MCN NOTES: M'M

CARE AND MANAGEMENT OF INTRAPARTAL

Intrapartum - it extends from the beginning of contraction that causes
cervical dilation

5 things to considere before admitting the laboring mother

1. Personal Data
2. Baseline Data
3. Obstetric Data
4. Physical Exam
5. Pelvic Exam

5 theories
1. Uterine stretch theory - it is an hallow organ that stretches to its
maximum potential
2. Prostaglandin Theory - it is an arachidonic acid
3. Progesterone Deprivation - sudden drop of progesterone
4. Theory of Aging Placenta - placenta begins to degenerate
5. Oxytocin Stimulation Theory - production of pituitary gland

4 P's in Labor and Delivery

1. PASSENGER
TERMINOLOGIES
Fetal Head
- largest part of the newborn's body
Anterior Fontanel Bregma Posterior Fontanel Lambda
- diamond shape - triangular in shape
- 3 x 4 cm in size - 1 x 1 cm in size
- closes at 12-18 mos - closes at 2-3 mos

Important Measures of Fetal Head

Transverse Diameter (TD)
- Biparietal - 9.25 cm (largest transverse)
- Bitemporal - 8.0 cm
- Bimastoid - 7.0 cm (smallest transverse)
Antero-Posterior Diameter (APD)
- Occipitomental - 13.5 cm (hyperextension)
- Occipitofrontal - 12.0 cm (partial flexion)
- Submentobregmatic - (face presentation)
- Suboccipitobregmatic - 9.5 cm (complete flexion)
2. PASSAGEWAY
Under this we have
> 4 main types of pelvic
1. Gynecoid - it is round
2. Anthropoid - it is oval
3. Android - it is heart shape
4. Platypelloid - it is flat
3. POWER
Under this we have
> it was all about expelling the fetus and the placenta
4. PSYCHE AND PERSON
> it is an psychological stress when the mother is fighting their labor experience

NORMAL LABOR AND DELIVERY

PRE-EMINENT SIGNS OF LABOR
A. LIGHTENING - settling of presenting part into pelvic brim. Occurs 2 weeks prior to
delivery in primipara
B. SHOOTING PAIN RADIATING TO LEGS - (Leg cramps during labor due to pressure of
gravid uterus to the lumbosacral nerve plexus. Urinary frequency.
C. ENGAGEMENT - Settling of presenting part into pelvic inlet.
D. BRAXTON HICKS CONTRACTIONS - painless or irregular uterine contractions.
E. INCREASED ACTIVITY OF THE MOTHER - Also known as the "nesting instinct," caused
by hormone epinephrine. Nursing Intervention: let the mother save her energy as
fatigue can affect the type of analgesia needed.
F. RIPENING OF THE CERVIX - "butter softness" of the cervix.
G. DECREASE IN WEIGHT - 1.5 - 3.0 lbs. prior to labor.
H. BLOODY SHOW - pinkish vaginal discharge (leukorrhea, operculum and
blood combined).
I. RUPTURE OF MEMBRANES - Nursing Intervention: check FHT. Check temperature
every 2 hrs because mother is moreprone to inFx after membranes rupture

DURATION OF LABOR
Primipara: 14 hours but not more than 20 hours.
Multipara: 8 hours but not more than 14 hours.

STAGES OF LABOR
First Stage
- Stage of Cer vical Dilation
- Begins with onset of regular contractions and ends with complete dilation
3 PHASES:
- Latent: 0-3 cm
- Active: 4-7 cm
- Transitional: 8-10 cm
Effacement - softening and thinning of cer vical canal denoted in percentage.
Dilatation - widening of the external cervical os to 10 cm

Second Stage
- Stage of Expulsion
- Begins with complete cervical dilation and ends with delivery of fetus
Third Stage
- Placenta Stage
- Begins immediately after fetus is born and ends when the placenta is delivered
Fourth Stage
- Maternal Homeostatic Stabilization Stage
- Begins after the delivery of the placenta and continues for 1 to 4 hours
after delivery

