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Course: Maternity Nursing

Topic: Gestational Diabetes Mellitus

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Module Goals

The learner will be able to:

Differentiate between pre-existing and gestational diabetes
List possible complications of Gestational Diabetes
Explain how diabetes is diagnosed in pregnancy
Explain the teaching points for managing gestational diabetes

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Diabetes Mellitus (DM)

It is a chronic metabolic condition where :

the body cannot absorb the glucose into the cells as B- cells of the pancreas

produces less insulin or no insulin

resulting in the glucose remaining in the bloodstream and not absorbed into the cells

Diabetes Mellitus

Type-1

Type-2

Gestational Diabetes Mellitus

Types of Diabetes Mellitus:�

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Type-1:

Types of Diabetes Mellitus:

Type-1:

B- cells of the pancreas are destroyed and no insulin is produced.

Juvenile
Insulin Dependent
Idiopathic Cause

Type-2:

B- cells of the pancreas produces insulin, but either it is not enough, or the body resists the insulin.

Adult-onset.
Insulin Resistant
Idiopathic Cause: Risk factors associated

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Gestational Diabetes Mellitus

Type-2 diabetes

Idiopathic Cause: Hormonal changes might contribute
Usually detected at 24-28 weeks
Approx. 5% of all pregnancy develops Gestational Diabetes
Usually resolved after childbirth
Some may develop type-2 DM in later life

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Pre Existing Diabetes Vs Gestational Diabetes

Early: Pre-Existing DM⎯ present < 20 weeks’ gestation or before conception

Late: Gestational diabetes (GDM)⎯present > 20 weeks’ gestation

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Who is at the Risk of Gestational Diabetes Mellitus?

Previous history of DM during Pregnancy
History of having large babies (macrosomia) (more than 4.5 kg)
BMI with 40 or more
Polyhydramnios
History of intrauterine death
Family History of Diabetes

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Signs and Symptoms of Gestational Diabetes Mellitus

Glycosuria
Polydipsia
Polyphagia
Frequent Urination
Fatigue
Nausea
Blurred Vision
Frequent Vaginal, bladder, and skin infection

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Gestational Diabetes Mellitus: Possible Maternal Complications

May lead to fetal and maternal morbidity and mortality

Maternal

Infection: UTI, Bacterial Vaginosis
Spontaneous abortion
Cesarean Section
Preeclampsia
Postpartum Hemorrhage
Damage to the heart, lungs, and kidneys

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Gestational Diabetes Mellitus: Possible Fetal Complications

Congenital Abnormalities
Fetal Macrosomia
Shoulder Dystocia
Still Birth
Respiratory Distress
Hypoglycemia, hyperbilirubinemia
Risk of developing diabetes later life

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Fetal Macrosomia: Weight of fetus more than 4000 gm. or 4500 gm. at the time of birth
Shoulder dystocia: A condition where the anterior shoulder of fetus cannot pass through pelvic region of mother during vaginal birth.
Respiratory Distress: Difficulty breathing
Stillbirth: A condition where the fetus dies inside the uterus of mother after 20 weeks or hours before labor.
Hypoglycemia: Level of glucose below normal limit.
Hyperbilirubinemia : High level of bilirubin in blood (results in jaundice).
Hypocalcemia: Low level of calcium in blood

During the first trimester, uncontrolled (preexisting or gestational) diabetes can cause congenital abnormalities and malformation in the fetus. The neonates born to such mothers are at the risk of developing respiratory distress, hypoglycemia, hypocalcemia, hyperbilirubinemia, polycythemia. Fetal Macrosomia (i.e. fetal weight more than 400 grams or more than 450 grams at birth) due to the high amount of glucose concentration in blood. The fetus may also develop shoulder dystocia, and have a high risk of stillbirth.

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How to Avoid These Complications?

