04.05 Gestational Diabetes (GDM)

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Study Tools

Outline

Overview

  1. Patient may have DM to start with or develop gestational DM
  2. Pregnancy can cause insulin resistance

Nursing Points

General

  1. Gestational DM is diabetes that is diagnosed in pregnancy in someone who has never been diagnosed with it otherwise.
  2. The pancreas can’t respond to the increased insulin requirements coupled with increased insulin resistance from hormone increases
  3. Changes in carb metabolism change insulin requirements
  4. Baby makes own insulin but needs glucose, therefore pulls glucose from mom and can make mom more likely to be hypoglycemic

Assessment

  1. Maternal changes are as follows:
    1. 1st trimester: insulin needs go down
    2. 2nd and 3rd trimester: insulin resistance occurs when hormones increase
    3. Right after delivery: after placenta is delivered, hormones and insulin requirements decrease
      1. Gestational diabetics should no longer require insulin or diet management post delivery
  2. Newborn changes/issues
    1. The baby grows faster and larger, but their function is still reflective of age and not size
    2. Macrosomic = 4000g
  3. Assessments
    1. Screen for diabetes mellitus during prenatal visits
    2. Screen for glucose and protein in urine at regular prenatal visits (glucosuria and ketonuria)
    3. Check blood sugar between 24-28 weeks with glucola testing

Therapeutic Management

  1. Ideal to control with diet and exercise
  2. Monitor for typical DM complications (signs of infection, HTN, edema, proteinuria)
  3. Closely watch mother and newborn’s glucose during labor and delivery as labor depletes glycogen
  4. Make dietary recommendations based on what you note their glucose is and their insulin requirements (if any)
  5. Referral to endocrinology

Nursing Concepts

  1. Glucose Metabolism
  2. Patient Education

Patient Education

  1. Hypoglycemia/hyperglycemia symptoms
  2. Management of blood glucose
  3. Insulin administration
  4. Self-monitoring of glucose
  5. Use of a daily log for glucose levels
  6. Diet and exercise requirements
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Transcript

In this lesson I will explain gestational diabetes and you role in providing care for this patient.

Gestational diabetes is diagnosed in pregnancy around 28 weeks. This is in a patient that has never been diagnosed with diabetes. The body can’t respond to the increased insulin requirements and there is also insulin resistance occurring from hormone increases. Carbohydrate metabolism also changes insulin requirements. The fetus can make its own insulin so it will secrete its own insulin to battle the blood sugar. The baby is getting sugar from mom because sugar crosses the placenta. This can make mom hypoglycemic. So a fun fact is that Baby makes own insulin but needs glucose, therefore pulls glucose from mom and can make mom more likely to be hypoglycemic. Another piece to this is if too much sugar is crossing the placenta because of maternal hyperglycemia then the baby makes more insulin for it and insulin is a growth hormone. So insulin is what grows a large baby in a diabetic mom secondary to the high sugar.

A lot of changes are occurring on the maternal side. In the first trimester the insulin needs go down. The bodies metabolism has sped up and is working hard to grow a baby so blood sugars are low at first and the body doesn’t require a lot of insulin. Then in the 2nd and 3rd trimester the insulin resistance starts. The hormone levels have increased and so insulin needs increase. This is why the glucola screening for gestational diabetes is done at this time. So what happens after the baby is born? Right after delivery the hormones take a plummet and insulin requirements decrease. This patient will usually get one more blood sugar check the next morning but should not require any more insulin or diet control.
So what is happening with the newborn? The baby is growing faster and larger. They are more likely to be macrosomic which is a child over 4000g. 4000g is going to be over 8.5 pounds, around 8 pounds 8 oz! So big baby! Keep in mind that the baby is growing faster and larger, but it doesn’t mean that the baby is able to function earlier on the outside just because they are bigger. After delivery blood glucose monitoring will happen for the infant because remembered the glucose crossed the placenta so if mom had a bunch of blood sugar crossing the placenta and the baby makes extra insulin then that constant sugar source is gone after the baby is born. So because of this we need to monitor the blood sugar on the baby. The blood sugar range is 40-50 on a baby so lower then on an adult.
Therapeutic management will involve giving education on diet and exercise. If they are on insulin then they need to learn how to dose based on their blood sugar. We also need to monitor for typical complications with diabetes. These would be signs of infection, hypertension, extra edema, and, proteinuria. Glucose will be closely monitored for the mother and then the baby will be monitored after delivery. A referral to endocrinology will be done to help with management.

The key points to know for gestational diabetes is that gestational diabetes only occurs in pregnancy. There is greater insulin resistance because of all the extra hormones. The increased weight puts the patient at greater risk also. Our treatment will include diet changes and or insulin therapy.

There is a lot of education needed for gestational diabetes. Hypoglycemia and hyperglycemia symptoms need to be taught so the patient knows what to watch for. They need to know how to manage their blood glucose. So how much insulin to give based on the reading or how much to eat if the blood sugar is low. Insulin administration needs to be taught if they require insulin. So this is instructions on drawing it up and using the needle and properly disposing of it. They need to know how to self-monitor their glucose because they are going to be at home and needing to take control of it. The patient should also be educated on keeping a daily log for glucose levels so she can see what different food items do to the blood sugar and also have a reference to give to the physician. Diet and exercise requirements should also be educated on. What kind of exercises would be good? What are healthy food items? How to carbohydrate count? Healthy snack options.

Make sure you check out the resources attached to this lesson and review the things that make it worse. Now, go out and be your best selves today. And, as always, happy nursing.

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