|Year : 2016 | Volume
| Issue : 2 | Page : 48-56
Gestational diabetes mellitus
T Dorathy Devakirubai, Anne Jarone
Professor, College of Nursing, CMC, Vellore, India
|Date of Web Publication||9-Jun-2020|
Source of Support: None, Conflict of Interest: None
Pregnancy may be complicated by a variety of disorders and conditions that can profoundly affect the health of a woman and her fetus. Some of them may exist prior to the woman becoming pregnant, while some may begin with pregnancy. Diabetes mellitus is the most common metabolic complication of pregnancy, which affects the progress of pregnancy and development the fetus. This article reviews the types, pathophysiology, risk factors, diagnosis, effects of diabetes on pregnancy and the fetus and aims to equip the nursing personnel with the knowledge required to provide appropriate care to such women with gestational diabetes mellitus.
Keywords: gestational diabetes mellitus, pregnancy, metabolic disorder, fetus, nursing care
|How to cite this article:|
Devakirubai T D, Jarone A. Gestational diabetes mellitus. Indian J Cont Nsg Edn 2016;17:48-56
| Introduction|| |
Diabetes is a disease of later life, which may account for the low incidence of this complication in pregnancy. Most pregnant women produce more insulin to compensate and keep blood sugar levels normal while some pregnant women cannot produce enough extra insulin and therefore their blood sugar level rises, and gives rise to a condition called Gestational Diabetes Mellitus (GDM). GDM affects nearly 5% to 18% of women during pregnancy, and it generally disappears after delivery. However it is important to recognize and treat this condition to minimize the risk of complications to the mother and the baby. It is also vital for women with a historyof GDM to be tested for diabetes after pregnancy, because they are up to six times more likely to develop type 2 diabetes in the years following delivery, than women without diabetes in pregnancy (Erem, Kuzu, Deger, & Can, 2015).
| Definition and Prevalence of GDM|| |
Gestational diabetes mellitus is defined as any degree of glucose intolerance with onset or first recognition during pregnancy (American Diabetic Association, 2004). It can also be simply defined as carbohydrate intolerance of variable severity, with an onset or first recognition during pregnancy (Erem et al., 2015). Some define GDM as diabetes diagnosed during the second and the third trimester of pregnancy usually recognised at 24 to 28 weeks of gestation (Seely&Zera,2016).
Approximately 7% of all pregnancies are complicated by GDM, resulting in more than 200,000 cases annually (American Diabetic Association, 2004). The prevalence of GDM is increasing worldwide and varies between 1% and 14% in all pregnancies depending upon the genetic characteristics and environment of the population under study, screening and diagnostic methods employed on the prevalence of type 2 diabetes mellitus (Erem et al., 2015). The prevalence of GDM in India varies from 3.8% to 21% (Raja et al., 2014) depending upon the diagnostic methods used. In 2013, 6 million women in India had some form of hyperglycemia in pregnancy of which 90% were found to have GDM (Bhavadharini et al., 2016). In Tamil Nadu the prevalence of GDM was estimated to be 14.6% and the differential prevelance in the urban and rural areas of the state was found to be 19.8% and 16.1% respectively (Bhavadharini et al., 2016). A random survey done in various cities in India in the year 2002 to 2003 revealed the prevalence of GDM in Chennai to be 16.2% (Rajput, Yadav, Nanda, & Rajput, 2013). Racial and ethnic differences have also been documented with a higher prevalence among native American, Asian, African-American and Hispanic populations compared to non-Hispanic whites (as cited by Bhavadharini et al., 2016). Based on demographic projections made by United Nations Population Division (UNDP) for the year 2025, World Health Organization (WHO) has issued estimates of adults with diabetes in all countries of the world and has reported a potential rise in the number of women with diabetes than men and thereby a rise in the burden of gestational diabetes (Jali, Desai, Gowda, Kambar, & Jali 2011).
| Pathophysiology|| |
Insulin is the primary hormone produced in the beta cells of the pancreatic islets of Langerhans. It plays a key role in regulating the body’s blood glucose level and stimulates cells in the skeletal muscle and fat tissue to absorb glucose from the bloodstream. In the presence of insulin resistance, this uptake of blood glucose is prevented and the blood sugar level remains high (Daftary, Chakravarti, & Daftary, 1998). Pregnancy causes changes in maternal carbohydrate metabolism that result in optimisation of maternal-fetal fuel transfer and fetal growth. Beginning in early pregnancy there are constantly elevated levels of estrogen and progesterone that stimulate the pancreatic beta cells resulting in hyperplasia and hyperinsulinaemia. As pregnancy advances, levels of human placental lactogen (HPL) increase, and HPL along with Cortisol, counter the effect of insulin leading to insulin resistance (Thomas, Jeyaraman, Asha, & Velavan, 2016). Eventually these hormones will begin to block the effects of insulin from around the 18th week of pregnancy. This reduction in maternal insulin sensitivity requires a threefold increase in maternal insulin secretion to maintain normal glucose tolerance by the third trimester of pregnancy. Women with insufficient beta cell reserve become glucose intolerant to cope with these demands and subsequently end up with the diagnosis of GDM (Turner, 1999).
