Diabetes as a Preexisting Condition Influencing Childbirth - Coursework Example

B.INDEX C. INTRODUCTION TO DIABETES2 D. PATHOPHYSIOLOGY OF DIABETES ON CHILD BEARING WOMEN5 E. CRITICALLY EXAMINE ROLE OF MIDWIFE AND MULTI DISCIPLINARY TEAM IN WOMEN WITH DIABETES10 F. EXPLORING THE AVAILABLE RESOURCES FOR NEEDS17 PHYSICAL PSYCHO SOCIAL EDUCATIONAL G. LISTING OF RESOURCES28 H. CONCLUSION34 I. REFERENCES36 PATHOLOGY OF DIABETES AND ITS IMPLICATIONS ON CHILD BEARING WOMEN C.INTRODUCTION Diabetes is a serious and chronic condition of the body when it is not able to produce or use Insulin properly. "Diabetes is the leading cause of death and disability in the US, the fifth leading cause of death in Asian and Pacific islanders in 45 to 64 age groups".(Diabetes and Asian Americans and pacific Islanders,(2002),National Diabetes educational program) According to (CEMACH (Confidential Enquiry into Maternal and Child Health)2002)) "IN UK,approximately one pregnant woman in 250 has pre-existing (type 1 or type 2) diabetes and an increasing number of young people are being diagnosed with type 2 diabetes." It has long-term complications affecting a person's quality of life. According to insulin availability and severity Diabetes is Classified as, Type 1 (also known as Juvenile Diabetes). The body's immune system attacks and destroys its own insulin producing cells when this occurs and hence the patients would need daily injections of insulin to live. Type 2 Either the body does not make enough insulin, or, cannot make efficient use of it. It usually occurs in adults above 40. This is more prevalent among Asian and Pacific Islander Americans. It is a disorder of impaired glucose (carbohydrate) metabolism due to insulin deficiency either relative or absolute or,peripheral tissue resistance to the action of insulin, resulting in Hyperglycemia. The broad CLINICAL classifications is, Type 1: IDDM (Insulin Dependent Diabetes Mellitus) Characterized by Early onset (Juvenile) and absolute insulinopenia (decreased or absent levels of insulin).The patients are thin and tendency for ketosis is more marked. Type 2: NIDDM (Non Insulin Dependent Diabetes Mellitus) NIDDM is a disease of late onset, the women present with overweight and their peripheral tissue (skeletal muscles and liver) show insulin resistance. There is also genetic predisposition. Being disease of late onset may account for the low incidence of this complication in pregnancy. These patients are usually obese and tendency for ketosis is Low. There is also GESTATIONAL diabetes (GD) which develops, or, is discovered during pregnancy. This usually disappears after delivery, but these women have a risk of developing type 2 diabetes later in lives. There is a whole spectrum of afflictions with Diabetes on pregnant women, and included in this spectrum are also emotions ; feelings of anxiety, difficult labour, and fear of future diabetes risks. Often such anxiety responses from the patients have even led to a debate that a GD diagnosis may be unnecessary. But a positive and management oriented approach must be reached whereby mechanisms of coping with the disease, supportive institutions which are friendly to GD women, must be fostered. Childbirth is one of the defining moments of many women's lives; a difficult pregnancy of birth experience can have a lasting impact on a woman's emotional life. (Mom k,1998). Thus there is every reason to pay importance to the issue and be proactive in the Healing. D. THE PATHOPHYSIOLOGY OF DIABETES IN PREGNANCY: Let us have an overview of the disease with special reference to its implications for pregnancy. Diabetes Mellitus is a chronic metabolic disorder of impaired glucose (carbohydrate) metabolism due to either insulin deficiency (relative or absolute) or, peripheral tissue resistance to the action of insulin, resulting in Hyperglycemia. CLASSIFICATION OF DIABETICS IN PREGNANCY: The onset of Diabetes in pregnancy can be grouped into two categories: 1. Overt Diabetes: 2. Gestational diabetes: Up to 14% of pregnancy complications are of diabetes and of this 90 % are gestational diabetes Melitus.Nearly 50% of women with GDM would become overt Diabetics (Type 2) over a period of 5 to 20 years (MUDALIAR,2005) The typical candidates for GDM are those with a positive family history of Diabetes episodes of overweight baby of 4 kg Presence of polyhydramnios Prolonged labour Dystocia still births and unexplained perinatal loss recurrent vaginal candidiasis during