GESTATIONAL DIABETES MELLITUS

(GDM)
It is defined as abnormal carbohydrate
tolerance with onset or first detected during
pregnancy. This condition usually presents
late in second or during the third trimester
 As obesity and GDM are frequently comorbid conditions, obesity and excessive gestational weight gain

may compound these risks in GDM6. Because fat is an endocrine organ and interacts with diabetes, it is possible that

the increased accumulation of fat has a differential effect on perinatal outcomes for women with GDM 7.

n an obese individual, the amount of NEFA, glycerol, hormones, cytokines, proinflammatory

substances, and other substances that are involved in the development of insulin resistance are
increased. Insulin resistance with impairment of β-cell function leads to the development of
diabetes
RISK FACTORS
1. Diabetes in a first degree relative parents /siblings)
2. Recurrent abortion
3. Unexplained stillbirth
4. Congenital abnormality
5. A baby whose birth weight was 4kgs or more at 40 weeks
6. Previous gestational diabetes or impaired glucose tolerance
7. Persistent glycosuria
8. Age over 30 years
9. obesity
SCREENING
Women considered to be at risk of gestational diabetes
undergo a glucose tolerance test.this will indicate
whether they have normal or impaired glucose tolerance
test ,or have developed diabetes ,before proceeding to a
full glucose tolerance test ,a fasting blood sample may
be examined for glucose.
GLUCOSE TOLERANCE TEST

The method employed is by using 50grams of oral glucose challenge test

without regard to time of day or last meal between 24 and 28 weeks of
pregnancy. A blood sugar level of 140 mg/dL (7.8 mmol/L ) to less than
190 mg/dL (10.6 mmol/L ) signals the need for a three-hour glucose
tolerance test to diagnose gestational diabetes. A blood sugar level of 190
mg/dL (10.6 mmol/L ) or higher indicates gestational diabetes.
EFFECTS OF DIABETES
ON PREGNANCY
1. Infertility
2. Increase chances of spontaneous abortion and stillbirth
3. Increase incidence of macrosomia and birth trauma
4. Increase perinatal mortality
5. Women more prone to urinary tract infection
6. Increase incidence of preeclampsia and polyhydramnios
EFFECTS OF DIABETES
ON FETUS

1. Intrauterine fetal death

2. Increased change of neural tube heart and kidney defects
3. IUGR
4. Increased incidence of macrosomia
NEONATAL COMPLICATIONS
INCULDES
1. Hypoglycemia
2. Respiratory distress syndrome
3. Hyperbilirubinemia
4. Polycythemia
5. Hypocalcemia
6. Hypomagnesemia
 MANGEMENT

1. Antenatal supervision should be done at monthly intervals up to 20th weeks and thereafter

at 2 weeks interval up to 30th week

2. Diet : diet with 2000 -2500 KCAL /day od normal weight and restriction to 1200-1800

Kcal day for overweight women is recommended complex carbohydrates are preferred

because simple carbohydrates produces significant postprandial hyperglycemia.

1. The control of high blood glucose is done by restriction of diet, exercise with or

without insulin. Human insulin should be started if fasting plasma glucose levels

exceeds 90mg/dl and 2 hours post prandial value is greater than 120mg/dl even on

diet control.

2. Excersie ( aerobic ,brisk walking) are safe in pregnancy and may obviate the need

of insulin therapy

3. Frequent blood glucose estimation is requires estimation of glycosylated

hemoglobin should be done at the end of first trimester and 3 month thereafter .
6.Sonographic evaluation is helpful to detect fetal macrosomia ,growth retardation

and other congenital malformations

7Assessment od fetal well being is to be made from 32 weeks onwards

8.The midwife should alert the women of her predisposition to UTI and vaginal

infections so that she will seek treatment as soon as possible if symptoms

develop .it is important to teach the women about maintenance of hygiene

9.Check maternal weight and abdomen to detect polyhydramnios.

 10. In uncomplicated cases the woman is admitted in hospital at 34th

week early hospitalization facilitates for stabilization of diabetes

11.Minimizes incidence of polyhydramnios, preeclampsia, preterm labor

12.Selection of appropriate time of hospitalization

OBSTERTIC MANAGEMENT

Women with good glycemic control and who do not

required insulin may wait for spontaneous onset of labor
.however elective delivery (induction or cesarean
section) is considered in patients requiring insulin or
with complications at around 38weeks
FOLLOW UP

Nearly 50% of women with gestational diabetes mellitus would

develop overt diabetes over a follow up period of 5-20years .women

with fasting hyperglycemia have worse prognosis to develop type 2

DM and cardiovascular complications .recurrence risk in subsequent

pregnancy is more than 50%

NURSING MANGEMENT
NURSING DIAGNOSIS
1.Fluid volume deficit related to osmotic diuresis

GOAL;
Demonstrate adequate hydration evidenced by stable vital
signs ,palpable peripheral pulse, skin turgor and capillary
refill well, individually appropriate urinary output
electrolyte levels within normal limits.
NURSING INTERVENTION

1.Monitor vital signs

RATIONALE
1.Hypovolemia can be manifested by hypotension and tachycardia
Assess peripheral pulse ,capillary refill skin turgor and mucus membranes.
RATIONALE
2.This is an indicator of the level of dehydration, or an adequate circulating
volume
Monitor input and output record the specific gravity of urine.
Cont.…
RATIONALE
3.To provide estimates of the need for fluid replacement renal function
effectiveness of the therapy given
Measure weight every day
RATIONALE
4.To provide the best assessment of fluid status of ongoing and future to
provide a replacement fluid
Provide fluid therapy as indicated
NURSING DIAGNOSIS

2.Imbalanced nutrition less than body requirements related to

insufficient insulin, decreased oral put

GOAL
1.Digest the amount of calories right
Shows the energy level is usually
Stable or increasing weight
NURSING INTERVENTION
Determine the patients diet and eating patterns and compared with foods
that can be eaten by the patient
RATIONALE
1.Identify deficiencies and deviations from the therapeutic need
Check weight regularly
2.Assessing adequate food intake (including absorption and utilization)
Identification of preferred food: include the needs of ethnic /cultural
3.If the patients food preferences can be included in meal planning this
cooperation can be pursued after discharge
Cont.…
4.Involve patients in planning the family meal as
indicated
5.Increase the sense of involvement provide information
on the family understand the patients nutrition
6.Give regular insulin treatment as indicated
Regular insulin has a rapid onset and quickly and
therefore can help move glucose into cells
NURSING DIAGNOSIS
3.Risk of infection related to hypoglycemia
Goal
Identify interventions to prevent/reduce the risk of
infection
Demonstrate techniques lifestyle changes to prevent
infection
 NURSING INTERVENTION
Observed signs of infection and inflammation
RATIONALE
1. Patients may have entered with an infection that usually has sparked a state
of ketoacidosis or may have nosocomial infections
2. Improve efforts to prevention by good hand washing for all people in
contact with the patients including the patients themselves
3. Prevention cross infection
4. Maintain a septic technique invasive procedures
5. High glucose levels in blood would be the best medium for the growth of
germs
Cont.…
6.Provide skin with regular care and earnest
7.The peripheral circulation may be disturbed that
puts patients At increased risk of damage to the
skin irritation and infection
8.Makes changes to the position effective
coughing and encouraged deep breathing