| Classification|| |
There are two different methods of classifying diabetes in pregnancy (World Health Organization, 1999). First is White’s classification and the second is American Diabetic Association classification (see [Table 1] & [Table 2].
| Risk Factors|| |
Studies worldwide have identified 11 to 12% higher chance of developing GDM in pregnant women whose first degree family members have diabetes (Goud, Kumar, & Ramesh, 2014). The risk is doubled with advanced maternal age (> 40 years) as well as with polycystic ovarian syndrome and almost tripled when BMI of the woman is > 30 kg/ m. Increased risk factors for gestational diabetes include ethnic groups with a high prevalence of diabetes especially Asian American women (Seely & Zera, 2016), women who have given birth to large infants (> 4 kgs), history of recurrent fetal loss; stillbirth; unexplained neonatal death; congenital malformations and prematurity. Other risk factors include past history of glucose intolerance/ diabetes in previous pregnancy, history of traumatic delivery with an associated neurological disorder in the infant. A history of preeclampsia, polyhydramnios, chronic hypertension, recurrent severe moniliasis/ urinary tract infections and persistent glycosuria also increase the risk for developing GDM during pregnancy (Gopalan & Jain, 2005).
| Diagnosis|| |
Women with a risk of developing diabetes during pregnancy need to be identified and managed in order to have a favorable outcome. To diagnose GDM (World Health Organization, 1999) recommends a standard Oral Glucose Tolerance Test (OGTT) that is performed after overnight fasting for 8 to 14 hours and administering 75 grams anhydrous glucose in 250 to 300 ml of water orally to the woman. Plasma glucose is measured at fasting and after 2 hours of taking a meal. The criteria for diagnosis of GDM include a fasting blood sugar of 92 mg/ dl, blood sugar atl hour 180 mg/ dl, and at 2 hours 153 mg/dl. Any two abnormal values indicate the presence of GDM. Universally screening has been performed at 24 to 28 weeks of gestation (Reeder, Martin, & Griffin, 1992). In the early part of pregnancy during the first trimester and the first half of the second trimester fasting blood sugar of 92 mg/dl and post prandial blood sugar of 140 mg/dl are indicative of GDM. A random Blood Sugar or a Glucose Challenge Test (GCT) with 75 g oral glucose with a plasma glucose value of 140 mg/ dl of glucose may also be recommended for diagnosis (Thomas et al.,2016).
| Effects of Pregnancy on Diabetes|| |
In women diagnosed with GDM the pregnancy itself can cause inadvertent effects on the disease state. This includes progression of diabetic retinopathy, worsening of diabetic nephropathy, increased risk of death for patients with diabetic cardiomyopathy, myocardial infarctions and an increased need for more insulin to achieve metabolic control (Thomas et al.,2016).
Several studies have reported that diabetes can cause serious effects during pregnancy and can lead to poor delivery and neonatal outcomes. GDM increases the maternal risk of pre-eclampsia, polyhydramnios and caesarean section (Erem et al., 2015). GDM also increases the risk of preterm labour, placental abruption, trauma during delivery, still births (Mandal, 2016) recurrent abortions, post partum haemorrhage and infections such as chorioamnionitis, endometritis, polynephritis as well as asymptomatic bacteriuria (Gilmartin, Ural, & Repke, 2008). Fetal complications such as congenital abnormalities, intrauterine growth retardation, macrosomia, hyperviscosity syndrome, hyaline membrane disease, fetal apnea and bradycardia and unexplained fetal demise have been associated with GDM. Further newborns of mothers with GDM are more prone for respiratory distress, hypoglycemia, hypocalcaemia, hyperbilirubinemia, cardiac hypertrophy and may also have long term effects on cognitive development (Thomas et al., 2016). Long term effects on the child also include obesity, diabetes during childhood, impaired motor function and higher rates of inattention and hyperactivity (Gilmartin et al., 2008).
