Diabetes Mellitus is an endocrine disorder that
effects insulin production. It is a syndrome characterized by chronic
hyperglycemia and improper metabolism of nutrients (McCance, 2002). Improper
metabolism is related to the inability of the pancreas to produce enough
insulin facilitate glucose movement into the cells. Insulin is the
determining factor that allows glucose to enter the cells. Therefore, glucose
remains in the blood stream and causes hyperglycemia to occur (Olds, 2000).
Gestational diabetes is the occurrence of diabetes during pregnancy.
Approximately seven percent of all pregnancies are complicated by gestational
diabetes (American Diabetes Association, 2002).
This topic was chosen out of curiosity as well
as the need to gain knowledge of this disease. Diabetes is complicated in
itself and gestational diabetes is a more acute risk that entails two lives
instead of one. It is a disease that requires careful monitoring of both
mother and child to ensure a safe pregnancy. Although some women have
diabetes before becoming pregnant, the purpose of this paper is to further
explore diabetes that is acquired during pregnancy.
Pathophysiology and Detection
As stated above, diabetes mellitus is related
to the inability of the pancreas to produce enough insulin. In the case of
gestational diabetes, the cause of the increased demand for insulin is related
to the fetus. The fetus receives insulin from the mother, therefore pregnancy
drastically alters the insulin demand.
Increased insulin requirements usually begin late in the first trimester as
glucose and glycogen stores begin to be depleted. Signs and symptoms can
range from glucosuria, ketonuria and polyuria to no symptoms at all (Shaw,
Detection is the single most important factor
in managing a woman with gestational diabetes. Risk assessment should be
performed during 24-28 weeks gestation. Women at a greater risk for
contracting gestational diabetes include those with a history of gestational
diabetes, obesity, glycosuria or a family history of diabetes. These women
need to be assessed for diabetes at the first prenatal visit and if no
symptoms are present, they need to be screened a second time at 24-28 weeks
gestation (American Diabetes Association, 2000).
Screening begins with a urinalysis to detect
the presence of glucose or ketones in the urine. A glucose challenge test is
also performed. This test involves a blood glucose test that is taken one
hour after ingestion of 50 grams of oral glucose. If her blood sugar level is
greater than 140, further testing is necessary (McFarland, 1997).
If a client does not ‘pass’ the glucose
challenge test, a glucose tolerance test is completed to either rule out or
diagnose gestational diabetes. This is a three hour, 100 gram oral glucose
test. The woman eats a high carbohydrate diet for three days before her test.
She is then instructed to fast for 8-14 hours. The morning of the test, she
ingests 100 grams of glucose. The plasma glucose is taken first at fasting,
then one, two and three hours after ingestion of the glucose. Actual
diagnosis of gestational diabetes occurs if two or more of the following
results are positive:
· Fasting with blood glucose >105
· 1 hour glucose level >190
· 2 hour glucose level > 165
· 3 hour glucose level > 145 (Olds, 2000).
Pharmacological and Non-pharmacological Treatments
Both pharmacologic and non-pharmacologic
measures are taken to manage care of a woman with gestational diabetes.
Nutrition counseling, exercise and insulin administration (if necessary) are
the three major interventions used.
In a study done in 2001, it was found that
light exercise following meals could help control blood glucose and
potentially avoid insulin therapy. Light exercise with an increased heart
rate of nine beats per minute is recommended in patients that do not have a
medical or obstetrical contraindication (Garcia-Patterson, 2001).
Nutrition is probably the most important factor
in trying to manage gestational diabetes. It is possible to control glucose
levels with diet alone. Counseling by a diabetic educator or dietician is
strongly encouraged. If this is not feasible, caloric intake and monitoring
should be taught to the patient. A diet should be well balanced with a
reduction of ‘sweets’. A pregnant woman needs about 300 more calories a day
compared to a non-pregnant woman. These calories should be divided into
small, frequent meals and include both complex carbohydrates and proteins to
prevent hypoglycemia during the night (McFarland, 1997). Monitoring blood
glucose is also essential in determining the diet. It can aid in assessing the
effect of the patients diet and let the patient know when to regulate her
If a client is unable to control her diabetes by diet, insulin must be
initiated. As pregnancy progresses the demand for insulin becomes greater. A
typical insulin regimen begins with small doses of intermediate and/or
regular insulin. This amount is adjusted throughout pregnancy as insulin
resistance increases. Oral glucose lowering agents are not recommended in
pregnancy because their safety has not yet been established (McFarland,
As a nurse, it is important to encourage
compliance to diet and exercise to try and prevent the use of insulin.
Teaching is a critical role the nurse plays in the case of gestational
diabetes. The more educated the patient, the better the chance she has of
managing and even controlling her disease and ensuring the safety of her
child. Fetal evaluation during pregnancy is essential as well. An ultrasound
is typically done at 18 weeks gestation and again at 28 weeks. Non-stress
tests are also performed at 28 weeks. Evaluation of maternal blood glucose
levels is also a responsibility of the nurse. Postpartum women usually have a
drastic decrease in insulin requirements. Assessment for hypoglycemia and establishing
a safe glucose level after birth are priority for the nurse (Olds, 2000). As
with all pregnancies, gestational diabetes or not, maternal-child bonding is
another priority for the nurse.
Risk to the Fetus
There are many risks to the fetus in a woman
who is diagnosed with gestational diabetes. These risks have been directly
related to the disease. Congenital anomalies and
severe maternal ketoacidosis put a fetus at risk for death. The anomalies are
often related to the nervous, cardiac and skeletal systems. Some infants are
born LGA, large for
gestational age, which results from increased levels of glucose crossing the
placenta. This case is commonly known as macrosomia. Intrauterine growth
restriction is another common problem in babies of gestational diabetes.
Other complications related to the fetus include respiratory distress
syndrome, hyperbilirubenemia and hypocalcemia (Olds, 2000).
Impact on Family
The impact on the family depends on the
severity of the outcome. If death is a result of complications from
gestational diabetes, the entire family is affected. These families need
special attention from the nurse and medical staff. Although the situation
may only last a few moments, the death of a child will be with the family
forever. Resources out of the hospital such as counseling should be
recommended and appropriate information should be given.
Gestational diabetes probably has the greatest
impact on the mother simply because she has to change her entire lifestyle in
order to protect herself and her child. The family may be impacted by the
emotional changes of the mother as well as lifestyle changes (i.e. diet).
There may have to be an increase in support due to the stress that is created
with a high-risk pregnancy.
Women that do end up with gestational diabetes
are at a higher risk to develop diabetes mellitus after pregnancy. It is
important to monitor for signs and symptoms
related to diabetes postpartum. Although gestational diabetes is a common
complication of pregnancy, it has an encouraging outcome if it is detected
early and appropriate interventions are taken. The primary goal of a nurse
caring for a mother with gestational
diabetes is to ensure the appropriate care of her and safe passage her child
throughout pregnancy and birth.
American Diabetes Association. (2002). Gestational diabetes mellitus.
Diabetes Care, 25(1), S94.
Garcia-Patterson, A.; Martin, E.; Ubeda, J.; et. al. (2001). Evaluation of Light
Exercise in the Treatment of Gestational Diabetes. Diabetes Care, 24 (11),
McFarland, K.; Pasui, K. (2002). Management of Diabetes in Pregnancy.
American Family Physician, 55 (8), 2731.
Olds, S., London, M., Ladewig, P. (2000). Maternal-Newborn Nursing. (6th ed.)
New Jersey: Prentice Hall Health.
Shaw, M. (Ed.). (2000). NCLEX-RN Review Made Easy. Pennsylvania: Springhouse