IMPACT OF GESTATIONAL DIABETES ON MATERNAL AND NEONATAL

OUTCOMES: A COHORT STUDY

By
Aisha Hassan Elsayed
(B.Sc. Nursing)

Clinical Instructor /Maternity and Newborn Health Nursing Department

Thesis Submitted for Partial Fulfillment of the Requirements of Master science in nursing

Degree (Maternal and Newborn Health Nursing).

Thesis Supervision

Prof. Shadia Abdel Kader Hassan Prof. Abdel Hamid Attia

Professor of Maternal & Newborn Professor of Obstetrics & Gynecology
Health Nursing
Faculty of Medicine
Faculty of Nursing
Cairo University
Cairo University

Dr. Hanan Fahmy Azzam

Assistant Professor of maternal and
Newborn Health Nursing
Faculty of Nursing
Cairo University

Faculty of Nursing
Cairo University
2012
 APPROVAL PAGE

This Thesis for Master Degree in Nursing

By

Aisha Hassan

Has Been Approved for the Department of Maternal and

Newborn Health Nursing

By

Prof. Shadia Abdel Kader Hassan

Professor of Maternal and Newborn Health Nursing
Faculty of Nursing
Cairo University

Prof. Abdel Hamid Attia

Professor of Obstetrics & Gynecology
Faculty of Medicine
Cairo University

Dr. Hanan Fahmy Azzam

Assist. Professor of Maternal & Newborn Health Nursing
Faculty of Nursing
Cairo University

Date
 ACKNOWLEDGEMENT

First of all I have to thank Allah, the most gracious who gave me an amazing

opportunity to life and who helped me in bringing this work to light.

I would like to express my gratitude and greatest indebtedness to Prof. Dr. Shadia

A. Hassan, Professor of Maternal and Newborn Health Nursing, Faculty of Nursing,

Cairo University, who devoted great deal of her valuable time, untiring effort,

continuous guidance, providing scientific comments and encouragement to accomplish

this work.

I would like to express my deep thanks and appreciation to Dr. Abd El-Hamid

Attia, Professor of Obstetrics and Gynecology, Faculty of Medicine, Cairo University,

for providing me with valuable knowledge and experience that helped me to conduct the

practical part of this study. I have the highest respect and admiration for his personality

in providing scientific comments, generous and valuable advices, insightful suggestions,

continuous support and precious cooperation to accomplish this work.

I would like to express my sincere thanks and appreciation to Dr. Hanan Fahmy

Azzam, Assistant Professor of Maternity and Newborn Health Nursing, Faculty of

Nursing, Cairo University, for her valuable guidance, support and great help in

supervising this work, no words can express my feelings, respect and gratitude to her as

regards her continuous encouragement and constructive criticism given to me at every

stage of this work. Indeed she was a continuous source of guidance and support for me.

Special thanks to all women who participated actively in this study and being

appreciative and very cooperative, and tolerated me till the accomplishment of this

work.
 I found this opportunity to express my greatest appreciation to all physicians and

nurses at Fetal Medicine Unit for their help.

Finally, special thanks to my teachers, colleagues in the Maternal and Newborn

Health Nursing Department, and in the faculty for their continuous support, help and

cooperation to accomplish this work.

The candidate

Aisha Hassan
 Impact of Gestational Diabetes on Maternal and Neonatal Outcome: A Cohort Study

Abstract

By

Aisha Hassan Elsayed

Gestational diabetes mellitus (GDM), a common medical complication of pregnancy, is

defined as any degree of glucose intolerance with onset or first recognition during
pregnancy. GDM affects 7% of all pregnancies; so, the aim of this study was to assess
the impact of gestational diabetes on maternal and neonatal outcomes. A Cohort study
design was utilized in this research study to assess the impact of gestational diabetes on
maternal and neonatal outcome. A total sample of 200 pregnant women attending
antenatal outpatient clinic at El-Manial University Hospital for follow-up were
recruited for the study. Tools were used to collect data included: maternal sheet,
newborn sheet, Apgar score, anthropometric measurements by the 10th and 90th
percentile. Findings of this study indicated that, gestational diabetes is associated with,
preterm labor, pregnancy induced hypertension (PIH), polyhydramnios, caesarean
section, and vaginal infection the most common maternal complications. Macrosomic
baby (LGA), respiratory distress, stillbirth, intrauterine fetal death, and hypoglycemia,
the most common neonatal complications. The study recommended that, there is an
urgent need to apply nursing care protocol for women affected with gestational
diabetes mellitus to minimize maternal and neonatal complications.