Pregnancy & pancreatic inlet hyperplasis revealed on autopsy (MUDALIAR,2005) Pathophysiology Pregnancy by itself might induce diabetogenic response. Because insulin requirements are increased during pregnancy from third month till end of term. This is because of the presence of insulin antagonizing hormones during this period. These are human Placental Lactogens, Progesterone and cortisols. The placenta produces enzymes, which results in degeneration of insulin. This brings the renal glucose threshold down. In many cases, the Glucose Threshold comes to normal after delivery. In view of this, the nomenclature: "Pregnancy induced glucose tolerance" (DUTTA,2004) is found to be more appropriate Retinal changes during Gestational Diabetes may be aggravated during pregnancy. These are the effects of Pregnancy on Diabetes (MUDALIAR,2005) The effects of Diabetes on Pregnancy : In cases of OVERT Diabetes: The pregnant women have diabetics before pregnancy. They may be Insulin Dependent or non-dependent. In these cases of uncontrolled diabetics, Abortion, fetal malformation and preterm delivery often occur, though the cause may not be identified. Gestational Diabetics: Gestational diabetes is defined as glucose intolerance that is first detected during pregnancy (Gestational diabetes milletus,1999) .IT is a temporary form developing during pregnancy; it is usually symptom free and it is detected during the course of pregnancy. Its severity varies. It also puts the mother at high risk of developing type 2 diabetes later in life, and of gestational diabetes in Subsequent pregnancies and may even transfer diabetes and other health problems to the child Overweight, polyhydramnios Prolonged labor & Dystocia: In both types, resultant maternal hypoglycemia causes fetal hyper insulinemia stimulating excessive somatic growth (as Insulin is a growth stimulator or somatogenic).This results in conditions of Fetal macrosomia (OVERWEIGHT). Fetal polyuria causes poly hydramnios. Fetal malformation (such as renal agenesis Neural tube and Heart valve Defects) and fetal polyuria as a secondary to fetal hyperglycemia. (MUDALIAR,2005) There is often alteration in Lipid metabolism in this type of diabetes and a decrease in HDL (High Density Lipoprotein).HDL acts as plasma antioxidant, fall in HDL could cause congenital malformation, as oxidative stress is a potential factor. (DUTTA,2004) Large baby leads to a prolonged labor & predisposes to Shoulder Dystocia Recurrent vaginal candidacies Diabetes increases susceptibilty to urinary tract infection and monilial vulvovaginities in pregnant women. Diabetic women are prone to have for PIH. (Pregnancy Induced Hypertension). (MUDALIAR,2005) "For most Diabetic women because of their Large babies, a caesarean section is indicated..this predisposes Caesarean section on subsequent pregnancies" (The Journal of Reproductive Medicine [Dec 2000].) Because of Diabetes the wound healing in caesarean is delayed. After her delivery, the mother should be again checked for her blood sugar in 6 weeks time as some women develop Type 2 Diabetes after Gestational diabetes. (Mom,.K(1998) Gestational Diabetes: Post-Partum Care and Concerns. Follow-Up Glucose Testing) E.CRITICAL EXAMINATION OF THE MIDWIFE'S ROLE in Supporting women with Diabetes Physical Needs of the mother: The management of gestational diabetes and that for Type 2 Diabetes is essentially the same.Both require strict control .But greater regularity in medical and obstetric review is required in Gestational diabetes. Mother's blood glucose levels needs constant monitoring. After delivery, gestational diabetes usually goes away. Education of mother and family: The importance of a lifelong lifestyle Changes must be impressed on the mother. The mother maintains a proper weight, healthy diet and regular physical activity. Emotional Impact on the mother: It is an area that has received scant attention and that too only superfluously. The doctors are more concerned about the outcome of the delivery than on the tremendous stress it poses on the mother. The diagnosis also impacts the child-bearing woman. Some experience considerable guilt that they were responsible for the problem. They have a mounting anxiety for the future of the foetus.Frequent health care visits make for life disruptions. Changes in food and preparation modes add to the stress. The diagnosis changes the very experience of pregnancy. blood sugar monitoring becomes a must, as many as 3 to 4 insulin injections