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Evidence-Based Strategies for Managing Gestational Diabetes in Women With Obesity

Donnay Elkins, MSN, RN, FNP-C Julie Smith Taylor, PhD, RN, WHNP-BC

Objectives
Upon completion of this activity, the learner will be able to:

INTRODUCTION
In the United States, an estimated one-third of women of ages 20 to 39 are obese, with a body mass index (BMI) > 30 kg/m2 (Nodine & Hastings-Tolsma, 2012). Pregnancy complications related to obesity include, but are not limited to, gestational diabetes mellitus (GDM), gestational hypertension and cesarean surgical birth (see Box 1; Nodine & Hastings-Tolsma). Moreover, pregnant women with obesity are 1.6 times more likely to develop pre-eclampsia, 2.5 times more likely to develop gestational hypertension and more than 8.5 times more likely to develop GDM when compared with pregnant women with BMIs < 30 kg/m2 (Shirazian & Raghavan, 2009). Even in the absence of maternal obesity, GDM during pregnancy is associated with fetal complications, such as macrosomia, miscarriage, neonatal hypoglycemia, neural tube defects and preterm delivery (Nielsen, deCourten, & Kapur, 2012; Reece, 2008; Reece, 2010; Schneiderman, 2010; see Box 2). However, when a pregnancy is complicated by both obesity and GDM, each extra kg of body weight above a BMI of 30 kg/m2 increases the risk of adverse pregnancy outcomes by 6.6 percent, and each increase of 10 mg/dL in fasting plasma glucose levels above 95 mg/dL raises the adverse outcome risk by another 15 percent (Langer, Yogev, Most, & Xenakis, 2005). Because of the increased maternal and fetal risks associated with maternal obesity and GDM, the development of evidencebased strategies (see Figure 1) for screening and management of GDM and for timing of birth in these women will provide a comprehensive approach needed to optimize outcomes for both women and newborns. Thus, the aim of this article is to formulate best practice guidelines for the care of women with obesity during pregnancies complicated by GDM to reduce adverse maternal and fetal outcomes.

1. Describe risks associated with gestational diabetes mellitus (GDM) and obesity in pregnancy. 2. Describe methods to screen for GDM. 3. Describe evidence-based strategies for managing GDM in women with obesity.

Continuing Nursing Education (CNE) Credit

A total of 1 contact hour may be earned as CNE credit for reading Evidence-based Strategies for Managing Gestational Diabetes in Women With Obesity and for completing an online post-test and participant feedback form. To take the test and complete the participant feedback form, please visit http://JournalsCNE. awhonn.org. Certicates of completion will be issued on receipt of the completed participant feedback form and processing fees. Association of Womens Health, Obstetric and Neonatal Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Centers Commission on Accreditation. Accredited status does not imply endorsement by AWHONN or ANCC of any commercial products displayed or discussed in conjunction with an educational activity. AWHONN is approved by the California Board of Registered Nursing, provide #CEP580.

THEORETICAL FRAMEWORK AND LITERATURE REVIEW

The Health Belief Model describes how personal perceptions about a disease and the strategies available to decrease a disease both impact the occurrence of a disease (Rosenstock, 1966). The Health Belief Model revolves around four perceptions that influence a persons health behaviors: perceived seriousness, perceived susceptibility, perceived benefits and perceived

Donnay Elkins, MSN, RN, FNP-C, is a family nurse practitioner at Chair City Family Medicine in Thomasville, NC. Julie Smith Taylor, PhD, RN, WHNP-BC, is an associate professor and graduate coordinator at the University of North Carolina Wilmington School of Nursing in Wilmington, NC. The authors and planners of this activity report no conflicts of interest or relevant financial relationships. No commercial support was received for this learning activity. Address correspondence to: taylorjs@uncw.edu.

