Gestational

Diabetes Mellitus

Submitted by: Airan katriel Manalo

Gestational diabetes mellitus (GDM)

  Is defined as any degree of glucose intolerance with onset or first recognition during pregnancy.
The definition applies whether insulin or only diet modification is used for treatment and
whether or not the condition persists after pregnancy. It does not exclude the possibility that
unrecognized glucose intolerance may have antedated or begun concomitantly with the
pregnancy.

 Approximately 7% of all pregnancies are complicated by GDM, resulting in more than 200,000
cases annually. The prevalence may range from 1 to 14% of all pregnancies, depending on the
population studied and the diagnostic tests employed.

 Gestational diabetes usually has no symptoms. That's why almost all pregnant women have a
glucose-screening test between 24 and 28 weeks.

Consider these facts about GDM:

 It affects 7% of all pregnant women in the United States.

 More than 200,000 cases are diagnosed annually according to ADA (American Diabetes
Association).
 Women with GDM have an evidence of islet cell autoimmunity.
 67% reduction in their beta- cell compensation compared with normal pregnant women.

Gestational diabetes is usually diagnosed between the 24th and 28th week of pregnancy when the
results of insulin resistance are clinically present.

Subtypes:

 Type A1abnormal oral glucose tolerance test but normal glucose level during fasting 2 hrs after
meals; diet modification is sufficient to control
  Type A2 abnormal (OGTT) compounded by normal glucose level during fasting 2 hrs after meals,
additional therapy with insulin or other medication regularly

 Any type of diabetes mellitus during first in pregnancy type A,B,C,D,E,F,R,RH,H,T

Greater risk for gestational diabetes:

 Are older than 25 when you are pregnant

 Have a family history of diabetes

 Gave birth to a baby that weighed more than 9 -pounds or had a birth defect

 Have high blood pressure

 Have too much amniotic fluid

Symptoms

Usually there are no symptoms, or the symptoms are mild and not life threatening to the pregnant
woman. The blood sugar (glucose) level usually returns to normal after delivery.

Symptoms may include:

-Blurred vision
-Fatigue
-Frequent infections, including those of the bladder, vagina, and skin
-Increased thirst
-Increased urination
-Nausea and vomiting
-Weight loss despite increased appetite
DIAGNOSIS

Women with the following clinical characteristics consistent with a high risk for GDM should receive

testing with first prenatal visit:

 Marked obesity
 Personal history of GDM
 Glycosuria
 Strong family history

Low-risk status requires no glucose testing, but this category is limited to those women meeting all of
the following characteristics:

 Age <25 years

 Weight normal before pregnancy
 Member of an ethnic group with a low prevalence of GDM
 No known diabetes in first-degree relatives
 No history of abnormal glucose tolerance
 No history of poor obstetric outcome (2005, Setji, Brown, & Feinglos, p. 23)

Diagnostic Criteria for GDM using the 50-g glucose Challenge Test

 Blood glucose levels less than 139 mg/dl requires no further testing.
 Blood glucose levels 140 mg/dl to 184 mg/dl indicate a positive result and additional testing
with a 3-hour 100 –g oral glucose tolerance test is needed.
 Blood glucose levels 185 mg/dl or greater indicates a diagnosis of gestational diabetes and no
further testing is needed.

Diagnostic Criteria for 100-g glucose Challenge Test

Two or more of the following indicates diagnosis of gestational diabetes mellitus:

 95 mg/dl or higher fasting blood glucose

  180 mg/dl or higher at 1-hour postprandial blood glucose
 155 mg/dl or higher at 2-hour postprandial blood glucose
 140 mg/dl or higher at 3-hour postprandial blood glucose (Setji, Brown, & Feinglos, 2005)

MATERNAL AND FETAL COMPLICATIONS OF GDM

Negative Maternal Health Outcomes:

 Greater increase in cesarean delivery rates - 22 to 30% for mothers with GDM and 17% for
those without GDM
 Higher risk of third or fourth-degree laceration in women with GDM
 Polyhydramnios (an excess of amniotic fluid)
 Pregnancy induced hypertension
 Increased risk of gestational diabetes in subsequent pregnancies
 Possible increased risk for pre-eclampsia
 Higher risk for development of type 2 diabetes

Negative Neonatal Health Outcomes:

 Macrosomia (birth weight greater than 8 lbs)

 Brachial plexus injury
 Clavicular factures
 Hypoglycemia
 Increased possibility of a preterm birth
 Hypocalcemia
 Polycythemia
 Hyperbilirubinemia

Possible Complications

 Delivery-related complications due to the infant's large size

 Development of diabetes later in life
  Increased risk of newborn death and stillbirth
 Low blood sugar (glucose) or illness in the newborn

Routine screening for gestational diabetes

 Initial glucose challenge test. You'll begin the glucose challenge test by drinking a syrupy glucose
solution. One hour later, you'll have a blood test to measure your blood sugar level. A blood
sugar level below 130 to 140 milligrams per deciliter (mg/dL), or 7.2 to 7.8 mill moles per liter
(mmol/L), is usually considered normal on a glucose challenge test, although this may vary at
specific clinics or labs. If your blood sugar level is higher than normal, it only means you have a
higher risk of gestational diabetes. Your doctor will diagnose you after giving you a follow-up
test.
 Follow-up glucose tolerance testing. For the follow-up test, you'll be asked to fast overnight and
then have your fasting blood sugar level measured. Then you'll drink another sweet solution —
this one containing a higher concentration of glucose — and your blood sugar level will be
checked every hour for a period of three hours. If at least two of the blood sugar readings are
higher than normal, you'll be diagnosed with gestational diabetes.