a day may become necessary. These aggravate the stress. But some do not agree.They say that women easily adjust to these stresses.Intensive therapy regimens bring sugar levels under control ,giving the women reassurance they say. But the overwhelming findings are that GD affects a woman's self perception about her own health and worries about the foetus.Some women may respond with gratitude to the treatment which will supposedly save the child, when they are told of the mortality risk for the fetus posed by GD. Women are usually assumed to pass through 5 stages Five stages are usually listed: Denial, anger, bargaining, depression and acceptance. A GD mother may blame an outside source for the problem, and feel the child to be the cause or direct it to herself. They may feel ashamed of their fatness which had yet again caused them problem. Role of the health Team: Only the active response from a CARING Health Persona would help the patient to modulate her own perception, she would be helped not to perceive the illness negatively and enter a phase of suffering. Health providers must point out that even Thin women get GD and gain weight during pregnancy and tendency of insulin resistance are not the sole cause. It is her duty to give her a clear explanation Health providers must aim at making them accept the possible risks, and tutor them against over reaction and panic. Educate them about doing whatever is necessary for getting a healthy baby and improve our health for the future After delivery, there is the stress of establishing breast-feeding. All this take their toll. There is also post partum depression. Some are able to recover by concentrating on their babeis.Other may be anxious over the implications of the health of the baby. Not much attention has been given to the post partum depression Doctors may ignore as irrelevant such issues, or, just administer in an offhand manner some drugs to deal with the depression instead of spending time in counseling. (Mom,.K(1998) Gestational Diabetes: Post-Partum Care and Concerns:Emotional Impact of a GD Pregnancy) Multi disciplinary team: A Multi Disciplinary Team includes a "Diabetologist,obstretician with special interest in diabetes, a specialist diabetes nurse,specialist midwife, laboratory technician and a dietician. The diabetes specialist nurse has a key role in teaching techniques providing advise and supporting women to be self caring. The midwife specialist's role could overlap that of the nurses but their value is in providing support women on issues relating to pregnancy and in educating other midwifes on issues specific to diabetic pregnancy". (Diabetes National Service Framework (NSF),Dec 2001) As part of antenatal care the general practitioner should refer the women with pre existing diabetes to specialist antenatal care.General practitioners should be aware of the Local referral pathways. (Diabetes National Service Framework (NSF),Dec 2001) "Patient should view herself as a member of the multi-disciplinary Diabetic team and not as one cared by them" (Alvin Powers .C,2005) A MIDWIFE forms the core of the Team in measuring the Fundal Height, physical examination of the patient, look out for any weight Gain or Blood pressure Changes on each visit of the patient. She should give a proper advice to the patient and explain her present situation, allay her fears; tell her about the warning signs. provide Iron and Folic supplements in need was felt after the second trimester. Group or Individual sessions on Nutrition, self-Care and proper Parent-hood. An Immunization against Tetanus is also considered a must in most Third world Countries. A proper Referral services to bring the attention of the team when the need arises.(Park.K,2001) A laboratory technician is a must in the multidisciplinary team.Glycaemic control is best monitered using HbA1c. (Consensus statement of British Diabetic association and Association of Clinical Biochemists,2000). In situations where HbA1c testing is not ideal(anaemia and haemoglobinopathies) frutosamine may be clinically helpful but cannot be used to assess the risk of long term diabetes complications.