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Case Study On Gestational Diabetes Mellitus

Gestational diabetes mellitus (GDM), also known as type III diabetes mellitus, is one of the most common type of diabetes mellitus and considered the most common complications of pregnancy. This health problem is like pregnancy-induced hypertension (PIH) that develops during pregnancy and disappears after the delivery of the 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.

FACTS ABOUT INSULIN

Knowing the facts about insulin facilitates the understanding of gestational diabetes mellitus. Or any form of diabetes for that matter. This creates/develop ideas on how and why such health problems occur.

  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:
      1. Carbohydrates—utilization of glucose by the cells
      2. Proteins—conversion of amino acids to replace muscle tissues
      3. Fats—conversion of excess glucose to fatty acids and store them to adipose tissues
      4. Endothelial and nerve cells are the only cells/tissues that can use glucose even without insulin.
      5. Low insulin level causes the rise in plasma glucose concentration and glycosuria.
      6. Diabetes mellitus develops as the body secretes low amount or as body cells reject its utilization.

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 automatic 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 placental lactogen, estrogen, and progesterone to cause the following effects: 1. antagonizes the effects of insulin, 2. prolong the elevation of stress hormones (cortisol, epinephrine, and glucagon), and 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 protective mechanism that predisposes a pregnant mother in the triggering of her pre-diabetic state or heighten 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 in glucose level and return to its pre-pregnant state.

CAUSES AND INCIDENCE

The primary cause of is almost the same with the other types of diabetes. The inability of the body to produce or synthesize sufficient amount of insulin in response to glucose level (as in type I DM), or the body’s rejection of insulin (as in type II DM) shows significant relationship on the development of any form or diabetes. The existence of either of these problems, plus, the interaction of protective mechanism in pregnancy doubles the occurrence of GDM.

The incidence of gestational diabetes mellitus is almost 3% in all pregnancies and 2% in all women with diabetes before pregnancy.

GDM causes high incidence of fetal morbidity and unwanted complications such as polyhydramnios and macrosomia in fetus.

RISK FACTORS

For some clear and unclear pathological reasons, the following are considered the risk factors in the occurrence/development of GDM:

  1. Obesity
  2. Family history of DM
  3. Age of 45 or older (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 Americans, Latino, and native Americans
  7. History of previous GDM
  8. With any level of hypertension
  9. With elevated high-density lipoprotein

SIGNS AND SYMPTOMS

The clinical manifestations of gestational diabetes mellitus coincide with the signs and symptoms of the other types of diabetes mellitus. These are popularly known as the “3 P’s” or polydipsia (excessive thirst), polyphagia (excessive hunger), and polyuria (frequent urination). Aside from these manifestations, there are also other signs and symptoms that are general manifestations and pregnancy-specific manifestations.

GESTATIONAL DIABETES MELLITUS

DIABETES MELLITUS (GENERAL)

  1. Higher glucose level (20-30 mg/dL) than the pre-pregnant level
  2. Very rapid weight gain
  3. Polyhydramnios
  4. Recurrent monilial infections
  5. Glycosuria
  6. Nocturia
  7. Large for gestational age (LGA) or small for gestational age (SGA) fetus
  8. More severe state of edema
  1. Blurred vision
  2. Vulvar pruritus
  3. Paresthasia
  4. Peripheral neuropathy
  5. Weakness
  6. Normal/elevated pulse rate and temperature
  7. Normal/decreased blood pressure
  8. Kussmaul’s respirations
  9. Dehydration
  10. Recurrent infections
  11. Non-healing wounds

PATHOPHYSIOLOGY

COMPLICATIONS

The chronic effects or the uncontrolled glucose level during pregnancy would lead to the development of the following complications:

  1. Urinary tract infection (UTI)
  2. Infertility
  3. Stillbirth
  4. Preterm labor and delivery
  5. Pregnancy-induced hypertension (PIH)-pre-eclampsia and eclampsia
  6. Congenital anomalies
  7. Spontaneous abortion

Also, a woman who developed or experienced gestational diabetes mellitus is expected to have type II diabetes mellitus within 5 years for the rest of her life.

PROGNOSIS

The prognosis or the chance of the mother and/or fetus for survival depends on the maternal ability to tolerate and adjust to high glucose level, medical management, and obedience to treatment regimen. This means that, the more cooperative and responsive the mother to treatment regimen is, the better chances of both maternal and fetal well being are.