Abstract: Pregnancies complicated by both obesity and gestational diabetes mellitus (GDM) increase the risk of maternal and fetal complications, including but not limited to gestational hypertension, cesarean surgical birth, fetal macrosomia and postpartum hemorrhage. Because of the increased maternal and fetal risks associated with maternal obesity and GDM, the development of evidence-based strategies for screening for and management of GDM and for timing of birth will provide a comprehensive approach needed to optimize outcomes for both women and newborns. DOI: 10.1111/1751-486X.12065 Keywords: gestational diabetes | maternal obesity | pregnancy | obesity

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BOX 1 MATERNAL RISKS ASSOCIATED WITH GDM AND OBESITY DURING PREGNANCY
Gestational hypertension Pre-eclampsia Cesarean surgical birth Wound infections Thromboembolism
Source: Nodine and Hastings-Tolsma (2012).

barriers. Perceived seriousness indicates the belief about the severity of a particular disease. Perceived susceptibility is how likely a person believes she is to acquire a disease. Perceived benefits explain how a health behavior will affect the chances of developing a disease or experiencing sequelae from a disease. Lastly, perceived barriers are personal hindrances to adopting a health behavior that will decrease disease (Rosenstock). While these four perceptions influence an individuals beliefs about her health, these perceptions are influenced by modifying variables, cues to action and self-efficacy (Rosenstock, 1966). Variables such as culture, education, experiences and motivation influence an individuals perceptions. Cues to action from events or people also influence someones perception of health beliefs. Self-efficacy determines peoples ability to do something about their health despite their perceptions, variables or cues to action (Rosenstock).

28 weeks gestation because evidence indicates that when treatment is initiated at this gestational age, there are profound decreases in perinatal complications such as fetal death, shoulder dystocia, bone fracture and nerve palsy (Hillier et al., 2008). Also, physiologically this timing is most appropriate due to a natural increase in insulin resistance starting in the second trimester as a result of an increase in human placental lactogen and other pregnancy hormones (Schneiderman, 2010). These higher physiologic levels of human placental lactogen result in ever-increasing levels of insulin secretion. When the amount of insulin secreted can no longer keep pace with the higher levels of glucose, GDM develops. GDM screening before 24 weeks gestation is associated with early interventions, which decrease incidences of largefor-gestational-age infants, APGAR scores < 7 at 5 minutes, instrumental vaginal deliveries and cesarean deliveries (P < 0.05;

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When preconception or early prenatal care is initiated, it may be possible to prevent GDM completely
Berg, Adlerberth, Sultan, Wennergren, & Wallin, 2006). However, the United States Preventive Services Task Force (USPSTF, 2008) reports limited evidence in the improvement of outcomes when GDM treatment is initiated before 24 weeks gestation, and recommends establishing decisions on a case-by-case basis,

PREVENTION
When preconception or early prenatal care is initiated, it may be possible to prevent GDM completely. Exercise started before 20 weeks gestation reduces the risk of GDM development by 46 percent (Weissgerber, Wolfe, Davies, & Mottola, 2006). If physical activity is initiated a year before conception and is continued consistently during the first 20 weeks of pregnancy, the risk of developing GDM decreases by 60 percent (Weissgerber et al.). Furthermore, introducing a walking regimen 3 to 4 days per week that reaches 30 percent of maximum agepredicted heart rate for 30 minutes in conjunction with carbohydrate restriction to 200 g/day has been shown to prevent the development of GDM (Weissberger et al.).

BOX 2 FETAL RISKS ASSOCIATED WITH GDM AND OBESITY DURING PREGNANCY
Neural tube defect Heart defects Macrosomia Birth trauma Preterm birth Neonatal respiratory distress Miscarriage Intrauterine fetal demise Hypoglycemia Hyperbilirubinemia Jaundice
Sources: Kendrick (2011); Nielsen et al. (2012); Reece (2008, 2010) ; Schneiderman (2010).

SCREENING
Screening Schedule
Currently, there is no ideal approach to the best time to screen for GDM (American College of Obstetricians and Gynecologists [ACOG], 2011). ACOG and the American Diabetes Association (ADA, 2011) recommend screening between 24 and

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30 weeks gestation using both screening methods have demdepending on the presence of risk factors such as increased maonstrated that the 2-hour 75-g OGTT has better sensitivity at ternal age or history of GDM in a previous pregnancy, for each diagnosing GDM in women with obesity and can lead to depatient scenario (Scheneiderman, 2010; see Box 3). Further, creased rates of macrosomia, hypoglycemia, hyperbilirubineother research has demonstrated comparable outcomes when mia and stillbirth by at least 10 percent (DeSereday, Damiano, screening occurred between 15 and 19 weeks or 24 and 28 Gonzalez, & Bennett, 2003; Hillier et al., 2008). Theoretically, weeks, with no differences in rates of cesarean, preterm birth, improved outcomes can be attributed to more patients receiving 5-minute APGAR < 7, macrosomia, presence of meconium or treatment for GDM when screened with the 2-hour 75-g OGTT neonatal intensive care unit (NICU) admissions (Kerr, 2008; due to the lower cutoff values and the requirement of only one Hillier et al., 2008). In general, a possible management plan to abnormal glucose measurement for diagnosis (Sinha, 2012). satisfy the spectrum is to screen all high-risk pregnant women between 16 and 18 weeks gestation and if the screen is negative, perform a follow-up screening at 28 weeks gestation (Serci, 2008). FIGURE 1 EVIDENCE-BASED STRATEGIES