| Management|| |
Once a diagnosis of GDM is made the woman has to have regular checkups with the physician. This enables monitoring of the woman and fetus directed towards minimizing risks that can develop as a result of GDM. The principles of management include control of blood sugar levels with diet, drugs and exercises, obstetric management and timing of delivery as well as specialized care for the newborn (Gopalan & Jain, 2005).
| Antenatal Care|| |
Control of blood sugar
According to Gopalan and Jain (2005) optimum control of blood sugar can be achieved by (1) Medical Nutrition Therapy (MNT): The goals of MNT are to achieve normoglycemia, prevent ketosis, provide adequate weight gain and contribute to fetal wellbeing. A total calorie intake of30 - 35 kcal/kg of ideal body weight is given as three meals and three snacks. Abedtime snack is insisted to prevent ketosis in fasting. Carbohydrates should be restricted to 40% to 45% of the total calorie intake and the remaining should be divided between proteins and fats. (2) Physical activity: Planned physical activity for a period of 30 min/day is recommended. Exercise such as brisk walking is said to reduce the need for insulin and it also helps the woman to achieve better glycemic control. (3) Pharmacological therapy: Insulin is administered if the Fasting Plasma Glucose (FPG) is more than or equal to 120mg/dl or with a FPG of more than or equal to 95mg/dl after MNT and 1 hour post prandial glucose is more than or equal to 120mg/dl. Basal bolus or premixed insulin is administered in order to control fasting and post prandial blood glucose levels. Long acting insulin is not licensed in pregnancy. Self administration of insulin and home monitoring needs to be taught to the woman. (4) Monitoring of blood glucose : Blood glucose monitoring at home is ideally done using a glucometer at least four times a day. Oral antidiabetic agent namely Metformin is found to be safe during pregnancy (Thomas et al.,2016).
Ultrasound is done in the first trimester to detect major congenital malformations and also to estimate the gestational age accurately. Estimation of gestational age is important as many women with GDM will require induction of labour. Maternal serum alpha-feto protein is estimated at 16-20 weeks of gestation to detect neural tube defects in the fetus. Fetal echocardiography is recommended in all diabetic pregnancy to detect fetal cardiac anomaly between 24 - 26 weeks of gestation. Biweekly antenatal check up is done till 32 weeks of gestation to rule out complications such as pregnancy induced hypertension; polyhydramnios as well as macrosomia. Women with GDM who are diagnosed to have poor control of blood sugar levels or complications are hospitalized for close monitoring and prevention of further complications. Non stress test is done from 32 weeks onwards. Biophysical profile and fetal umbilical and middle cerebral artery Doppler Velocimetry are done after 32 weeks of gestation if intrauterine growth restriction is diagnosed in the fetus. In women with good glycemic control and no fetal compromise, pre-eclampsia or hypertension, delivery is recommended at 39 - 40 weeks of gestation. In women with poor glycemic control delivery is intended by 37 weeks, while in women with maternal or fetal compromise delivery is done as soon as the abnormality is identified (Gopalan & Jain, 2005).
Management in Labour
Labour is induced with oxytocic agents and prostaglandins if required. Intravenous Normal Saline or 5% Dextrose with neutralizing dose of Insulin is started to maintain glucose levels in the woman and in turn prevent hypoglycemia in the newborn baby. Further infusion is decided based on blood sugar levels which are monitored every 2 hours. Prophylactic antibiotics are also administered. Progress of labour is closely monitored and plotted on a partograph. This helps to identify complications such as prolonged labour, arrest of dilatation or descent. Electronic fetal monitor is used to monitor the fetus closely to detect fetal distress. Artificial rupture of membranes is done to detect meconium stained amniotic fluid when the mother is in active labour. Vaginal delivery of a big baby (macrosomic baby) can cause shoulder dystocia and brachial plexus injury during delivery and so a caesarean section is usually performed (Fraser & Cooper, 2003).
Management in Puerperium
Insulin is often not required during puerperium for women with GDM. However women with overt diabetes may require alteration in the dosage of Insulin after estimation of blood sugar levels. Antibiotics are administered to prevent infection (Gopalan & Jain, 2005).
To prevent pregnancy loss as well as congenital malformations in infants of diabetic mothers, medical care along with patient counseling is recommended. These include (a) Baseline glucose control (b) Assessment of organ damage (c) Estimation of glycosylated hemoglobin (d) Folic acid supplementation (Gopalan & Jain 2005).
| Nursing Management|| |
Nursing care of the woman with GDM mellitus can be dealt under broad topics of monitoring blood glucose levels, maintaining blood sugar levels through diet, prevention of complications by regular antenatal check-ups and by promoting adequate knowledge to the woman and the family.
