Question

Bridget is a 39 year-old female G1P0 and 24 weeks gestation with a history of Type II diabetes mellitus, who presents to her prenatal appointment for a routine scheduled visit. Her BMI is 34 and her most recent Hemoglobin A1C 9%. When discussing her recent A1C results, Bridget admits to being noncompliant in her diabetic treatment. Prior to her pregnancy Bridget managed her diabetes by taking Glyburide 5mg daily and diet control. As a result of Bridget’s history of noncompliance and an increase in her A1C, the physician switched her to insulin for the remainder of her pregnancy.

1. Identify the primary goal when caring for a pregnant woman with pregestational diabetes. (3 points)

2. Explain the standard of care in monitoring blood glucose levels in pregnancy. (2 points)

3. As the nurse, how would you counsel Bridget about her diabetes, regarding her noncompliance? (5pts)

4. Explain two (2) fetal and/or neonatal risks and complications associated to the mother’s poor management of her blood glucose levels. (5 points)

Answer 1

1) For the purpose of this review PPC is defined as the following either as sole intervention or in combination
1. Glycemic control by insulin and/or diet aiming at fasting blood glucose ≤5.7 mmol/l or/and postprandial blood glucose ≤7.8 mmol/l and/ or HbA1C ≤7.0%).
2. Women counseling and /or education about diabetes complications during pregnancy, the importance of glycemic control and self monitoring of blood glucose level.
3. Pre-pregnancy screening and treatment of complications of diabetes.
4. The use of contraception until optimization of glycemic control is achieved.
5. Intake of multivitamin or folic acid in the pre-pregnancy period.

2) slightly depending on your health care provider, but generally include: Initial glucose challenge test. You'll drink a syrupy glucose solution. One hour later, you'll have a blood test to measure your blood sugar level.Strict monitoring of postprandial glucose levels is paramount during pregnancy. Many studies have shown that postprandial hyperglycemia beyond the 16th week of pregnancy is the main predictor for fetal macrosomia. Peak plasma glucose levels during pregnancy occur between 60 and 90 minutes after eating. It is recommended to perform SMBG one hour after food intake to evaluate potential adjustments in meal composition and/or in the prandial insulin dose. In special circumstances, like women with slowed gastric emptying, a high-fat meal, or women who use regular insulin for a prandial bolus, it might be more appropriate to perform SMBG two hours after meals instead of one. SMBG performed before eating is the most useful parameter to identify optimal basal insulin doses. Evaluating glycemic levels during the night is recommended to diagnose and prevent nocturnal hypoglycemia.One randomized study of 66 women with GDM observed better neonatal outcomes by aiming for 1-hour postprandial glucose levels less than 140 mg/dL as opposed to a preprandial target of 59 to 106 mg/dL. In another study, 61 women with type 1 diabetes were randomly assigned into two groups at 16 weeks gestation. Women either monitored blood glucose levels preprandially or postprandially. Postprandial capillary blood glucose monitoring significantly reduced the incidence of preeclampsia and neonatal triceps skinfold thickness compared to preprandial monitoring. These studies have been criticized for not using comparable target blood glucose levels for pre- and post-prandial monitoring. Regardless, most specialists prefer postprandial testing at least partly, for the physiologic changes discussed earlier.

3) GDM is defined as any degree of glucose intolerance that first appears or is diagnosed during pregnancy.With an incidence of 1 in every 25 pregnancies, GDM is one of the most common complications associated with pregnancy.Complications related to diabetes are less common in pregnant women with GDM than in those with pre-GDM. Babies of pregnant women with GDM are at risk of developing life threatening complications such as macrosomia, birth trauma, stillbirth, prematurity, respiratory distress syndrome, hypoglycemia, jaundice,Women with GDM are at risk of developing pre-diabetes, type II DM, and recurrent episodes of GDM. Effective management of GDM during pregnancy and proper follow up care can prevent these complications.One of the most important factors affecting GDM management is patients’ compliance with the prescribed treatment regimen. Despite this, little is known about factors affecting treatment compliance; exploring these could help nurses and other healthcare professionals provide better medical care and more appropriate patient education, thereby considerably improving the lives of the affected women and their children. The aim of this study was to explore factors that affect women's compliance with GDM treatment.

4)1. Infants born to mothers with glucose intolerance are at an increased risk of morbidity and mortality related to the following: Respiratory distress. Growth abnormalities (large for gestational age [LGA], small for gestational age [SGA]) Hyperviscosity secondary to polycythemia.
2.Babies born to mothers with diabetes are at an increased risk of developing low blood sugar or hypoglycemia shortly after birth and during the first few days of life, since they are already producing an excess of insulin.