Key words: Gestational Diabetes, Hypoglycemia, Neonatal outcome, Maternal outcome,

Cohort study, Macrosomic baby, Intrauterine fetal death.

Chairperson of Thesis

…………….
 CONTENTS

Chapter Page

I Introduction 1

Introduction 1

Significance of the study 6

Aim of the study` 7

Theoretical framework 7

II Review of Literature 15

O Overview on gestational diabetes 15

Definition and incidence of gestational diabetes 17

Pathophysiology of gestational diabetes 18

Etiology and risk factors 22

Effect of gestational diabetes on pregnancy outcome 23

1. Maternal complications 23

- Pregnancy induced hypertension 23

- Polyhydramnios 24

- Maternal Ketoacidosis 24

- Caesarean section 25

- Preterm labor. 25

- Dystocia 26

-Vaginal infection 26

v
 CONTENTS (cont.)

Chapter Page

2. Fetal and neonatal complication 27

- Congenital Malformation 27

- Macrosomia and large for gestational age 28

-Intrauterine growth retardation 30

-Intrauterine fetal death 30

-Neonatal hypoglycemia 30

-Hypocalcaemia 31

- Hyperbilirubinemia 31

- Respiratory distress syndrome 32

Diagnosis of Gestational Diabetes 33

Diagnostic tests 33

-Glucose challenge test 35

-Oral glucose tolerance test 35

-Glycosylated Hemoglobin (HBA1C) 36

-C-peptide 37

Nursing Management For Women With Gestational Diabetes 38

-Nursing assessment& history taking 38

- Antenatal management 40

vi
 CONTENTS (cont.)

Page
Chapter
- Metabolic management during pregnancy 41

- Antepartum fetal assessment 46

- Intrapartum management 47

- Postpartum management 50

-Prognosis 52

III. Subjects and methods 54

Design 54

Sample 54

Setting 55

Ethical considerations 56

Tools 56

Pilot study 60

Procedure 60

Limitations of study 64

Data management and statistical analysis 64

IV Results 65

V Discussion 93

VI Summary, conclusion and recommendations 103

References 111
Appendices 126
Thesis proposal
Arabic summary vii
 LIST OF TABLES

Table Title Pages

1 Distribution of The Sample According to Socio-Demographic Characteristics 67

2 Distribution of The Sample According To Socio-Demographic Characteristics 67

(Cont.)

3 Distribution of The Sample According to The Obstetric Code 72

4 Distribution of The Sample According to The Complication with Previous 72

Pregnancy.

