GESTATIONAL DIABETES MELLITUS
placental lactogen, estrogen, and
Gestational Diabetes Mellitus (GDM) is
one of the most common types of diabetes
mellitus and considered the most
complication of pregnancy. This health
problem is like pregnancy-induced
hypertension (PIH) that develops during
pregnancy and disappears after delivery of
fetus, or as maternal body returns to its pre-
pregnant state.
Gestational Diabetes Mellitus may or may
not with co-existing maternal diabetes. It
heightens the level of diabetes (if with
previous diabetes) by a notch in response to
the rise in fetal carbohydrate demand. 40%
of pregnant mothers who develops GDM will
eventually develop non-insulin dependent
diabetes mellitus (NIDDM or Type II DM)
within 5 years.
TYPES OF GDM
 Gestational Diabetes Mellitus (GDM)
Type A1: abnormal oral glucose
tolerance test (OGTT) but normal blood
glucose levels during fasting and 1-2
hours after meals; diet modification is
sufficient to control glucose levels
 Type A2: abnormal OGTT compounded
by abnormal glucose levels during fasting
and/or after meals; additional therapy
with insulin or other medications is
required
ANATOMY AND PHYSIOLOGY
A normal body uses insulin as a channel for
glucose to enter the cells for utilization. This
process is also applicable with the fetus
(during pregnancy) for growth and
development. As the fetus grows, the
maternal body executes autonomic response
by doubling the level of glucose level
through lowering insulin secretion and with
the aid of some gestational hormones that
antagonizes the effects of insulin a process
known as protective mechanism. Along with
this, this mechanism causes the rise of
progesterone to cause the following effects:
1. Antagonizes the effects of insulin
2. Prolong the elevation of stress hormones
(cortisol, epinephrine, and glucagon)
3. Degradation of insulin by the placenta
The total effect of these mechanisms raises
the maternal glucose level for fetal usage.
Hyperglycemia normally occurs with the
protective mechanism that predisposes a
pregnant mother in the triggering of her pre-
diabetic state, or heightens an existing
diabetes mellitus.
The effects of pregnancy on diabetes mellitus
are summarized as:
1. First Trimester – glucose level is
relatively stable or may decrease
2. Second Trimester – there is rapid
increase in glucose level
3. Third Trimester – there is rapid
decrease glucose level and return to its
pre-pregnant state
FACTS ABOUT INSULIN
1. The insulin is a normal body hormone
that is produced by the beta cells of the
Islets of Langerhans in the pancreas.
2. The release of insulin is regulated by a
negative feedback in response to high
glucose level. The high glucose level may
come from excessive glucagon action or
through high carbohydrate intake.
3. The insulin secretion of the pancreas and
its action on the liver makes it maintain a
normal value of 80-120 mg/dL.
4. Insulin is essential in the following
actions:
a. Carbohydrates – utilization of glucose
by the cells
b. Proteins – conversion of amino acids to
replace muscle tissues
c. Fats – conversion of excess glucose to
fatty acids and store them to adipose
tissues
d. Endothelial and nerve cells are the only
cells/tissues that can use glucose even
without insulin.
e. Low insulin level causes the rise in
plasma glucose concentration and
glycosuria.
f. Diabetes mellitus develops as the body
secretes low amount or as body cells
rejects its utilization.
Etiology
Gestational diabetes is a disorder of
late pregnancy (typically), caused by the
increased pancreatic stimulation associated
with pregnancy.
RISK FACTORS
1. Obesity
2. Family history of DM
3. Age of >45 years old (when got
pregnant)
4. Previous delivery of baby weighing 9 lbs
or more
5. History of any autoimmune disease
6. Belonging to/with ethnic background from
African American, Latino, and native
Americans
7. History of previous GDM
8. With any level of hypertension
9. With elevated high-density lipoprotein
CLINICAL MANIFESTATIONS
The clinical manifestations of GDM coincide
with the signs and symptoms of other types
of diabetes mellitus. These are popularly
known as the “3Ps” or polydipsia, polyuria,
and polyphagia. Aside from these
manifestations, there are also other sign and
symptoms that are general manifestations
and pregnancy-specific manifestations.
GDM:
 Higher glucose level (20-30 mg/dL) than the
pre-pregnant level
 Very rapid weight gain
 Polyhydramnios
 Recurrent monilial infections
 Glycosuria
 Nocturia
 Large for gestational age (LGA) or small for
gestational age (SGA) fetus
 More severe state of edema
DM:
 Blurred vision
 Vulvar pruritus
 Paresthasia
 Peripheral neuropathy
 Weakness
 Normal/elevated pulse rate and temperature
 Normal/decreased blood pressure
 Kussmaul’s respiration
 Dehydration
 Recurrent infections
 Non-healing wounds
ASSESSMENT FINDINGS
1. Associated findings include a poor
obstetric history, including spontaneous
abortions, unexplained stillbirth,
unexplained hydramnios, premature
birth, low birth weight or birth weight
exceeding 4,000 g (8lb, 13 oz), and birth
of a newborn with congenital anomalies.