DIAGNOSTIC TEST:

 Several blood tests are used to measure blood glucose levels, the primary test for diagnosing
diabetes. Additional tests can determine the type of diabetes and its severity.
 Random blood glucose test — for a random blood glucose test, blood can be drawn at any time
throughout the day, regardless of when the person last ate. A random blood glucose level of 200
mg/dL (11.1 mmol/L) or higher in persons who have symptoms of high blood glucose (see
“Symptoms” above) suggests a diagnosis of diabetes.
 Fasting blood glucose test — fasting blood glucose testing involves measuring blood glucose
after not eating or drinking for 8 to 12 hours (usually overnight). A normal fasting blood glucose
level is less than 100 mg/dL. A fasting blood glucose of 126 mg/dL (7.0 mmol/L) or higher
indicates diabetes. The test is done by taking a small sample of blood from a vein or fingertip. It
 must be repeated on another day to confirm that it remains abnormally high (see “Criteria for
diagnosis” below).
 Hemoglobin A1C test (A1C) — The A1C blood test measures the average blood glucose level
during the past two to three months. It is used to monitor blood glucose control in people with
known diabetes, but is not normally used to diagnose diabetes. Normal values for A1C are 4 to 6
percent (show figure 3). The test is done by taking a small sample of blood from a vein or
fingertip.
 Oral glucose tolerance test — Oral glucose tolerance testing (OGTT) is the most sensitive test for
diagnosing diabetes and pre-diabetes. However, the OGTT is not routinely recommended
because it is inconvenient compared to a fasting blood glucose test.
 The standard OGTT includes a fasting blood glucose test. The person then drinks a 75 gram
liquid glucose solution (which tastes very sweet, and is usually cola or orange-flavored). Two
hours later, a second blood glucose level is measured.

ANATOMY AND PHYSIOLOGY:

Every cell in the human body needs energy in order to function. The body’s primary energy source is
glucose, a simple sugar resulting from the digestion of foods containing carbohydrates (sugars and
starches). Glucose from the digested food circulates in the blood as a ready energy source for any cells
that need it. Insulin is a hormone or chemical produced by cells in the pancreas, an organ located behind
the stomach. Insulin bonds to a receptor site on the outside of cell and acts like a key to open a doorway
into the cell through which glucose can enter. Some of the glucose can be converted to concentrated
energy sources like glycogen or fatty acids and saved for later use. When there is not enough insulin
produced or when the doorway no longer recognizes the insulin key, glucose stays in the blood rather
entering the cells.

PATHOPHYSILOGY
The precise mechanisms underlying gestational diabetes remain unknown. The hallmark of GDM is
increased insulin resistance.

Pregnancy hormones and other factors are thought to interfere with the action of insulin as it binds to
the insulin receptor. The interference probably occurs at the level of the cell signaling pathway behind
the insulin receptor.

Since insulin promotes the entry of glucose into most cells, insulin resistance prevents glucose from
entering the cells properly. As a result, glucose remains in the bloodstream, where glucose levels rise.
More insulin is needed to overcome this resistance; about 1.5-2.5 times more insulin is produced than in
a normal pregnancy.
Because glucose travels across the placenta (through diffusion facilitated by GLUT3 carriers), the fetus is
exposed to higher glucose levels. This leads to increased fetal levels of insulin (insulin itself cannot cross
the placenta).

The growth-stimulating effects of insulin can lead to excessive growth and a large body (macrosomia).

After birth, the high glucose environment disappears, leaving these newborns with ongoing
high insulin production and susceptibility to low blood glucose levels (hypoglycemia).

Management:

The goal is to prevent adverse pregnancy outcomes.

o A multidisciplinary approach is used.
o Patient is seen every 1-2 wks until 36 wks gestation and then weekly.
o Patient is asked to keep an accurate diary of their blood glucose concentration.

Intrapartum:

The goal is to maintain normoglycemia in order to prevent neonatal hypoglycemia.

 Check patient’s glucose q1-2 hours.

 Start insulin drip to maintain a glucose level of between 80 - 110 mg/dL.

 Observe infant closely for hypoglycemia, hypocalcemia, and hyperbilirubinemia after birth.

Postpartum Care:

After delivery:

 Measure blood glucose.

-fasting blood glucose concentrations should be <105 mg/dL and one hour postprandial concentrations
should be < 140 mg/dL.
  Administer one half of the pre-delivery dose before starting regular food intake.

Follow up:

 Per American Diabetes Association, a 75 g two hours oral GTT should be performed 6-8 wks
after delivery.

Follow up:

 If the pt’s postpartum GTT is normal, she should be re-evaluated at a minimum of 3 years
interval with a fasting glucose.
 All pts should be encouraged to exercise and lose wt.
 All pts should be evaluated for glucose intolerance or DM before a subsequent pregnancy.

NURSING INTERVENTIONS:

 Advice patient about the importance of an individualized meal plan in meeting weekly weight
loss goals and assist with compliance.
 Assess patients for cognitive or sensory impairments, which may interfere with the ability to
accurately administer insulin.
 Demonstrate and explain thoroughly the procedure for insulin self-injection. Help patient to
achieve mastery of technique by taking step by step approach.
 Review dosage and time of injections in relation to meals, activity, and bedtime based on
patients individualized insulin regimen.
 Instruct patient in the importance of accuracy of insulin preparation and meal timing to avoid
hypoglycemia.
 Explain the importance of exercise in maintaining or reducing weight.
 Advise patient to assess blood glucose level before strenuous activity and to eat carbohydrate
snack before exercising to avoid hypoglycemia.
 Assess feet and legs for skin temperature, sensation, soft tissues injuries, corns, calluses,
dryness, hair distribution, pulses and deep tendon reflexes.
 Maintain skin integrity by protecting feet from breakdown.
 Advice patient who smokes to stop smoking or reduce if possible, to reduce vasoconstriction
and enhance peripheral flow.