5-10% of the general population diagnosed with diabetes have type 1 pregnancies diabetes • Symptoms tend to be mild • Typically appears prior to age 30

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Type 2 Diabetes Mellitus

• Combination of resistance to insulin Why is diabetes a potential concern?? action & an inadequate compensatory insulin secretory response Diabetes can affect all aspects of nutrient • Approximately 90-95% of the general metabolism, impacting mom’s pregnancy and population diagnosed cases of diabetes fetal development are Type 2 Diabetes Prior to the introduction of Insulin 100 • Typically onset is slower and may be symptom-free for years years ago moms with diabetes were not advised to ever become pregnant because of • May be controlled with diet and exercise, but most women need insulin the risk of maternal death and fetal for ideal control during pregnancy mortality!

Hyperinsulinemic State Metabolic Changes Lipogensis, which means mom can store During the First Half of Pregnancy energy in the form of fat

In pregnant women without diabetes approximately at 8- 15weeks gestation Progesterone & Estrogen This is necessary to help prepare for the demands of growing this fetus in the second

half of pregnancy Which then causes an increase in the number of beta-cells which in turn causes an increase in These changes may put mom at an increased insulin production and secretion risk of hypoglycemia

There is an increased tissue sensitivity to insulin - ↑in fat Insulin dependent diabetic moms may not and glucose storage and ↓in blood glucose by 10% need as much insulin during this time frame

Metabolic Changes During the Second and Third In Women Who Cannot Meet the Demands for Insulin Production Trimesters in Pregnancy • Leads to an altered carbohydrate metabolism – Protein and fat breakdown characterized by: which progresses to hyperglycemia: • ↑insulin resistance due to production of placental hormones : – ↑ in hPL – Prolactin – ↑ in estrogen, progesterone, blood triglicerides, – Human placental lactogen (hPL) free fatty acids and corticosteroids – Cortisol – Growth hormones All of these hormones act as insulin antagonist and are aimed at giving the fetus more nutrient

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Impact on Pregnancy Does Maternal Glucose Control Matter? Mothers with diabetes have higher risks for YES complications when compared to mothers without • When a pregnant woman has glucose control it diabetes, including: plays a major role in reducing perinatal mortality in diabetic pregnancies • Hydramnios • Fetal hyperglycemia and hyperinsulinemia can • Preeclampsia/Eclampsia increase the risk for fetal hypoxia in the fetus of • Hyperglycemia a mother with diabetes • Ketoacidosis • Difficult labor

High Risk Patients General Population Should be screened for diabetes as soon as possible. This includes: • Non Caucasian • Prior history of GDM or birth of an LGA infant • Marked obesity (BMI > 30) • Diagnosis of polycystic ovarian syndrome • Hypertension • Presence of glycosuria • Strong family history of type 2 diabetes mellitus

When to Screen for GDM

There is not enough evidence to Women at a gestational age of 24 support screening an weeks, or less, that show glucose asymptomatic pregnant woman intolerance may actually be prior to 24 weeks gestation. undiagnosed preexisting type 2 So typically the screening is diabetes. performed between 24-28 weeks gestation.

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Blood Glucose Values in Pregnancy General management of pre-gestational

Ideal* Goal diabetes Fasting blood glucose 60-89 mg/dL <90 mg/dL During pregnancy:

• Glucose controlled: most commonly achieved One- hour postprandial 100-129 mg/dL <140 mg/dL through- Monitoring of blood sugars, diet, exercise, insulin therapy Mean blood glucose >87 mg/dL <100 mg/dL • Screening for diabetic neuropathy, retinopathy, Glycosylated 2-5% < 6.5% assessment of thyroid and cardiac function hemoglobin (HgbA1C) • Accuracy in dating of the pregnancy *Values are demonstrated in women with neither diabetes nor carbohydrate intolerance during • Preconception counseling is recommended pregnancy (2014). Core Curriculum for Maternal-Newborn Nursing, 5th ed., AWHONN

General management of Gestational General management of Diabetes Diabetes • Twice a month prenatal visits during During pregnancy: the first two trimesters • Glucose controlled: most commonly achieved • Weekly prenatal visits during the last through- Monitoring of blood sugars, diet, exercise trimester • New diagnosis needs education about expectations • Goal: for weight gain, exercise, and proper food choice –Make sure insulin is available and options glucose is properly utilized to result in a healthy mother and newborn

