Pathophysiology  

The
exact pathophysiology of gestational diabetes is unknown. One main aspect of
the basic pathology is insulin resistance, where the body’s cells fail to reply
to the hormone insulin in the usual way. Several pregnancy hormones are thought
to disrupt the usual action of insulin as it binds to its receptor, most
probably by interfering with cell signaling pathways.  (Mandal, 2014)

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Insulin
is the primary hormone produced in the beta cells of the islets of Langerhans
in the pancreas. Insulin is key in the regulation of the body’s blood glucose
level. Insulin stimulates cells in the skeletal muscle and fat tissue to absorb
glucose from the bloodstream. In the presence of insulin resistance, this
uptake of blood glucose is prevented and the blood sugar level remains high.
The body then compensates by producing more insulin to overcome the resistance
and in gestational diabetes, the insulin production can be up to 1.5 or 2 times
that seen in a normal pregnancy. (Mandal, 2014)

During
early pregnancy, increases in estrogens, progestin’s, and other
pregnancy-related hormones lead to lesser glucose levels, promotion of fat
deposition, delayed gastric emptying, and increased hunger. As gestation
progresses, nevertheless, postprandial glucose levels gradually increase as
insulin sensitivity steadily decreases. For glucose controller to be maintained
in pregnancy, it is necessary for maternal insulin secretion to increase
sufficiently to counteract the fall in insulin sensitivity. GDM occurs when
there is insufficient insulin secretion to counteract the pregnancy-related
decrease in insulin sensitivity.  (Patry, 2004)

The
glucose present in the blood crosses the placenta via the GLUT1 carrier to
reach the fetus. If gestational diabetes is left unprocessed, the fetus is
exposed to an excess of glucose, which leads to a rise in the amount of insulin
produced by the fetus. As insulin stimulates growth, this means the baby then
develops a larger body than is normal for their gestational age. Once the baby
is born, the exposure to extra glucose is removed. However, the newborn still
has increased insulin production, meaning they are susceptible to low blood
glucose levels. (Mandal, 2014)

 

 

 

 

 

 

 

 

Effect of the mother &
baby

Gestational
diabetes affects the mother in late pregnancy, after the baby’s body has been
formed, but while the baby is busy growing. Because of this, gestational
diabetes does not cause the kinds of birth defects sometimes seen in babies
whose mothers had diabetes before pregnancy.

However,
untreated or poorly controlled gestational diabetes can hurt your baby. When
you have gestational diabetes, your pancreas works overtime to produce insulin,
but the insulin does not lower your blood glucose levels. Although insulin does
not cross the placenta, glucose and other nutrients do. So extra blood glucose
goes through the placenta, giving the baby high blood glucose levels. This
causes the baby’s pancreas to make extra insulin to get rid of the blood
glucose. Since the baby is getting more energy than it needs to grow and
develop, the extra energy is stored as fat.

This
can lead to macrosomia, or a “fat” baby. Babies with
macrosomia face health problems of their own, including damage to their
shoulders during birth. Because of the extra insulin made by the baby’s
pancreas, newborns may have very low blood glucose levels at birth and are also
at higher risk for breathing problems. Babies with excess insulin become
children who are at risk for obesity and adults who are at risk for type 2
diabetes.  (AmericanDaibeticAssociation, 2016)

Hypoglycemia
states to low blood sugar in the baby immediately after delivery.
This problem occurs if the mother’s blood sugar levels have been consistently
high, causing the fetus to have a high level of insulin in its circulation.
After delivery, the baby continues to have a high insulin level, but it no
longer has the high level of sugar from its mother, resulting in the newborn’s
blood sugar level becoming very low. (StanfordChildrensHealth, n.d.)

Respiratory
distress (difficulty breathing), too much
insulin or excessive glucose in a baby’s system may slow down lung maturation
and cause respiratory difficulties in babies. This is more likely if they are
born before 37 weeks of pregnancy.   

Women
with gestational diabetes have a greater chance of needing a Cesarean birth
(C-section), in part due to big infant size. Gestational diabetes may rise the
risk of preeclampsia, a maternal condition characterized by high blood pressure
and protein in the urine. (StanfordChildrensHealth, n.d.)

