UK Health Promotion related to Diabetes in Pregnancy - Essay Example

________________ ID: ____________ ID: ____________ Introduction Diabetes is as common in pregnant women as it is among other individuals. The outcome results in unnecessary foetus complications involving abnormality and deaths. The major cause of such complications has been seen due to lack of proper knowledge of diabetes and insulin during pregnancy. In this context it is essential to promote the understanding of diabetics in pregnancy. The aim of the essay is to explore the issues around diabetic pregnancy, how it can be managed, and in what ways we can educate young mothers about diabetic management and prevention. UK Health Promotion related to Diabetes in Pregnancy In the UK, diabetes is still the most common cause of blindness in the working population. 20-25% of patients entering end-stage renal failure replacement programmes have diabetes. The health commission reported that, there are almost two million people who are undiagnosed diabetics and the majority are women. Many people have diabetes for several years before it is diagnosed. (Daily Post, 2006, p. 17) Pregnancy in women with diabetes has a poorer outcome for the foetus than a non-diabetic pregnancy. (Diabetes, 2006) Approximately 6.4% of all pregnancies are complicated by diabetes in UK excluding those 1.9% pregnancies where the mother had insulin-dependent and gestational diabetes. (Lowy et al) The majority (90%) of diabetics in UK are gestational diabetics defined as onset or recognition of abnormal carbohydrate metabolism during pregnancy. Type 1 diabetes is characterised by pancreatic beta cell dysfunction with a resultant lack of insulin production requiring exogenous insulin therapy as a mainstay of treatment as well as dietary management. The average age of diagnosis for type 1 in UK women is less than 30. Type 2 diabetes is usually diagnosed at greater than 40 years of age, so this type of diabetes is not encountered as frequently in pregnancy, although it is by far the most prevalent type of diabetes nationwide. (Kendrick, 1999, p. 224) Significance The risk for adverse pregnancy outcome in UK women with diabetes has improved considerably over the last two decades due to improved obstetric care and tighter glycemic control. In this context, folic acid is mostly recommended. According to Howell et al, “The benefit of folic acid is a simple health promotion message of proven effectiveness that is particularly pertinent to a young population with a high birth rate”. (Howell, 2001) In spite of advances in the gestational health care, pregnancies are complicated by diabetes, whereas foetal and neonatal mortality remains at 2-4%. (Lisa & Nan, 1999) The major cause of perinatal mortality with diabetes can be attributed to congenital malformations and unexplained foetal death. Congenital malformations account for approximately 40% of perinatal deaths in diabetes with no specific associated malformation. The congenital malformations associated with diabetes are usually multiple, more severe, and more often fatal than birth defects found in offspring of nondiabetic women. As early maternal hyperglycemia is associated with a higher incidence of congenital malformations therefore, the incidence of babies with birth defects born to mothers with diabetes increase the rate significantly with preconception control as evidenced by lower glycosylated hemoglobin levels at the time of organogenesis. (Lisa & Nan, 1999) Pre-conceptual and ante-natal Educational Programs Ideally women with pre existing diabetes should have planned pregnancies for preconceptual assessment, counselling and management. However only 20% of diabetic women seek prepregnancy care. This is not unusual considering that approximately 60% of all pregnancies are unintended. The primary goal of preconception care is to improve the metabolic profile before conception and throughout the early weeks of pregnancy to decrease the risk of first trimester spontaneous abortion and major congenital anamolies. (Miller, 1994) Preconception programs with the goal of normalisation of blood glucose levels in the preconception period have significantly decreased the incidence of congenital anamolies among infants of insulin-dependant diabetics. (Greene, 1993) The goal of education is to empower the woman to take control of her disease. Due to the overwhelming amount of information the woman with diabetes needs, education may need to be provided in several scheduled sessions. Education should be individualised and be provided in a variety of formats. Written materials that emphasize the material covered will allow the woman to review at