Transcription
Hey everyone, it's Sarah Thread Sterner. Sorry and calm. In this review, we're going to talk about gestational diabetes.
As always, whenever you get done watching this YouTube video, you can access the free quiz that will test you on this content. So let's get started.
Gestational diabetes is a type or form of diabetes that occurs during pregnancy. Now, it tends to occur during the second or third trimester.
Now, why does a woman develop diabetes during her pregnancy? Well, to help us understand this, we need to lay out the risk factors for why a woman may be at risk for developing gestational diabetes.
To help us remember those risk factors, because you want to remember those risk factors for exams, we're going to remember the word "mama" because we're talking about risk factors for mama.
So, M is for maternal age over 25. O is for overweight or obese, and we're talking about a BMI, a body mass index. So being overweight would be greater than 25, and obese would be greater than 30.
M for macrosomia, and we're talking about a large baby for gestational age. What we're looking for here is if she has previously had a baby that was larger than 9 pounds.
Then the other M is for multiple pregnancies. And then A is for a history, specifically we're looking for a previous diagnosis of gestational diabetes in the past or a family history of diabetes.
Now let's talk about the pathophysiology of gestational diabetes and why it is occurring.
To help us understand why it's occurring, let's remember three key players. The first key player is the pregnancy itself, specifically the hormones that are being produced to help support that pregnancy and that baby's growth.
The second key player is mom's body, specifically the changes that are occurring to her metabolic system. Because that first key player, those hormones, are going to influence that metabolic system and make her less sensitive to insulin.
So we're going to have low insulin sensitivity. The third key player is the baby. We're talking really about the baby's growth because at different stages, this baby is going to require different nutrients.
So all three of these things together are really going to create this perfect storm for gestational diabetes to develop.
So what is diabetes? Well, there are different types or forms of diabetes. However, in a nutshell, what's occurring with someone who has diabetes is there is an issue with insulin.
Now, insulin is produced by the pancreas, specifically by the beta cells. What insulin is, is it's a hormone that influences the cells' receptiveness to glucose.
So you eat foods broken down into glucose. It hangs out in your blood. Well, that glucose wants to get into your cells because your cells need glucose for energy.
So insulin will influence those cells to take in that glucose so you can use it. However, some people have issues with insulin.
People who have type 1 diabetes, this is like an autoimmune condition. There is an issue with these beta cells not working or either destroyed or they're just not there.
So no insulin is being secreted. You have glucose hanging out in the blood, causing hyperglycemia, and those cells aren't getting their glucose.
So the person has to take insulin artificially through injections. Then we have type 2 diabetes, and this is an insulin-resistant issue.
The cells just really aren't receptive to that insulin, so they don't take in the glucose, and the glucose stays in the blood, causing hyperglycemia.
Then we have gestational diabetes, and this is very similar to type 2 diabetes. There's an insulin resistance issue, and it occurs during pregnancy, during that second to third trimester.
However, it tends to disappear after birth once that baby has left mama's body. But an interesting statistic by CDC.gov is that women who have gestational diabetes, about 50% of them will actually go on to develop type 2 diabetes.
So that is a very alarming statistic. Half of those women who have gestational diabetes will end up developing type 2 diabetes later on.
So as a nurse, we want to be sure that we're educating our patient about this, that they're getting tested postpartum after they have their baby, and then later on, like one to three years, to see and check that glucose level.
So now let's talk a little bit more about insulin. We've already established that this is a hormone produced by the pancreas of beta cells, and insulin influences cells to take in glucose so they can use it for energy.
Now, during pregnancy, there are so many changes occurring in mom's body. One change is to the metabolic system, and one thing that's going to be affected is insulin, specifically insulin sensitivity.
So how receptive those cells are to take in glucose is actually beneficial to mom and baby, but it can go wrong, and that's where we get gestational diabetes.
So during the beginning of pregnancy, early pregnancy, we have a high insulin sensitivity, meaning those cells are being influenced by insulin, and they're readily taking in the glucose from mom's blood.
Now, this is beneficial because the body knows that, hey, we're carrying a baby, so we need to have growth on our adipose tissue to support mom and baby.
So the glucose goes into those cells, helping with the growth of adipose tissue. Now, mama will probably have some side effects of this high insulin sensitivity because what can happen to her?
She has those blood sugar shifts where she feels really nauseous, weak, tired, the hypoglycemia from where glucose is leaving her blood and going into the cells.
