Gestational diabetes is a complication of pregnancy in which individuals with no history of diabetes have persistently elevated glucose levels. While the cause is not fully understood, hormone changes and dysfunction of pancreatic beta cells lead to an inability to regulate blood glucose levels during pregnancy. 

During a normal pregnancy, the mother’s body adapts across all body systems to accommodate the developing fetus. A key adaptation relates to insulin sensitivity and blood glucose levels. In the beginning stages of pregnancy, the mother becomes more sensitive to insulin and excess glucose is stored as fat for later use as pregnancy progresses. As gestation continues, placental hormones lead to insulin resistance and this causes glucose levels to increase. This extra glucose is transferred to the fetus to support its development and the mother’s pancreatic beta cells grow or shrink in response to changes in glucose levels. After the infant is born, the metabolic changes typically resolve within a few days.

Who is most at risk for this disease?

It’s important to note that all pregnant individuals have some level of insulin resistance during the later stages of pregnancy. Women who have insulin resistance prior to becoming pregnant start their pregnancies requiring more insulin and are more likely to develop gestational diabetes. Some specific risk factors include: 

  • Advanced maternal age
  • Pregnant with multiples
  • Decreased physical activity or being overweight 
  • History of gestational diabetes, prediabetes, hypertension, or polycystic ovary syndrome (PCOS)
  • Family history of diabetes
  • Prior delivery of an infant weighing more than 9 pounds (approx 4.1 kg)
  • Certain ethnicities: Black, Hispanic, American Indian, and Asian American

What are the complications of this condition?

Complications related to gestational diabetes can affect both the mother and the infant. 

Maternal complications include higher risk for hypertension and preeclampsia as well as an increased risk for developing type 2 diabetes or having gestational diabetes with future pregnancies. If a vaginal birth is attempted, other complications include prolonged labor, tears to the perineum, uterine rupture, and postpartum hemorrhage.

Fetal complications for unmanaged gestational diabetes include: 

  • Macrosomia, which is when an infant is significantly larger than average. An infant weighing more than ~9 pounds is considered macrosomic. This is due to elevated glucose levels causing the developing fetus to essentially be overfed and grow too large. Macrosomia increases the rate of a difficult birth, cesarean section and birth injuries such as shoulder dystocia, bone fractures, nerve palsy, cerebral palsy, and even infant death.
  • Preterm birth may be spontaneous or planned due to the large size of the fetus, and comes with many complications of its own including breathing problems and feeding difficulties.
  • Hypoglycemia can occur after the infant is born. In unmanaged gestational diabetes, the neonate’s system responds by secreting more insulin. Once born, the excess glucose source is no longer present and the infant becomes hypoglycemic.
  • Long term complications for the child include higher risk for type 2 diabetes and obesity.
  • Increased risk for death prior to or within months of birth.

Now let’s dive into the nursing implications using the Straight A Nursing LATTE Method.

L: How does the patient LOOK?

Gestational diabetes often does not have any presenting signs and symptoms for the mother, and is only discovered through routine lab testing. When symptoms are present they can include the three hallmark signs of diabetes – polyphagia, polydipsia and polyuria. When blood glucose levels are persistently elevated, the patient may also complain of fatigue, blurred vision, nausea, vomiting, and weight loss despite an increase in appetite. Additionally, the individual may also have more frequent infections, especially bladder or vaginal infections.

An infant born to a mother with unmanaged gestational diabetes may show outward signs such as: 

  • Larger than normal size
  • Hypoglycemia
  • Preterm birth and any associated difficulties with breathing or feeding
  • Jaundice
  • Birth injury due to cephalopelvic distortion

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A: How do you ASSESS a patient with gestational diabetes?

Two key assessments for a patient with gestational diabetes are to monitor for signs of hypoglycemia and hyperglycemia. Hypoglycemia is a risk for anyone taking glucose lowering medications and often manifests as shakiness, irritability or confusion, sweating, cool skin, palpitations, headache, dizziness, and hunger. When severe, hypoglycemia can cause a decreased level of consciousness.

Common signs of hyperglycemia include increased urination, thirst and hunger. Other signs include blurred vision, nausea, and vomiting. If the hyperglycemia progresses to diabetic ketoacidosis, the hallmark signs are fruity smelling breath, Kussmaul respirations (which are rapid and deep) and altered or decreased LOC.

T: What TESTS will be conducted for gestational diabetes? 

Screening

Screening for gestational diabetes is conducted on all pregnant individuals between their 24th and 28th week, though early screening may be warranted for those at high risk. There are two types of tests – the glucose challenge test and the glucose tolerance test. 

