Reply to Gina 

  Question 1- Gestational Diabetes Mellitus (GDM)

During pregnancy, around the 24th week, many women develop gestational diabetes. But what is gestational diabetes and how this medical condition may impact a pregnant woman? 

In 2014, the U.S. Preventive Services Task Force updated its 2008 statement to recommend that asymptomatic pregnant women be screened for GDM after 24 weeks of gestation. This recommendation applies to pregnant women who have not been previously diagnosed with type 1 or 2 diabetes mellitus (Hartline, 2013). Screening for and detecting GDM provides a potential opportunity to prevent adverse outcomes such as preeclampsia, fetal macrosomia which can cause shoulder dystocia and birth injury, and neonatal hypoglycemia (Hartline, 2013).

 Most clinicians in the United States use a two-step approach, first administering a 50-g non-fasting oral glucose challenge test at 24 to 28 weeks, followed by a 100-g fasting test for women who have a positive screening result. Gestational Diabetes is screened for in pregnancy by drinking a solution containing 50-g of glucose and testing blood glucose level one hour after drinking it. If the screening threshold is met or exceeded 130 mg/dL, 135 mg/dl, or 140 mg/dL blood sugar level, the patient is subjected to another test involving drinking a solution containing a higher amount of glucose (100g). In this case, the blood glucose should be checked first before administering the 100g glucose and then three more times such as 1 hour after drinking the solution, 2 hours after drinking the solution and the last check after three hours after drinking the solution. Cut off values will be: 1 hour 180 mg/dl, 2 hours 155 mg/dl, 3 hours 140 mg/dl, fasting 95mg/dl. Two abnormal values will meet the diagnosis of gestational diabetes (Hartline, 2013).

Alternatively, clinicians may use a one-step approach and administer only a 75-g two-hour fasting oral glucose tolerance test. The one-step approach may be cost-effective in high-risk patients or populations (Hartline, 2013).  A diagnosis of GDM is made when two or more glucose values fall at or above the specified glucose thresholds (Hartline, 2013).

The frequency of screening is based on the presence of risk factors: family history, pre-pregnancy BMI, or need for insulin or OAD medications during pregnancy. Woman with risk factors for type 2 diabetes, such as obesity, family history of type 2 diabetes, or previous fetal macrosomia may be screened earlier than 24 weeks of gestation (Hartline, 2013).

        Describe how this information will impact your care and monitoring of a pregnant woman?

The patient diagnosed with GDM require frequent evaluations and monitoring (Hartline, 2013). After receiving a diagnosis of GDM, patients should begin monitoring their blood glucose, initially with fasting levels and one or two-hour postprandial levels. Fasting glucose levels should be less than or equal to 95 mg per dL, one-hour postprandial levels less than or equal to 140 mg per dL, and two-hour postprandial levels less than or equal to 120 mg per dL. (Hartline, 2013).

As a healthcare provider, it would be my responsibility to encourage the patient to attain moderate gestational weight gain, based on their prepregnancy BMI, and to participate in a physical activity based on their clinician’s recommendations. Attention to maternal weight gain is important in minimizing the risk of fetal macrosomia. Maternal obesity, excess gestational weight gain, and GDM are independent and additive risk factors for macrosomia (Black, 2013).

Treatment of GDM results in a statistically significant decrease in the incidence of preeclampsia, shoulder dystocia, and macrosomia. Initial management includes glucose monitoring and lifestyle modifications. Antenatal testing is customary for women requiring medications. Induction of labor should not occur before 39 weeks in women with GDM unless glycemic control is poor or another indication for delivery is present. In women with an estimated fetal weight greater than 4,500 g a scheduled cesarean delivery should be considered (Black, 2013).

                                                                 Higher Level of Care

All women with GDM should receive nutritional counseling, by a registered dietitian when possible, consistent with the recommendations by the American Diabetes Association, and in some difficult cases, the patient may be referred to an endocrinologist (Black, 2013).

Women with a history of GDM are at high risk of subsequently developing diabetes. These patients should be screened six to 12 weeks postpartum for persistently abnormal glucose metabolism and should undergo screening for diabetes every three years after that (Black, 2013).

                                                                        References

Hartline, L. Dryden, D. Guthrie, A., Muise, M. Vandermeer, B., and Donovan, L. (2013). Benefits and harms of treating gestational diabetes mellitus. Annals of Internal Medicine.

Moyer VA (2014). U.S. Preventive Services Task Force. Screening for gestational diabetes mellitus: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. ;160(6):414–420.

Black MH, Sacks DA, Xiang AH, Lawrence JM. (2013).  The relative contribution of prepregnancy overweight and obesity, gestational weight gain, and IADPSG-defined gestational diabetes mellitus to fetal overgrowth. Diabetes Care.36(1):56–62

Reply to Hollie

Pregnancy-related conditions necessitating referral

 Pre-eclampsia and gestational diabetes are two conditions that may need a higher level of obstetrical management. Pre-eclampsia is multi-system disorder that includes hypertension, proteinuria and possibly end-organ dysfunction (August & Sabai, 2019). Although the condition resolves after delivery, during pregnancy it can cause significant problems for both the mother and the baby (August & Sabai, 2019). Among many other things, women can have grand mal seizures as part of the condition (August & Sabai, 2019).

            Gestational diabetes (GDM) can cause hypertensive disorders in pregnancy as well as pre-eclampsia, premature delivery, c-section, macrosomia, large for gestational age infants, neo-natal jaundice, and stillbirth (Sweeting et al., 2015). The prevalence of GDM is increasing due to obesity and advanced maternal age (Sweeting et al., 2015).

Resources

 In my community there are a number of resources at my disposal. First are certified nurse midwife colleagues with home birth experience. The vast knowledge developed by these colleagues has given me the confidence to call on them when a situation with a pregnant mother is questionable. For pre-eclampsia, if a pregnant woman with no previous hypertension presented with a consistent blood pressure over 140/90, it would be a red flag. She would then be checked for protein in her urine which may or may not be present. Other signs and symptoms to look out for are visual disturbances such as flashes of light, incapacitating headaches, altered mental status or severe right upper quadrant pain with no obvious cause (August & Sabai, 2019).

For pregnant women with GDM, she would be referred to a registered dietician in the community. Our local Kaiser clinic has one as well as at least two of our community clinics. The goals of care for a mom with GDM would be to achieve a normal blood sugar level, prevent ketosis from occurring, achieve normal weight gain in pregnancy and to contribute to the well being of the fetus.

References

August,P., & Sabai, B. (2019). Preeclampsia: Clinical features and diagnosis. Retrieved from https://www.uptodate.com/contents/preeclampsia-clinical-features-and-diagnosis#H1039781115

Durnwald, C. (2019). Gestational diabetes mellitus: Glycemic control and maternal prognosis. Retrieved from https://www.uptodate.com/contents/gestational-diabetes-mellitus-glycemic-control-and-maternal-prognosis?search=gestational diabetes&source=search_result&selectedTitle=1~88&usage_type=default&display_rank=1

Sweeting, A. N., Ross, G. P., Hyett, J., Molyneaux, L., Constantino, M., Harding, A. J., & Wong, J. (2015). Gestational Diabetes Mellitus in Early Pregnancy: Evidence for Poor Pregnancy Outcomes Despite Treatment. Diabetes Care, 39(1), 75-81. doi:10.2337/dc15-0433