Early Diagnosis: Blood and Urine tests, observe for signs of diabetes

Management & Treatment: Lifestyle, diet, insulin therapy

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Diagnosis of Gestational Diabetes Mellitus

Urine Test

Urine sample

Blood Test

Fasting
Random
HbA1C
OGTT

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Urine Test

Urine Test: Every Antenatal Visit

+1 Glycosuria: A random blood glucose is done

Repeated or marked glycosuria: Should be investigated further for diabetes

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Blood Test (Fasting & Random)

Fasting Blood Sugar:

Common Test
Performed on an empty stomach
Can be done at home or lab
Values depend upon the unit of measurement
Reading more than 6.9 mmol/l or more indicates diabetes

Random Blood Sugar

Can be taken without any preparation
Can be done at home or lab
Value less than eight mmol/l is normal

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Blood Test- Glycosylated Hemoglobin Test (HbA1C)

Called the A1C test
Gives an average blood sugar level over the last three months
No preparation is required
Should be done in lab
Calculated in percentage
Ranges from 4- 14%
Less than 5.7% indicates no diabetes

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A glycosylated hemoglobin test is also called A1C or HgbA1C test. It gives an idea of the average blood sugar level of a client for the last 3 months. This test needs no preparation (fasting or eating). It is usually done in a lab or clinic with a blood sample.

It is calculated in percentage. It might range from 4% to 14 %. If the result of the blood test is near or above 6.4%, a client may have diabetes. If it is near or around borderline, certain care on diet and exercise has to be given.

Less than 5.7%: No diabetes.
More than 5.7% but less than 6.4%: This is a warning (pre-diabetes): lifestyle and diet should be changed. Healthy eating and increased physical activities are important.
More than 6.4%: Indicates Diabetes and requires treatment. The higher the number, the more likely a person will have an emergency or serious health problems. It requires continuous monitoring.

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Blood Test (Oral Glucose Tolerance Test)

Has two steps

Take a fasting sample of blood
Sweet drink containing 75 gm of glucose orally
A blood test taken after 2 hours
Value should be less than 155 mg/dl (8.6 mmol/l)

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In this test, a pregnant woman’s fasting blood sample is obtained, and then she is encouraged to take a sweet drink containing 75 gm of glucose. And a blood sample is obtained either in one hour or after 2 hours of intake.

Value of OGTT:

At One Hour

If the blood glucose level is higher than 140 mg/dL (7.8 mmol/L) after the one-hour test, the doctor will recommend the three-hour test. If the blood glucose level is higher than 190 mg/dL (10.6 mmol/L) after the one-hour test, a patient will be diagnosed with gestational diabetes.

At Two Hour

A normal fasting blood glucose level: less than 95 mg/dL (5.3 mmol/L).

Two hours after drinking the glucose solution: Lower than 155 mg/dL (8.6 mmol/L).

For the three-hour test:

A normal fasting blood glucose level is lower than 95 mg/dL (5.3 mmol/L).
One hour after drinking the glucose solution, a normal blood glucose level is lower than 180 mg/dL (10 mmol/L).
Two hours after drinking the glucose solution, a normal blood glucose level is lower than 155 mg/dL (8.6 mmol/L).
Three hours after drinking the glucose solution, a normal blood glucose level is lower than 140 mg/dL (7.8 mmol/L).

If one of the results is higher than normal, the patient will likely need to test again in four weeks. If two or more of the results are higher than normal, she will be diagnosed with gestational diabetes.

Even though a woman is diagnosed with gestational diabetes, she can prevent complications by carefully managing her blood glucose level throughout the rest of her pregnancy.

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What would the nurse do?

Mrs. Preet, 32 years, 24 weeks pregnant, has +1 glycosuria in her urine. She is scheduled for fasting blood tomorrow morning. She looks worried and asks the nurse why she needs this test and what will happen. She also adds that her blood sugar was normal at nine weeks of gestation and does not understand why it might change now.

How should the nurse respond to Mrs. Preet’s concerns?

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Reassure Mrs.Preet that this is a normal screening obtained on all pregnant women. It involves drinking a sweet drink that is followed by a blood test to determine how her glucose levels after the drink. She can expect to be in the lab for a few hours.

Three Questions:

How the test will be carried out?

Mrs. Preet should arrive for testing in the early morning before and has not had anything to eat or drink (nothing except water) from midnight the night before. A technician Will draw her blood and send it for analysis.