Screening Method
A single, random glucose measurement should not be used as a screening tool for GDM, because of poor sensitivity and specificity (van Leeuwen et al., 2011). Depending on gestation, a womans insulin sensitivity naturally varies, making a random glucose measurement unreliable (Hillier et al., 2008). However, this screening tool can be useful for early detection of undiagnosed type 2 diabetes in high-risk gravida populations (Cundy, 2012). One standard procedure of GDM screening includes an initial screening with a nonfasting, 1-hour 50-g oral glucose tolerance test (OGTT) followed by a fasting, 3-hour 100-g OGTT if the 1-hour OGTT is elevated (ACOG, 2011). The exact cutoff value considered elevated for the 1-hour OGTT remains elusive and under debate. A diagnosis of GDM is made when at least two values are above the normative cutoff values for the 3-hour OGTT (see Box 4). A second screening option endorsed by the International Association of Diabetes and Pregnancy Study Groups (IADSPG), National Institute for Clinical Excellence (NICE) and ADA that emerged from the Hyperglycemia and Adverse Pregnancy Outcomes (HAPO) study and the Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS) is the single 2-hour 75-g OGTT (ADA, 2011; Cundy, 2012; Dennedy, O-Sullivan, & Dunne, 2010). Diagnosis of GDM can be made with only one abnormal glucose level fasting (>92 mg/dL), at 1 hour (>180 mg/dL) or at 2 hours (>153 mg/dL) (ADA, 2011). ACOG (2011) does not currently endorse the 2-hour OGTT method as it would predictably increase health care costs. Studies comparing the screening methods in more than 450 pregnant women between 26 and

FOR MANAGING GDM

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Screening Population
Because of its better sensitivity and practicality, universal screening is recommended over selective screening based on risk factors (Kendrick, 2011). In an observational study (n = 1,600), Cosson et al. (2006) found universal screening, as compared to selective screening, decreased the prevalence of preterm birth, large-for-gestational-age infants, neonatal hyperglycemia, neonatal jaundice and NICU admissions (P < 0.05) while also decreasing rates of shoulder dystocia (5 vs. 17), neonatal hypoglycemia (2 vs. 26) and neonatal respiratory distress syndrome (3 vs. 14).

BOX 3 RISK FACTORS TO INFLUENCE TIME OF GDM SCREENING

Family history of mother with diabetes mellitus Hispanic, Asian, Native American, African American or Pacic Islander ethnicity History of GDM in a previous pregnancy Hypertensive disorders in current pregnancy Multiple gestation Prior birth of infant weighing > 9lbs Polycystic ovary syndrome
Source: Schneiderman (2012).

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MANAGEMENT OF GDM
Health Education
Health education programs about GDM management, as brief as 10 to 30 minutes, have shown to improve maternal and neonatal outcomes (Elnour, El Mugammar, Jaber, Revel, & McElnay, 2008). Effective teaching programs include one-on-one conversations about diet, exercise, normal blood sugar ranges, timing and frequency of plasma glucose self-monitoring and treatment of abnormal results, while also supplying an educational take-home booklet filled with information about diabetes in general, GDM specifically, the role of diet and exercise in treatment and actions to take in response to hypoglycemic or hyperglycemic episodes (Elnour et al.). In a randomized controlled trial (n = 165), researchers found that participants in the structured educational program experienced improved glycemic control and statistically significant reductions (P < 0.05) in the incidence of cesarean deliveries, preterm birth, shoulder dystocia, macrosomia in infants, neonatal hypoglycemia, neonatal respiratory distress and neonatal hyperbilirubinemia (Elnour et al., 2008). This study shows that providing women with quality information about their diagnosis and disease management increases the rate of blood glucose self-monitoring and enables patients to readily identify hyperglycemia and hypoglycemia, which positively influences patients engagement in their own care (Elnour et al.). The researchers concluded that this active participation by women in the management of their GDM results in more favorable outcomes.

continuous glucose monitoring compared to traditional glucose monitoring (Kestila, Ekblad, & Ronnemaa).

