Gestational Diabetes Mellitus

High-Risk OB Care Plan: Gestational Diabetes Mellitus

Under Development

 

Basic Information

Maternal History and Data Collection

• EDC: estimated date of conception
• Gestational age: 37 weeks
• Prenatal history:G₃ T₃ P₀ A₀ L₃
• Delivery type: vaginal delivery, cesarean delivery

Clinical Manifestations of GDM

Signs of Hypoglycemia and Hyperglycemia

• Hypoglycemia: “Cold and clammy, need some candy,” and the TIRED acronym
• Hyperglycemia: “Hot and dry, sugar high,” and the 3 P’s of Hyperglycemia

The 3 P’s of Hyperglycemia

• Polydipsia
• Polyuria
• Polyphagia

Hypoglycemia Acronym: TIRED

• T: Tachycardia
• I: Irritability
• R: Restlessness. The patient may feel anxious
• E: Excessive hunger
• D: Diaphoresis
• C: Confusion. The brain requires an adequate glucose stores for proper functioning
• C: Cold and clammy skin

Possible Assessments Findings in the Newborn 

• Macrosomia, or a baby that’s large for the gestational age
• Alert
• Reddish skin tone
• Hypoglycemia

Diagnosis of Gestational Diabetes Mellitus

1-Hour Glucose Screening Test

• 24 and 28 weeks gestation, a glucose pre-load drink is given and then the woman’s glucose is checked in 1 hour
• Normal findings are under 140mg/dL
• If abnormal findings are discovered, the provider will order a GTT next

2-Diagnostic Criteria for GMD

• Abnormal OGTT accompanied by an abnormal 1 hour glucose screening test
• Two out-of-range results for both the OGTT and the 1 hour glucose screening test must occur at least two times on separate days to meet the diagnostic criteria for GDM

Abnormal OGTT Glucose Values

• Fasting glucose levels: greater than 95 mg/dL
• OGTT 1 hour: greater than 180 mg/dL
• OGTT 2 hour: greater than 155 mg/dL
• OGTT 3 hour: greater than 140 mg/dL

Treatment of GDM

Management of Gestational Diabetes Mellitus

• If the condition is minor, the provider may initially recommend lifestyle changes, including increased physical activity and dietary modifications
• If the initial findings are severe or if lifestyle changes have failed to produce the desired results, pharmacology therapy is used
• The first-line treatment approach is insulin, oral hypoglycemia agents are generally not used to manage GDM
• There is a high level of patient teaching involved in insulin therapy, including equipment, storage, and administration techniques
• The patient will be scheduled for more frequent visits in order to provide diligent monitoring
• A non-stress test is often performed in order to assess fetal stability
• Due to the risks associated with macrosomia, planned induction is usually scheduled prior to 40 weeks
• GDM usually discontinues shortly after delivery as glycemic function is restored to pre-disease levels but it may persist past the postpartum period in some cases
• Following delivery, the newborn’s glucose levels are monitored as the infant is at an increased risk of being hypoglycemic

Insulin for Gestational Diabetes Mellitus

• Rapid-acting
• Regular or short-acting
• Intermediate

Fetal and Neonatal Complications

Potential Risks to the Fetus

• Intrauterine oxygen insufficiency
• Ketoacidosis: this complication is especially dangerous for the unborn infant- it poses a mortality rate of 50%

Potential Risks to the Neonate

• Congenital anomalies (50% more likely)
• Respiratory distress syndrome (RDS) is more common
• The infant may be small for gestational age (SGA) if the mom has vascular problems, or be large, with a birth weight above the 90th percentile
• Macrosomia: large birth weight (over 4,000 grams) resulting from excessive intrauterine growth secondary to abundant glucose supply. Although infants often appear healthy and robust, it’s important to remember that they may still be internally undeveloped for their gestational age
• Neonatal hypoglycemia: may be present upon birth due to the infant’s loss of the intrauterine “sugar IV”
• Hyperinsulinemia fluctuates glucose levels and promotes maternal blood involvement, which decreases oxygenation
• Injury related to traumatic birth: shoulder dystocia (Hoffert-Gilmartin, Ural, & Repke, 2008)
• Premature birth

Neonatal Predispositions to Abnormal Lab Values

• Hyperbilirubinemia
• Hypoglycemia
• Cord blood serum C-peptide level: often above the 90th percentile (Hoffert-Gilmartin, Ural, & Repke, 2008)

Maternal Complications

Why the Mother is at Risk

The woman faces increased risks of a traumatic delivery and is more likely to need a cesarean section, both planned and emergency. Delivering a large infant predispositions her to genital lacerations and associated issues such as hematoma and hemorrhage. Complications secondary to GDM that not related to gestation are similar that of type I and type II diabetes mellitus except that there’s less time to develop long-term damage from chronic hyperglycemia. For instance, vascular damage occurs over time so the patient is unlikely to develop issues such as neuropathy.

Potential Risks to the Mother

• Uterine infection
• Genital lacerations: trauma from delivering an infant that is excessively large
• Cesarean delivery

Nursing Care

Maternal Assessment Data Collection

• Obtain weight, height, and BMI
• Check blood glucose
• Check bilirubin levels and monitor for signs of jaundice
• Assess vital signs and status frequently
• Coordinate tasks for additional monitoring, including increased frequency of visits to with the provider and non-stress test

Newborn Assessment Data Collection

• Obtain weight
• Check blood glucose
• Assess vital signs and status frequently
• Monitor frequently for thermoregulation function
• Listen to heart sounds and report any suspicions of a murmur to the provider

Potential Nursing Diagnoses for the Infant

• Hypoglycemia

Potential Nursing Diagnoses for the Mother  

• Hyperglycemia or hypoglycemia

Labor Assessment

Cervical Exam

• Dilation
• Effacement
• Station

Membranes

• Intact or ruptured
• Signs of placenta previa or abrupto placenta?

Contraction

• Regular or irregular
• Frequency
• Duration
• Intensity

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