Now, as the pregnancy progresses, the baby is growing bigger. They need more nutrients, specifically they need some glucose to help them with their energy.
Their demands for glucose really increase, especially during that second to third trimester. So the body knows this; the placenta is very smart.
What it does is it is going to lower insulin sensitivity, meaning those cells aren't going to be as receptive to the insulin, so they're not going to readily take in glucose as much.
More glucose is going to stay in mom's blood. If more glucose is staying in mom's blood, that means some more of it can go to baby.
Now, why this is occurring is due to these hormones being produced. One hormone that's being produced is human placental lactogen. This is majorly going to influence insulin sensitivity; it's going to lower it.
Also, estrogen, cortisol, and progesterone play a role with that as well. So normally, mom's body is going to be able to compensate for this low insulin sensitivity.
Because when we have this, we have more glucose staying in her blood, which can increase her blood glucose level, which could potentially cause hyperglycemia.
But moms who don't get gestational diabetes, her metabolic system is compensating because it wants to maintain euglycemia. Normal glucose levels are about 70 to 130 milligrams per deciliter.
It doesn't want her getting any higher because it can be detrimental to her and the baby. So what it does is it increases the size and number of those beta cells so we can have those normal glucose levels.
However, patients who develop gestational diabetes, they're having insulin resistance. This compensatory thing that's going on up here really isn't occurring with them.
So more glucose is staying in their blood, and they're going to have hyperglycemia. Now, this is going to lead to some issues.
So we have more glucose in our blood. When our kidneys, because our kidneys filter our blood, this extra glucose in the blood is going to drip down through Bowman's capsule, enter in those tubules, and go into the urine.
So we're going to have glucose in our urine. Now, this can cause issues because back to love glucose sodas, yeast. The woman is more at risk for urinary tract infections and yeast infections.
So that is why whenever a woman goes to her prenatal visits, they're always having a pee in a cup, and they're checking it for glucose to make sure this isn't occurring.
Now, also, these high glucose levels are going to be hard on the cardiovascular system because, as we learned in our diabetic videos, that sugar, I think of sugar being hard, is going to harden those vessels in her system.
So that can lead to hypertension, which can cause preeclampsia, and we get protein in the urine where protein is going to leak in that urine. That can also cause preterm labor, so having issues with that.
Also, as we talked about earlier, that increases her chances of developing type 2 diabetes whenever they get gestational diabetes.
And because we have more glucose in her blood, that's going to cause more glucose to go to this baby, and that can increase the baby's size. So it increases her risk of having a cesarean section.
So let's talk about baby. So baby can get all this extra glucose, so they make more insulin to deal with this glucose, but they're also going to increase in their size because they're going to start putting on more fat.
That can cause problems, and we call a large baby for their gestational age macrosomia. So the baby is larger.
Now, also what can happen is that we can have some issues at birth. So once the baby is born, they're no longer going to be receiving all that extra glucose from mom, but they built up insulin to deal with that.
So once we sever the cord, what happens is that they're cut off from their glucose supply, but they have this insulin here. So they can have hypoglycemia at birth, where they have a low blood sugar.
So definitely, we want to monitor baby's blood glucose level very closely, and a lot of times they will have to have some type of glucose solution to help keep them within normal range.
Another thing that can happen with these babies is because they've been receiving all this extra glucose, that can affect their lung maturity, specifically that surfactant.
So they're at risk for respiratory distress at birth. So what are some signs and symptoms of gestational diabetes?
Well, they are very similar to hyperglycemia because your patient is going to have a high blood glucose level. So to help you remember the signs and symptoms, remember those three P's.
So the first P is polyphagia, and this is where they are constantly hungry. Then polydipsia, this is where they are very thirsty all the time.
Then you have polyuria; this is where they have to urinate all the time. And then the S is for sugar in the urine. So whenever their urine is tested, it will have glucose in it.
Some miscellaneous signs and symptoms would be like a fruity breath, they're hot and very dry, like dry mouth, along with urinary tract infections and yeast infections.
Now let's wrap up this lecture and let's talk about the nurse's role in the treatment used to help treat a patient with gestational diabetes.
So what we're going to do is we're going to take everything that we've learned with patho and our role as a nurse, and we're going to put it in a mnemonic to help us keep this information straight.
So remember the word "sugar babe" because we have a baby who is getting lots of sugar from mom.