1.Objective: To maintain blood glucose levels of fasting < 90mg/dl and post prandial <145 mg/dl
Screen the woman for predisposing factors of diabetes as this is helpful in identifying women at risk of developing GDM early. Assist them in preparing for oral glucose tolerance testing by explaining the purpose so that the woman is able to understand and follow instructions properly. Monitor blood glucose levels accurately before and after food. Watch for signs and symptoms of hypoglycemia and hyperglycemia so as to provide early treatment. Plan and provide diet with the recommended allowances as three meals and three snacks. Administer Insulin or oral hypoglycemic agent as prescribed in order to restore normal metabolism of carbohydrates, proteins and fats. Make sure that the blood glucose levels and treatment provided are adequately documented and communicated to improve the care provided to the woman.
2.Objective: To maintain adequate placental tissue perfusion in order to deliver a healthy term infant without any complications
Monitor maternal vital signs and watch for edema so as to identify maternal complications early and to initiate appropriate treatment. Encourage the woman to maintain left lateral position during resting in bed as this position is said to increase uteroplacental perfusion. Perform continuous monitoring of fetal heart while in the hospital so that fetal distress can be recognized early and potential fetal problems may be identified. The woman needs to be instructed to maintain fetal movement count and report any significant changes as early as possible since fetal movement is correlated with fetal well being. Prepare and perform various diagnostic tests such as Non Stress Test which is useful in detecting fetal distress. Weekly or biweekly ultrasonography can be done to assess the fetal growth and development. Biophysical profile helps to identify fetal compromise and fetal lung maturity can also be determined from assessing levels in the amniotic fluid. Explain the need for these investigations to the woman and her family.
3.Objective: To maintain optimal levels of nutritional status so as to maintain and control blood glucose levels
The exact calories required by the client is calculated and provided in such a way that it is evenly distributed as three meals and three snacks throughout the day. This will help in maintaining good metabolic control. Dietary allowances are recalculated based on the blood glucose levels that is being monitored prior to and after meals. Desired weight gain is assessed by monitoring weight regularly.
4.Objective: Early detection and prevention of potential maternal and fetal complications
The nursing care plan is developed in cooperation with the woman and her family and a variety of specialists are also involved in the care. Counseling regarding the effects of diabetes on the mother and the fetus is given. Ambulatory self monitoring and community based care is provided to those without maternal or fetal compromise. Hospitalization is recommended for a woman who has a poor glucose control. Antenatal assessment is done to identify signs and symptoms of diabetes. Ultrasound is done to evaluate fetal growth and also detect congenital malformations. Blood glucose level is maintained with meticulous diet planning based on the caloric requirement and well as planned exercise is performed. The woman should be constantly encouraged to keep her appointments for checkups as indicated so that she can be assessed for any oedema or alterations in urine albumin and sugar levels and blood pressure. This will assist the nurse to report any deviations early. Women with GDM should be directed to check for leaking or bleeding per vagina and premature contractions.
| Conclusion|| |
Pregnancy has been traditionally described as a transient excursion into the metabolic syndrome. Metabolic changes are necessary to meet the growth and development of the fetus. Glucose is said to be the major substrate for the human fetus during pregnancy and glucose metabolism has thus been the subject of most studies on metabolism in pregnancy. The incidence of diabetes in pregnancy has increased over the recent years. Despite great gains achieved in modern obstetric management, perinatal mortality and morbidity remain significantly higher in diabetic pregnancies than in normal pregnancies. Early recognition and prompt treatment by the skilled personnel enhance survival of the fetus. Nurses working in obstetric settings must be knowledgeable in identifying and providing appropriate care to women with GDM so as to both maternal and fetal prevent complications.
Conflicts of Interest: The authors have declared no conflicts of interest.