What reading indicates diabetes?

Fasting blood glucose less than 6 mmol/l is normal. A result above 8 mmol/l or is diagnostic of diabetes.

Can diabetes harm her or her child?

Yes, it may cause fetal and maternal mortality and morbidity if the glucose concentration is higher and left untreated (Slide no. 7 & 8).

Will I have diabetes forever?

Gestational diabetes resolves within a day after delivery. There is a risk of developing type-2 diabetes in later life.

Regarding her previous blood glucose reading, there is a possibility that a patient with initially normal blood glucose may develop diabetes in later pregnancy. This may be possible due to an increase in the number of placental hormones as the pregnancy progresses. Placental hormones tend to increase blood glucose concentration, This may explain why some patients only become diabetic during their pregnancies.

If she is diagnosed with gestational diabetes, she can prevent complications by carefully managing your blood glucose level through a healthy diet throughout the rest of your pregnancy.

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Managing Gestational Diabetes Mellitus

Ideally begins before conception

Diet
Exercise
Blood glucose monitoring
Insulin therapy
Close communication with Care Providers

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Diet: Adopt Healthy Foods Habits

Replace starchy food with vegetables
Whole grains are better
Fiber-rich foods
Protein-rich foods
Avoid: Packaged foods, sweet drinks, and alcohol
Eat Small Frequent Meals

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Healthy Food Habits:

Replace starchy foods with vegetables: Starchy foods such as rice, maize, wheat, yam, potatoes, are often the main foods people eat. But starchy foods turn into sugar in our bodies. A person with diabetes might be able to handle small amounts of starchy foods, but not larger amounts. Replacing some starchy foods with vegetables and leafy greens adds vitamins and nutrients that will benefit the diabetic patient.
Whole grains are better: Grains are a starchy food and provide us energy. The whole gains with germ and bran like brown rice, whole wheat are healthier.
Eat foods with fiber: Fibers helps to slow down the quick sugar absorption into the blood. Thus manages the blood sugar and improves digestion. Fiber food includes green leafy vegetables, vegetables, beans, fruits, legumes, nuts, seeds, whole grains.
Eat protein foods: Blood sugar does not tend to rise if one consumes a good mixture of healthy foods like protein. Protein foods include foods such as eggs, meat, nuts, seeds.
Eat less packaged food and limit sweet drinks and avoid alcohol: Packaged food looks attractive, tastes good, and easy to store so most of us might be attracted to such foods and drinks. But packaged foods usually have too much sugar, salt, and unhealthy ingredients. It feels good to consumes such foods and drinks when we are hungry and tried but we feel worse when the effect of sugar passes. Alcohol should never be consumed during pregnancy as it is harmful to the fetus. Package foods and sweet drinks lead to over calorie consumption.
How often to eat: Small frequent meal is helpful for diabetes patient. Having a large meal can raise blood sugar fast so it is wise to eat the same amount of food 3-4 times a day.

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Exercise

Get more physical activity
Reduce stress
Lose Weight
Meditation, prayer, or exercise

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Get more physical activity;

All kind of physical activities helps us to keep our blood sugar down. Fast walking, dancing, swimming, or any light exercise for 30 minutes a day helps and treats diabetes in pregnancy. However, exercise may make our blood sugar drop low. In order to prevent this, eating protein-rich food at the meal before exercise helps. If we know that our sugar is dropping, we can stop and have fresh fruit juice, have some glucose water to reverse it.

Reduce stress

Stress is an inevitable and constant stress in our life cause several health problems, including raising our blood sugar. So it is a good practice to manage stress in our lives and learn coping strategies. Some yoga, meditation, prayers may also help in lowering stress levels.

Losing weight: Weight gain is one of the risk factors for type-2 diabetes mellitus. Losing weight increases self-confidence, lead to a healthier and better life. For many people, losing weight is very hard to stay focused on controlling your blood sugar, increasing physical activity, eating healthy, and lowering stress will also contribute to losing weight.

