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Preexisting diabetes

Preexisting diabetes. Pathophysiology of Normal Pregnancy Nutrients; glucose, AA, and FA pass across the placenta to the fetus. In 1st trimester, maternal glycogen storage and endogenous glucose production increase.

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Preexisting diabetes

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  1. Preexisting diabetes

  2. Pathophysiology of Normal Pregnancy • Nutrients; glucose, AA, and FA pass across the placenta to the fetus. • In 1st trimester, maternal glycogen storage and endogenous glucose production increase. • Pregnancy hormones, estrogen, progesterone, and the constant fetal demand of glucose lower fasting maternal blood glucose levels, • The maternal appetite ; consumption of • additional calories, Fasting and • postprandial glucose levels.

  3. Elevated hormonal levels increase insulin resistance. • Insulin resistance peaks by the latter part of the third trimester, • After delivery, insulin production returns to prepregnancy levels. • 1. Type 1 Diabetes • Blood glucose levels remain elevated as insulin deficiency, thhe risk of diabetic ketoacidosis in the absence or lack of insulin. • Women in optimal glycemic control • may experience insulin sensitivity • and decreased insulin requirements • in the first trimester. • With pregnancy advancement, insulin resistance and additional insulin is necessary

  4. Type 2 Diabetes • Associated with impaired insulin secretion, insulin insensitivity, and • pancreatic beta-cell dysfunction. • Clients usually older and heavier. • The fetal pancreas secretes additional insulin due to hyperglycemia; macrosomia.

  5. Complications Associated with Preexisting, Diabetes • 1. Fetal; During 1st trimester; spontaneous abortions and congenital malformations including CNV, heart, lungs, GIT, kidneys, urinary tract, skeleton, and placenta. During 2nd and 3rd; macrosomia, neonatal hypoglycemia and hypocalcemia, hyperbilirubinemia, polycythemia, RDS, preterm delivery, and stillbirth are expected.

  6. الخضار

  7. الفواكه

  8. 2.Maternal • Preconceptional maternal complications include nephropathy, neuropathy, retinopathy, hypertension, and diabetic ketoacidosis. • Diabetic nephropathy is associated with • other complications including • preeclampsia, anemia, IUGR, fetal • termination, and preterm delivery. • Complications that develop during pregnancy include hypertensive disorders, polyhydramnios, preterm delivery, and cesarean section.

  9. Nutrition therapy: • The goals are • to provide adequate nutrients for • maternal-fetal nutrition, • to provide sufficient calories for • appropriate weight gain, and • to achieve and maintain optimal • glycemic control.

  10. الحمضيات

  11. . Weight gain; Excessive wt gain may lead • to macrosomia, CS, and postpartum • wt retention. Overweight women • with diabetes need to gain minimum • wt to minimize risk of macrosomia.table • 10-2, p.140 • II. Energy Requirements; • First trimester: no calorie increase • Second trimester: usually need +160 kcal (8 kcal/week × 20 weeks) + 180 kcal

  12. Third trimester: usuall +272 kcal (8 • kcal/week × 34 weeks) + 180 kcal • The energy requirements depend on; age, height, weight, and physical activity level • Adequate calories are required to avoid starvation ketosis and ketoacidosis. • A comprehensive nutrition history/ questionnaire, food record/diary • and blood glucose records, and regular monitoring of weight are used to develop individualized meal plans. • Fluctuating blood glucose levels may necessitate frequent adjustments in the meal plan.

  13. III. Macronutrients • Requirement of protein is 71 g/day (1.1 g/kg/day >18 years), high-fat diets are not recommended with adequate carbohydrate intake in pregnancy (175 g/day) to ensure sufficient glucose for fetal brain growth and development. • IV. Micronutrients • Calcium, vitamin D, magnesium, iron, and folic acid are frequently consumed in • inadequate amounts in pregnancy. Supplements are required. Folate deficiency is associated with maternal megaloblastic • anemia, neural tube defects, spontaneous abortions, and low birth weight • V. Nonnutritive Sweeteners; five are recommended including saccharine.

  14. Postpartum, insulin requirements usually decrease, also, there are no contraindications to lactation for the woman with diabetes, and women • should be encouraged to breastfeed. The meal plan is adjusted to include additional • snacks to avoid hypoglycemia

  15. 3. GESTATIONAL DIABETES MELLITUS • It is estimated that 90% of cases of diabetes in pregnancy is GDM. • similar to type 2 diabetes, as it is associated with insulin resistance and insensitivity. • With increased hormonal levels, • beta-cells are unable to produce • or secrete sufficient insulin for • glucose regulation. • Lactogen and cortisol block insulin receptors causes inadequate circulating insulin.

  16. Complications: • Maternal risks include hypertension, higher rates of CS and preterm deliveries • Fetal; Congenital anomalies are rare, macrosomia is the most common. Other complications include neonatal hypoglycemia and hypocalcemia, hyperbilirubinemia, and polycythemia. The risk for RDS decreases with full term.

  17. Risk Factors for GDM: • Obese • Previous history of GDM • Glycosuria • Strong family history of diabetes

  18. Nutrition Therapy • Goals; 1. keep normoglycemia, • 2. provide sufficient calories to • promote appropriate wt gain • and avoid maternal ketosis, and • 3. provide adequate nutrients for • maternal and fetal health

  19. Dietary recommendations: • The amount, source, and distribution of carbohydrates are determined in conjunction with blood glucose monitoring. • It’s recommended to restrict • CHO content to 40–45% of total calories, • but not < 175 g/day to achieve blood • glucose goals.

  20. Carbohydrate sources include whole grains, dried beans and peas, and lentils, which are more nutrient dense and have a lower glycemic response than processed foods (e.g., cereals, rice, and potatoes). • The distribution of CHO into three meals and two to four snacks will help control • postmeal blood glucose levels. • Carbohydrate intake is more restricted at breakfast than at other meals, as hormonal levels are higher in the morning. • The total amount of CHO at • Breakfast 15 to 45 g.

  21. Breakfast cereals, milk, and fruit may need to be consumed at other meals or snacks. • Carbohydrate distribution at lunch and dinner is usually 30–45 g or higher,. • The distribution of snacks is 15–45 g, with a smaller snack in the morning. An evening snack will help avoid overnight starvation ketosis. • Protein intake increases to 25–25% of total calories as the CHO level is reduced, > 71 g/day or 1.1 g/kg/day. • Fat makes up 35–40% of the

  22. total calories, with the majority as monosaturated and polyunsaturated fats. • Postpartum; • Breastfeeding, unless contraindicated, is recommended for women with GDM • Lactation may improve glucose control, mobilize fat stores, promote weight loss, and protect against future risk of developing diabetes

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