Gestational Diabetes Mellitus: an Overview Gestational diabetes mellitus (GDM) is defined as any degree of glucose intolerance with the onset or first recognition during pregnancy. Ninety percent of those diagnosed with diabetes during pregnancy will resolve after delivery (Scollan-Koliopoulos, Guadagno, & Walker, 2006). Pregnancy causes estrogen, progesterone and human placental lactogen to become elevated which provokes malfunctioning insulin, which can lead to insulin resistance and decreased cellular glucose uptake.
The growing placenta causes the production of even more hormones, producing higher glucose levels and increased insulin resistance. When the pancreas can’t satisfy the demands for additional insulin, GDM results (Gattullo & Olubummo, 2009). Approximately 7%, or 200,000 pregnant women are diagnosed each year in the United States. Advanced maternal age, family history of diabetes, prior GDM, history of infant with macrosomia, and elevated BMI are all major risk factors for developing GDM. GDM is more often found in women of Asian, Hispanic or Native American descent (Cheng & Caughey, 2008).
GDM can have negative effects on both the fetus and the mother. These mothers experience an increased number of Caesarian deliveries and use of forceps or vacuum extractions, resulting in severe perineal lacerations, related to fetal macrosomia. Along with the risks associated with macrosomia, the mother is also at risk for developing hypertension and preeclampsia, leading to preterm labor, as well as, developing Type 2 diabetes after the birth of her baby (Cheng & Caughey, 2008). The increased amount of glucose in the gestational diabetic is correlated with macrosomia and childhood obesity (Scollan-Koliopoulos et al. 2006). Maternal hyperglycemia can increase the risk of hypoglycemia, respiratory distress syndrome, jaundice and hypocalcemia in the neonate. The negative effects of macrosomia include shoulder dystocia, brachial plexus injuries and clavicle fractures, resulting in a traumatic birth (Cheng & Caughey, 2008). Poor glycemic control in the mother can also injure the fetus in other ways such as causing intrauterine hypoxia and placental insufficiency, leading to fetal polycythemia, which causes problems before and after birth (Fink, 2006). Case Study Pertinent History The patient, R.
B. , of Hispanic descent, presented to the Eagle Care Clinic, on May 24, 2010, at 14 2/7 weeks. She is “sure” that her LMP was February 12, 2010. She is G4P2SAB1. She will be 35 years old at EDB (November 20, 2010) and is considered advanced maternal age. She is overweight. She has a history of two previous term vaginal deliveries, in 1995 and 2000, with both neonates weighing almost 9 pounds, which is considered macrosomia. She reports that she does not recall any complications. (The pregnancies took place in Mexico, and therefore we are not able to obtain records. She also had a SAB in 1997, resulting in a D&C. She denies bleeding, nausea, vomiting, pain or contractions but does complain of fatigue and breast tenderness. She denies any other medical history or surgeries. She is taking prenatal vitamins and no other medication. She has no known allergies. She eats a typical Mexican diet, high in carbohydrates and fats and does not exercise. She does not use tobacco, alcohol or drugs and neither does her husband. This is an unplanned pregnancy, but her family, including two children and her husband, are very supportive and happy about the new baby.
She is a stay-at-home mother, and her husband is currently working in the construction industry. They are from Mexico and only speak Spanish. They practice Catholicism. Family medical history is negative except for sister with twins. PHYSICAL EXAM Vital signs: BP- 128/66, P- 70, RR- 16, T- 98. 7 Height- 168cm, Weight- 92 kilos, BMI- 32. 92 General: Pleasant, Hispanic woman, appears overweight, in no acute distress. HEENT: WNL. Teeth intact and evidence of good oral hygiene. Cardiovascular: Heart rate and rhythm regular. No MCR. Respiratory: Lungs clear all fields.
Breasts: Assymetrical- right>left, everted nipples, no discharge, no dimpling, tender bilaterally, no masses, no axillary nodes. Abdomen: Nontender; no organomegaly, bowel sounds x 4. FHT heard-152 bpm, +FM Pelvic: Cervix closed, parous os, creamy white discharge. Gravid uterus, S>D, fundus U-2, no active bleeding, no CMT, no adnexal tenderness. Vulva without erythema, lesions. Extremities: No edema. Pedal pulses 2+. No joint irregularities. Labs: CBC, RPR, Type and screen, Hep Bs Ag, Rubella, urine culture, Rh screen, genprobe, pap, obtained today.
UA in office shows trace of nitrites. U/S planned for next week with Dr. Petrie. Quad screen discussed for between 16-20 weeks. GTT planned for 20 weeks. R. B. returned to the clinic on June 1, 2010, for second prenatal visit. Lab and ultrasound results were as follows: Blood type: O+ Rh: negative Rubella: non immune Pap: normal RPR: negative GC: negative Chlamydia: negative HCT: 44. 3 Hgb: 15. 1 Hep B: nonreactive Urine culture: contaminated; clean catch obtained this visit. U/S: Viable fetus 16 5/7 weeks, EDC November 11, 2010, limited survey, posterior placenta, not previa.