Hypoglycemia may happen quickly in Hyperglycemia and Ketoacidosis may pregnancy so mom needs to know the develop more slowly & more common in potential indications: the second half of pregnancy

• Sweating • Clammy skin • Polyuria • Nausea • Polydipsia • Hot flushed skin • Periodic tingling • Irritability • Dry mouth • Rapid deep • Disorientation • • Fatigue breathing Hunger • Drowsiness • Abdominal cramps • Shakiness • Headache • Depressed reflexes • Acetone breath • Oliguria • Pallor • Headache • Blurred vision • Anuria • coma • Stupor

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ANTEPARTUM TREATMENT Hyperglycemia is treated with insulin and should be considered a serious • Timing of delivery situation because most problems for –GDMA1 39-41 weeks the baby are due to maternal –GDMA2 39-39 6/7 weeks hyperglycemia –Uncontrolled GDM/DM 34-39 weeks

ACOG Committee Opinion number 560, April 2013[Reaffirmed26 2017]

Oral Antidiabetic Medications • Insulin is the ADA recommendation for first-line therapy Medications • Oral antidiabetic medications are being used more often with women with GDM, but this has not been approved by the U.S. Food and Drug Administration for this indication • Metformin crosses the placenta with levels that may be as high as the mother’s concentration • Glyburide should not be recommended for first line Power Point Template pharmacologic treatment Created by Smile Templates

• METFORMIN ANTEPARTUM TREATMENT – may be a reasonable second-line approach to treat gestational diabetes after Insulin • GLYBURIDE – Limitations of Metformin – This drug should NOT be recommended as -increased preterm birth a first-line pharmacologic treatment -placental transfer of the drug because, in most studies, it does not yield -lack of long-term data in exposed offspring. equivalent outcomes to insulin or -between 26% and 46% of women who took metformin metformin alone eventually required insulin

Glibenclamide, metformin, and insulin for the treatment of gestational diabetes: a systematic review and meta-analysis. ANTEPARTUM TREATMENT Balsells M, García-Patterson A, Solà I, Roqué M, Gich I, Corcoy R. 29 30 BMJ. 2015 Jan 21;350:h102. doi: 10.1136/bmj.h102. Review.

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Last Edited: Insulin Infusion July 16, 2015 Pump

The basics: • Delivers prescribed basal and bolus doses through a pump worn 24 hours daily • Basal rate refers to the number of unit(s) the insulin pump is set up to deliver each hour • Bolus rate is the amount of insulin required with meals and in response to blood sugar readings

Insulin does not cross through to the placenta Methodist Hospital Policy, last reviewed 5-15

Overweight/Obese

Caring for a In the United States the CDC in 2011 estimated that the starting weight in about 30% of the mother in pregnancies were classified as obese and 8% were morbidly obese Postpartum The higher the pre-pregnancy BMI of a woman with diabetes the more risk there is of adverse outcomes for both her and the baby

Potential for Hemorrhage How do these hormones impact a mom’s blood sugar level?

These mothers may have had a large baby, prolonged, or induced labor After the placenta delivers Human placental lactogen (hPl),

Progesterone, and Estrogen decrease This puts them at a greater risk for hemorrhage

Decreases mom’s blood glucose levels

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Insulin resistance during pregnancy resolves quickly • For about 24 hours the insulin needs in the post-delivery of the placenta pre-gestational patients with diabetes are dramatically reduced, usually below pre- pregnant needs • A mom with GDM returns to non-pregnant carbohydrate metabolism

Infections

A diabetic mother has a higher rate of Patient Education postpartum infections • Patient education will vary based on if mom Educate parents of signs/symptoms of had GDM, Type I or Type II Diabetes infection • Home blood glucose monitoring is important, • Mastitis along with effective insulin use, and a diet and exercise plan. • Endometritis • Incision from cesarean or episiotomy

At delivery the major newborn complications include: • Macrosomia • Hypoglycemia • Respiratory distress syndrome • Hypocalcemia • Hypomagnesemia • Polycythemia • Hyperbilirubinemia

