Diabetes in the Pregnant Woman

3. Describe the effects of late pregnancy on the body's fuel metabolism. Why do these occur?

During weeks 20-40, fetal growth accelerates and placental hormones (estrogen, progesterone, human placental lactogen) create resistance to insulin in maternal cells to create abundant supply of glucose for the fetus. Carbohydrate metabolism changes to gluconeogenesis from noncarbohydrate sources such as protein and fat. This preserves glucose for use by the central nervous system and the fetus.

6. Would insulin requirements for insulin-dependent, diabetic woman increase or decrease as pregnancy progresses? Why?

Insulin requirements would increase because as pregnancy progresses, the hormones created by the placenta are antagonistic to insulin.

8. Do pregnant woman only experience gestational diabetes.

No, many have undiagnosed type 2 diabetes.

4. Do you think that pregnancy is considered to be a Diabetogenic stage

Yes, because there is an alteration of insulin production, and hormonal changes causing insulin resistance, glucose levels are affected and can become too high or too low in some situations.

5. When would Gestational Diabetes GDM most likely occur and why?

Gestational diabetes would most likely occur in the second half of pregnancy because of hormones which decrease effects of insulin, and if there is already an underlying problem of inadequate insulin production by the pancreas, it will be more obvious in this stage.

7. Compare the risk factors for each type of diabetes, are there similarities, and are there differences?

All forms of diabetes have risk factors of race/ethnicity. All except type 1 have risk factor of obesity, and age. Type one has peak incidence of ages 4-7, and 10-14. Family history plays a part in all forms of diabetes.

1. Describe the body's response to Hyperglycemia

The body responds to high blood glucose (which cannot be utilized by cells because the lack of insulin) by attempting to dilute it by any means possible. The first strategy is to increase thirst (polydipsia), a classic symptom of diabetes mellitus. Fluid from intracellular spaces is drawn into vascular bed, leaving cells dehydrated but fluid volume excess in vascular compartment. Kidneys then attempt to excrete large amounts of this fluid plus the heavy solute of glucose (osmotic diuresis). This is known as "polyuria" and "glycosuria". Without glucose cells starve and weight loss occurs even though person ingests large amounts of food (polyphagia). Because the body is unable to metabolize glucose, it begins to metabolize protein and fat to meet energy needs. Metabolism of protein produces a negative nitrogen balance, and metabolism of fat results in the buildup of ketone bodies. Periods of hypo and hyperglycemia result in the destruction of small blood vessels such as in the kidneys, eyes and heart.

9. How does each type of glucose abnormality associated with various types of diabetes effect the outcome for mom, fetus and neonate.

-Woman with diabetes often develop pre-eclampsia. Particularly woman with type 1 diabetes who acquire infection or missed doses of insulin develop ketoacidosis, which can progress to fetal or maternal death. Woman also develop more UTI's more commonly likely d/t glucose rich urine which provides a good medium for bacterial growth. Woman with diabetes can also develop hydramnios which increases risks for difficult labor (shoulder dystocia, postpartum hemorrhaging, need for c-section) -Fetal effects from uncontrolled blood glucose levels during the first trimester may lead to spontaneous abortion or major fetal malformations. The most common major congenital malformations are neural tube defects. Elevated blood glucose leads to macrosomia (increased growth hormone) and damaged vasculature from diabetes can cause vascular impairment which leads to small for gestational age fetus. Neonatal effects have 4 major complications; hypoglycemia, hypocalcemia, hyperbilirubinemia, and respiratory distress syndrome. Newborns of a woman with uncontrolled diabetes with no vascular impairment are more likely to be very large.

11. Please describe preconception guidelines that should be provided to women with pre-existing diabetes who want to become pregnant.

Control glucose to ideally 6.5% A1C. Provide information on risks of development and progression of diabetic retinopathy and eye exams should be provided every trimester to those with retinopathy.

2. Describe the early effects of pregnancy on the body's fuel metabolism. Why do these occur?

Early pregnancy (1-20 weeks), insulin release in response to serum glucose levels increases, resulting in significant hypoglycemia (may occur). Particularly in woman who experience N/V and anorexia in early pregnancy. In an uncomplicated pregnancy the availability of glucose favors the development of fat during first half of pregnancy, which prepares mother for rise of energy use by growing fetus during 2nd half of pregnancy.

10. What are the risks of uncontrolled diabetes in pregnancy?

Risk for having uncontrolled diabetes in pregnancy include having a miscarriage, fetal birth defects, preeclampsia, fetal demise, macrosonmia, neonatal hypoglycemia and hyperbilirubinemia, risk of diabetes in childs later life, and increased risk of child obesity.

12. Woman with diabetes should get what pre-conception testing?

Rubella, Hepatitis B, Syphilis, HIV, PAP smears, Cervical cultures, Blood type, Diabetic specific testing such as A1C.