Key Clinical Information
Gestational diabetes occurs in 4–7% of all pregnant women in the United States (ADA, 2003). There is s significant increase in fetal malformations in pregnant women with persistently elevated glucose levels. This risk is noted to be higher for women with Hgb A1c levels that are elevated early in pregnancy compared to those pregnant women whose Hgb A1c levels are normal in spite of abnormal glucose metabolism.
It is especially important to enlist the participa- tion of the mother when gestational diabetes pres- ents. Daily attention to diet is imperative, with food sources providing excellent nutrition and a balance of proteins, fats, and complex carbohydrates. A food diary can be very helpful in determining what foods are preferred by the client and making rec- ommendations for changes that are culturally and financially reasonable.
Client History:
Components of the History to Consider
• G, P, gestational age
• Identify risk factors for GDM
•• Maternal age > 35
•• BMI > 25 kg/m2
•• Previous FBS 110–125 mg/dl
•• Suspected or documented previous GDM
■ Previous infant weighing > 4100 g
•• Previous unexplained fetal demise
•• Polyhydramnios
•• Previous birth of a child with a congenital anomaly
• Ethnic heritage
•• African
•• Alaskan native
•• Hispanic
•• Native American
•• South or East Asian
•• Pacific Islands
• Family history of diabetes
• Symptoms of GDM
•• Glycosuria
•• Preeclampsia or chronic hypertension
•• Polyhydramnios
Physical Examination:
Components of the Physical Exam to Consider
• VS, including weight
• Body mass index (BMI)
• Weight gain
• Monitor fundal heights
•• IUGR
•• Fetal macrosomia
•• Polyhydramnios
Clinical Impression:
Differential Diagnoses to Consider
• Gestational diabetes
• Abnormal glucose metabolism
• Diabetes mellitus
• Fetal macrosomia secondary to
•• Gestational diabetes
•• Constitutionally large fetus
• Polyhydramnios
Care of the Pregnant Woman with Gestational Diabetes 69
Table 4-2 Screening and Diagnostic Testing for Gestational Diabetes
DOSE/TIME PLASMA
Fasting—Normal glucose metabolism < 105 gm/dl
Fasting hyperglycemia > 105 < 126 gm/dl
Diagnostic of GDM—Fasting > 126 gm/dl
Diagnostic of GDM—Nonfasting > 200 gm/dl
50 gm glucose challenge test (GCT) 1 hr 130–140 gm/dl 100 gm glucose tolerance test (GTT) fasting > 95 gm/dl 100 gm glucose tolerance test (GTT) 1 hr > 180 gm/dl 100 gm glucose tolerance test (GTT) 2 hr > 155 gm/dl 100 gm glucose tolerance test (GTT) 3 hr > 140 gm/dl
Source:ADA, 2003.
Diagnostic Testing:
Diagnostic Tests and Procedures to Consider
• Dip U/A for glucose at each prenatal visit
• Screening women withrisk factors
•• First visit or first trimester
•• 24–28 weeks
•• 34–36 weeks
•• Onset of
■ Glucosuria
■ Macrosomia
■ Polyhydramnios
■ Pregnancy-induced hypertension
• Screening women withoutrisk factors
•• 24–28 weeks
•• Testing with indications only
• No screening option for women who meet all of the following criteria
•• Age < 25 years
•• Normal BMI before pregnancy
•• Member of an ethnic group with a low prevalence of GDM
•• No known diabetes in first-degree relatives
•• No history of abnormal glucose tolerance
•• No history of poor obstetric outcome
• Screening methods
•• Fasting blood sugar (FBS)
•• One-hour glucose challenge test (GCT)
• If screen is elevated
•• Obtain 3-hour glucose tolerance test (GTT)
•• Consider Hgb A1c testing
• Diagnosis
•• Elevated fasting or random glucose
•• Two or more elevated blood levels in 3-hour GTT