DIAGNOSIS

The performance of the following diagnostic tests aims to determine the level of diabetes present in the pregnant mother and determine its extent of damage or impending effects. This serves as the basis for the plan of care for the mother and the fetus.

  1. 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.
  2. Glucose tolerance test (GTT)—to evaluate the response of insulin to loading glucose.
  3. Glycated haemoglobin (Glycohemoglobin)—measures glycemic control byy evaluating the attachment of glucose to freely permeable erythrocytes during their whole life cycle.
  4. C-peptide Assay (connecting peptide assay)—useful when the presence of insulin antibodies interferes with direct insulin assay.
  5. Fructosamine assay—is much more useful than glycosylated haemoglobin tests in cases of haemoglobin variants.
  6. 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.
  7. Amniocentesis
  8. Non-stress test
  9. 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

The overall goal of management for gestational diabetes mellitus is the control of the maternal glucose level and keep it on normal or near-normal level to prevent the development of complications that might compromise both the mother and the fetus. The most significant of these managements is the use of insulin. This is the most potent, yet, requires accuracy and monitoring of its unwanted effect (hypoglycaemia) that brings immediate danger to both the mother and the fetus. Proper timing, dosage, and knowledge on counteractions of its over-reaction are vital concepts to be incorporated in the health education.

Along with this, health promotion and disease prevention activities like diet, exercise, and fetal monitoring are of great importance.

NURSING MANAGEMENTS

Assessment

History taking on:

    1. First presentation of the manifestations of diabetes (3 P’s)
    2. First diagnosis of DM
    3. Family members with DM

Review of systems:

  1. Weight gain, increasing fatigue/weakness/tiredness
  2. Skin lesions, infections, hydration, signs of poor wound healing
  3. Changes in vision—floaters, halos, blurred vision, dry/burning eyes, cataract, glaucoma
  4. Gingivitis, periodontal disease
  5. Orthostatic hypotension, cold extremities, weak pedal pulses
  6. Diarrhea, constipation, early satiety, bloating, flatulence, hunger and thirst
  7. Frequent urination, nocturia, vaginal discharge
  8. Numbness and tingling of the extremities, decrease pain and temperature sensation

Intervention

1. Nutrition

    • Assess timing and content of meals
    • Instruct on importance of a well-balanced diet
    • Explain the importance of exercise
    • Plan for a weight reduction course

2. Insulin use

    • Encourage verbalization of feelings
    • Demonstrate and explain insulin therapy
    • Allow client to do self-administration
    • Review mastery of the whole process

3.  Injury from hypoglycaemia

    • Monitor maternal blood glucose level
    • Instruct on insulin-activity-diet interaction
    • Teach on the signs and symptoms of hypoglycaemia
    • Teach/present list of things/foods that need to be available at all times (in cases of hypoglycaemic attacks)
    • Have identification band indicating the health condition (DM) for fainting instances

4. Activity tolerance

    • Plan for regular exercise
    • Increase carbohydrate intake before exercise
    • Instruct to avoid exercise if blood glucose level exceeds 250 mg/dL and urine ketones are present
    • Advise to use abdomen for insulin injection if arms and legs are used for exercise

5. Skin integrity

    • Avoid alcohol use, instead, lotion
    • Teach on proper foot care
    • Advise to stop smoking and alcohol use

6. Fetal well-being

    • Continuous monitoring of fetal activities and fetal heart tone
    • Monitor fetal activities during maternal activities
    • Monitor early signs of labor
    • Advice to report of any discharge coming from the vagina
    • Monitor daily weight and advice to report on rapid weight gain

7. Educative

    • Teach on lifestyle modifications
    • Advice to see  psychologists with other family members for therapy on the possibilities of fetal abnormalities
    • Advice to call emergency response team in cases of emergency
    • Advise to religiously follow health instructions

EVALUATION

  1. Body weight is within the normal range for the age of gestation.
  2. Demonstrates proper technique in self-administration of insulin
  3. No episodes of hypoglycaemia as claimed by the client
  4. No skin problems/lesions
  5. Verbalizes readiness on the possible fetal defects.
  6. Stable fetal heart rate

Originally posted 2013-06-30 05:09:14. Republished by Blog Post Promoter

A Registered Nurse with Master of Arts in Nursing, Major in Medical-Surgical Nursing. Worked as a Clinical Instructor for 5 years.

