INTRODUCTION:

Gestational diabetes is more commonly found in the third trimester of pregnancy. There is alteration in insulin and CHO metabolism. Increasing level of estrogen, progesterone and prolactin enforces pancreatic beta cells to produce excessive insulin progesterone, human placental lactogen. The cartisol being insulin antagonist reduces its effectiveness, therefore large quantities of glucose add up in maternal blood circulation and are transferred to fetus via placenta. It gives rise to maternal as well as fetal morbidity and mortality. The perinatal mortality rate in diabetic pregnancy has grately improved in recent years and is now below 5% and this is largely due to the improved diabetic management of the pregnant diabetic women. In cases where diabetic control is poor, the perinatal mortality rate is likely to be higher.

India has the second largest number of people with diabetes in the world. Not surprisingly therefore, the prevalence of gestational diabetes mellitus (GDM) in India is also alarmingly high.

Indian women are more likely to develop GDM compared to Caucasian women. Estimates on the prevalence for GDM in India vary greatly; from low figures in the northern region of Jammu, to higher figures reported in the southern state of Tamil Nadu. Gestational diabetes mellitus (GDM) is a severe and neglected threat to maternal and child health. IDF estimates that 16.8% of live births are affected by some form of hyperglycaemia in pregnancy in 2013, and 6 million in India alone, of which 90% are due to GDM.

WHO has predicted that between 1995 and 2025 there will be a 35% increase in the world wide prevalence of diabetes. It is variously estimated that 3% to 5% of pregnancies are complicated by diabetics.

Aims of treatment:

1. To maintain blood glucose level near to the normal range.

2. To minise the risk of long term complications of diabetes mellitus

Care during pregnancy:

There is a need to visit antenatal clinic more frequently in order to maintain good glycemic control. Collaborative care is essential for pregnant women who have diabetes: medical, obstetric and midwifery input, together with informed self care by the women can help pregnancy to as fulfilling for the women with diabetes as for her non diabetic counterpart. Regular monitoring of the blood glucose at home by the pregnant women has proved successful in achieving good diabetic control.

Each time you check your blood glucose, write down the results in a record book. Take the book with you when you visit your health care team. If your results are often out of range, your health care team will suggest ways you can reach your targets.

Diet:

The CHO energy content of the diet should be related to the energy requirement of the individual. In most cases it does not exceed 40%, but it can be higher without adverse effects. Fat intake should be restricted because of the increased risk of arterial disease in diabetics. A high fibre intake is recommended because the slower gastric emptying delays the absorption sugar in to the blood stream. Hypoglycemia may exacerbate the effects of morning sickness; glucose and sugary foods should be avoided, and hypoglycemia avoided by taking milk and a light snack. Glucagon should be available to women diabetics, for use in emergencies. Dietary considerations for such women should avoid sweets such as gul ab jumun halwa and jelabi, and where the woman is also over weight, foods fried in ghee or oil should be reduced.

Physical Activity:

Physical activity, such as walking and swimming, can help you reach your blood glucose targets. If you are already active, tell your health care team what you do.

Insulin:

Insulin requirements usually increase in pregnancy owing to the rise in energy requirements and the production of diabetogenic hormones from placenta. Better diabetic control is generally achieved if a combination of short and intermediate-acting insulin are administered twice daily (Gillmer and Hurely,1999)

Three descriptions have been applied to control of blood glucose in pregnancy complicated by diabetes;

Very tight control, tight control and moderate control.

1 Very tight control; aims for blood glucose below 5.6mmol/l

2 Tight control; aims for blood glucose 5.6-6.7mmol/l

3 Moderate control; aims for blood glucose 6.7-8.9mmol/l

In normal pregnancy, blood glucose levels rarely exceed 6.6mmol/l.

The effect of these degrees of control have not been thoroughly researched, but evidence suggests that tight control coupled with a holistic approach to the woman’s care results in reduced incidence of macrosomia, UTI, RDS ,hypertension, and Perinatal mortality.