MANAGEMENT OF GESTATIONAL DIABETES R. B. presented with the risk factors for GDM including obesity, previous history of macrosomia, Hispanic descent and advanced maternal age. It is for this reason that I chose the management of gestational diabetes for the topic of discussion for this paper. GDM is occurring in five to nine percent of pregnancies in the United States; however, criteria for diagnosing and appropriate treatment is controversial, with conflicting guidelines and protocols (Hollander, Paarlberg, & Huisjes, 2007. According to recent studies, the diagnosis and management of GDM do have favorable effects on maternal and neonatal outcomes, such as reduced shoulder dystocia, fractures, nerve palsies, preeclampsia, preterm labor and Caesarian births (Serlin & Lash, 2009. ) Diagnosis of GDM is made using a universal screening at 24-28 weeks, unless the patient has increased risk factors (as did my patient), in which case, the testing can be done at the initial encounter (Colorado Clinical Guidelines Collaborative, 2006. (My preceptor, who is a CNM and FNP, elected to wait until week 20 to do the initial screening. ) The screening test involves using a 50 gram one hour glucose challenge test, followed by a 100 gram three hour oral glucose tolerance test if the screening was positive (130-140 mg/dL). Diagnosis is made if fasting level of 95 mg/dL, one hour level of 180mg/dL, two hour level of 155 mg/dL or three hour level of 140 mg/dL (Serlin & Lash, 2009. ) There is a consensus among researchers that first line therapy for gestational diabetics is diet modification (medical nutrition therapy).
It is usually prescribed by a dietician, taking cultural preferences into account, and involves carbohydrate counting and specific meal recommendations, as well as lowering caloric intake for those with a BMI greater than 30. Although further research is necessary for definitive conclusions, low glycemic index (LGI) diets have been found to be beneficial to both mother and child. These diets aim to slow down the digestion of the food which allows the body to compensate for the sugar load which comes after the meal (Tieu, Crowther, & Middleton, 2008. Moderate exercise is a safe, practical and inexpensive intervention to utilize in the management of GDM. Fasting glucose and insulin resistance can be decreased by physical activity and is one of the most effective interventions for controlling hyperglycemia in the gestational diabetic. Increased hormonal activity associated with pregnancy can cause joint laxity and enlargement of the breasts and uterus which, in turn, can result in higher risk of soft tissue injury due to joint instability and altered sense of balance.
Since many women with GDM were physically inactive before pregnancy, it is recommended they start with a light to moderate exercise program, 3-5 days per week for 20-30 minutes, of walking, stationary bike riding or swimming, as long as there are no contraindications. This can be modified based on the client’s physical abilities and symptoms (Dawes, 2006. ) There is no consensus regarding specific glucose targets. The ADA recommends 90 to 99 mg/dL in the fasting state; less than 140 mg/dL one hour postprandial, and less than 120 to 127 mg/dL two hours postprandial.
Blood glucose should be self-monitored and a glucometer given to the client upon diagnosis. BG should be checked and recorded four times daily, fasting and one or two hours postprandial, for two weeks. If diet and exercise do not result in what is thought to be the acceptable glucose levels after two weeks of diet and exercise (20 percent of blood glucose values exceed target), then medication therapy should be considered (CCGC, 2006. ) Insulin is the only FDA approved drug for GDM and is the first line pharmacologic therapy.
The oral agent, Glyburide, is still under investigation, although it has been found not to cross the placenta, and it is used in many practices as an acceptable alternative for women unwilling or unable to take insulin. There is inconclusive evidence about Metformin; therefore, it is not recommended. For women who are willing to start insulin, the dose is usually 0. 7 units per kilogram per day, in divided doses. NPH and short acting insulin are used together, but the dose must be modified based on amount of exercise, glucose level and BMI (Serlin & Lash, 2009. Diagnosis and treatment of GDM remains controversial. There is no gold standard for either diagnosis or treatment, but the existing studies have shown that comprehensive patient education and follow-up of diet, exercise and blood glucose control are important in the management of GDM and can decrease the risks for adverse outcomes, including the development of Type 2 Diabetes later in life for both the mother and the baby (Mulholland, Njoroge, Mersereau, & Williams, 2007. ) IMPLICATIONS FOR ADVANCED PRACTICE NURSING
Patient management for GDM can be clinically challenging, and the best possibility for success is early detection and intervention. As nurse practitioners, our focus should be on teaching the mother to maintain glycemic control with diet, exercise or pharmaceutical interventions, thereby creating a healthy intrauterine environment. When a pregnant woman is seen in the clinic, her risk factors for GDM are assessed, either at the initial OB visit or at subsequent prenatal appointments or when she is seen for any other reason. Is she obese? Is there a family history of diabetes?