5 Distribution of The Sample According to Contraceptives Methods 73

6 Distribution of The Sample According to Anthropometric Measurements 74

7 Distribution of The Sample According to Body Mass Index 74

8 Distribution of The Sample According to Complication During Current Pregnancy 75

9 Distribution of The Sample According to Complication During Current Labor 75

10 Distribution of The Sample According to Blood Sugar 76

11 Distribution of The Sample According to Apgar Score 80

12 Distribution of The Sample According to Anthropometric Measurement 80

13 Distribution of The Sample According to Insulin And C-Peptide Level 81

14 Distribution of The Sample According to Neonatal Complication 82

Viii
 LIST OF FIGURES

Figure Title Pages

In {

review
1.Suggested Theoretical Framework of the Thesis 12

2. Macrosomia 27

3. Large for gestational age 27

In
result

1 Distribution of the sample According to the educational level 68

2 Distribution of the sample According to mode of previous delivery 73

3 Distribution of the sample According to Mode of delivery 76

4 Distribution of the sample According admitted to NICU 80

5 Distributions of the sample According to 10th &90th percentile 81

6 Predictors that might affect of maternal outcome 85

7 Predictors that might affect neonatal outcome 86

8 Effect of gestational diabetes on maternal outcome 87

9 Effect of gestational diabetes on neonatal outcome 90

10 Factors that might affect neonatal outcome con't 91

Predictors of Measurements That Might Affected by Gestational Diabetes 92

11

viiii
 LIST OF ABBREVIATION

AC Abdominal circumference

ACOG American college of obstetrician& gynecologists

ADA American diabetes association

AGA Appropriate for gestational age

AFI Amniotic fluid index

BMI Body mass index

CS Cesarean section

DCCT Diabetes Control and Complications Trial

EDD Expected date of delivery

FHR Fetal heart rate

GA Gestational age

GDM Gestational diabetes mellitus

HAPO Hyperglycemia and pregnancy outcome

HbA1c Glycosylated hemoglobin

HC Head circumference

HMD Hyaline membrane disease

HPL Human placental lactogen

IDMs Independent diabetes mellitus

IDF International Diabetes Federation

IGT Impaired Glucose Tolerance

IFG Impaired Fasting Glucose

IUFD Intrauterine Fetal Death

IUGR Intrauterine growth retardation

JOGC Journal of Obstetrics and Gynecology Can

LGA Large for gestational age

LMP Last menstrual period

L/S Lecithin/sphnigomylin

MNT Medical nutrition therapy

NDDG National Diabetes Data Group

NICU Neonatal intensive care unit

OGCT Oral glucose challenge test

OGTT Oral glucose tolerance test

PIH Pregnancy induced hypertension

PG Phosphatidyglycerol

PROM Premature rupture of membrane

RDS Respiratory distress syndrome

SGA Small for gestational age

SMBG Self-monitoring of blood glucose

WHO World of health organization

 1

CHAPTER I

Introduction

Gestational diabetes mellitus (GDM) is one of the most common medical

complications of pregnancy. It is defined as carbohydrate intolerance of variable

degrees, with an onset or first recognition occurring during pregnancy;started during

second half of pregnancy. It usually begins in the fifth or sixth month of pregnancy

(between the 24th &28th weeks), and disappears after delivery of the infant. GDM is

a condition in which women without previously diagnosed diabetes exhibit high blood

glucose levels during pregnancy. (American Diabetes Association, 2004&Moore et

al., 2005).

The GDM generally has few symptoms and it is most commonly diagnosed by

screening during third trimester. No specific cause has been identified but, it

represents an insulin resistance state, possibly due to the placental production

of progesterone, cortisol, prolactin and other hormones which interfere with

normal glucose metabolism. Insulin resistance usually appears in the second

trimester of pregnancy and increases as the pregnancyadvances. Thus, as the

pregnancy progresses, more insulin is required to maintain normal blood

glucose levels. Most women are able to meet the increased demand for insulin.

While women with GDM are unable to produce sufficient insulin to cope with

the increased demand(Buchanan & Xiang, 2005).

 2

Sachdev, (2011) reported that, any woman can develop GDM during

pregnancy but, certain factors increase the risk for developing it. As: overweight or

obese (body mass index [BMI] ≥ 30), age (25- 35 years or older), family history of

diabetes mellitus and previous macrosomic baby (weight is ≥ 4kg).

Worldwide statistics reported that, the prevalence of GDM is 3-10 % of all

pregnant women, represented as (200.000 case) the United States each year

(American Diabetes Association, 2007). In relation to the prevalence of GDM in

Arabic world it represents 20% in the united Arab Emirate (UAE),4.7 -8.9%.in Iran;

very high prevalence rates were observed in Saudi Arabia (12.5%), Bahrain (13.5%)

medium to high levels were observed in different studies in Iran and 7.2%, in Japan

(Hossein-Nezhad, 2007).

Diabetes during pregnancy increases neonatal and maternal morbidity and

mortality. Recent evidence has clarified the relationship of maternal glycemia to fetal

and neonatal outcomes and demonstratedthat, appropriate detection and treatment to

improve outcomes. Maternal complications associated with GDM included:

preeclampsia which occurs more often in the woman with diabetes than in unaffected

population; and urinary tract infections, which are more common possibly because

glucose–rich urine provides a good medium for bacterial growth(Cunningham et al.,

2001). Other effects included: hydramnios which may result from fetal hyperglycemia

and consequently fetal dieresis, premature rupture of membrane, which may be

caused by over distention of the uterus by hydramnios, and preterm labor which may

be due to poor glycemic control, and polyhydramnios (Yogev, Xenakis,& Langer,

2004).
 3

In addition, large fetal size increasesthe likelihood of cesarean birth, which

increases the risk for postpartum hemorrhage. Also, infant's head may enter the birth

canal but the shoulders will be too large due to macrosomic baby, causing dystocia.

Shoulder dystocia occurs in 1%–2% of pregnancies, which necessitates the use of

special procedures to deliver the baby. These procedures can cause nerve damage,

fractured bones or rarely, brain damage to the neonate. The challenges of delivering a

macrosomic baby can also lead to birth canal injuries and large episiotomy for the

mother (ACOG, 2005; Cunningham et al., 2005).