TERMINOLOGIES
1ST TERM:
STATION - relationship of presenting part to the ischial spine denoted in centimeters.
PRESENTATION – Relationship of the LONG AXIS of the FETUS to the LONG AXIS of
the MOTHER
LONGITUDINAL (PARALLEL) OR VERTICAL LIE - 99% of all presentations.
CEPHALIC - is 95% of all presentations.
> Vertex - fetus is completely flexed.
> Brow - partial flexion or the military attitude
> Chin - means fetus is in hyperextension.
> Face - poor flexion
BREECH - is 4% of all presentation
> COMPLETE BREECH - thighs rest on abdomen while legs rest on thighs.
> INCOMPLETE BREECH
a. Frank - thighs rests on abdomen while legs extend to head.
b. Footling - Single: 1 leg flexed and 1 foot is extended; Double: 2 legs unflexed
and extended.
c. Kneeling - the knees presents.
TRANSVERSE LIE (PERPENDICULAR) - Shoulder presentation represents 1% of all
the deliveries
POSITION - RELATIONSHIP OF THE FETAL PRESENTING PART TO SPECIFIC QUADRANT OF THE
MOTHER’S PELVIS
MONITORING THE CONTRACTIONS AND FETAL HEART TONES:
Related Terminologies:
Ø Increment or Crescendo - from the beginning of contraction until it increases.
Ø Acme or Apex - height/peak of contraction.
Ø Decrement or Decrescendo - from the height of contraction until it decreases.
Ø Duration - beginning of the contraction to the end of the same contraction.
Ø Interval - end of one contraction to the beginning of next contraction.
Ø Frequency - beginning of one contraction to the beginning of next contraction.
Ø Intensity - strength of contraction.

MATERNAL ANALGESIA AND ANESTHESIA

Narcotic and Analgesic Drugs (Per Doctor’s Order)
1. Meperidine HCL or Pethidine (Demerol)
2. Fentanyl (Sublimaze)
3. Butorphanol (Stadol)
4. Epidural Anesthesia
5. Spinal Anesthesia

KEY STAGES OF LABOR

Descent
-Here the baby decends through the pelvic inlet towards the pelvic floor
Occurs Due To:
- Uterine Contractions
- Amniotic fluid pressure
- Abdominal muscle contraction

Engagement
Occurs when
- Largest diameter of the fetal head fits into the largest diameter of the
maternal pelvis
- As the fetal head engages, the head moves towards the pelvic brim in either the left
or right occipto- transverse position
- Allows the widest part of the fetal head to fit through the widest part of the
pelvic inlet
Neck flexion
- As the fetal head comes into contact with the pelvic floor, cervical flexion occurs
- Allows the presenting part of the fetus to be sub- occipito bregmatic
- In this position, the fetal skull has a smaller diameter, which assists passage through
the pelvis
Internal rotation
- The pelvic floor has a gutter shape, with a for ward and downward slope
- Allows the head to rotate from a left or right occipto- transverse position to an
occipto- anterior position
Crowning
- Extension of the presenting part
- The occiput slips beneath the suprapubic arch as the head extends and the nape of the
neck is pivoting against the arch
Restitution
External rotation
- The head externally rotates to face the right or left medial - thigh of the mother
Lateral flexion

PERINEAL TEARS
1st Degree - Vaginal Mucosa torn
2nd Degree - Perineal muscles torn
3rd Degree - Anal sphincter torn
4th Degree - Rectum torn

REPAIR OF EPISIOTOMY
Note: It is important that absorbable sutures be used for closure.

Vaginal mucosa
1. Identify apex
2. Begin suturing - 1.0 cm above apex
3. Continuous sutures
4. Ends at the level of vaginal opening
TYPES OF ANESTHESIA
Natural Anesthesia
- Pressure of fetal presenting part against the perineum is so intense that the nerve
endings for pain are temporarily numbed.
Pudendal Anesthesia
- Local anesthesia produced by blocking the pudendal ner ves near the ischial spine of
the ischium.