2. Common clinical
manifestations include:
 Glycosuria on two successive
office visits
 Recurrent monilial vaginitis
 Macrosomia of the fetus on
ultrasound
 Polyhydramnios
3. Laboratory and diagnostic study
findings.
 Fasting blood sugar test will
reveal elevated blood glucose levels.
 A 50-g glucose screen (blood
glucose level is measured 1 hour
after client ingests a 50-g glucose
drink) reveals elevated blood
 glucose levels. The normal plasma
threshold is 135 to 140 mg/dL.
 A 3- hour oral glucose tolerance
test (performed if 50-g glucose
screen results are abnormal) reveals
elevated blood glucose levels. (Table
1)
 The glycosylated hemoglobin
(HbA 1c) test (measures glycemic
control in the 4 to 8 weeks before
the test is performed; performed on
women with pre-existing diabetes)
results reflect enzymatic bonding of
glucose to hemoglobin A amino
acids. This is a useful indicator of
overall blood glucose control. The
upper normal level of HbA1c is 6%
of total hemoglobin.
 Screens for fetal (and later,
neonatal) complications, including:
 Maternal serum alpha-fetoprotein
level to assess risk for neural tube
defects in newborn.
 Ultrasonography to detect fetal
structural anomalies, macrosomia,
and hydramnios.
 Nonstress test (as early as 30
weeks), contraction stress test,
and biophysical profile because of
risk of unexplained intrauterine
fetal demise in the antepartum
period.
 Lung maturity studies (by
amniocentesis) to determine
lecithinsphingomyelin (L/S) ratio
and to detect phosphatidylglycerol
(PG); the adequacy of L/S and PG,
predictor of the newborn’s ability
to avoid respiratory distress
PATHOPHYSIOLOGY
1. In gestational diabetes mellitus (type
III, GDM), insulin antagonism by
placental hormones, human placental
lactogen, progesterone, cortisol, and
prolactin leads to increased blood
glucose levels. The effect of these
hormones peaks at about 26 weeks of
gestation. This is called the
diabetogenic effect of pregnancy.
2. The pancreatic beta cell functions are
impaired in response to the increased
pancreatic stimulation and induced
insulin resistance.
3. Pregnancy complicated by diabetes
puts the mother at increased risk for
the development of complications,
such as spontaneous abortion,
hypertensive disorders, and preterm
labor, infection, and birth
complications.
4. The effects of diabetes on the fetus
include hypoglycemia, hyperglycemia,
and ketoacidosis. Hyperglycemic
effects can include:
 Congenital defects
 Macrosomia
 Intrauterine growth restriction
 Intrauterine fetal death
 Delayed lung maturity
 Neonatal hypoglycemia
 Neonatal hyperbilirubinemia
COMPLICATIONS
The chronic effects or the uncontrolled
glucose level during pregnancy would lead to
the development of the following
complications:
 Preterm labor and delivery
 Urinary tract infection (UTI)
 Infertility
 Stillbirth
 PIH – pre-eclampsia – eclampsia
 Congenital anomalies
 Spontaneous abortion
Also, a woman who developed or
experienced GDM is expected to have type 2
diabetes mellitus within 5 years for the rest
of her life.
DIAGNOSIS
  Blood glucose monitoring—this can
either be done through fasting blood
sugar (FBS) or randomly. This reveals
the glucose level and indicates the
plan of care needed.
 Glucose tolerance test (GTT)—to
evaluate the response of insulin to
loading glucose.
 Glycated haemoglobin
(Glycohemoglobin)—measures
glycemic control by evaluating the
attachment of glucose to freely
permeable erythrocytes during their
whole life cycle.
 C-peptide Assay (connecting peptide
assay)—useful when the presence of
insulin antibodies interferes with direct
insulin assay.
 Fructosamine assay—is much more
useful than glycosylated hemoglobin
tests in cases of hemoglobin variants.
 Urine glucose and ketone monitoring—
may be performed in cases where
blood glucose monitoring is not
available, but, is not as accurate as
the former.
 Amniocentesis
 Non-stress test
 Sonography
NURSING DIAGNOSES
1. Altered nutrition: more or less than
body requirements related to weight
gain
2. High risk pregnancy: high risk for
infection, ketosis, fetal demise,
cephalopelvic disproportion,
polyhydramnios, congenital
anomalies, preterm labor.
3. Knowledge deficit related to disease
and insulin use and interaction.
MANAGEMENT
Information is crucial to help women
understand the importance of good glucose
control for her health and the health of her
baby. Good glucose control throughout
pregnancy will reduce the risk of fetal
macrosomia, trauma during birth, induction
of labour and/or caesarean section, neonatal
hypoglycaemia and perinatal death (14).
Alongside strict monitoring of blood glucose
with input from an endocrinologist, women
will also be offered an increased antenatal
care package including more frequent
ultrasound scans to assess the size and well-
being of the baby and liquor volume.
Blood glucose monitoring kits should be
given to women and self-monitoring should
be taught with repeat prescriptions for
necessary equipment and medications e.g.
needles, sharps bins.
Treatment
The main form of treatment is blood glucose
control and the initial treatment offered is
dependent on the results of the OGTT (see
Table 2).
