Gestational Diabetes Quiz

Gestational Diabetes Mellitus (GDM)

• GDM is defined as carbohydrate intolerance of variable severity, beginning or first detected during pregnancy.
• It is different from Type 1 or Type 2 diabetes.
• GDM prevalence varies internationally and among different racial and ethnic groups within a country.
• GDM complicates 4% of pregnancies globally.
• 60% to 80% of women with GDM are obese and experience insulin resistance alongside GDM.

Etiology of GDM

• Pregnancy often leads to a pre-diabetic state.
• Pregnancy-related hormonal changes can cause significant insulin resistance.
• Increased insulin requirement is a common outcome of GDM.
• Placental hormones (HPL, cortisol), insulin antagonists exacerbate insulin resistance.
• Glucose readily crosses the placenta.
• Fetal blood glucose levels mirror maternal levels.

Physiological Changes During Pregnancy

• A state called the diabetogenic state is prevalent during pregnancy, peaking around 28-32 weeks.
• Placental hormones (HPL, cortisol) increase, leading to relative insulin resistance.

Diagnosis of GDM

• A two-step strategy is used to diagnose GDM.
• 50g oral glucose challenge to screen for GDM.
• A single serum glucose measurement is taken 1 hour after the challenge.
• Plasma glucose levels of <7.8 mmol/L (<140mg/dL) are considered normal.
• Follow-up with a 100g oral glucose challenge is necessary if initial screening shows elevated glucose levels.
• Serum glucose measurements are taken in fasting state and at 1, 2, and 3 hours post-glucose ingestion.
• Specific normal values exist for fasting and 1-hour, 2-hour and 3-hour, glucose levels that need to be applied to test results to determine GDM.
• Overnight fast and 3 days of unrestricted diet and physical activity should precede initial testing, a common practice in the diagnosis of GDM.
• Urine glucose monitoring is not a reliable diagnostic tool for GDM.
• Urine ketone monitoring may aid in detecting inadequate caloric or carbohydrate intake in women undergoing calorie restriction.

Pregnancy Pathophysiology

• Elevated glucose levels during pregnancy can be teratogenic.
• Insulin resistance is present during pregnancy, due to hormonal changes.
• Increased glucose transfer from mother to fetus happens due to the resistance.
• Fetal growth and development are aided by the glucose transfer.

GDM Diet

• Water-based foods, such as vegetables, fruits, grains, and legumes, are the dietary staples in managing GDM.
• Low-fat and non-fat dairy products are preferred.
• Saturated fats, processed foods, fast foods, high-sugar foods, alcohol and high-sodium foods are to be avoided.
• Drinking ample fresh water every day is important.
• Portioning meals into 5-6 small meals spread across the day is recommended.
• Maintaining regular mealtimes daily supports stable blood sugar control.
• Caloric requirements are adjusted according to weight categories (normal, overweight, morbidly obese).
• Carbohydrate intake is 50%, protein 20%, and fats 25%-30% in the typical GDM diet.
• Typical meal portioning includes 25% of total intake for breakfast, 30% for lunch, and 30% for dinner.

Screening for GDM

• All Indian women should be screened for GDM.
• Women categorized as "low risk" for GDM would not be screened until established high-risk factors are noted
• Low risk factors include age under 25, BMI <25kg/m2 , no prior maternal macrosomia or diabetes or having a first relative with GDM or other diabetes.
• Women not fitting these parameters are in the intermediate or high-risk category.
• Screening for GDM should occur between 24-28 weeks of pregnancy, or sooner if high-risk factors exist.
• Retesting is necessary for women with negative initial tests but relevant high-risk conditions, for example obesity or age over 33 years.

Effects of GDM on pregnancy

• Increased complications for mother and fetus are possible with GDM.
• Risks to mother can include abortion, preterm labor, infection, preeclampsia, and polyhydramnios .
• Additional risks include maternal distress, diabetic retinopathy, diabetic nephropathy, and diabetic ketoacidosis. Complications can also include prolonged labor, shoulder dystocia, postpartum hemorrhage (PPH), and puerperal sepsis.
• Potential Fetal and neonatal complications can include macrosomia, congenital malformation, birth injuries, growth restriction, fetal death, hypoglycemia, respiratory distress syndrome, hyperbilirubinemia, polycythemia, hypocalcemia, and hypomagnesemia.