The GDM is also associated with neonatal complications including large for

gestational age. Neonatal macrosomia has been defined in several different ways,

included birth weight of 4000-4500g or greater than 90th percentile for gestational age

after correcting for neonatal sex and ethnicity. Macrosomia affects 1-10% of all

pregnancies. Macrocosmic babies can cause problems during delivery because of their

size (Martin et al., 2006). Furthermore, newborn of women with GDM may develop

hypoglycemia immediately after birth. Hypoglycemia is the most common metabolic

problem in neonates; a blood glucose value of less than 40 mg/dL represents

hypoglycemia. This occurs because the neonate's body is still producing extra insulin

to process the extra sugar that was in his blood in utero (Hilarie, 2002).

In addition, premature baby and Respiratory distress syndrome (RDS) is

occurring as a result of GDM that require medical interventions until the lungs are

improved. Fetal hyperinsulinemia retards cortisol production, which is necessary for

synthesis of surfactant needed to keep the newborn's alveoli open, thereby increasing

the risk for respiratory distress syndrome. Also, after delivery, some neonates may

develop polycythemia, up to 50% have low levels of serum calcium [Hypocalcaemia

 4

(<7 mg/100 mL)], and approximately 25% have hyperbilirubinemia (Roberts, 2004;

&Donovan, 2010).

The diagnostic test for GDM is screening with 50 g oral glucose challenge test

(OGCT) followed by 100 g oral glucose tolerance test (OGTT). The oral glucose

tolerance test at 24 to 28 week of gestation, which requires the woman to fast

overnight and two to four blood samples to be taken over a two to three hour period.

The oral glucose load differs (75gm or 100gm) according to which organizations'

criteria are utilized to perform and interpret the test results (Vidaeff et al., 2003). The

World Health Organization and Australian Diabetes in Pregnancy Society

recommend that, a 75gram oral glucose tolerance test load;one or more abnormal

results are considered diagnostic for GDM. The Hyperglycemia and Adverse

Pregnancy Outcomes (HAPO) is a large prospective study on GDM.In which the

researcher adopted the 75gram oral glucose tolerance test for Diagnosis and

Classification of Hyperglycemia in Pregnancy (Crowther et al., 2005; HAPO Study

Cooperative Research Group, 2008& HAPO, 2009).

The ideal outcome of every pregnancy is a healthy newborn and women.

Nurses can be pivotal in realizing this outcome for women with GDM by

implementing measures to minimize maternal and neonatal complications. Nursing

management of GDM emphasizes regular monitoring of blood sugar levels, eating a

carefully controlled diet prescribed by a health care professional and regular exercise

appropriate to pregnancy. If these measures do not adequately control glucose levels,

some women may need insulin injections until blood glucose levels return to normal

after delivery. Prompt treatment of diabetes can reverse high glucose levels in the

blood and minimize or eliminate possible complications such as;preeclampsia,

 5

premature birth, respiratory distress syndrome, and macrosomic baby (Alwan,

Tuffnell &West, 2009).

The diet should provide the calories and nutrients needed for maternal and

fetal health, avoid ketosis, and promote appropriate weight gain. Calories should be

distributed in a way similar to that for preexisting diabetes. Simple sugars found in

concentrated sweets should be eliminated from the diet. Based on a non obese pre-

pregnancy weight, an average of 30kcal/kg/day is recommended. Calories restriction

to 25kcal/kg each day may be recommended for the obese woman. Calories should be

divided among three meals and at least three snacks (ACOG, 2001; Franz, 2002; and

Moore, 2004).Crowther, et al.,(2005)showed that, the rate of serious Perinatal

conducted a randomized clinical trial to determine whether treatment of women with

gestational diabetes mellitus reduced the risk of perinatal complications.

Complications were significantly lower among the infants of the women in the

intervention group than among the infants of the women in the routine-care group.