Oral hypoglycaemic drugs:

It is not recommended in pregnancy as they cross the placenta and may cause severe hypoglycemia in the baby after birth because of their slow metabolism in the infant’s immature liver.

Fetal well-being:

It must be monitored closely throughout pregnancy. It may be assessed by ‘Kicks Counts’ and cardiotocography, and growth is monitored by clinical examination and USG.

Obstetric care:

The frequency of attendance at the antenatal clinic varies but is often every 2weeks until 32 weeks and then weekly. The incidence of pre-eclampsia is increased in women with diabetes; thus particular care is taken to record the BP and examine the urine for protein. Hospitalization before 38weeks is necessary only if complications such as polyhydramnios, IUGR, infection or inadequate diabetic control occur.

Assessment of HbA1c level:

It should be measured every 2-4 weeks and helps to assess diabetic control. It is a type of adult haemoglobin where one part of the beta chain has been combined with glucose.HbA1 levels are not indicators of present diabetic status but of blood glucose levels during the preceding 1-3months.Levels of 10% or lower are considered a sign of good control, while levels of more than 10% indicate poor control.

Care during labour:

Labour may be spontaneous or induced, or delivery may be by elective caesarean section if there are obstetric indications.

Dextrose/Insulin varies; Gillmer and Hurely suggest intravenous 10% dextrose 100ml per hour: it is important that this does not change. Changes in response to blood glucose results should be to the insulin infusion (usually Human Actrapid insulin 6 units in 60ml normal saline(1 unit in 10ml given according to a sliding scale).The aim is to keep blood glucose levels between 4-6mmol/l. Blood glucose levels are checked hourly and the insulin infusion rate adjusted if necessary. If oxytocin is necessary, it should be infused in normal saline. Satisfactory pain relief may be achieved by epidural anaesthesia.

Fetal monitoring should be continuous, by external cardiotocography or fetal scalp electrode, and is essential because of the increased risks of fetal distress during labour.

After labour, insulin requirements usually revert to pre pregnancy levels and women who began insulin therapy during pregnancy will not normally now require this.

Postnatal care:

`Maternal insulin requirements fall sharply after delivery, so frequent blood glucose estimations are made to detect hypoglycaemia. The insulin dosage is reduced and the woman is gradually reestablished..

Breastfeeding should be encouraged, and woman may need additional CHO to facilitate this .De Swiet suggests an additional 50g per day, with less long acting insulin given at night to prevent nocturnal hypoglycaemia, which may occur during night feeding. High standards of hygiene are necessary to combat the increased risk of infection in diabetic women.

Family planning advices:

Diabetic women require careful advice on family spacing. The combined oral contraceptive pill may alter CHO metabolism and some women may need a higher dose of insulin. The IUD method is effective and there is no higher rate of pelvic infection for woman with diabetes. Barrier methods may be used by women for whom further pregnancy would not severely exacerbate diabetic complications.

REFERENCES:

· Dr. G. K. Sandhu, “Obstetric and Midwifery” Lotus Publishers, 2013, P.No 315-317

· Mrs. A. Rama Devi et al, “Midwifery and Obstetrical Nursing” Florence Publishers, 2012, P.No 7.137-7.14

· D. C. Dutta’s, “Text Book of Obstetrics” New Central Book Agency [P] Ltd, 2011, P.No 281-287

Journal Article

· International diabetic federation, [1] 2014

· Journal of Diabetes Nursing 17: 220-4

· Canadian Diabetes Association (2013). Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diabetes 37 (Suppl), S1-S212

· Kaiser, B., and Kazurel, C. (2013). Determinants of postpartum physical activity, dietary habits and weight loss after gestational diabetes mellitus. Journal of Nursing Management, 21, 58-69.

Received on 06.08.2014 Modified on 18.08.2014

Int. J. Adv. Nur. Management 2(3): July-Sept.,2014; Page 177-179