4/15/2013. Maribeth Inturrisi RN MS CNS CDE Perinatal Diabetes Educator

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1 Maribeth Inturrisi RN MS CNS CDE Perinatal Diabetes Educator List the potential complications associated with diabetes during labor. Identify the 2 most important interventions essential to avoiding newborn hypoglycemia. Demonstrate confidence in your ability to facilitate a safe delivery when diabetes complicates labor. Doula-ensures the mother feels safe and confident before, during, and after delivery Diabetes Doula-acutely aware of potential complications induced by diabetes yet confident as to how to prevent them. 1

2 A safe and uncomplicated delivery is additionally dependent on Well controlled maternal BG Avoidance of newborn hypoglycemia Maternal hyperglycemia Excessive maternal weight gain/obesity Fetal macrosomia Preeclampsia Preterm Induction Abnormal labor/cesarean birth Newborn hypoglycemia/birth injuries BG>110mg/dL - risk of newborn hypoglycemia BG>180mg/dL- risk of ketoacidosis, fetal distress, increased insulin requirement Increased risk of infection: Chorioamnionitis Urinary tract Wound mastitis 2

3 3 fold risk for Macrosomia except with tight BG control 2-3 fold risk for preeclampsia even with tight BG control Abnormal labor patterns: soft tissue dystocia, failure to descend, cephalopelvic disproportion with a trend towards cesarean birth wound separation and infection *Bariatric Preparation Rate of macrosomia with untreated DM= 26%. General Population rate = 10% LGA : Large for Gestational Age (GA) OR 4000 gms at any GA Macrosomia- Before birth: ultrasound of fetal abdominal circumference (AC)>75th% After birth: fat folds Risks: Fetal demise in last 4 wks GA Labor dystocia Shoulder dystocia Cesarean birth Hypoglycemia Polycythemia Fatty liver /heart Fetal abdomen >95% for 36 wk. GA 3

4 Reduced perfusion (HTN) Necrosis (End Organ disease- Proteinuria) Hemorrhage (HEELP Syndrome) Type 1,2, and GDMA2, generally induced by 40 weeks GA GDMA1 may await spontaneous labor Amniocentesis required for delivery<39 weeks GA Make every effort to reach 39 weeks GA to avoid late preterm morbidity Indications for induction: Maternal Preeclampsia Poor BG Control Fetal indications Low amniotic fluid IUGR or macrosomia Insulin-treated GDM with AGA fetuses at 38 wks. randomized to induction of labor within 1 week or expectant management. No difference in cesarean delivery rates Smaller proportion of LGA babies if induced Less shoulder dystocia 10% of the expectant management group beyond 40 weeks of gestation 1.4% in the group induced at weeks of gestation. 4

5 Greatest risk first 2-3 hrs. of life levels as low as 30mg/dL are common without being symptomatic in normal NB BG < 20mg/dL has been associated with seizures, neurological damage and death. April 19, 1970 What you need to know: Type of DM Target BG BG monitoring frequency How to enhance maternal coping Management of oral and IV fluids Medication management Problem-solving: hypo/hyperglycemia Reducing risks by being prepared Autoimmune destruction of pancreas Makes no insulin Must take exogenous insulin Will require insulin during labor but reduced amounts TYPE 1 Insulin resistance due to genes, obesity, meds, or pregnancy hormones Makes insulin but it doesn t work effectively May require insulin during labor except for GDMA1 TYPE 2, GDMA2, GDMA1 5