Lifestyle changes
Simple lifestyle changes are enough in many
women to control their glucose level and all
women should be referred to a dietician to
review their diet and provide information on
low glycaemic index foods. In addition to
this, exercise has been shown to stabilise
post prandial blood glucose and reduce the
need for insulin.           
Metformin
Metformin is a well-established drug that
reduces the amount of glucose created in the
liver and makes the body more sensitive to
insulin. In detail, metformin is a biguanide
oral antidiabetic medication and it works by
suppressing hepatic gluconeogenesis,
increasing insulin sensitivity and decreasing
the absorption of glucose from the
gastrointestinal tract. This glucose-lowering
therapy should be offered first to women
who have uncontrolled hyperglycaemia glibenclamide and insulin should maintain a
unless contraindicated. blood glucose above 4mmol/l in order to
prevent problematic hypoglycaemias.
When metformin was compared to insulin it
was found to have no significant differences NURSING MANAGEMENTS
between outcomes such as shoulder dystocia
and infants born large for gestational age. Assessment
Additionally the administration is considered History taking on:
much easier and preferred compared to
insulin. a. First presentation of the
manifestations of diabetes (3 P’s)
Glibenclamide b. First diagnosis of DM
Glibenclamide is also a well-established c. Family members with DM
medicine that drives the pancreas to produce Review of systems:
more insulin. In more detail, glibenclamide is
a sulphonylurea and acts by stimulating 1. Weight gain, increasing
insulin release from the beta-cells in the fatigue/weakness/tiredness
pancreas. There are no significant 2. Skin lesions, infections, hydration,
differences between the use of insulin and signs of poor wound healing
metformin compared to glibenclamide for the 3. Changes in vision – floaters, halos,
prevention of shoulder dystocia or large for blurred vision, dry/burning eyes,
gestational age, however there is no long- cataract, glaucoma
term data for the effects of glibenclamide in 4. Gingivitis, periodontal disease
pregnancy and therefore metformin and 5. Orthostatic hypotension, cold
insulin are used preferentially. extremities, weal pedal pulses
6. Diarrhea, constipation, early satiety,
Insulin bloating, flatulence, hunger and thirst
When oral medications don't control 7. Frequent urination, nocturia, vaginal
gestational diabetes, insulin is needed. discharge
Exogenous insulin is used in conjunction with 8. Numbness and tingling of the
diet, exercise and metformin if required for extremities, decrease pain and
glucose control. Insulins that are used temperature sensation
preferentially are isophane/detemir insulin INTERVENTIONS
and lispro/aspart insulin as long-acting and
short-acting insulin respectively. It is 1. Nutrition
important to warn women of the effects and  Assess timing and content of
prevention of hypoglycaemic events. Users meals
must also be made aware of DVLA guidelines  Instruct on importance of a
with insulin use. well-balanced diet
 Explain the importance of
Blood glucose aims exercise
Women should record their blood sugar  Plan for a weight reduction
monitoring daily. If they have repeatedly course
high blood glucose they should seek medical 2. Insulin use
advice in order to change or increase their  Encourage verbalization of
current management. Those on feelings
  Demonstrate and explain insulin  Monitor daily weight and advice
therapy to report on rapid weight gain
 Allow client to do self- 7. Educative
administration  Teach on lifestyle modifications
 Review mastery of the whole  Advice to see psychologists
process with other family members for
3. Injury from hypoglycemia therapies on the possibilities of
 Monitor maternal blood glucose fetal abnormalities
level  Advice to call emergency
 Instruct on insulin-activity-diet response team in case of
interaction emergency
 Teach on the signs and  Advise to religiously follow the
symptoms of hypoglycemia health instructions
 Teach/present the list of
EVALUATION
things/foods that need to be
available at all times (in case of 1. Body weight is within the normal
hypoglycemic attacks) range for the age of gestation.
 Have identification band 2. Demonstrates proper technique in
indicating the health condition self-administration of insulin
(DM) for fainting instances 3. No episodes of hypoglycemia as
4. Activity tolerance claimed by the client
 Plan for regular exercise 4. No skin problems/lesions.
 Increase carbohydrate intake 5. Verbalized readiness on the possible
before exercise fetal defects.
 Instruct to avoid exercise of 6. Stable feta heart rate.
blood glucose level exceeds 250
mg/dL and urine ketones are References:
present
Gestational Diabetes Mellitus:
 Advise to use abdomen for
insulin injection if arms and legs https://www.google.com/amp/s/www.rnspea
are used for exercise k.com/gestational-diabetes-mellitus-case-
5. Skin integrity study/amp/
 Avoid alcohol use, instead,
lotion https://www.nursinginpractice.com/gestation
 Teach on proper foot care al-diabetes-primary-care
 Advise to stop smoking and
https://www.rnpedia.com/nursing-
alcohol use
notes/maternal-and-child-nursing-
6. Fetal well-being
notes/gestational-diabetes/
 Continuous monitoring of fetal
activities and fetal heart tone
 Monitor fetal activities during
maternal activities
 Monitor early signs of labor
 Advise to report of any
discharge coming from the
vagina