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Blood Sugar Monitoring

Teach mothers about frequent glucose monitoring to determine insulin need (at least four checks during the day)

Want blood glucose level between 80-100
Fasting Before Lunch
2 hr Postprandial (after a meal)
Dinner
2 hours after dinner

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If Insulin Therapy is Required…

Patient education is essential for the patient with gestational diabetes. The mother will need to know the signs and symptoms of hypoglycemia and the necessary actions to take and the method of calculating and self administering insulin.

Actions for hypoglycemia( blood sugar below 80):

Crackers
Glucose tablets
Juice
Glucagon injection

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Insulin therapy is a critical part of treatment for people whose sugar level is cannot be maintained in normal parameters. The goal of insulin therapy is to maintain the glucose (sugar) level within the normal target range. In this process, insulin is given subcutaneously or intravenously using syringe or syringe pump tubings, or by an insulin pen. During this process, a mother and a healthcare provider are aware that the sugar level may fluctuate and even drop down below the normal level at times. Both parties should have a clear understanding of the signs and symptoms of hypoglycemia. Certain protocols are to be followed during hypoglycemia (may vary with the centers and hospitals). Overall, glucose tablets, glucose water, crackers, sugar biscuits, juice are generally given for a hypoglycemic episode. Glucagon injection is the last resort to revert the glucose level to normal.

Glucagon: It's used to treat severe low blood sugar (severe hypoglycemia). Glucagon works by telling your body to release sugar (glucose) into the bloodstream to bring the blood sugar level back up. Sometimes you might miss a meal, exercise too much, or not eat enough food for the amount of insulin you've taken.

Patients with diabetes should be aware of the symptoms of hypoglycemia (low blood sugar). These symptoms may develop in a very short time and may result from:

using too much insulin (“insulin reaction”) or as a side effect from oral antidiabetic medicines
delaying or missing a scheduled snack or meal
sickness (especially with vomiting or diarrhea)
exercising more than usual.

Unless corrected, hypoglycemia will lead to unconsciousness, convulsions (seizures), and possibly death. Early symptoms of hypoglycemia include anxious feeling, behavior change similar to being drunk, blurred vision, cold sweats, confusion, cool pale skin, difficulty in concentrating, drowsiness, excessive hunger, fast heartbeat, headache, nausea, nervousness, nightmares, restless sleep, shakiness, slurred speech, and unusual tiredness or weakness.

Symptoms of hypoglycemia can differ from person to person. A patient with diabetes must learn the signs of low blood sugar so that s/he can treat it quickly. It is also a good idea to check the blood sugar to confirm that it is low.

He/she should know what to do if symptoms of low blood sugar occur. Eating or drinking something containing sugar when symptoms of low blood sugar first appear will usually prevent them from getting worse, and will probably make the use of glucagon unnecessary. Good sources of sugar include glucose tablets or gel, corn syrup, honey, sugar cubes or table sugar (dissolved in water), fruit juice, or non-diet soft drinks. If a meal is not scheduled soon (1 hour or less), he/she should also eat a light snack, such as crackers and cheese or half a sandwich, or drink a glass of milk to keep the blood sugar from going down again. One should not eat hard candy or mints because the sugar will not get into your bloodstream quickly enough. Such patients also should not eat foods high in fat such as chocolate because the fat slows down the sugar entering the bloodstream. After 10 to 20 minutes, blood sugar should be checked again to make sure it is not still too low.

If the symptoms do not improve after eating or drinking sweet foods, Such a condition needs medical help he/she has to go to the hospital right away. It, not a good idea to drive, use machines, or anything dangerous until sweet food is taken.

Glucagon may cause serious allergic reactions, including anaphylaxis. Anaphylaxis can be life-threatening and requires immediate medical attention. A doctor has to be called in case of rash, itching, trouble breathing, trouble swallowing, any swelling of hands, face, or mouth, or lightheadedness, dizziness, or fainting while receiving this medicine.

If severe symptoms such as convulsions (seizures) or unconsciousness occur, the patient with diabetes should not be given anything to eat or drink. There is a chance that he or she could choke from not swallowing correctly. Glucagon should be given and the patient's doctor should be called at once.