Physical Activity
In a review of the literature, Weissgerber et al. (2006) report findings from an earlier study (Clark, Thornley, Tomlinson, Galletley, & Norman, 1998) that demonstrated a decrease in the rate of miscarriage from 75 percent to 18 percent in obese, previously infertile, women who participated in a 6-month physical activity intervention. Physical activity during pregnancy can decrease the rate of miscarriage from 75 percent to 18 percent in certain populations of pregnant women with obesity (Weissgerber et al., 2006). Walking, stationary bikes, aquatic exercise and low-impact aerobics are the activities most recommended during pregnancy (Mottola, 2009). Davenport, Mottola, McManus, and Gratton (2008) found through a casecontrol study of 30 overweight, pregnant women with GDM that low-intensity walking 3 to 4 days per week for at least 6 weeks starting at 25 minutes/day and working up to 40 minutes/

Home Blood Glucose Monitoring

A continuous glucose monitoring system is optimal for the tighter glucose control recommended with GDM (Kestila, Ekblad, & Ronnemaa, 2007). In a randomized controlled trial of 73 patients, 31 percent of users were prompted to self-medicate abnormal glucose levels, compared with only 8 percent of participants using traditional monitoring with fasting and 2-hour postprandial readings (Kestila, Ekblad, & Ronnemaa). However, the traditional approach has most often been utilized in current practice, as no significant improvements in maternal or fetal outcomes have been demonstrated with the use of

BOX 4 ORAL GLUCOSE TOLERANCE TEST DIAGNOSTIC CRITERIA

Fasting > 105 mg/dL After 1 hour > 190 mg/dL After 2 hours > 165 mg/dL After 3 hours > 140 mg/dL
Note: Two values above these cutoffs are needed to diagnose GDM. Source: ACOG (2011).

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day lowered mean glucose levels by 11 mg/dL for the morning fasting level, about 9 mg/dL after breakfast, about 13 mg/dL after lunch and about 7 mg/dL after dinner, with an average of 10 mg/dL throughout the four blood glucose checks per day (P < 0.05). Walking also decreased frequency and amount of insulin treatment, with injections only needed at breakfast and

Health education programs about GDM management, as brief as 10 to 30 minutes, have shown to improve maternal and neonatal outcomes
bedtime. In a study of women ages 20 to 39, researchers determined that during any exercise program, target heart rate levels for overweight and obese pregnant women should be 102 to 124 beats per minute (bpm) for ages 20 to 29 and 101 to 120 bpm for ages 30 to 39 (Davenport, Charlesworth, Vanderspank, Sopper, & Mottola, 2008)

infants (Singh & Rastogi, 2008). Guidance with regard to food choices and nutrition appears to have a significant impact on the overall course of disease in many patients. Following diabetes nutrition guidelines should be recommended for overweight and obese pregnant women with GDM (Serci, 2008). However, severe caloric restrictions should be avoided due to the higher prevalence and risk of intrauterine growth restriction (IUGR) as well as small-for-gestational-age infants (Catalano, 2013; Serci, 2008). At least 175 g/day of carbohydrates should be consumed to enhance fetal brain development and prevent maternal ketosis, but these carbohydrates should comprise <45 percent of the total energy for the day to avoid hyperglycemia (National Guideline Clearinghouse, 2010).

Combining Exercise and Diet

Physical activity combined with diet modifications can improve fasting and postprandial glucose levels and insulin sensitivity (Singh & Rastogi, 2008). Furthermore, a walking regimen 3 to 4 days/week in which women reach 30 percent of their maximum age-predicted heart rate for 30 minutes, in conjunction with carbohydrate restriction of 200 g/day, is imperative to controlling blood glucose levels and helps pregnant women with obesity remain within the target weight gain recommendations outlined by the Institute of Medicine (Weissgerber et al., 2006).