• Maternal assessment
•• Hgb A1C
■ Normal range: 4.0–8.2%
■ < 6% preferable in pregnancy
•• Self-monitored blood glucose
■ All values within target range
■ Before meal and bedtime: 60 to 95 mg/dl
■ After meal
• < 120 mg/dl 2 hours after start of meal
• < 140 mg/dl 1 hour after start of meal
• Ultrasound for fetal anomalies
Providing Treatment:
Therapeutic Measures to Consider
• Dietary control
•• Caloric intake by weight
■ Underweight—40 Kcal/Kg/day
■ Average weight—30 Kcal/Kg/day
■ Overweight—24 Kcal/Kg/day
•• 6 small meals daily
■ Carbohydrates 55–60% of diet
■ Protein 12–20% of diet
■ Fat for the remainder (ADA, 2003)
• Medications
•• Glyburide (pregnancy category B)
■ Use after organogenesis
■ Consult for use and dosage
•• Initiate insulin 2-hour postprandial glucose
> 120 mg/dl (ACOG, 2001)
■ Consult for use and dosages
■ Titrate to maintain glycemic control
• FBS > 95mg/dl
• 1-hour postprandial values> 130–140 mg/dl
Providing Treatment:
Alternative Measures to Consider
• Macrobiotic or whole food diet
• Herbs
•• Bilberry (Foster, 1996)
•• Chicory
•• Dandelion
•• Nettle
•• Red raspberry tea (Weed, 1985)
Providing Support:
Education and Support Measures to Consider
• Risks and benefits of options for care
• Diabetic education
•• American Diabetes Association
■ 1-800-342-2383 or e-mail [email protected]
■ ADA publication # 4902-04 Gestational Diabetes:What To Expect, 4th Edition
•• Dietary control
■ Dietary recommendations for GDM
■ Physical activity recommendations
•• Medication instruction, if used
•• Daily home glucose monitoring (International Diabetes Center, 2003)
■ Meter with memory and log book
■ 6 to 7 times/day preferred until control established
• Before and 1 to 2 hours after start of meals
• Bedtime
■ 4 times/week minimum
• Fasting
• 1 to 2 hours after start of meals
• Warning signs and symptoms
•• Decreased fetal movement
•• S/S hypoglycemia
Follow-up Care:
Follow-up Measures to Consider
• Document
• Prenatal follow up
•• Maternal and fetal evaluation
•• Blood glucose follow up
■ Evaluate result biweekly
■ Office or lab testing for validation of
• Home monitoring results
• Glycemic control
■ Medication use
• Fetal assessment
•• Fetal kick counts begin at 28 weeks
•• Ultrasound
■ 28–32 weeks: Begin serial U/S for
• Asymmetric IUGR
• Macrosomia
•• NST weekly beginning at 34 weeks
•• Biophysical profile
• Labor plan
•• Consider induction of labor at 37–38 weeks
■ Client on insulin therapy
■ Fetal macrosomia
■ Poor or marginal control
■ Based on tests for fetal well-being
•• Plan birth at facility with newborn special care
■ Anticipate RDS
•• If the EFW > 4500 grams, C/S may decrease the likelihood of brachial plexus injury in the infant (ACOG, 2001)
•• Plan for pediatric care at birth
• Postpartum follow-up
•• FBS & 2 hr pp blood sugar× 7days (International Diabetes Center, 2003)
■ Evaluate ASAP for DM with
• FBS > 120 mg/dl, or
• 2 hr pp bs > 160 mg/dl
•• Fasting blood sugar at 6 weeks postpartum
•• > 126 mg/dl diagnostic of DM
Care of the Pregnant Woman with Gestational Diabetes 71
Collaborative Practice:
Consider Consultation or Referral
• Nutrition education and counseling
• Social services, as indicated
• Medical, obstetric or pediatric care
•• Gestational diabetic not controlled by diet
■ Initiation of insulin or glyburide
■ Ongoing medication dosage requirements
•• Fetal macrosomia, IUGR, or anomalies
•• Newborn care at birth
• For diagnosis outside the midwife’s scope of practice