Gestational diabetes is defined as any degree of glucose intolerance that has its onset or is first diagnosed during pregnancy. Kuhl, Hornnes, and Andersen (1985) state that gestational diabetes occurs when the pancreas of a pregnant woman fails to increase insulin production to compensate for the natural decrease in cells’ sensitivity to insulin.The cardinal signs of diabetes are polyuria (related to decreased reabsorption at the renal tubules because of the osmotic activity of glucose), polydipsia (related to polyuria), polyphagia (related to starved cells as a result of inability to transport glucose into cells), and weight loss (related to the use of fat and muscle tissues for energy). If left untreated, the extra glucose in the blood can pass to the baby through the placenta, causing the baby to boost insulin production. All that excess glucose is stored in the baby as fat leading to a large for gestational age size, which can complicate delivery.Also, the baby’s overproduction of insulin may increase his or her risk of obesity and type two diabetes later in life (Joslin Diabetes Center, 2008). This phenomenon occurs in about four percent of all pregnancies and is more common in women with one or more of the following risk factors: overweight, over 30 years of age, strong family history of diabetes, previously had a baby weighing more than nine pounds at birth, polycystic ovary syndrome, glycosuria, impaired fasting glucose or impaired glucose tolerance, and African-American, Hispanic, Asian, American Indian, or a Pacific Islander descent (Ladewig, London, and Davidson, 2009).
According to the text, the prognosis of gestational diabetes without significant vascular damage is positive (Ladewig et al. 2009). However, there are still more risks associated with the diagnosis compared to a normal pregnancy. One of the maternal risks of gestational diabetes is hydramnios, or increased amniotic fluid, can occur in 10-20% of diabetic pregnancies. This is thought to occur as a result of fetal polyuria and occasionally results in premature rupture of membranes and onset of labor (Ladewig et al. 2009).
Preeclampsia also occurs more often in diabetic pregnancies, especially when vascular change has already occurred. Hyperglycemia can slowly lead to ketoacidosis, which if left untreated can result in coma and death for the mother and the fetus. Women with GDM are also more susceptible to monilial vaginitis and urinary tract infections related to increased glycosuria (Ladewig et al. 2009). One fetal-neonatal risk is death from maternal ketoacidosis; however the major cause of death among infants of diabetic mothers is congenital anomalies.
Most anomalies involve the central nervous system, heart, and skeletal system. Sacral agenesis occurs almost exclusively in diabetic pregnancies (Ladewig et al. 2009). A large for gestational age baby or macrosomic baby is at increased risk for shoulder dystocia and traumatic birth injuries if delivered vaginally (Ladewig et al.
2009). After the umbilical cord is severed, the baby is cut off from the mother’s hyperglycemic blood supply but will continue to make excess insulin, resulting in hypoglycemia two to four hours after birth (Ladewig et al. 2009).Also, if a pregnant woman has vascular damage from diabetes, intrauterine growth restriction may occur as a result of decreased placental perfusion (Ladewig et al. 2009). Respiratory distress syndrome, polycythemia, and hyperbilirubinemia are also linked with diabetic pregnancies (Ladewig et al.
2009). Screening for Gestational Diabetes While a universal recommendation for an approach to screening and diagnosis of GDM does not exist, the Committee on Obstetric Practice continues to recommend a two-step approach.They state “All pregnant women should be screened for GDM, whether by patient history, clinical risk factors, or a 50-g, 1-hour glucose challenge test at 24–28 weeks of gestation. The diagnosis of GDM can be made based on the result of the 100-g, 3-hour oral glucose tolerance test, for which there is evidence that treatment improves outcome” (The American College of Obstetricians and Gynecologists, 2011).Hillier et al. (2008) qualitatively synthesized thirteen studies from 1607 abstracts to review evidence about the benefits and harms of screening for gestational diabetes.