6 Intrapartum and Immediate Postpartum Blood glucose targets type1/type 2 GDMA2 GDMA1 During active labor or NPO *80-110mg/dL mg/dL Immediate Postpartum Newborn FBG <110mg/dL Postmeal (1hr.) <160mg/dL FBG< 100 mg/dl Postmeal (1 hr.)<140mg/dl After the first 2-3 hrs. of life :50-120mg/dL Hypoglycemia in the first 2-3hrs., defined as below 40 mg/dl, and occurs from 25-40% in infants of women with diabetes. Intrapartum /Immediate Postpartum Blood Glucose Monitoring Frequencies : Begin with ON ADMISSION / Stage Type1/type2 GDMA2 GDMA1 Early labor/ Induction/ eating Active Labor/clear liquids/npo/ Recovery Fasting, before and after first bite of carb Every 1hr. or more as needed Every 1 hr. until stable x 2 (>80mg/dL. <160mg/dL.) Fasting and 1 hr. after first bite of carb Every 1-2 hrs. On admission to and discharge from recovery Every 2 hrs. once Newborn After at least 30 minutes and before 90 minutes ALL ABOVE BG FREQUENCIES ARE WHILE BG IS WITHIN TARGET RANGE Recognize the additional stress of laboring with diabetes and acknowledge it Reassure that you will assume the burden of all worry about DM so she can let go of it. Accentuate the positive: Labor=exercise=uterine muscle uses BG=lower BG (often without insulin) Pain management same as non diabetic Express confidence in a safe and healthy outcome from the start. 6

7 Intrapartum Management of Fluids: Use LR as main line IV with a dextrose solution immediately available Type 1/type 2 GDMA2 GDMA1 Orals Intravenous/ NPO Use non- caloric, non carbohydrate clear liquids CHO controlled liquids If BG is <100mg/dL use gms CHO every 2-3 hours If BG >100mg/dL use noncaloric clear liquids If BG <100 mg/dl use IV 100 ml per hour; reduce to 50ml/hr when BG reaches 100mg/hr If BG is >100 mg/dl use 100 ml per hour; use 50ml/hr if fluid is restricted Continuous Intravenous Insulin Infusion (CIII) Current BG mg/dl Type 1 Type 2 GDMA2 GDMA1 Solution of 250units regular insulin in 250mL normal saline. <70 Follow hypoglycemia protocol start No insulin unit/hr. unit/hr. If BG>110mg/dL repeat BG in 30 min. If>110mg/dL start 1 unit/hr. units/hr. units/hr. 4 units/hr. >190 Check urine ketones and call MD for further orders Modified from Inturrisi M, Lintner NC, Sorem KA. Diagnosis and treatment of hyperglycemia in pregnancy. Endocrinol. Metab. Clin. North Am. 2011; 40(4):721. When uterine activity is regular and patient is having clear non-caloric fluids, cut basal rates by 30% of the last pregnancy setting. When in active labor, cut basal rate by 50% of last pregnancy setting, If Correction Bolus is needed for BG >110 mg/dl, use half the pregnancy correction and check BG in 30min. 7

8 Consider source of elevated blood glucose: fever, infection, betamimetics (ephedrine or terbutaline), pain, anxiety, or IV dextrose, and treat the source. If blood glucose target of is not achieved within 2 hours of insulin/fluid adjustments, modify IV insulin algorithm Check BG every 30 minutes when not in target to evaluate interventions If current blood glucose is 50 to 70 mg/dl: (These orders should be included in orders for insulin drip) Stop insulin infusion (either CIII or CSII). Infuse IV D5 solution at 200 ml/hr. Check BG every min until BG >70 mg/dl x 2. When BG is >70 mg/dl, reduce D5 to 100 ml/hr. Notify MD may want to adjust insulin dosing. Abnormal FHR - continuous monitoring Abnormal Labor Preeclampsia Chorioamnionitis Shoulder Dystocia Emergency Cesarean Availability of OB, Anesthesia, Peds Newborn Issues hypoglycemia TTN 8

9 Insulin needs are generally cut in half with the delivery of the placenta For type 1 use CIII at half the labor algorithm until taking food. If using CSII or MDI reduce basal and bolus doses to 1/3 of their last pregnancy doses. For type 2, GDMA2, insulin infusion off with the delivery of the placenta. Insulin Requirement during *ALL pregnancies doubles by 28 wks., triples by 40 wks. Triple Insulin Double Insulin Usual Insulin Weeks: Conception Delivery Achieve normoglycemia during pregnancy and LABOR (Jovanovic, 1996). Facilitate breastfeeding within the first 30 minutes after birth 9

10 Dry baby thoroughly Place skin to skin Breastfeed early and often- Colostrum wakes up the liver so it can provide glucose when newborn BG starts to drop. 10