ESSENTIAL NEWBORN CARE

1. Immediate Drying
- Using a clean, dry cloth, thoroughly dry the baby, wiping the face, eyes, head, front
and back, arms and legs
2 Skin to Skin Contact
- Place the newborn prone on the mother's abdomen or chest skin-to-skin
3. Proper cord clamping and cutting
- Clamp and cut the cord after cord pulsations have stopped (typically at 1-3 mins)
4. Non - separation of baby from mother and breastfeeding initiation
- Obser ve the newborn
- Counsel on positioning and attachment
- Initiate breastfeeding

3RD STAGE TERMS:

- It begins immediately after the baby is born, until the placenta is delivered.
- The third stage lasts bet ween 5-15 minutes but any period up to 1 hour is normal.

PHYSIOLOGY OF THE THIRD STAGE OF LABOR

- Separation of the placenta
- Descent of the placenta
- Expulsion of the placenta
- Control of bleeding

SIGNS FOR PLACENTAL SEPARATION

1. GUSH OF BLOOD.
2. THE FUNDUS RISES AT THE LEVEL OF UMBILICUS.
3. UTERUS BECOMES GLOBULAR.
4. CORD LENGTHEN.
HIGH RISK PREGNANCIES
- Is any pregnancy wherein maternal and fetal life is endangered by a disorder co-existing
with or unique to the pregnancy.

CATEGORIES
1. Biophysical
2. Behavioral
3. Psychological Status
4. Socio - demographic

BIOPHYSICAL
1. Genetic
2. Medical
3. Obstetric
BEHAVIORAL
1. Nutritional Status
2. Substances Abuse
3. Dental Hygiene
4. Abuse and Violence
PSYCHOLOGICAL STATUS
1. Failure to seek prenatal care
2. Extreme Stress
SOCIO - DEMOGRAPHIC
1. Maternal Age
2. Parity
3. Marital Status
4. Residence
5. Ethnicity
6. Income
7. Racial and Ethnic Origin
8. Occupational Hazard

ROLE OF THE NURSE

- Identify risk factors and estimate the potential effect of the pregnancy outcome

CAUSE OF MATERNAL MORTALITY

1. Normal Delivery and other complications r/t pregnancy occurring in the course of labor,
delivery, and puerperium.
2. Hypertension complicating pregnancy, childbirth and puerperium
3. Postpartum Hemorrhage
4. Pregnancy with abortive outcome
5. Hemorrhage r/t pregnancy
ANTEPARTUM COMPLICATION

1. Hemorrhagic (Chronic Hypertension)

2. Hypertensive Disorders (Gestation Hypertension, Proteinuria, Pre- eclampsia, Eclampsia)
3. Gestational Diabetes Mellitus
4. Heart Disease
5. Multiple Pregnancies
6. Substance Abuse in pregnancy

GENERAL MANAGEMENT
HEMORRHAGIC DISORDERS
> CBR
> Avoid Coitus
> Approximation or assess for bleeding
- Counting of pads
- Saturation: Fully Saturated, 30-40 cc
- Weight: 1mg = 1ml = 1cc
- Assess for complications: hypovolemic shock
- Save discharges for histopathology: to determine if product of conception has
been expelled
- Prepare the mother for sonography or UTZ to determine the integrity of the sac
- First Trimester Bleeding
- Second Trimester Bleeding
- Third Trimester Bleeding

FIRST TRIMESTER BLEEDING

1. Abortion
SPONTANEOUS
a. Threatened
b. Invetible
c. Complete
d. Incomplete
e. Missed
INDUCED
a. Therapeutic Abortion
b. Illegal Abortion

