1. Disorders affecting nutrition: diabetes mellitus
    1. Pathophysiology - increased demand for insulin exceeds pancreatic reserve —» inadequate insulin production; enzyme (insulinase) activity breaks down circulating insulin —» further reduction in available insulin; increased tissue resistance to insulin; glycogenolysis/gluconeogenesis —> ketosis.
    2. Etiology - increased metabolic rate; action of placental hormones (see below), enzyme (insulinase) activity.
    3. Normal physiologic alterations during pregnancy that may affect management of the diabetic woman, or precipitate gestational diabetes in susceptible women:
      1. Hormone production:
        1. Human placental lactogen (HPL)
        2. Progesteron
        3. Estrogen.
        4. Cortisol.
      2. Effects of hormones:
        1. Decreased glucose tolerance.
        2. Increased metabolic rate.
        3. Increased production of adrenocortical and pituitary hormones.
        4. Decreased effectiveness of insulin (increased resistance to insulin by peripheral tissues).
        5. Increased gluconeogenesis.
        6. Increased size and number of islets of Langerhans to meet increased maternal needs.
        7. Increased mobilization of free fatty acids.
        8. Decreased renal threshold, increased glomerular filtration rate; glycosuria common.
        9. Decreased CO2 - combining power of blood; higher metabolic rate increases tendency to acidosis.
      3. Effect of pregnancy on diabetes:
        1. Nausea and vomiting - predispose to ketoacidosis.
        2. Insulin requirements - relatively stable or may decrease in first trimester; rapid increase during second and third trimesters; rapid decrease after birth to prepregnant level.
        3. Pathophysiological progression (nephropathy, retinopathy, and arteriosclerotic changes) may appear; existing pathology may worsen.
    4. Effect of poorly controlled diabetes on pregnancy - increased incidence of:
      1. Infertility.
      2. UTI.
      3. Vaginal infections (moniliasis).
      4. Spontaneous abortion.
      5. Congenital anomalies (three times as prevalent).
      6. Preeclampsia/eclampsia
      7. Polyhydramnios.
      8. Preterm labor and birth.
      9. Fetal macrosomia - cephalopelvic disproportion (CPD).
      10. Stillbirth.
    5. Assessment: gestational diabetes (mellitus)
      1. History:
        1. Family history.
        2. Previous infant 9 lb or more.
        3. Unexplained fetal wastage - abortion, stillbirth, or early neonatal death.
        4. Obesity with very rapid weight gain.
        5. Polyhydramnios (excessive amniotic fluid).
        6. Previous infant with congenital anomalies.
        7. Increased tendency for intense vaginal or urinary tract infections.
        8. Previous history of gestational diabetes
      2. Symptoms: 3 “Ps” - polydipsia, polyphagia, polyuria - and weight loss.
      3. Abdominal assessment:
        1. Fetal heart rate.
        2. Excessive fundal height.
          1. Hydramnios.
          2. Large-for-gestational-age (LGA) fetus. Note: With vascular pathology, small-for-gestational-age (SGA) fetus.
      4. Medical diagnosis - procedures:
        1. 50 g oral glucose tolerance test (GTT): woman ingests 50 g oral glucose solution; 1 hr later plasma glucose obtained. If   >140 mg/dl, 3 hr oral GTT ordered.
        2. Abnormal GTT: two or more of the following findings are diagnostic of gestational diabetes.
          1. Fasting blood sugar (FBS) >105 mg/dl.
          2. One hour  >190 mg/dl.
          3. Two hours >165 mg/dl.
          4. Three hours >145 mg/dl.
        3. Diabetic classification criteria
          1. Class A - gestational or chemical diabetes (abnormal GTT).
          2. Class B - overt diabetes, onset after age 20, duration less than 10 year, no vascular involvement.
          3. Class C - overt diabetes, onset before age 20, duration 10-20 year, no vascular involvement.
          4. Class D - overt diabetes, onset before age 10, duration longer than 20 year, vascular involvement, benign retinopathy, leg calcification.
          5. Class F - renal impairment.
      5. Woman with known diabetes - all classes.
        1. Knowledge and acceptance of disease and its management:
          1. Signs and symptoms of hyperglycemia/hypoglycemia.
          2. Appropriate behaviors (e.g., skim milk for symptoms of hypoglycemia).
        2. Skill and accuracy in monitoring serum glucose (dextrometer use).
        3. Skill and accuracy in preparing and administering insulin dosage; site rotation; subcutaneous injection.
        4. Close monitoring - prenatal status assessment every 2 week until 30 week, then weekly until birth. Alert to signs of emerging problems (need for insulin adjustment, polyhydramnios, macrosomia).
        5. Other - as for any pregnant woman.