Treatment for GDM

• The physician determines the optimal course of treatment (i.e. medications, therapies) depending on various factors like the patient’s age, overall health, medical history, and the extent of gestational diabetes, the mother’s tolerance to specific medications or procedures and expectations of the course of the disease.
• Insulin management is often required to control blood glucose during active labor or if levels drop below 70mg/dL
• Insulin dose calculation is based on patient weight.
• Various insulin types, according to trimester, include adjustments as follows:
  • First trimester: weight x 0.7
  • Second trimester: weight x 0.8
  • Third trimester: weight x 0.9
• Frequent blood glucose monitoring (1-4 hourly) and medical nutrition therapies are crucial.
• A special diet, exercise, and daily blood glucose monitoring are also included in treatment.
• Medical nutrition therapy includes consumption of approximately 30 kcal/kg, mostly carbohydrates (40-45%), distributed among 6-7 meals and snacks.
• Bedtime snacks to prevent ketosis are a key component.
• Calories require adjustments according to fetal health, maternal weight gain, and measured blood sugars and ketones.

Fetal Monitoring

• Baseline ultrasound fetal size assessment.
• At 18-22 weeks : major malformations & detailed fetal echocardiogram.
• From 26 weeks: regular monitoring of fetal growth and amniotic fluid volume.
• During the third trimester : increased frequency of fetal ultrasounds, focused on tracking accelerated growth and head circumference.

Insulin Management During Labour & Delivery

• Intermediate-acting insulin is typically administered at bedtime.
• Insulin is withheld during the morning before labor management.
• Intravenous normal saline infusion is started.
• Normal saline solution infusion is converted to 5% dextrose at 2.5 mg/kg/min, if glucose levels drop below 70mg/dL
• Glucose levels are checked and adjusted hourly via portable glucose meter.
• Regular (short-acting) insulin infusions are often used to manage elevated glucose levels above 140mg/dL.

Puerperium

• Monitoring for potential complications in the postpartum period is required.
• Medication is generally required to support the continuation of blood glucose control in the postpartum period.
• Antibiotics, blood glucose monitoring, breast feeding and baby care are part of the care required in the postpartum period.

Contraception

• Barrier methods for contraception.
• Low-dose combined oral pills .
• Intrauterine device (IUD).
• Permanent sterilization.

Value of Screening

• Early screening and treatment can reduce GDM complications.
• Screening prevents macrosomia, cesarean births, and related birth injuries.
• Screening helps lessen neonates’ risk of hypoglycemia, hypocalcemia, hyperbilirubinemia, and polycythemia.
• Screening can identify the risk posed to the mother and fetus, and also aids in identifying women at future risk for diabetes, and women with insulin resistance.

Introduction

• Gestational diabetes mellitus (GDM) occurs when the mother develops insulin resistance due to hormones related to pregnancy, thereby demanding an insulin infusion to maintain healthy glucose levels, and reduce complications.
• GDM is different from a pre-existing condition, as it resolves after birth and is temporary, while the existing diabetes is not temporary.
• The prevalence of GDM is 3-10% of all pregnancies.

Diabetes Mellitus

• A chronic disorder involving the body's reduced cell use or production of insulin to maintain blood glucose levels, therefore, resulting in uncontrolled high glucose levels.
• Symptoms include excessive thirst, hunger, urination, and tiredness.
• The persistent elevation of blood glucose can result in health conditions like kidney damage, heart disease, stroke and blindness.

Definition of gestational diabetes

• Gestational diabetes is a form of diabetes occurring only during pregnancy.
• With gestational diabetes the mother's body has a reduced response to its own insulin production.
• The hormonal imbalances of pregnancy typically cause short-term insulin resistance.
• This type of diabetes typically resolves after childbirth.

Types of Diabetes

• Gestational diabetes: occurs during pregnancy. The maternal body can't manage blood sugar levels due to the hormonal changes of pregnancy.
• Pre-existing diabetes: is a condition present before pregnancy.

Etiology of Gestational Diabetes

• The precise cause of GDM is unclear, although placental hormones are believed to play a critical role.
• These hormones (estrogen, cortisol, and human placental lactogen -hPL) are thought to increase insulin resistance.

A growing placenta produces increasing amounts of these hormones. The growing demands of the fetus and maternal body cause a demand for sustained insulin secretion. The body's capacity can not keep pace with these changes and the excess hormones of pregnancy cause an insulin resistance, thus GDM.

Diagnoses

• High risk women should be screened for gestational diabetes early in pregnancy.
• Other women are screened during weeks 24-28 of pregnancy.
• A screening test (oral glucose tolerance test) is administered to detect elevated glucose levels .
• Confirmed elevated glucose levels trigger formal testing after fasting for several hours.
• This test will help confirm diagnosis in women who fall within a risk category, as well as in normal pregnancies to confirm the detection of GDM if elevated glucose levels occur during pregnancy.