So S is for screening for gestational diabetes. Most pregnant women will be screened for this at about 24 to 28 weeks gestation.
What they'll have to do is they'll have a one-hour oral glucose tolerance test, and fasting is not required for this test.
What they'll do is they'll come in, and they will drink about a 50-gram solution of glucose, and then one hour later, they will have their blood drawn.
The result will come back and it will be abnormal if the glucose level is greater than 140 milligrams per deciliter. So if they have this, they will have to take the three-hour oral glucose tolerance test.
So they will do this on a different day; they won't do this on the same day. For this test, they all fast before it, and they want to follow an unrestricted diet with carbs.
So they will get their blood drawn at several different times with this one: one at fasting, and then they'll drink the glucose solution. It's about a 100-gram solution.
Then they'll have their blood drawn at one hour, then two hours, and then the three-hour mark. What they're looking for is if there are two or more abnormal results with their glucose.
If they have this, they are diagnosed with gestational diabetes. So what are those results? You want to be familiar with these results for each time that blood is drawn.
So at fasting, an abnormal result would be greater than 95 milligrams per deciliter. At one hour, it would be greater than 180. At two hours, it would be greater than 155, and then at three hours, it would be greater than 140.
Notice as time goes down from the one hour, the two hour, the three hour, that glucose level should be decreasing.
Then U for use diet and exercise to manage blood glucose. This is usually what is ordered for women who have gestational diabetes to do because this can help keep that blood glucose within normal range.
However, some patients may need insulin or oral medication like glyburide. G for glucose monitoring. The pregnant mom would want to, on a daily basis, monitor her blood glucose at home.
A general rule of thumb is she would want her blood glucose during fasting periods, where she hasn't had any food on her stomach for a while, to be anywhere between 70 to 95 milligrams per deciliter.
Then after she's had a meal, about one hour after a meal, you would want it to be less than 140 milligrams per deciliter, but of course, within that normal range greater than 70 because we don't want her to have hypoglycemia.
A would be assess urine for glucose at the prenatal visits. We talked about this earlier because, again, glucose starts to leak into the urine because there's too much in the blood.
So another thing you'd want to do is ask her if there's a burning sensation with voiding. This could be a red flag that she might have a urinary tract infection, and you would want to get a doctor's order and have her urine sent for urinalysis to make sure she does not have an infection.
R for risk factors for mama. So those risk factors that we went over earlier with that mnemonic, you definitely want to assess for at those prenatal visits to make sure that the woman is not at risk for gestational diabetes.
B for blood glucose swings during and after labor. So during this time, you'll want to monitor the blood glucose levels very closely because we want to try to maintain euglycemic levels where they're about 70 to 130.
We want to decrease the baby's risk of getting hypoglycemia at birth, so we can maintain mom within a normal range. That can help baby whenever they're born and decrease their chances of having hypoglycemia.
So during labor, sometimes the woman may have to have IV regular insulin or glucose to maintain those levels.
So after labor, you want to watch for, in both baby and mom, for hypoglycemia because remember, gestational diabetes tends to disappear after birth.
So watch the levels because they can go down. For hypoglycemia in mom, you want to be watching for sweating, feeling cold and clammy, like the little sentence, "cold and clammy, give them some candy."
In baby, you want to watch out by checking their blood glucose levels, and sometimes they do need an oral glucose solution or some type of glucose solution to help with their levels.
A for adverse effects of gestational diabetes. We talked about that in our patho discussion, and again, you're going to be looking for preeclampsia, hypertension, protein in the urine, urinary tract infections, vaginal yeast infections, and she has a risk of c-section because of the large baby, preterm labor, and then the hypoglycemia and respiratory distress in the baby.
B for blood glucose monitoring postpartum. Because she has such a high risk of developing type 2 diabetes after having gestational diabetes, it's recommended that 6 to 12 weeks postpartum after delivery, she has a glucose test to look at that glucose level.
Typically, it's the two-hour oral glucose tolerance test. Lastly, E for educate her about the importance of regular diabetic testing due to her risk of developing type 2 diabetes.
Again, what was that percentage? It was 50%. So even if her diabetes does disappear, everything goes back to normal after the baby is delivered, there is still a risk.
So you definitely want to educate her about that, and typically they recommend being tested every one to three years.
Okay, so that wraps up this review over gestational diabetes, and don't forget to access the free quiz that will test you on this content.