What Are the Best Evidence-Based Nursing Management Techniques for Women with Gestational Diabetes Mellitus?

What are the best evidence-based nursing management techniques for women with Gestational Diabetes Mellitus?

Kayla Peters

Greenfield Community College NUR 108

Spring 2016

Professors Dent and Phillips

        Gestational Diabetes Mellitus (GDM) is increasing worldwide and is creating negative risks and outcomes for mothers and children. GDM is defined as the inability to meet the demand for increased insulin production in order to counteract the increase of insulin resistance caused by hormones produced in pregnancy. The American Diabetes Association (ADA) states “Diabetes is one of the most common complications of pregnancy and encompasses both GDM diagnosed during pregnancy, Pre- existing Type 1 Diabetes Mellitus (T1DM), Type 2 Diabetes Mellitus (T2DM) and other rare specific types of diabetes (ADA,2010)”. Pregnancy significantly affects diabetes due to the physiologic changes that occur within the mothers body during fetal growth and development within the uterus. The purpose of this literature review paper is to express the significance of the nurses role on education, interventions and prevention of  Gestational Diabetes Mellitus.

        Throughout pregnancy, many physiological changes occur such placental production within the uterus. The placenta acts as an endocrine organ that produces hormones such as estrogen, cortisol and Human Placental Lactogen (HPL). These placental hormones are produced in excess, most commonly inhibiting the function of insulin in the second (13-28wks) and third (29-40wks) trimesters of pregnancy. Evidence of insulin resistance is best identified by a rise in the mothers glucose levels. Specifically, HPL is the antagonist of insulin that increases the circulation of free fatty acids, aiding in maternal metabolic needs while decreasing the maternal metabolization of glucose; ensuring a continuous supply to promote fetal growth. As HPL breaks down fats provided by the mother, glucose is transported across the placenta to the fetus, providing fuel for the growing baby. The demand for glucose by the fetus negatively effects the mother by causing insulin resistance and carbohydrate intolerance. This creates a “diabetogenic effect of pregnancy” which has been addressed by systemic reviews and meta-analysis.

        In the original research article titled Reducing diabetes- related complications in pregnancy, Arya, Mills and Palmer express the importance of pre-conception counseling. The role of the nurse is to provide preconception counseling and “ is a key priority for implementation identified in the updated NICE (2015) guidance”. The goal in this prenatal period is to provide the tools and knowledge to women, “empowering them to optimize their own health, while reducing adverse pregnancy outcomes for both mother and baby”. As part of the disciplinary team, it is important to identify ways to provide glycemic control such as, eating a low glycemic index diet, exercising regularly, medication therapy and education on the disease.

        In 2011, Oostam,Wouters and van Mechelen illustrate the importance of identifying interventions that might prevent the development of glucose intolerance in pregnancy. In the research article entitled Interventions for preventing Gestational Diabetes Mellitus: A systematic review and Meta-analysis, the research article stresses and recognizes the need to diagnose women with prepregnacy diabetes and other risk factors as a necessity in the prevention of GDM. Since T2D and GDM have similar underlying pathophysiology it is important to take strategies that are effective in the prevention of T2D into consideration when treating GDM. GDM prevents many risk factors to the mother and baby throughout pregnancy such as pregnancy related maternal and perinatal morbidity as well as an increased risk for them to develop T2D post delivery.

        In the systematic review Oostam,Wouters and van Mechelen evaluated the effects of   Metformin therapy, Low Glycemic Index Diet, Dietary counseling and exercise, as interventions for women with GDM. The systematic review identified a significantly reduced risk for an infant  to be large for gestational among the women who received advice on a low glycemic index diet and/or followed an exercise program during pregnancy, compared to women who continued their usual care. The nurse is responsible for monitoring weight fluctuations as well as providing education on diabetes and potential outcomes if no changes in maternal care are implemented. This allows the patient to be aware of the complications and provides them with the education to make the correct choice after they leave the office.

        Due to patients with GDM being part a high risk population, Metformin therapy was another intervention studied. Metformin “ Is an insulin-sensitizing drug that is used to correct metabolic and endocrine abnormalities” and was thought to be an intervention for the prevention of GDM. Along with the authors Carroll and Kelley of Review of Metformin and glyburide in the management of gestational diabetes, it is stressed that nurses are to continuously be aware of changes in glucose levels when patients are on metformin. No significant differences in maternal fasting glucose, risk for GDM or macrosomia were established by Oostam,Wouters and van Mechelen with the use of Metformin therapy alone.