| Continuing Education Series No: 31 Gestational Diabetes Mellitus|| |
CE Test - 31 IJCNE
After reading the preceding article and taking this test, you should be able to:
- Define Gestational Diabetes Mellitus (GDM)
- List the classification of GDM
- Enumerate the risk factors of GDM
- Discuss the management of GDM
- Explain the nursing care of pregnant women with GDM
- The hormone that leads to insulin resistance during pregnancy is
- Follicular stimulating hormone
- Luteinizing hormone
- Human chorionic gonadotropin
- Human placental lactogen
- One of the risk factors for developing GDM is
- Maternal underweight
- Hyperemesis gravidarum
- Unexplained still births
- Primi para
- The investigation that is recommended to diagnose gestational diabetes is
- Glucose Tolerance TestA
- Urine sugar
- Random blood sugar
- 24 hour blood glucose profile
- Universally, screening for GDM needs to done at weeks of gestation
- 24 - 28
- 30 - 32
- The amount of glucose that should be administered for Glucose Tolerance Test is
- 50 gm
- 75 gm
- 100 gm
- Fetal abnormality in a diabetic woman can be detected preferably by performing the following procedure
- Biophysical profile
- Chorionic villus sampling
- The effect of diabetes on the pregnant woman may be manifested in the form of following complication
- Decreased cognitive development
- Cardiac hypertrophy
- Acommon side effect of diabetes on the fetus is
- Maternal serum alpha feto protein is done to detect fetal
- cardiac anomaly
- neural tube defect
- growth deficit
- lung maturity
- All the following tests are useful for fetal monitoring in a diabetic pregnant woman except
- Non-stress test
- Biophysical profile
- Fetal kick count
- Doppler flow study
- Identification of glycosuria during routine antenatal checkup indicates the need for
- Dietary restriction
- Insulin administration
- Glucose tolerance test
- Effect of gestational diabetes on the newborn baby could be
- Which is the most common complication that can occur when a diabetic women delivers vaginally?
- Uterine inertia
- Shoulder dystocia
- Postpartum haemorrhage
- Excessive moulding of head
- The daily calorie requirement (kcal/kg) for a pregnant woman with GDM is calculated as
- The recommended carbohydrate proportion in the diet for a GDM woman is
- The indication for caesarean section in a woman with GDM is
- Big baby
- Intrauterine death
- Gestational diabetic women with poor control of blood sugar levels need to be
- Monitored in the OPD
- Administered oral anti diabetic agents
- Hospitalized for monitoring
- Managed at home
- When an insulin - dependent diabetic woman gives birth, the nurse expects the woman’s insulin requirement in the first 24 hours after delivery to
- drop significantly
- gradually return to normal
- increase slightly
- stay the same as before
- The prevalence of GDM in India is approximately
- A woman with GDM is started on IV Insulin for severe hyperglycenia. She should be monitored for the following side effect
| Continuing Education Series No: 31 Gestational Diabetes Mellitus|| |
Select the best answer and shade the circle against the suitable alphabet in the answer form provided.
Evaluation : Listed below are statements about the CNE on Gestational Diabetes Mellitus. Please circle the number that best indicates your response.
Strongly Disagree Disagree Agree Strongly Agree
The stated objectives were met 1 2 3 4
The content was clearly presented 1 2 3 4
Thecontentwasrelatedtotheobjectives 1 2 3 4
The test questions were clearly stated 1 2 3 4
PRESENT MAILING ADDRESS: ___________
Cut out or photocopy thisform,fill andmail before June 30,2017 to The Editor-in-Chief, IJCNE, College of Nursing, CMC, Vellore - 632 004, along with a Demand Draftfor Rs. 100/- (Rupees hundred only), drawn in favour of CMC, Vellore Association. A certificate will be awarded to all the participants and a merit certificate to those who secure marks 80% and above. Participants who secure 100% will be awarded one yearfree subscription of IJCNE. Also, all those who score marks 80% and above will be awarded 2 credit hours (1 creditpoint).
| References|| |
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(lOthed.).Chennai: Orient Longman.
Jali, M. V., Desai, B. R., Gowda, S., Kambar, S., & Jali, S. M. (2011). A hospital based survey of prevalence of gestational diabetes mellitus in an urban population of India. European Review for Medical and Pharmacological Sciences, 15
, 1306 - 1310. Retrieved from http://www.europeanreview.org/wp/wp- content/uploads/1069.pdf
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, 191 - 194. doi: 10.5455/ijmsp h.2013 .211120131
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, 728. Retrieved from https://www.ncbi.nlm.nih.gov/ pmc/articles/PMC3724253
Reeder, S. J., Martin, L.L., & Griffin, D. K. (1992). Maternity nursing
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Thomas, N., Jeyaraman, K., Asha, H. S., & Velavan, J. (2012). A practical guide to diabetes mellitus
(7th ed.). New Delhi: Jaypee Brothers Medical Publishers (P) Ltd.
World Health Organisation. (1999). Definition, diagnosis, and classification of diabetes mellitus and its complications
. Geneva: Department of Noncommunicable Disease Surveillance. Retrieved from http://apps.who .int/iris/bitstream /10665/66040/1/WHONCDNCS99.2.pdf
[Table 1], [Table 2]