her own pace. In the training context, registered dieticians should be part of the diabetic management team and be included in the initial assessment and on an ongoing basis. Dietary manipulations may be necessary and should be individualised to the patient’s lifestyle and activity level. Supplementation with folic acid and prenatal vitamins during the preconception period and first trimester may decrease the risk of neutral tude defects resulting from gestational diabetes. (Czeizel & Dudas, 1992) Metabolic Alterations of Diabetic Pregnancy Providing metabolic prevention for pregnant women with diabetes mellitus or gestational diabetes requires knowledge of the normal metabolic adaptations to pregnancy. The metabolic alterations associated with pregnancy allow for the availability of glucose and other nutrients for the growth and development of the foetus even with maternal fasting and intermittent feeding. The beta cells of the pancreas become hypertrophied in early pregnancy as a result of stimulation by increased circulating levels of estrogens and progesterone. This results in an increased response (hyperinsulinemia) to glucose, which allows increased tissue storage of glycogen and peripheral glucose utilization. This prepares the diabetic mother for the increased demands of the foetus for amino acids and glucose in the latter half of pregnancy. The foetal demand for glucose and amino acids is met during maternal fasting by hepatic glucose production, which increases 15-30% by late third trimester. The liver begins to supply glucose within 6 hours of the last meal when absorption of nutrients from the intestinal tract ceases resulting in the depletion of glycogen which stores results from this accelerated glucose production. (Kendrick, 1999, p. 226) Metabolic Management for the prepregnant and pregnant Diabetic Type 2 diabetes is less common than type 1 diabetes during the reproductive years, but management prior to and during pregnancy should follow the same intensive programme of metabolic, obstetric and neonatal supervision. (Diabetes, 2006a) Following are some of the guidelines, which are followed by UK gestational diabetes program: Diet Therapy: The gestational diabetes management in UK involves diet therapy with the goal of attainment and maintenance of euglycemia and adequate weight gain during pregnancy avoiding hypoglycemia and ketosis. Caloric intake for pregnant women suggests with a current weight of less than 80% ideal body weight are 35-40 kcal/kg daily; for those 80-120%, 30kcal/kg; for those 120-150%, 24 kcal/kg; and for those >150%, 12-15 kcal/kg. (ACOG, 1994) This represents a caloric restricted diet (1080-1350 calories per day) for obese women, who comprise the majority of Type 2 and gestational diabetics. (Lisa & Nan, 1999) Exercise: Exercise involving cardiovascular conditioning facilitates glucose utilization by increasing insulin binding and affinity for its receptor. Exercise during pregnancy in women with diabetes should be discontinued if uterine activity results. Women with diabetes who are already involved in an exercise program should be allowed to continue during their pregnancy but should be counselled that a decrease in exercise may be required as pregnancy progresses. They also should be instructed to check their blood glucose before and after exercise with the understanding that in an insulin-deficient state, glucose levels will rise. Exercise during euglycemia may cause hypoglycemia during the exercise or hours later. (Plovie, 1991) Other measures to include safety of exercise in pregnancy include exercising postprandially at the same time everyday. (Plovie, 1991) Mild exercise programs such as walking can safely be encouraged in Type 1, Type 2 and gestational diabetes. Pregnant women with diabetes who have not achieved metabolic control should not exercise nor should those with complications of diabetes such as vasculopathy, hypertension, proliferative retinopathy, and severe neuropathy of the lower extremities. (Kendrick, 1999) Education and self-management: The diagnosis of gestational diabetes requires extensive, individualised education for the pregnant women of UK. According to Amanda Eden of the charity Diabetes UK, “It is unacceptable that women are losing their babies or giving birth to babies with major defects unnecessarily”. (BBC, 2006) The role of diet therapy and self-monitoring of blood glucose and the necessity for controlling diabetes in pregnancy should be discussed, along with the possible fetal and neonatal complications so the woman understands the importance of compliance with the diabetic regimen. The use of a reflectance meter including quality