Has she had previous infants with macrosomia? Does she have PCOS? What ethnicity is she? Does she exercise? These are all important questions with which to begin our assessment (Fink, 2006. ) Following the Colorado Collaborative guidelines, routine screening for GDM is offered at 24-28 weeks gestation, unless the patient is in the high risk category, in which case, the screening should be done earlier–either at the initial meeting or by 20 weeks. If screening is positive and the GTT also exceeds the normal range, the patient is then diagnosed with GDM (CCGC, 2006. Once we have a diagnosis of GDM, a referral to the registered dietician and diabetic educator can be made, depending on the setting. The NP may serve in this role. The patient should be instructed to manage her condition by eating a culturally sensitive, balanced, low glycemic diet, as well as, safely increasing or starting an exercise program suitable for her level of conditioning. She will also be given a glucometer and be instructed to record her levels in a log which she will bring to each prenatal visit.
Our patients will be taught signs and symptoms of hypoglycemia and hyperglycemia and appropriate interventions. If glycemic control is unable to be maintained after 2 weeks of implementing diet and exercise therapy, pharmaceutical interventions such as Glyburide must be considered. If this is not an available alternative, the patient would need to be switched to insulin, and depending on the setting and level of experience of the clinician, a physician may need to be consulted for this now high risk pregnancy.
Along with the standard screenings and surveillance of pregnancy, the patient may need additional ultrasounds to assess fetal growth and evaluate the placenta, as well as, NST’s starting at 32 weeks to monitor the fetus closely (Gatullo & Olubummo, 2009. ) Women with GDM have approximately 50 percent risk of developing Type 2 diabetes within the next 5 to 10 years and 80 percent risk if they have impaired fasting glucose or glucose tolerance postpartum (CCGC, 2006. ) Therefore, it is critical that the patient return to see the provider 6-12 weeks postpartum for the appropriate follow up, testing and education.
Patients are encouraged to continue breastfeeding, not only for the benefits provided to the baby, but also to help the mothers lose weight. Our role as NP’s is also to encourage the patient to maintain her healthy eating habits and exercise regime to reduce the chance of diabetes occurring. She will need to have screenings preferably annually, and if considering another baby, preconception care is recommended (Gatullo & Olubummo, 2009. ) Nurse practitioners who care for gestational diabetic patients can offer holistic counseling and support that considers the long and short term health of women and their babies (Scollan-Koliopoulos et al. 2006. ) An innovative area where NP’s could expand their role is in CenteringPregnancy. Studies have shown that CenteringPregancy may have a potential for improved outcomes in at-risk populations. Patients were shown to be more involved in their care and have higher satisfaction with group care versus individual care. The patients also bond with each other and feel a sense of camaraderie (Klima, Norr, Vonderheid & Handler, 2009. ) Perhaps this would be effective for our GDM patients, where they could come and learn and share their thoughts and feelings in a safe environment.
Our support is a critical component of nursing care and listening to our patients’ concerns and showing our desire to help can alleviate the stress and anxiety that often accompanies the diagnosis of gestational diabetes. With our interventions, along with appropriate referrals, we will continue to improve outcomes. REFERENCES Cheng, Y. , & Caughey, A. (2008). Gestational diabetes: diagnosis and management. Journal of Perinatology, 28(10), 657-664. doi:10. 1038/jp. 2008. 62 Dawes, J. (2006). Special populations. The role of exercise in the prevention and treatment of gestational Diabetes mellitus.
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Journal Of Midwifery & Women’s Health, 54(1), 27-34. Retrieved from MEDLINE database. Mulholland, C. , Njoroge, T. , Mersereau, P. , & Williams, J. (2007). Comparison of guidelines available in the United States for diagnosis and management of diabetes before, during, and after pregnancy. Journal of Women’s Health (15409996), 16(6), 790-801. Retrieved from CINAHL with Full Text database. Scollan-Koliopoulos, M. , Guadagno, S. , & Walker, E. (2006). Gestational Diabetes Manage-ment: Guidelines to a Healthy Pregnancy. (Cover story). Nurse Practitioner, 31(6), 14-25.
Retrieved from Academic Search Premier database. Serlin, D. , & Lash, R. (2009). Diagnosis and management of gestational diabetes mellitus. American Family Physician, 80(1), 57-62. Retrieved from CINAHL with Full Text data base. Tieu J. , Crowther C. A. , Middleton, P. Dietary advice in pregnancy for preventing gestational diabetes mellitis. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No. : CD006674. DOI: 10. 1002/14651858. CD00674. pub2 CCGC: Colorado Clinical Guidelines Collaborative http://coloradoguidelines. org/pdf/guidelines/gestationaldiabetes/gdm_guideline_long. pdf