If it becomes necessary to inject glucagon, a family member or friend should know the following:

After the injection, turn the patient on her left side. Glucagon may cause some patients to vomit and this position will reduce the possibility of choking.
The patient should become conscious in less than 15 minutes after glucagon is injected, but if not, a second dose may be given. Get the patient to a doctor or hospital emergency care as soon as possible because being unconscious too long can be harmful.
When the patient is conscious and can swallow, give him or her some form of sugar. Glucagon is not effective for much longer than 1½ hours and is used only until the patient can swallow. Fruit juice, corn syrup, honey, and sugar cubes or table sugar (dissolved in water) all work quickly. Then, if a snack or meal is not scheduled for an hour or more, the patient should also eat some crackers and cheese or half a sandwich, or drink a glass of milk. This will prevent hypoglycemia from occurring again before the next meal or snack.
The patient or caregiver should continue to monitor the patient's blood sugar. For about 3 to 4 hours after the patient regains consciousness, the blood sugar should be checked every hour.
If nausea and vomiting prevent the patient from swallowing some form of sugar for an hour after glucagon is given, medical help should be obtained.

The doctor has to be informed of any hypoglycemic episodes or use of glucagon even if the symptoms are successfully controlled and there seem to be no continuing problems. Complete information is necessary for the doctor to provide the best possible treatment of any condition.

In the case of another hypoglycemic episode, the supply of glucagon has to be made ready.

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Close communication with Care Providers

It is equally important to remain in close contact with the health care provider so that a pregnant woman and provider discuss progress
Routine check-ups and follow-ups
Set glycemic Targets
Close monitoring of baby
Making essential preparation for delivery

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What Would the Nurse Do?

Ms. Ambi, 30 years old female, comes to your clinic and says she has diabetes and wants to become pregnant. She is currently under oral diabetic medications and says that her glucose has remained normal for long time.

What would the nurse want to be sure to share with Ms.Ambi?

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Nurse's Response: "If you have diabetes and want to become pregnant, it is best to control blood sugar levels before starting your pregnancy. The care provider might run a few tests to see how medications are working to control your blood sugar level.”

The woman should consult a Diabetologist if she is taking medication for diabetes (medication may need to be changed during the pregnancy).

Though a mother does not pass diabetes to the fetus, diabetes may affect the infant’s development in the womb including macrosomia (large infant).

Infants need to be monitored closely after birth because their blood sugar levels may drop in response to their mother’s high glucose levels.

The nurse should also share information on exercise, diet, weight, and the importance of maintaining a normal glucose level before and during pregnancy.

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Red Flags

Symptoms of increased Nausea, vomiting, polyuria, polydipsia, and changes in mental status could indicate diabetes
Note alteration in lab tests: Hyperglycemia, ketonemia, and renal dysfunction during 3rd trimester of gestation
Decreased movement of the baby (stillborn). Be sure to teach the mother how to record fetal daily movements

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Cultural Considerations

In some communities, people follow the elders advice for the diet of diabetes rather than the visiting the doctor
There are some communities in Nepal where People believe that eating for two during pregnancy expected, and more weight gain and eating sweets are considered beneficial

How would the nurse address these considerations?

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References:

BetterCare Learning programs (n.d). Medical problem during Pregnancy, labor and the puerperium: Diabetes Mellitus in pregnancy. Retrieved on 23^rd of September 2020 from https://bettercare.co.za/learn/primary-maternal-care/text/07.html#diabetes-mellitus-in-pregnancy

Friel. L. A. (2020). Merck Manual: Diabetes Mellitus in Pregnancy. Retrieved on 23^rd of September 2020 from https://www.merckmanuals.com/professional/gynecology-and-obstetrics/pregnancy-complicated-by-disease/v1071954?query=gestational%20diabetes

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References:

Health Wiki (2020). New Where There Is No Doctor : Diabetes. Retrieved on 22^nd of September 2020 from https://en.hesperian.org/hhg/New_Where_There_Is_No_Doctor:Chapter_21:_Diabetes

Nation Health Service (2019). Gestational diabetes: Symptoms. Retrieved on 24th September 2020 from https://www.nhs.uk/conditions/gestational-diabetes/

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