Risk factors

• Age (older than 25)

• Family history or personal history of diabetes

• Obesity

• Race (African American, Hispanic, American Indian, or Asian)

• Other risk factors - not physically active, high blood pressure or cholesterol, polycystic ovary syndrome, or history of cardiovascular disease.

Nursing Assessment

• Conducting a thorough history and physical examination of the woman during the first prenatal visit.
• Gathering information about the duration, management, and current status of the woman’s diabetes.
• Reviewing her current insulin regimen, dietary adjustments, vascular status, and glucose testing technique.
• Collecting information on any prior conception counselling.

Laboratory and Diagnostic Testing

• Results should be reviewed and used to chart and inform the management and care plan for the mother.
• Tests used include maternal and fetal well-being assessments.
• These assessments inform the approach for the care of mothers and fetuses with suspected complications (gestational diabetes).

Screening

• The American Congress of Obstetricians and Gynecologists (ACOG) and the American Diabetes Association (ADA) recommend that all pregnant women have a risk analysis assessment and screening for GDM performed during the first prenatal visit, and again between weeks 24–28, or earlier if high-risk factors are present. This assessment can help identify women who need close monitoring for the best possible outcomes for the mother and fetus.

Surveillance

• Urine checks for protein (proteinuria) and ketones.
• Kidney function evaluation every trimester.
• Eye examination in the first trimester to assess the retina for vascular changes.
• Fetal surveillance with ultrasound to evaluate fetal growth, activity, and amniotic fluid volume and to confirm gestational age.

Nursing Management

• Providing counseling, education, and emotional support.

• Supporting the successful management of glucose levels.

• Facilitating consistent, accurate self-monitoring of blood glucose

• Reviewing signs and symptoms associated with hypo/hyperglycemia

• Implementing measures to minimize risks and complications.

• Monitoring antepartum visits for high-risk conditions twice or more times per week during the active stages of pregnancy, based on risk assessment.

• Teaching clients how to measure and manage their blood glucose levels.

• Emphasizing important preventative care measures to mitigate medical concerns

Promoting Optimal Glucose Control

• Reviewing maternal blood glucose levels and self-monitoring results.
• Reinforcing the importance of blood glucose monitoring.
• Evaluating the clients' glucose monitoring techniques
• Instructing how to give injections, if required by the physician, and providing support during the injections and care process

Providing Client Teaching

• Assessing client's understanding of diabetes and pregnancy.
• Teaching about problems associated with diabetes
• Reviewing signs and symptoms of hypo/hyperglycemia and prevention/management.
• Sharing written material relating to diabetes and care needed for control.
• Ensuring clients are able to perform essential monitoring and administer insulin correctly.
• outlining acute and chronic complications as a means of promoting awareness of importance of glucose control.

Evidence-Based Practice

• Considering different methods of Insulin Administration for a holistic approach to support both mom and baby.

Study

• A pregnant woman with pre existing diabetes is at risk of complications for both her and her developing fetus.
• Maintaining glucose levels within the normal range is the mainstay of treatment.
• Blood glucose levels during pregnancy are dynamic and differ in required treatment across trimesters, requiring vigilant ongoing management that is determined by physician's orders
• Administering insulin subcutaneously in multiple doses or by continuous infusion is common in treatment for the regulation of blood glucose levels during pregnancy.

Findings

• Mothers receiving continuous insulin infusion experienced a higher birth weight compared to those receiving multiple daily doses.
• However, this difference in birth weight was not clinically significant.
• No significant difference was found in perinatal mortality, fetal anomalies, or maternal hypo/hyperglycemia between the two groups.
• The absence of difference is attributed to the study's small sample size and the limited number of trials reviewed.
• Further studies using larger samples and more rigorous methodologies are suggested.
• Providing appropriate knowledge about diabetic management in pregnancy should be a goal for all healthcare providers to support the ongoing glucose control required for best possible health outcomes for both the mother and the growing fetus.

Nursing Implications

• The study underscores the need for consistent glucose control for pregnant women with pre-existing diabetes.
• Nurses should be aware of the findings of the study and utilize this knowledge to support the women.
• This approach to education and prevention supports optimal outcomes for both the mother and the fetus.

Test your knowledge on gestational diabetes with this quiz. Answer questions related to the condition's effects on fetal health, dietary recommendations, and caloric intake. Enhance your understanding of managing gestational diabetes effectively.