                                                                 

 

                                                              

 

 

 

 

Treatments

Treatment
for gestational diabetes focuses on keeping blood glucose levels in the normal
range. Treatment may include:

Ø  Special diet management  

Eating the right varieties of food in healthy portions is one of
the best ways to control your blood sugar and it inhibit too much weight gain,
which can put you at higher risk of complications. Doctors don’t instruct
losing weight during pregnancy — because mother’s body is working too hard to
support growing baby. But your doctor can help you set weight gain goals based
on your weight before pregnancy. 

 

Ø  Exercise

As an additional advantage, daily exercises can help relieve some
common discomforts of pregnancy, including back pain, muscle cramps, swelling,
constipation and trouble sleeping. Exercise can also help get you in shape for
the hard work of labor and delivery.

 

Ø  Daily blood glucose monitoring

Follow-up blood sugar checks are also important. Having gestational
diabetes increases   your risk of
developing type 2 diabetes later in life. Work with health care team to keep an
eye on your levels. Maintaining health-promoting lifestyle habits, such as a
healthy diet and regular exercise, can help reduce your risk.

 

Ø  Insulin injections or prescription drugs   

If diet and exercise aren’t enough, you may need insulin injections
to lower your blood sugar. Between 10 and 20 percent of women with gestational
diabetes need insulin to reach their blood sugar goals. Some doctors prescribe
an oral blood sugar control medication, while others believe more research is
needed to approve that oral drugs are as safe and as successful as injectable
insulin to control gestational diabetes.

 

Ø  Close monitoring of baby

An important part of your treatment plan is close observation of
your baby. Your doctor may monitor your baby’s growth and development with
repeated ultrasounds or other tests. If you don’t go into labor by your due
date — or sometimes earlier — your doctor may induce labor. Delivering after
your due date may increase the risk of complications for you and your baby.

(Mayoclinic, 2017)

 

 

 

Nursing Care plan

Nursing
Diagnosis: 
Risk for Altered Nutrition: Less Than Body Requirements related to Inability
to utilize nutrients appropriately.   (Paul Martin, nurses lab , 2016)

Intervention

Rationale

–         
Assess and
record dietary pattern and caloric intake using a 24-hour recall. 
 
–         
Assess
understanding of the effect of stress on diabetes. Teach patient about stress
management and relaxation measures 
 
–         
Teach the
importance of regularity of meals and snacks (e.g., three meals or 4 snacks)
when taking insulin.

–         
To help in
evaluating client’s understanding and/or compliance to a strict dietary
regimen.  
 
–         
It is proven
that stress can increase serum blood glucose levels, creating variations in
insulin requirements. 
 
–         
Eating very
frequent small meals improves insulin function.

 

Nursing
Diagnosis: Risk for Injury related to anemia (Martin, 2016)

             Interventions

             Rationale

–         
Assess client
for vaginal bleeding and abdominal tenderness.
–         
Assess for
any signs and symptoms of UTI.
–         
Monitor for
signs and symptoms of pre-term labor. Hydramnios may predispose the client to
early labor.

–         
Vascular
changes associated with diabetes place client at risk for abruptio
placenta. 
–         
Early
detection of UTI may prevent the occurrence of pyelonephritis, which can
contribute to premature labor. 
–         
Over
distention of the uterus caused by macrosomia.

 

Nursing
Diagnosis:  risk for injury related to
Changes in circulation or elevated maternal serum blood glucose levels.  (Paul Martin, 2016)

                  
Intervention

            Diagnosis

–         
Determine
client’s diabetic control before conception. 

 
–         
Monitor
fundal height each visit. 
 
–         
Assess fetal
movement and fetal heart rate each visit as indicated. Encourage client to
periodically record fetal movements beginning about 18 weeks’ gestation, then
daily from 34 weeks’ gestation on.

–         
Strict
control (normal HbA1c levels) before conception helps reduce the risk of
fetal mortality and congenital abnormalities.
–         
Useful in
identifying abnormal growth pattern (macrosomia or IUGR, small or large
gestational age SGA/LGA). 
 
–         
Fetal
movement and fetal heart rate may be negatively affected when placental
insufficiency and maternal ketosis occur.

Health Education     

Educating
about the disease condition is an important tool in the health care
setting.  The more healthy habits patient
can adopt before pregnancy, the better. If patient had gestational diabetes,
these healthy choices may also reduce your risk of having it in future
pregnancies or developing type 2 diabetes down the road.  

Lose
excess pounds before pregnancy. 