control, cleaning and the technique for blood glucose testing with return demonstration is vital to the success of self-management. Self monitoring in pregnant women with Type 1 and Type 2 diabetes consists of more intensive surveillance than is required in gestational diabetes. Diagnosis of pregnancy in women with pregestational diabetes who have not been enrolled in a preconception program may require hospitalisation for institution of intensive therapy if they are in or near the period of organogenesis (gestation 5-8 weeks) Women who have Type 2 diabetes who are being controlled by oral hypoglycemics will need to be instructed on insulin administration. Insulin Therapy: If diet therapy and exercise fail to control maternal glycemia in gestational diabetes, then women must taught about the insulin therapy after self-administration. They should be trained about the usage of insulin during pregnancy and the reproductive years due to the possible reason of stimulating anti-insulin antibodies that may cross the placenta and contribute to foetal macrosomia. (Menon et al, 1990) Most women with gestational diabetes can be controlled with 1-2 injections daily of a mixed dose of intermediate action insulin and a short acting insulin. Education should include a discussion of the types of insulin with duration and peak of action of the types to be used. The importance of eating meals and snacks to avoid hypoglycemia should be stressed. Women should be educated about how to check their insulin bottles for the expiration date and to discard any bottles that have any clumping, frosting or change in clarity or colour. They should be taught to store unused bottles in the refrigerator and to use open bottles within 30 days. Most gestational diabetics can use the abdoman exclusively in pregnancy, avoiding a 2-inch area surrounding the umbilicus. Absorption from the abdomen is the most rapid and most consistent, followed by the arms, thighs, and buttocks. Pregnant women should be taught to wash hands prior to injection. Good hygiene prevents the need for alcohol cleansing of the skin. Alcohol should, however be used to cleanse the tops of the insulin bottles. Women on insulin therapy should be taught the signs and symptoms of hypoglycemia and appropriate treatment. Disposal of syringes should be in a puncture resistant disposable container. This health promotional session ends when the women with gestational diabetes demonstrate correct technique for drawing up and administering insulin. (Lisa & Nan, 1999) Conclusion Gestational Diabetes, whatever the cause, is a matter of immediate concern in pregnancy. The need is to promote and educate women of all ages so that they can up to every possible extent manage their pregnancy while looking forward towards a healthy delivery. There is a need to manage diabetic pregnancy not only through diet and exercise, but also through self-assessing the appropriate dosage of insulin therapy. Women should be educated enough so that they can handle their diabetes even without any supervision. Might be in this way we would be able to promote the education of diabetic pregnancy thereby seeing a healthy and diabetic conscious generation of tomorrow. Works Cited & References BBC, June 2006 Czeizel, A. E., & Dudas, I. (1992) Prevention of the First occurrence of neutral tube defects by periconceptional vitamin supplementation. New England Journal of Medicine, 327, 1832- 1835. Diabetes, 2006 < http://www.sign.ac.uk/guidelines/fulltext/55/section1.html> Diabetes, 2006a. SIGN Publication No. 55 Greene, M. F., (1993) Prevention and Diagnosis of congenital anamolies in diabetic pregnancies. Clinics in Perinatology, 20, 533-547 Howell Sian, Barnett Adrian & Underwood Martin (2001) Family Practice In Oxford Journals. < http://fampra.oxfordjournals.org/cgi/content/full/18/3/300> Kendrick M. Jo. (1999) Diabetes Mellitus in Pregnancy in Lisa K. Mandeville & Nan H., Troiano (1999) “High Risk and Critical Care”. Lisa K. Mandeville & Nan H. Troiano. (1999) “High Risk Critical Care: Intrapartum Nursing”: Second Edition: Lippincott Lowy C, Beard RW & Goldschimidt J, “The UK Diabetic Pregnancy Survey” Menon R.K, Cohen R. M., Sperling M. A., Cutfield & Khoury, J. C. (1990) Transplacental Passage of insulin in pregnant women with insulin dependant diabetes mellitus. “New England Journal of Medicine”. Miller, E. H., (1994). Metabolic Management of Diabetes in Pregnancy. Seminars in Perinatology, 18, 414-431 Plovie, B (1991) “Diabetes in Pregnancy” (Series 2 Module 10) New York: March of Dimes Viva: Are You Diabetic without Knowing? (2006) How bad diet is leading to secret epidemic? In Newspaper: Daily Post: March 21, 2006 Read More