(CEMACH,2002) A complete Urine, stool and hemoglobin count. Blood grouping, Rh Typing and Chest X-ray If need exists. (Park.K,2001) Pre conceptional counseling: The primary goal is to take tight control of diabetes before pregnancy sets in. There has to be a joint panel of Diabetologist and Dietician to tend a diabetic woman in pregnancy. In such women fetal congenital malformation were very low (0.8-2%). These women are taught in self glucose monitoring, are appropriately advised in diet and insulin. Joint consultation by a multidisciplinary team places the woman at the centre of the service and avoids fragmentation of care. This is a key area for development by trusts. (Diabetes National Service Framework (NSF),Dec 2001) Maternity units should have agreed plans as to which local health professional is best placed to offer appropriate and expert advise out of hours. Women should be clear on how to access this advice. (CEMACH,2002) "A study that why women don't attend pre-conception counseling was conducted.It is well recognised that pregnant women with diabetes go to great lengths to maintain very tight blood sugars to safeguard the health of the baby and indeed, their own health, so it is surprising that so few women attend. Perhaps the term 'Pre-conception counselling' is not one that appeals to people! The word counselling alone can be off-putting for some people. With a little imagination a better name should be produced." (Diab Med 2002, Vol 19:605) F. AN EXPLORATION OF THE AVAILABLE RESOURCES FOR WOMEN WITH DIABETES. PHYSICAL NEEDS : Women with diabetes should only be delivered in hospitals with neonatal intensive care facilities. (Scottish Intercollegiate guidelines Networks(SIGN Guideline No.9)) Having -OBSTETRITIAN It is always essential, for the Obstetrician to take a proper History always, a proper Clinical assessment to detect any mal-presentation ,hydraminos etc.. Providing proper medications for your gestational diabetes and make sure that those drugs do not affect the foetus by crossing the Placenta. (Park.K,2001) A non-stress test [NST] or biophysical profile is essential to make sure that your baby is getting enough oxygen and nourishment, especially nearer to the due date. This is a non-invasive test and causes your baby no stress. It takes about 30 minutes and does not require hospitalisation and is a simple test that checks how often your baby moves and how much the baby's heart rate increases with this movement.(DUTTA,2004) It is essential on the part of the Doctor to be aware of Pregnancy Induced Hypertension and treat it immediately with drugs having no teratogenic value. -Peadiatrician and Neonatologist He should be available at the time of delivary to deal with any emergency like respiratory distress or hypoglycemia. -Physiotherapist He teaches Safe aerobic activities to lower blood sugars, then build up your exercise levels gradually until she carries out moderate aerobic exercise on most days.Stretching and strength training exercises combined with aerobic exercise at the same time everyday is the best combination. Varying your exercise routine and working out with other pregnant women helps her stay motivated.( Diabetes Care ,May 2006) -Obstetric Surgeon: He should be available to perform any emergency cesarean section.the person should be skilled in operating Diabetic mothers as their healing takes time. (National Institute for Clinical Excellence [NICE], April 2004) - SONOGRAPHER The Ultrasound pictures are most essential in determining the Growth of the Baby in adequate in all the Trimesters, Early Detection of any Fetal Anomalies.It is Important in assessment of Expected date of Delivery.(MUDALIAR,2005) - HEALTH VISITOR He/she would record all pregnant women from 3 months onwards. An Ideal multi purpose health worker records all Married women in reproductive age group. She should be a person from that locality and so she can interact with the family well which is essential in developing trust and dissemination of Information. Usually a mother is relaxed at home so better acquaintance can be made. The health visitor can also get to know the atmosphere of home. (Park.K,2001) -RECORD KEEPING The Antenatal Record is Created. It should contain a registration Number, Identifying Data, previous Health History, and major health events. This Record should be always in the Centre for Follow up (Park.K,2001) -DIETITIAN Dietician's Role is to Provide * an appropriate meal plan * Timing meals and snacks * Planning physical activity * Choosing time and site of insulin injections * Using carbohydrate and glucagons for hypoglycemia * Reducing stress, coping with denial * Testing capillary blood glucose * Self-adjusting insulin doses to Pre-prandial whole blood glucose 70-100 mg/dl (3.9-5.6 mmol/l) & Postprandial whole blood glucose 1 h Read More