2. Fetal Demise
a. Antenal Demise
b. Intrapartum Demise

3. Ectopic Pregnancy
a. Unruptured
b. Ruptured
FETAL DEMISE
- It is the termination of pregnancy after the age of viability
ANTENATAL DEMISE – occurs before labor
INTRAPARTUM DEMISE – occurs after onset of labor
RISK FACTORS:
> Mostly Idiopathic
> Antiphospolipid Antibody Syndrome (APAS)
> Maternal Diabetes
> Maternal Trauma
> Severe maternal isoimmunization
> Fetal aneuploidy
> Fetal InfX

ECTOPIC PREGNANCY
UNRUPTURED ECTOPIC PREGNANCY
- Missed Period
- Abdominal Pain w/in 3-5 weeks of amenorrhea
- Scanty, dark brown vaginal bleeding
- Vague Discomfort

RUPTURED ECTOPIC PREGNANCY

- Sudden, sharp, knifelike, unilateral severe pain
- Shoulder pain (pos. intraperitoneal bleeding that extends to diaphragm and
phrenic nerve)
- (+) Cullen Sign or the bluish-tinged umbilicus
- syncope
SECOND SEMESTER BLEEDING
> Hydatidiform Mole (H-Mole) or Gestational Trophoblastic Disease
H-MOLE
1. Bunch of Grapes
2. Gestational Anomaly of the Placenta
3. It is a neoplasm
4. Swelling of chorionic villi and lost nucleus of the fertilized egg
5. Sperm's nucleus duplicates, producing a diploid number 46XX
6. Grows and enlarges the uterus rapidly

ASSESSMENT
EARLY SIGNS
> Vesicles passed thru vagina
> Hyperemesis
> Gravidarum
> High Fundic HGT
> xFHT
> Vaginal Bleeding
> Metastasis
> High HCG Levels
> Preeclampsia @ 12 weeks
LATE SIGNS
> Hypertension before 20th Week
> Snowstorm on Sonogram
> Anemia
> Abdominal Cramping
SERIOUS LATE COMPLICATION
> Hyperthyroidism
> Pulmonary Embolus

THIRD TRIMESTER BLEEDING - Placental Anomalies

PLACENTA PREVIA
ASSESSMENT:
> FRANK BRIGHT RED, PAINLESS VAGINAL BLEEDING
> Engagement (Usually has not occurred)
> Fetal Distress
> Presentation of placenta
DIAGNOSTIC TEST:
> Ultrasound
> Blood Tests
NURSING INTERVENTIONS:
> NO SEX, NO IE, NO ENEMA
> CBR S BRP
> Prepare to induce labor if cervix is ripe or dilated
> Administer IV Fluids
> Put mother on NPO in case of delivery via CS
> Prepare for double set-up
> Secure Consent

ABRUPTIO PLACENTA
PREDISPOSING FACTORS:
> Preeclampsia and hypertensive disorders
> Illicit drug use
> Accidents
> History of placental abruption
> High Multiparity
> Increase maternal age
> Cigarette Smoking
ASSESSMENT:
> DARK RED, PAINFUL VAGINAL BLEEDING
> Concealed hemorrhage- rigid board like abdomen
> Couvelaire Uterus
> Severe Abdominal Pain
> Drop in Coagulation factor
COMPLICATION:
> Disseminated Intravascular Coagulopathy (DIC)
MEDICAL MANAGEMENT:
> Emergency CS
> Vaginal Delivery
> Conservative in-hospital observation
NURSING INTERVENTIONS:
> Infuse IV Fluids as ordered
> Blood Typing and cross matching for blood transfusion
> Monitor FHT (Fetus) and Monitor VS for shock (Maternal)
> Insert Foley Catheter
> Measure blood loss; STRICT I&O
> Report S&Sx of DIC
HYPERTENSIVE DISORDERS DURING PREGNANCY
- Incidence
- Definitions
- Etiology/pathophysiology
- Role of Nutrition