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Benefits for Mom Promote & Encourage • Breastfeeding may help to delay the onset of type 2 Diabetes in women that had Breastfeeding Gestational Diabetes Mellitus • Postpartum weight loss • Reduced long term obesity • Lower prevalence of metabolic syndrome

Additional support • Breastfeeding decreases blood glucose • May need more education about lactation due to potential delayed levels onset of lactation • Snacks shouldPostpartum be encouraged for breastfeeding mothers because blood glucose levels may vary • Monitoring blood glucose levels in postpartum women is ideal

Questions about Medication & Breastfeeding Mother’s Need to Know…

• The composition of is not The discussion should be done in the altered by diabetes hospital so the mother is confident prior • Infant of mother with diabetes gain to going home. weight appropriately • Women who have diabetes may be more Good Resource is Lactmed.com prone to infection… mastitis • Candidal infections are more common

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Gestational Diabetes Mellitus

• Women with GDM usually don’t need Follow insulin during the postpartum time frame Up • At the 6 week postpartum checkup her blood glucose should be assessed Care – ACOG July 2017 states follow up at 4-12 weeks postpartum • If her level is within normal range she should have this rechecked every one to three years

Development of Type 2 Diabetes Women with GDM Mellitus post delivery • Women with GDM and their children have • DM can lead to health concerns and potential an increased risk for: early death due to the changes in the large – Developing hypertension (macrovascular) and small (microvascular) blood vessels in the tissues and organs – Obesity • These mothers have are 17-63% more likely to – Overt diabetes develop Type 2 Diabetes Mellitus, when compared to mothers that had normoglycemic To help reduce the risk a healthy diet and regular pregnancies, especially if they are using insulin exercise should be promoted. Weight management to maintain glucose control can help reduce these risks.

Gestational Diabetes Mellitus in Future Pregnancies Follow up Care is Critical • Stress the importance of the follow up glucose testing at the postpartum appointment There is about a 60-70% chance that a woman will develop GDM – In 2010 several studies in the U.S. showed that follow up glucose monitoring occurred about 23-54% of the in her subsequent pregnancies time. – It has been estimated that roughly 15-70% of the mom’s with GDM will develop diabetes (mostly type 2) later in life.

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• Be aware that mom is at an increased risk for: Infection, Hemorrhage, Preeclampsia Key Take /Eclampsia • Insulin requirements post delivery will Away Points decrease • Breastfeeding is encouraged, if mom is stable, and there may be a delay in the onset of lactation • Follow up Care is Critical

References

Davidson,M., London, M., & Ladewig, P. (2016). Olds Maternal-Newborn Nursing & Women’s Health Across the Lifespan, 10th ed. Boston: Pearson Education, Inc.

Video Gabbe, S., Niebyl, J., & Simpson J. (2017) : Normal and problem pregnancies, 7th ed. Philadelphia, PA: Elsevier

https://www.guideline.gov/syntheses/synthesis/48531

Pregnancy and Childhood Nutrition & Lawrence, R. & Lawrence, R. (2016) Breastfeeding: A guide for the medical profession, 8th ed. Philadelphia, PA: Elsevier

Mannel, R., Martens, P., & Walker, M. (2013). Core Curriculum for Lactation consultant practice (3rd ed.). Burlington, MA: Jones & Bartlett Learning Workouts Mattson, S. & Smith, J.E. (2014). Core Curriculum for Maternal-Newborn Nursing, 5th ed., AWHONN. St. Louis, MO: Elsevier Published on May 24, 2017 Simpson, K.R. & Creehan, P.A. (2014). AWHONN Perinatal Nursing, 4th ed. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins

Swearingen, P. (2016). All-in-one Nursing care planning resource. St. Louis, MO: Elsevier

The American college of Obstetricians and Gynecologists. ACOG Committee . Medically Indicated Late-Preterm and Early- Term Deliveries. Number 560, April 2013, Reaffirmed 2017

The American college of Obstetricians and Gynecologists. ACOG Practice Bulletin. Clinical Management Guidelines for Obstetrician-Gynecologists. Number 180, July 2017

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