Glucose challenge test – This test is conducted as a routine part of prenatal care and is the first test done to evaluate the patient for gestational diabetes. In this test, the patient drinks a solution containing 50 gram glucose and has their blood sugar tested in one hour. If the blood glucose level is abnormal, then a glucose tolerance test is conducted.

Glucose tolerance test – In this test, the patient fasts prior to the exam and a baseline glucose level is measured prior to the ingestion of a solution containing 75 grams glucose. Blood is drawn after one hour and then again at the two hour mark. A third sample may be taken at the three hour mark if needed.

Diagnostic criteria for gestational diabetes:

  • 180 mg/dL or higher at the one hour mark 
  • 153 mg/dL or higher at the two hour mark 
  • 140 mg/dL or higher at the three hour mark

During pregnancy and labor

Throughout pregnancy, the patient will have frequent prenatal visits as gestational diabetes places them into the high-risk category. At these visits the patient will have their blood glucose , blood pressure, and dipstick urine protein assessed (remember, these patients are at higher risk for preeclampsia!). The baby’s growth and development will also be carefully monitored via ultrasound and nonstress testing. The non-stress test (NST) involves the patient wearing a monitor to assess fetal heart rate while at rest for a period of 20 – 30 minutes (longer assessment periods may be utilized if the patient has been involved in a trauma, is bleeding, or has experienced decreased fetal movement.)

During active labor or with an epidural, blood sugar levels are often tested hourly due to the risk for both hypoglycemia and hyperglycemia.

After delivery

Since 15 to 60% of individuals with gestational diabetes develop type 2 DM, blood glucose levels are also evaluated after delivery and again six to twelve weeks later. 

T: What TREATMENTS are provided for gestational diabetes?

The evidence shows that outcomes for both mom and baby are significantly improved when gestational diabetes is detected and treated in a timely manner. Treatments for gestational diabetes include diet, exercise, and medication when needed. 

  • Diet – Diet is first line therapy for women with gestational diabetes. A dietician helps the patient develop an eating plan that accommodates food preferences, weight, and blood glucose levels. Studies show that about 75% of pregnant women with gestational diabetes can positively impact their blood glucose levels with diet and exercise.
  • Physical activity – The American Diabetes Association recommends pregnant individuals aim for at least 20 minutes of physical activity per day or 150 active minutes per week.
  • Medication – When needed, the most commonly prescribed medication for gestational diabetes is insulin since most types do not cross the placenta. 

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E: How do you EDUCATE the patient about gestational diabetes?

Just like with type 1 and type 2 diabetes, gestational diabetes requires a lot of patient education around blood glucose monitoring, lifestyle modifications and follow up care. Note that not only is the goal to manage blood glucose during pregnancy but to also decrease the individual’s risk for developing type 2 diabetes after pregnancy.

Blood glucose monitoring – Ensure the patient understands how and when to measure their blood glucose. Initially, most patients will be advised to check their blood sugar four times per day – before breakfast and one to two hours after each meal. If taking insulin, blood sugar may be measured prior to eating and again at bedtime.

Nutrition – Teach patients that nutrition plays the most important role in managing gestational diabetes. If they do not have a personalized meal plan designed by a dietician, some general nutritional guidelines are: 

  • Choose foods high in fiber and low in fat and calories. The American Diabetes Association recommends half the plate consist of non-starchy vegetables, one quarter of the plate dedicated to complex carbohydrates, and one quarter of the plate for protein foods.
  • Avoid sweetened foods such as desserts and sodas. If desired, alternative sweeteners such as stevia may be utilized.
  • Eat three small meals and three to four healthy snacks per day.

Physical activity – Teach patients that regular physical activity can improve glucose tolerance and reduce insulin needs. The ADA recommends at least 20 minutes of activity a day, which can include a mix of aerobic and strength activities.

Weight management – Prior to becoming pregnant, teach the patient about the importance of maintaining a healthy weight as a way to reduce the risk for gestational diabetes. If already pregnant, active weight loss efforts are not advised. Instead, ensure the patient understands the benefits of a healthy diet and physical activity as well as how much weight gain is recommended. For example, a woman of normal weight should gain between 25 and 35 pounds, while a woman with a BMI greater than 30 should gain between 11 and 20 pounds. In the postpartum period, teach the patient that weight loss can reduce the risk of developing type 2 diabetes.

Insulin – Approximately 15% of women with gestational diabetes require insulin. Ensure the patient understands when and how to take their insulin.  It’s also important they understand how to recognize the signs of hypoglycemia and how to treat it. Typically this involves ingesting 15 grams carbohydrate (such as 4 oz juice) and rechecking blood glucose in 15 minutes.

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