Case Study

A 29-year-old woman at 20 weeks' gestation visits your office for a routine prenatal examination. This is her second pregnancy, and she has gained 15 lb (6.8 kg). According to her medical record, the patient's prepregnancy body mass index (BMI) was 27 kg per m2. She mentions that her father was recently diagnosed with diabetes, and she asks whether she should be tested for diabetes.

Case Study Questions

  1. Based on the U.S. Preventive Services Task Force (USPSTF) recommendation on screening for gestational diabetes mellitus, what is the most appropriate approach to this patient?

    • A. Screen for gestational diabetes at this visit with a one-hour oral glucose challenge test.

    • B. Schedule a three-hour oral glucose tolerance test at her 24-week visit.

    • C. Explain the risk factors for gestational diabetes, and discuss potential benefits and harms of screening.

    • D. Do not screen for gestational diabetes because she did not have gestational diabetes with her first pregnancy or pregestational diabetes.

    • E. Do not screen for gestational diabetes because a false-positive test could cause prolonged psychological harm.

  2. Which one of the following statements is the best assessment of the patient's risk of gestational diabetes?

    • A. She is at increased risk if she is white.

    • B. Her age puts her at lower risk of gestational diabetes.

    • C. She is not at increased risk because she did not have gestational diabetes in her previous pregnancy.

    • D. Her age and prepregnancy BMI increase her risk of gestational diabetes fivefold.

    • E. Her prepregnancy BMI increases her risk of gestational diabetes.

  3. Which of the following approaches to gestational diabetes prevention is/are recommended for this patient?

    • A. Encourage participation in physical activity.

    • B. Counsel her on achieving appropriate weight gain based on her prepregnancy BMI.

    • C. Prescribe an oral hypoglycemic agent.

    • D. Recommend an appropriate diet to regulate her blood sugar.

Answers

1. The correct answer is C. The USPSTF found insufficient evidence to assess the balance of benefits and harms of screening pregnant women for gestational diabetes mellitus before or after 24 weeks' gestation. It is not known whether screening for gestational diabetes improves health outcomes for mothers or infants; therefore, physicians and patients should make decisions on a case-by-case basis. Although positive screening results are common, fewer than one in five women with an abnormal glucose challenge test will meet criteria for gestational diabetes with an oral glucose tolerance test.

Women with diabetes diagnosed before pregnancy (pregestational diabetes) are at increased risk of maternal and fetal complications; however, the degree to which pregnant women with gestational diabetes are at increased risk of complications is less certain. The evidence is poor to determine whether important health outcomes such as mortality, brachial plexus injury, clavicular fracture, or admission to the neonatal intensive care unit are reduced by screening for gestational diabetes after 24 weeks' gestation.

In the United States, the most common laboratory screening test for gestational diabetes is the 50-g one-hour glucose challenge test. Most screening occurs between 24 and 28 weeks' gestation. There is little evidence on the value of screening earlier in pregnancy. If the glucose challenge test result is abnormal, the patient should undergo a 100-g three-hour oral glucose tolerance test to confirm the diagnosis of gestational diabetes.

Available evidence suggests that potential psychological and physical harms of gestational diabetes screening, such as short-term anxiety, do not persist late into the third trimester.

2. The correct answer is E. Without a history of previous gestational diabetes or a family history of diabetes, a woman is considered to be at low risk of gestational diabetes if all of the following factors apply: white ethnic origin, BMI less than 25 kg per m2, and age younger than 25 years. This patient is at increased risk of gestational diabetes because of her family history of diabetes, her age, and her prepregnancy BMI. Women of certain ethnic groups (e.g., Hispanics, American Indians, Asians, blacks) are at increased risk of gestational diabetes. Although women at low risk are less likely to benefit from screening for gestational diabetes, the absolute difference in the prevalence of gestational diabetes between low-risk patients (1.4 to 2.8 percent) and high-risk patients (3.3 to 6.1 percent) is relatively small.

3. The correct answers are A and B. Nearly all pregnant women should be encouraged to participate in moderate physical activity and to achieve moderate weight gain based on their prepregnancy BMI. Healthy pregnancy weight gain for women at normal weight is 25 to 35 lb (11.3 to 15.8 kg). Women who are overweight or obese should gain less weight.

For a confirmed diagnosis of gestational diabetes, treatment options include dietary management, physical activity, oral hypoglycemic agents, insulin, and insulin analogues.

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