Complications of pregnancy
Poorly controlled diabetes before conception and during the first trimester of pregnancy can cause major birth defects in 5 to 10 percent of pregnancies and spontaneous abortions in 15 to 20 percent of pregnancies.
Poorly controlled diabetes during the second and third trimesters of pregnancy can result in excessively large babies, posing a risk to both mother and child.
Impotence
Impotence is a common problem for men and is more common in men with diabetes. The relationship between diabetes and impotence is not clear and the reasons why men with diabetes are more prone to problems with impotence are not fully understood. Some people with diabetes suffer from hardened arteries, which may contribute to impotence by restricting the flow of blood to the penis. Nerve damage, another problem for people with diabetes, may also contribute to impotence. If blood glucose levels are kept in the normal range, it will help reduce the chance of these problems occurring.
Other complications
Uncontrolled diabetes often leads to biochemical imbalances that can cause acute life-threatening events, such as diabetic ketoacidosis and hyperosmolar (nonketotic) coma. People with diabetes are more susceptible to many other illnesses and, once they acquire these illnesses, often have worse prognoses. For example, they are more likely to die with pneumonia or influenza than people who do not have diabetes.
Management of some common complications
Hypoglycemia
<65 – dizziness, confusion, weakness, tremors.
<40 – coma, seizures, irreversible brain damage.
Treat with quickly absorbed glucose – orange juice, soft drinks, glucose tablets (15-20g), cake icing applied to the inside of the mouth.
Hyperglycemia
Blood glucose >130.
Dangerous when symptomatic, but must be identified and treated to avoid complications. Signs and symptoms are as above. If associated with infection, can lead to diabetic ketoacidosis. This results in severe dehydration, acidosis and sepsis. This is a potentially fatal illness; therefore, early recognition and avoidance is important. It is imperative not to skip insulin if the diabetic is unwell and not eating. Maintain adequate hydration. Get urgent medical help if unable to control blood glucose levels or if patient appears unwell.
Hyperosmolar non-ketotic state
In the elderly, Type 2 diabetes is more prevalent. Because there is no absolute lack of insulin, ketoacidosis does not occur. What does occur is a hyperosmolar non-ketotic state which can lead very quickly to coma. Again, prevention is better than cure.
Skin care
Diabetic patients suffer from skin problems for a number of reasons. First, they are more prone to developing infections due to impaired immunity; secondly, they develop peripheral neuropathies which allow easy disturbance of skin integrity; thirdly, they have microvascular disease, which prevents adequate perfusion and immensely compromises the ability to repair. It is imperative to educate patients in thorough cleansing and inspection of extremities. Good podiatry care is very important. Any injuries should be addressed quickly and treated aggressively to avoid chronic ulcers.
Foot ulcers
The primary goal in the treatment of foot ulcers is to obtain healing as soon as possible. The faster the healing, the less chance for an infection.
There are several key factors in the appropriate treatment of a diabetic foot ulcer:
• Prevention of infection
• Taking the pressure off the area, called “off-loading”
• Removing dead skin and tissue, called “debridement”
• Applying medication or dressings to the ulcer
• Managing blood glucose and other health problems
Not all ulcers are infected; however if the podiatric physician diagnoses an infection, a treatment program of antibiotics, wound care, and possibly hospitalization will be necessary.
There are several important factors involved in keeping an ulcer from becoming infected:
• Keep blood glucose levels under tight control
• Keep the ulcer clean and bandaged
• Cleanse the wound daily, using a wound dressing or bandage
• Do not walk barefoot
For optimum healing, ulcers, especially those on the bottom of the foot, must be “off-loaded.” Patients may be asked to wear special footgear, or a brace, or specialized castings, or to use a wheelchair or crutches. These devices will reduce the pressure and irritation to the ulcer area and help to speed the healing process.
The science of wound care has advanced significantly over the past ten years. The old thought of “let the air get at it” is now known to be harmful to healing. We know that wounds and ulcers heal faster, with a lower risk of infection, if they are kept covered and moist. The use of full strength betadine, peroxide, whirlpools and soaking are not recommended, as this could lead to further complications.
Appropriate wound management includes the use of dressings and topically-applied medications. These range from normal saline to advanced products, such as growth factors, ulcer dressings and skin substitutes, which have been shown to be highly effective in healing foot ulcers.
For a wound to heal there must be adequate circulation to the ulcerated area. The podiatrist can determine circulation levels with noninvasive tests.