Despite this extensive systematic review, researchers were unable to find sufficient evidence whether screening leads to a reduction in perinatal morbidity and mortality, but they did conclude that outcomes were much better when the patients properly managed treatment for GDM compared with those who did not.In one study of 1000 women in Australia and the UK who achieved a positive result for a 2-step 75-g oral glucose tolerance test and fasting plasma glucose at 16-30 weeks, the rate of serious perinatal complications was significantly lower among the infants of the 490 women in the intervention group than among the infants of the 510 women in the routine-care group. The intervention group received both individualized dietary advice and instructions to self-monitor glucose levels four times daily until glucose values were in the normal range.The untreated group received none of this and subsequently gained more weight during pregnancy and experienced worse perinatal complications. Complications for the treated group included seven shoulder dystocias compared with sixteen shoulder dystocias in the untreated group as well as one fractured humerus, three with nerve palsy, and five neonatal fatalities. These findings strongly support the treatment of gestational diabetes, which can only begin through screening (Hillier et al, 2008).
Treatment of Gestational Diabetes Goh, Sadler, and Rowan (2011) analyzed prospectively collected data at a single site from the National Women’s Health database for all women with gestational diabetes who delivered between January 2007 and December 2009. Starting in 2007, women were given a choice of either metformin or insulin treatment—except women with a fetal abdominal circumference less than the 10th percentile, who were not offered metformin. They found 1269 women with GDM.
Diet was the treatment of choice for 371 patients, insulin for 399, and metformin for 465—216 patients were treated with both metformin and insulin—and compared maternal and neonatal outcomes.Findings included all of the following: * Women treated with metformin and /or insulin had significantly higher BMIs compared with those in the diet group, possibly implying patients with greater BMIs cannot manage their condition through diet alone. * Women treated with insulin had higher rates of Caesarian delivery that women treated with metformin or diet. * Insulin-treated pregnancies also resulted in more preterm births, LGA babies, neonatal admissions, and neonatal intravenous dextrose use.
* Neonatal outcomes were similar between diet- and metformin-treated women. As evidenced by this research, metformin is an excellent choice for treatment of gestational diabetes, and should be preferred over insulin if blood sugar can be controlled by metformin alone. Also, metformin is much less overwhelming for a patient since it is taken by mouth unlike insulin injections.
Diet is also effective for patients with mild GDM and can always be included in a treatment plan in addition to metformin or insulin.While diet alone and metformin alone produced similar outcomes, metformin was associated with slightly less preterm births than diet alone; however, it should be noted that there was no research on the effect of metformin plus diet as an approach to treatment. Nursing Implications and Conclusions The following are appropriate nursing implications and conclusions related to gestational diabetes. Nurses should be aware of the risk factors for gestational diabetes to investigate the possibility of a GDM diagnosis for patients at high risk.
Nurses and other appropriate healthcare professionals should test all patients for GDM, especially those who are at high risk as evidenced by BMI, weight measurements, or health history. Unless contraindicated, metformin should be the pharmacological treatment of choice for hyperglycemia, and insulin should only be used if metformin is unsuccessful. Patients should be thoroughly educated about the importance of testing blood sugar and taking the proper medications and/or sticking to a therapeutic diet and the connection between noncompliance and increased maternal and neonatal complications.Education on the importance of follow up visits and proper weight gain is also crucial. Preferably, a certified diabetes educator would provide education in addition to the nurse.
Because a diagnosis of GDM and particularly a treatment of insulin injections can be overwhelming, the nurse should make sure that the patient fully understands the condition and what she is required to do for treatment and that she has a solid support system.Nursing implications during delivery include extensive preparation for the possibilities of respiratory distress syndrome, shoulder dystocia, and other traumatic birth injuries. The baby should be fed promptly after birth and checked for hypoglycemia at two to four hours after birth. Lastly, I would recommend that couples trying to conceive should be educated on how to reduce their risks of developing such conditions as GDM as early as possible to facilitate healthy future pregnancies.