INCIDENCE
> Second leading cause of maternal mortality in US
> 15% of maternal deaths (eclampsia: disseminated intravascular coagulation, cerebral
hemorrhgae, hepatic failure, acute renal failure)
> Hypertensive disorders occur in 6 to 8% of pregnancies
> Contribute to neonatal morbidity and mortality

HIGH RISK WOMEN

> Under age 20 or over 40
> Poor nutritional status
> Smoking
> Overweight
> Other health problems such as renal disease, endocrine disorders (diabetes), autoimmune
diseases (lupus)
> Multiple gestation
> Some fetal anomalies
> History of preeclampsia
> Risk 10% with mild preeclampsia late in pregnancy
> Risk 40% with severe preeclampsia started early in pregnancy

RISK ALSO ASSOCIATED WITH

> Primigravida
> Genetic disease factors
> Familial predisposition (family history of hypertension)

CHRONIC HYPERTENSION
> Known hypertension before pregnancy or rise in blood pressure to > 140/90 mm Hg before
20 weeks
> Hypertension that is diagnosed for the first time during pregnancy and that does not resolve
postpartum is also classified as chronic hypertension.
> 25% risk of superimposed preeclampsia

RISK TO WOMAN WITH CHRONIC HYPERTENSION

22% developed preeclampsia; of those:
> 48% had SGA baby
> 51% delivered before 37 weeks
Risk of preeclampsia higher with:
> High BMI
> Smoking
> Black ethnic origin
GESTATIONAL HYPERTENSION
> Hypertension detected for the first time in pregnancy with systolic BP 140 or greater &
diastolic BP 90 or greater; no proteinuria
> 25-40% of women with gestational hypertension advance to preeclampsia

PROTEINURIA
> defined as the urinary excretion of 0.3 g protein or greater in a 24-hour specimen.
> usually correlate with 30 mg/dL (“1+ dipstick”) or greater in a random urine
determination with no evidence of urinary tract infection.
> Because of the discrepancy between random protein determinations and 24-hour urine
protein in preeclampsia
> it is recommended that the diagnosis be based on a 24-hour urine if at all possible

PRE-ECLAMPSIA
> presence of hypertension accompanied by proteinuria in pregnancy, usually after 20 weeks
> Symptoms may include renal failure & HELLP syndrome (hemolysis, elevated liver enzymes,
low platelets)
> 4% of women with preeclampsia advance to eclampsia
> Treatment: close monitoring & delivery before mother’s health is at excess risk.

ECLAMPSIA
> Occurrence in a woman with preeclampsia, of seizures that can not be attributed to
other causes

POST - ECLAMPSIA
> high bp after delivering a baby
PATHOPHYSIOLOGY
> Appears to be strongly related to placenta
> When placenta is delivered begins to abate
> Initiating Scenario- Stage 1:
> Abnormal placental implementation & failed remodeling of maternal spiral arteries
> Reduced blood flow to placenta & reduced placental perfusion

NORMAL PREGNANCY:
> vascular luminal diameter increased 4 fold & vessel wall modified by loss of smooth muscle so
becomes flaccid

STAGE 1: Reduced Placental perfusion abnormal implantation/ vascular remodeling

STAGE 2: Maternal Syndrome
Reduced placental blood flow leads to
> Oxidative stress
> Production of cytokines, antiangiogenic factors, other products…
Abnormal function of maternal vascular endothelium:
> Liver
> Kidney
> Brain
> Other organs
Additional Characteristics:
> alterations in immune response at the maternal interface
> increase in inflammatory cytokines in placenta and maternal circulation, “natural killer” cells,
and neutrophil activation

EMERGING UNDERSTANDINGS
Early preeclampsia:
- appears to be more related to the evolution of an extremely altered cardiovascular response
- probably triggered by a placental disorder.
Late preeclampsia:
- seems to be more linked to maternal constitutional factors.
- Predisposing cardiovascular or metabolic risks

FETAL IMPACTS
> Decreased blood volume
> Decreased placental blood flow may occur 3-4 weeks before increased BP
~ Hypoxia
~ Decreased nutrient delivery
STATE OF NUTRITIONAL SCIENCE
Stage 1:
- very little known about the impact of nutrition early in placental development
Stage 2:
- many nutrition studies attempting to intervene on maternal responses
- Smooth muscle contraction
- Prostaglandin synthesis

PHYSICAL ACTIVITY TO PREVENT PREECLAMPSIA?

