Gestational Diabetes Management Quiz

Introduction to Gestational Diabetes Mellitus (GDM)

• GDM is defined as carbohydrate intolerance of variable severity with onset or first recognition during pregnancy.
• It is not the same as Type 1 or Type 2 Diabetes.
• GDM prevalence varies globally and within different racial/ethnic groups within a country.
• GDM complicates approximately 4% of all pregnancies.
• 60% to 80% of women with GDM are obese and/or experience insulin resistance.

Etiology of GDM

• Pregnancy can induce a pre-diabetic state.
• GDM is associated with marked insulin resistance and an increased insulin requirement.
• Placental hormones (HPL and Cortisol) promote relative insulin resistance.
• Glucose readily crosses the placenta, and the fetus's blood glucose closely mirrors the maternal level.

Physiological Changes During Pregnancy

• A diabetogenic state peaks during weeks 28-32 of pregnancy.
• Placental hormones (HPL, Cortisol) contribute to relative insulin resistance.
• Glucose crosses the placenta easily, mirroring maternal blood glucose levels in the fetus.

Diagnosis of GDM

• Two-step strategy:
  • 50g oral glucose challenge, followed by a single serum glucose measurement at 1 hour.
  • Values <7.8 mmol/L (<140 mg/dL) are considered normal.
  • Values >7.8 mmol/L (>140 mg/dL) trigger a 100g oral glucose challenge.
• Serum glucose measurements are taken fasting, 1 hour, 2 hours, and 3 hours after the glucose challenge.
• Normal blood glucose values are outlined.
• An overnight fast of at least 8 hours and 3 days of unrestricted diet and unlimited physical activity are required before testing.
• Urine glucose monitoring is not helpful for diagnosing GDM.
• Urine ketone monitoring can be useful in identifying insufficient caloric or carbohydrate intake in women on calorie restriction.
• Screening protocols and risk assessment are presented in a flow chart.

GDM Diet

• Water foods—vegetables, fruits, grains, and legumes—are the primary dietary components.
• Low-fat and non-fat dairy are encouraged.
• Saturated, fast, processed microwave foods, high-sugar foods, alcohol, and high-sodium foods should be avoided.
• Drink plenty of water daily.
• Eat 5-6 small meals daily.
• Maintain consistent meal times.
• Dietary recommendations are provided based on ideal, overweight and morbidly obese weight—kcal/kg.
• Carbohydrate (50%), protein (20%), and fat (25-30%) ratios are essential.

Effects of GDM on Mother and Fetus

• Mother:
  • Abortion
  • Preterm labor
  • Infections
  • Increased incidence of pre-eclampsia
  • Polyhydramnios
  • Maternal distress
  • Diabetic retinopathy
  • Diabetic nephropathy
  • Diabetic ketoacidosis
  • Shoulder dystocia
  • Prolonged labor
  • Postpartum hemorrhage (PPH)
  • Puerperal sepsis
• Fetus/Neonate:
  • Fetal macrosomia, congenital malformations, birth injury, and growth restriction
  • Fetal death
  • Hypoglycemia
  • Respiratory distress syndrome (RDS)
  • Hyperbilirubinemia
  • Polycythemia
  • Hypocalcemia
  • Hypomagnesemia

Screening Criteria for GDM

• Low risk groups:
  • Age <25
  • BMI <25 kg/m²
  • No history of maternal macrosomia
  • No history of diabetes
  • No first-degree relative with diabetes
  • Not member of high-risk ethnic group
  • Member of an ethnic group with low prevalence of GDM
  • No history of abnormal glucose tolerance
  • No history of poor obstetric outcome
• Intermediate risk:
  • Presence of at least one criterion from low-risk groups list
• High risk:
  • Marked obesity
  • Prior GDM
  • Glycosuria
  • Strong family history
• Screening is typically conducted between weeks 24-28 of pregnancy.
• Retesting may be required if negative initial test but risk factors are still present— obesity, >33 years of age, +1 hour screening with negative OGTT, 3+/4+ glucosuria

Treatment for GDM

• The total initial insulin dosage is calculated based on the patient's weight.
• Dosage adjustments may be made based on trimester of pregnancy (first trimester x 0.7; second x 0.8; third x 0.9).
• Medical Nutrition Therapy is necessary with approximately 30 kcal/kg of ideal body weight, >40-45% carbohydrates, 6-7 meals daily (3 meals, 3-4 snacks) with a bedtime snack to prevent ketosis.
• Calories are based on maternal wellbeing, and weight gain.
• Frequent monitoring of blood glucose and fetal development is necessary during pregnancy.

Nursing Care for GDM

• Assessment: Begins with the first prenatal visit, history and physical exam and laboratory/diagnostic tests, for an individualized care plan.
• Health history includes duration of condition, management of glucose levels, presence of vascular complications, current insulin regimen, and technique for glucose testing.
• Preconception counseling information is reviewed.
• Adequacy and pattern of dietary intake are assessed
• Laboratory & Diagnostic Testing: Results provide information on maternal and fetal well-being and require ongoing surveillance.
• Screening: ACOG and ADA recommend risk analysis, additional screening for all high-risk pregnant women in late second trimester, or sooner with risk factors.
• Surveillance: Includes urine check for protein and ketones, kidney function every trimester, and eye examination in the first trimester for vascular changes. Fetal surveillance includes ultrasound to evaluate fetal size, activity and amniotic fluid volume for gestational age validation.
• Management: Nurses implement measures to minimize complication and risks including blood glucose level monitoring, diet, and insulin administration.
• Promoting Optimal Glucose Control: Nurses review blood glucose levels at each visit (lab and self-monitoring). Reinforce the need for blood glucose monitoring (pre-meal, bedtime). Assess the woman's technique in monitoring and administering insulin.
• Client Teaching/ Education: Assess client knowledge of diabetes and pregnancy, review underlying problems associated with diabetes. Include hypo/hyperglycemia signs, symptoms, prevention and management. Provide written materials. Observe client techniques in administering insulin and self-monitoring blood glucose. Teach home treatment for symptomatic hypo/hyperglycemia.