Physical exercise program should be recommended by a physician taking into-

account each woman's' risk factors. Avery and Walker, 2001, reported that,

significant declines in blood glucose level were observed during low- and moderate-

intensity exercise compared to rest. If monitoring reveals failing in the control of

glucose levels with these measures, or if there is evidence of complications like

excessive fetal growth, treatment with insulin might become necessary. The most

common therapeutic regimen involves premeal fast-acting insulin to blunt sharp

glucose rises after meals. Care needs to be taken to avoid low blood sugar levels

(hypoglycemia) due to excessive insulin injections (ACOG, 2001; and ADA, 2004).
 6

Furthermore, nursing counseling about testing to identify fetal compromise may

begin as early as 28 weeks of gestation if the woman has poor glycemic control or by

34 weeks of gestation. The surveillance testing often includes "kick count"

ultrasonograghy for fetal growth and amniotic fluid volume, biophysical profile,

nonstress test, contraction stress test, or amniocentesis for fetal lung maturity (Moore,

2004).

Significance of the Study

The GDMis fast becoming a major health problem in developing countries

undergoing rapid changes in lifestyle, dietary habits and body mass index. Both

maternal and neonatal mortality and morbidity resulting from GDM can be prevented

by proper antenatal supervision and institutional care, facilities that exist in our

tertiary care units and even in most of the primary health centers. The major obstacles

to be crossed in Egypt include lack of education and socio-cultural taboos leading to

improper and substandard antenatal care, failure of screening of high risk pregnancies

and their referral to the appropriate health facilities at the proper time. (Randhawa,

Moin & Shoaib, 2003).

Moreover, if GDM is not properly treated, there is an increased risk of

adverse maternal complications (preeclampsia, recurrent vulvo-vaginal infections,

increased incidence of operative deliveries, obstructed labor & development of

diabetes mellitus later in life), fetal complications (macrosomia, polyhydromnios,

preterm labor, respiratory distress, unexplained intrauterine fetal death & traumatic

delivery) and neonatal complications (hypoglycemia, jaundice, polycythemia, tetany,

hypocalcaemia, hypomagnesaemia( Tamas, &Kerenyi , 2001).

 7

In Egypt, from clinical observation GDM is a significant phenomenon and the

commonest complications during pregnancy. It is associated with maternal and

neonatal complications. At the same time there were scattered nursing researches

related to assessing the impact of gestational diabetes on maternal and neonatal

outcomes. The nurse as an important member in caring for women experiencing

gestational diabetes should be aware of its impact on maternal and neonatal outcomes;

so she can contribute to improve the quality of the nursing care given to those women.

Aim of the Study

The aim of this study wasto assess the impact of gestational diabetes on
maternal and neonatal outcomes.

Research Question

What is the impact of gestational diabetes on maternal and neonatal outcomes?

Theoretical Framework

The proposed theoretical model in this study represents the impact of

gestational diabetes on maternal and neonatal outcomes. Concepts are mainly derived

from the Neuman theory.

Neuman Theory "Systems Model" (1972, 1989,& 1993) reflected general

systems, theory that is the nature of living open systems. The theory states that all the

elements are in interaction in a complex organization. It described adjustment as the

process by which the organism satisfies his needs (many needs exist and each may

disturb client balance or stability). Neuman added that, adjustment is a dynamic and

continuous process. She concluded that, when the stabilizing process fails, the
 8

organism will be unable to satisfy his needs, so, illness may develop, and if

compensatory process fails completely, death may occur. She also described stress as

a non-specific response of the body to any demand on it. Additionally, she reported

that, stress increases the demand for readjustment and adaptation to a problem,

whereas stressors are tension-producing stimuli, which may cause disequilibrium

(situational or maturational crisis).

According to Neuman, nurses deal with clients as a whole. Nursing clients are

people who are anticipating stress or who are dealing with stress (Neuman,& Young,

1972). Nurses focus their attention on responses that could be labeled stressful and

these responses are then within the domain of nursing. The nurse diagnoses the level

of stability, internal and external environmental stressors, and the effect of stressors

on client's system stability. Levels of stability can be determined through the analyses

of lines of defense, lines of resistance, basic structure energy resources or survival

factors, and five interacting dynamic variables: physiological, psychological, socio-

cultural, developmental, and spiritual(Neuman, 2001).

Stressors attempt to penetrate the flexible and normal line of defense and the

results are positive or negative responses. How a client system responds to stress is

determined by resistance demonstrated through lines of defense and by the dynamic

relationship of five variable areas. The five variable areas are: physiology, which

describes bodily structure and function; psychological, which is related to mental

process and relationships; socio-culture, which related to social and cultural functions;

developmental, referring to life development processes; and spiritual, referring to

spiritual life system (Neuman, 1989).