- "Regular physical activity, particularly when performed during the year before pregnancy
and during early pregnancy, is associated with a reduced risk of preeclampsia.”
- Any regular activity – 35% reduction of risk
- Vigorous activities – 54% reduction of risk

OTHER NUTRITION RELATED FACTORS

> Na: Pregnant women with proteinuric hypertension have lower plasma volume Na.
restriction is associated with accelerated volume depletion – not recommended
> Energy and Protein intake: increases not found to be useful
> Weight reduction or limited gain in pregnancy: not found to be useful
> Garlic & Chinese Herbs: - no good quality studies

PREGNANT WOMEN WITH CHRONIC HYPERTENSION

> Take prenatal vitamin mineral supplement
> Follow a diet that meets Dietary Guidelines
> Moderate physical activity
> Follow recommended weight gain patterns for BMI

WOMEN DIAGNOSED WITH PREECLAMPSIA

- No real dietary treatment
- Recommended levels of energy, protein, sodium
- Physical activity restrictions as medically recommended

POSTPARTUM WOMEN WHO HAD PREECLAMPSIA WHILE PREGNANT

> At higher risk for CVD and subsequent hypertension in pregnancy:
Follow healthy lifestyle
Specifically –
> Plenty of fruits & vegetables
> Adequate calcium status
> Healthy weight

GESTATIONAL DIABETES MELLITUS (GDM)

DEFINITION:
> defined as any degree of glucose intolerance with onset or first recognition during pregnancy.
> The definition applies whether insulin or only diet modification is used for treatment and
whether or not the condition persists after pregnancy.
> It does not exclude the possibility that unrecognized glucose intolerance may have antedated
or begun concomitantly with the pregnancy.
PREVALENCE
> 7% of all pregnancies are complicated by GDM in US
> more than 200,000 cases annually in US
> prevalence may range from 1 to 14% of all pregnancies, depending on the population studied
and the diagnostic tests employed.

INFANT CONCERNS IN GDM

Higher risk of:
> neural tube defects
> birth trauma
> hypocalcemia
> hypomagnsemia
> hyperbilirubinemia
> prematurity syndromes
> subsequent childhood and adolescent obesity and risk of diabetes
Macrosomia in infant
> due to high glucose levels from mother and fetal insulin response leading to increased fat
deposition, associated with complications at delivery.
Hypoglycemia of infant
> following delivery due to high fetal insulin levels at delivery and sudden withdrawal of
maternal glucose transfer

MATERNAL CONCERNS
Higher risk of:
> hypertension
> preeclampsia
> urinary tract infections
> cesarean section
> future diabetes

DIAGNOSIS
> Assess risk at first visit
> If high risk (marked obesity, personal history of GDM, glycosuria, or a strong family history
of diabetes) GTT ASAP
> Women of average risk should have testing undertaken at 24–28 weeks of gestation
> Low-risk status requires no glucose testing

LOW RISK CRITERIA

> Age <25 years
> Weight normal before pregnancy
> Member of an ethnic group with a low prevalence of GDM
> No known diabetes in first-degree relatives
> No history of abnormal glucose tolerance
> No history of poor obstetric outcome
NON GTT dx
> A fasting plasma glucose level >126 mg/dl (7.0 mmol/l) or a casual plasma glucose >200
mg/dl (11.1 mmol/l) meets the threshold for the diagnosis of diabetes, if confirmed on a
subsequent day, and precludes the need for any glucose challenge