Doctors
don’t recommend weight loss during pregnancy. But if patient is planning to get
pregnant, losing extra weight beforehand may help her have a healthier
pregnancy.

By
giving this information it will be very helpful for the patient if she want to
get pregnant next time.  She will be
educated that during pregnancy it is not good to lose weight but to eat healthy
foods. And she will reduce her weight before pregnancy if she is obese or fat.  This can focus on permanent changes to her
eating habits. Motivating herself by remembering the long-term benefits of
losing weight, such as a healthier heart, more energy and improved self-esteem.
(Mayoclinic, Mayo Clinic , 2017)

Eat
healthy foods. 

We,
nurses have to educate patient that during pregnancy healthy diet focuses on
fruits, vegetables and whole grains — we have to advise her to take foods that
are high in nutrition and fiber and low in fat and calories — and limits highly
refined carbohydrates, including sweets. No single diet is right for every
woman. So as she is diabetic we can also advise her to consult a registered
dietitian or a diabetes educator to create a meal plan based on her current
weight, portion sizes, pregnancy weight gain goals, blood sugar level, exercise
habits, food preferences and budget.  

Educating
more on healthy foods and diabetic meal plan in this way patient and her baby
will be more healthy and free from pregnancy complications. 

Exercising

Even
if patient is diabetic or not educating the patient to keep active. Teaching
and giving more information about exercising before and during pregnancy can
help protect her from developing gestational diabetes. Advise her aim for 30
minutes of moderate activity on most days of the week. Take a brisk daily walk.
Ride your bike. Swim laps.

If
she can’t fit a single 30-minute workout into her day, several shorter sessions
can do just as much good. For example Park in the distant lot when she run
errands. Get off the bus one stop before she reach her destination. Telling her
every step she take increases chances of staying healthy. 

For
the diabetic patients we should tell her to exercise. Because Regular physical
activity plays a key role in her wellness plan before, during and after
pregnancy. We have to provide enough information that exercise lowers blood
sugar by stimulating body to move glucose into cells, where it’s used for
energy. Exercise also increases cells’ sensitivity to insulin, which means body
will need to produce less insulin to transport sugar (Mayoclinic, Mayo Clinic, 2017)

 

Medication.

Advising
the patient about medication and follow up the appointments on days is the most
important advice.  Educating the patient
to take medication on time is necessary.

 If
diet and exercise aren’t enough, patient need insulin injections to lower your
blood sugar. Between 10 and 20 percent of women with gestational diabetes need
insulin to reach their blood sugar goals. Some doctors prescribe an oral blood
sugar control medication, while others believe more research is needed to
confirm that oral drugs are as safe and as successful as injectable insulin to
control gestational diabetes. (Mayoclinic, Mayo Clinic, 2017)

So
even if it is oral medication or insulin injections we should tell the patient
to take right dose on time. And explaining the medication dose, time, side
effects to the patient is must otherwise patient might get into trouble without
clear information’s. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Conclusions                                                                

In
conclusion it is important to maintain the trust of the pregnant mother when we
question her about her health condition. Telling her about pregnancy is at high
risk she might get shock and mix of emotions. So we have to be careful and
alert. The questions we ask and things we tell should be respectful and in
accessible language the woman can understand. Making a pregnancy diagnosis is
based on a combination of possible symptoms reported by the pregnant women, and
probable and positive signs and symptoms that we observe our self, or which can
be confirmed by a physical examination or chemical test.

Therefore
even if the pregnant mother is very young or older women, first-time mothers,
and women who have had many previous births are more likely to experience
antenatal problems, and should generally be referred to a health facility for
labor and delivery. So It is important to ask the woman clearly focused
questions to identify other risk factors, such as, previous miscarriage or
abortion, a prolonged or very short labor, caesarian surgery or heavy bleeding
before or after the birth, retained placenta; postnatal depression; a history
of medical conditions such as high blood pressure, diabetes, anemia,
pre-eclampsia or eclampsia, infections, and heart, kidney or liver problems.

So
overall understanding the patient risk condition and pathophysiology is very
important because to understand the patient condition and what patient is going
through. Understanding effects of mother and baby in risk conditions we have to
make sure to care with kindly to the patient and to provide the available
treatment conditions. At this point properly educating about the condition is
the best way to relive patient’s tension. And nurses should do proper education
in order to provide enough information about disease condition and to corporate
with the procedures.