Diabetes in Pregnancy and Diabetic Ketoacidosis (Nursing)

by Jacquelyn McMillian-Bohler, PhD, CNM

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    00:01 Now, you know I'm a sucker for physiology, so before we go any further in this lecture, we've got to breakdown what goes on with diabetes and the pregnancy, and it gets a really fancy name called diabetogenic effect.

    00:15 I think they should name that a dance, like right? Diabetogenic effect, okay? So let's talk about what it is.

    00:21 So, what you'll see here is that we have a placenta that's producing hormones, and specifically, we're thinking about estrogen, cortisol, human placental lactogen.

    00:31 Now, human placental lactogen is also known as HCS, or Human Somatomammotropin, another word, I don't have a dance for that, but it does work here.

    00:40 So those products are going to be produced by the placenta.

    00:44 They have a lot of responsibilities.

    00:46 So what do those hormones do in terms of gestational diabetes? Well, the baby doesn't have a 24-hour McDonald's in-utero so they're dependent on the glucose from the maternal bloodstream to go through the placenta, come into the fetal bloodstream so they have something to eat, you know, like an extra large fry.

    01:07 So, what happens when we release HCS and cortisol and estrogen, is that it causes some insulin resistance in the pregnant person.

    01:18 That way the cells don't use up all the glucose and there's some left for the baby.

    01:22 Now, the problem is, is that when we do that and the insulin isn't working well and we have some insulin resistance from the cells, if it overshoots, then there'll be too much glucose left in the maternal bloodstream and that will make the maternal bloodstream really hyperglycemic, so that's the diabetogenic effect.

    01:45 So let's superimpose what's going on with our insulin needs during the pregnancy so we know what the diabetogenic effect is. So, let's look at our needs.

    01:56 So on this graph, what you see is the level of insulin and the insulin requirements over the duration of pregnancy, so over the weeks.

    02:04 So you can see on this data points that we're looking at the time from conception all the way to after delivery, so you see that's represented by the dots, and the orange line shows how the insulin needs change.

    02:17 So at conception, during that first trimester which ends at the end of 12 weeks, you see the insulin needs actually drop, and then after 12 weeks you start to see the insulin needs increase all the way to about 36 weeks where it levels off.

    02:33 And then watch what it does after delivery - it just drops almost straight down like a cliff.

    02:38 This is going to be really important as we get through the lecture so make sure you sort of have this seared in your brain.

    02:44 So, now, if we have someone who has normal insulin resistance, that's a normal part of pregnancy, so that the baby has glucose, then our graph looks like this.

    02:56 Now, if we have someone with gestational diabetes and they have an impairment, then this is what their graph looks like.

    03:04 Ok. So you can see that the change is absolutely affected by the pregnancy and the gestation. So let's summarize again what the effects of pregnancy are on diabetes.

    03:15 So an altered carbohydrate metabolism is exactly what the diabetes effect is.

    03:21 So that's put a little more simply.

    03:24 We also have to remember that we have impaired insulin action.

    03:27 So the insulin remember that's the key that lets the glucose go into the cell is slightly altered as an effect of the pregnancy. A lot of that is normal.

    03:37 It's physiologic.

    03:38 When we get to gestational diabetes, it overshoots, which makes it pathologic and a complication. Remember what that graph showed? The insulin requirements increase as the pregnancy advances, so that happens at the end of the first trimester, all the way up to about the time of delivery, around 36 37 weeks.

    04:00 So let's talk about some of the other effects of the pregnancy on diabetes.

    04:04 So when we think about someone who might have a pre-existing disease, we know that vascular damage is something that can happen over time.

    04:12 Pregnancy actually accelerates those vascular changes.

    04:16 So someone who might have pre-existing diabetes actually can find that those consequences are sequelae happen a little faster while they're pregnant.

    04:25 Also, we have a situation where we have accelerated starvation.

    04:30 Now this is diabetic ketoacidosis or DKA, and we're going to talk about that a lot more in just a second.

    04:36 And finally, when we think about someone who has diabetic ketoacidosis, it can cause more complications than just on the person with a diabetes because we have Clitus inside the body and so we can also have fetal complications as a result of that.

    04:52 So I want to spend some time breaking down this accelerated starvation and reminding you of what DKA looks like.

    04:59 So I have a slide for that and let's work through it. So when we think about DKA, we know that the pancreas is responsible for producing insulin.

    05:09 That's our key.

    05:10 So our glucose is actually floating through our vessels and the insulin is going to allow that glucose to enter the cell.

    05:18 Well, someone with diabetes, whether it's pre-existing or whether it's gestational onset, they're going to have an issue with getting the glucose into the cell.

    05:26 So remember, we have insulin resistance and some degree of change in our ability of our insulin to open up the cells.

    05:33 So how does the body respond? It's starving, right? It needs energy, so it's going to use the fat cells.

    05:40 And so when it uses the fat cells, it needs a little bit of help.

    05:44 And that help comes from the liver.

    05:46 The liver is going to convert those fatty acids into ketones.

    05:50 And so those ketones are acidic.

    05:53 So it's actually going to change the acidity of the blood.

    05:57 And that's not so great.

    05:59 And that leads to acidosis, which is almost like filling the bloodstream full of poison.

    06:04 So too many ketones can actually lead to a coma or even death.

    06:10 So that's DKA.

    06:13 So how do we know when someone is experiencing DKA? So let's think about the manifestations.

    06:18 First the client might present with malaise or just a general feeling of sluggishness or being super tired.

    06:25 They may have a headache that's pretty significant.

    06:28 They may experience nausea, they may experience vomiting.

    06:32 In the worst cases, they may present in a coma or they may die themselves. And if they're pregnant the baby could die also.

    06:42 I want you to pay particular attention to that nausea and vomiting, because nausea and vomiting is something that can happen as a normal consequence of pregnancy, as could, having a headache, as could, having malaise.

    06:54 So we always wanna pay attention when those symptoms pop up for clients that it's not something else.

    About the Lecture

    The lecture Diabetes in Pregnancy and Diabetic Ketoacidosis (Nursing) by Jacquelyn McMillian-Bohler, PhD, CNM is from the course Diabetes in Pregnancy (Nursing).

    Included Quiz Questions

    1. Insulin requirements increase
    2. Insulin requirements remain the same
    3. Insulin requirements decrease
    4. Insulin requirements vary from client to client
    1. Insulin resistance
    2. No change to insulin levels
    3. Low glucose levels in the blood
    4. Normal glucose levels in the blood
    1. Accelerated vascular changes
    2. Altered carbohydrate metabolism
    3. Higher risk for ketoacidosis
    4. Impaired insulin action
    5. Decreased carb metabolism
    1. Estrogen
    2. Cortisol
    3. Human placental lactogen
    4. Progesterone
    5. Testosterone

    Author of lecture Diabetes in Pregnancy and Diabetic Ketoacidosis (Nursing)

     Jacquelyn McMillian-Bohler, PhD, CNM

    Jacquelyn McMillian-Bohler, PhD, CNM

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