ONE STEP APPROACH

> Perform a diagnostic oral glucose tolerance test (OGTT) without prior plasma or serum
glucose screening
> May be cost-effective in high-risk patients or populations (e.g., some Native-
American groups).
TWO STEP APPROACH
> Initial screening by measuring the plasma or serum glucose concentration 1 h after a
100-g oral glucose load
> Diagnostic OGTT on that subset of women exceeding the glucose threshold value on
the GCT

NUTRITIONAL THERAPHY IN GDM

Treatment started before 30 weeks reduces likelihood of serious neonatal morbidity
> Individualize MNT
> Daily self monitoring of blood glucose (SMBG)
> Insulin when needed (20% needed)
Goals:
> prevent perinatal morbidity and mortality by normalizing the level of glycemia
> prevent ketosis
> provide adequate energy and nutrients for maternal and fetal health
> dependent on maternal body composition

MONITORING
> Daily self-monitoring of blood glucose (SMBG)
> Urine glucose monitoring is not useful in GDM.
> Urine ketone monitoring may be useful in detecting insufficient caloric or carbohydrate
intake in women treated with calorie restriction.
> Blood pressure and urine protein monitoring to detect hypertensive disorders.
> Increased surveillance for pregnancies at risk for fetal demise is appropriate
> Assessment for asymmetric fetal growth by ultrasonography to assess need for insulin

NUTRITION MONTH
> All women with GDM should receive nutritional counseling, by a registered dietitian
when possible
> For obese women (BMI >30 kg/m2), a 30–33% calorie restriction (to 25 kcal/kg actual
weight per day) has been shown to reduce hyperglycemia and plasma triglycerides with no
increase in ketonuria
> Restriction of carbohydrates to 35–40% of calories has been shown to decrease
maternal glucose levels and improve maternal and fetal outcomes
INSULIN
Insulin therapy is recommended when MNT fails to maintain self-monitored glucose at the
following levels:
> Fasting whole blood glucose 95 mg/dl (5.3 mmol/l)
> Fasting plasma glucose 105 mg/dl (5.8 mmol/l)
> 1-h postprandial whole blood glucose 140 mg/dl (7.8 mmol/l)
> 1-h postprandial plasma glucose 155 mg/dl (8.6 mmol/l)
> 2-h postprandial whole blood glucose 120 mg/dl (6.7 mmol/l)
> 2-h postprandial plasma glucose 130 mg/dl (7.2 mmol/l)
> Oral agents (not recommended in 2004), in 2007:
> Glyburide (glibenclamide): studies indicate may be useful adjunct to MNT/PA; may be less successful
with obese patients
> Metformin: crosses placenta, insufficient evidence that prevents GDM
> Acarbose: safety not fully evaluated
EXERCISE FOR DIABETIC PREGNANT WOMAN
> 4 trials, 114 women with GDM
> Trials conducted in third trimester for about 6 weeks; exercising three times a week for
20-45 minutes
> “There is insufficient evidence to recommend, or advise against diabetic pregnancy women to enroll
in exercise programs…..further trials needed.”

FOLLOW - UP CARE
Reclassification of maternal glycemic status should be performed at least 6 weeks after delivery
> If glucose levels are normal post-partum, reassessment of glycemia should be undertaken at a
minimum of 3-year intervals
> Avoid medications that worsen insulin resistance (e.g., glucocorticoids, nicotinic acid)
> Seek medical attention if develop symptoms suggestive of hyperglycemia.
> Increased risk of congenital anomalies in subsequent pregnancies
> Use family planning to assure optimal glycemic regulation from the start of any
subsequent pregnancy

LONG TERM
> Majority will eventually develop diabetes-
> 35-60 percent within 10 years
> risk continues at least 1-2 decades after GDM pregnancy

“There is substantial research evidence that lifestyle change and use of metformin or
thazolidinediones can prevent or delay the progression of IGT to type 2 diabetes after GDM.”