Diet Modication and Education

Referral to a registered dietitian should occur simultaneously with GDM diagnosis and, ideally, women should meet with a registered dietitian within a week of diagnosis (National Guideline Clearinghouse, 2010). This early referral can prevent the need for pharmacotherapy as treatment, and at least three visits throughout the pregnancy can improve maternal and neona-

PHARMACOLOGIC MANAGEMENT OF GDM

Short-Acting Insulin
When dietary modifications and physical activity are not providing adequate glycemic control in women with GDM and obesity, short-acting insulin should be the first line of pharmacotherapy, because insulin treatment in women with obesity establishes better glycemic control and creates pregnancy outcomes comparable to normal women without GDM and obesity (Langer, Yogev, Xenakis, & Brustman, 2005; Serlin & Lash, 2009). Risk factors, such as high prepregnancy BMI, increase a womans likelihood of requiring insulin later in pregnancy (Sapienza, Francisco, Trindale, & Zugaib, 2010; see Box 5). Additionally, 80 percent of women with fasting glucose levels greater than 105 mg/dL will require the addition of insulin therapy during pregnancy (Akinci, Celtik, Yener, & Yesil, 2008).

Medical nutrition therapy (MNT) guided by an experienced registered dietitian should be a rst-line treatment for GDM because of the impact on maternal and neonatal outcomes when initiated early in pregnancy
tal outcomes (National Guideline Clearinghouse; Rugge, King, Davis, & Schechtel, 2009). Medical nutrition therapy (MNT) guided by an experienced registered dietitian should be a firstline treatment for GDM because of the impact on maternal and neonatal outcomes when initiated early in pregnancy (National Guideline Clearinghouse; Serlin & Lash, 2009). Providing individualized MNT following the ADAs Nutrition Practice Guidelines for GDM decreases the need for insulin, the rates of cesarean deliveries and prevalence of large-for-gestational-age

Oral Anti-Hyperglycemic Agents

Oral anti-hyperglycemic agents should be considered after diet and exercise interventions have failed to control GDM and when women either cannot afford the cost of insulin therapy or do not adhere to an insulin regimen (Silva et al., 2010). These agents are best at controlling GDM if GDM is diagnosed in the first trimester (Kerr, 2008). However, they are commonly used in current practice since they are noninvasive, inexpensive and better accepted by patients (Singh & Rastogi, 2008).

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Metformin appears to be more useful than glyburide, as metformin use is associated with fewer cesarean deliveries, large-for-gestational-age infants and macrosomia (Silva et al., 2010). Metformin is also associated with an increase in APGAR scores and a decrease in premature deliveries, neonatal jaundice, NICU admissions and macrosomic infants (Balani, Hyer, Rodin, & Shehata, 2009; Begum et al., 2008).

COMBINING MODALITIES TO MANAGE GDM

Dietary modifications and physical activity are the mainstays of GDM treatment for women with obesity, with the addition of self-monitoring of glucose levels, insulin therapy and oral antihyperglycemic agents when necessary (Landon et al., 2009; Rugge et al., 2009). In a randomized controlled trial of 958 women, combination therapy including nutrition counseling, dietary modifications, physical activity, self-glucose monitoring, insulin therapy and oral antihyperglycemic agents produced statistically significant decreases in the prevalence of large-for-gestational-age infants, macrosomia, shoulder dystocia, cesarean delivery, preterm delivery, NICU admission and hyperbilirubinemia (Landon et al.).

In creating plans of care based on estimated fetal weight by ultrasound, it is important to remember this method has a margin of error between 10 percent and 15 percent (Lalys, Pineau, & Guihard-Costa, 2010). However, if macrosomia with estimated fetal weight > 4,000 g via ultrasound is suspected, delivery should be considered between 38 and 39 weeks to reduce the risk of shoulder dystocia from 10 percent to 1.4 percent (Menato et al., 2008). If estimated fetal weight is > 4,250 g, cesarean

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Nurses can counsel and motivate women through support, education and compassion, by explaining the benets of adhering to evidence-based strategies to decrease the risk of complications
should be considered to decrease the likelihood of shoulder dystocia, postpartum hemorrhage, third- and fourth-degree lacerations and maternal infections (Sela et al., 2009). Currently, research is ongoing to compare maternal and neonatal outcomes in scheduled inductions between 38 and 39 weeks gestation and expectant management for women with GDM (Maso et al., 2011).

BIRTH TIMING
If a pregnant woman with GDM and obesity has experienced good glycemic control throughout her pregnancy, there is insufficient evidence and no medical indication to contradict the recommendation against elective induction of labor before 39 weeks gestation (ACOG Committee on Practice Bulletins Obstetrics, 2009; March of Dimes, n.d.). Expectant management should be utilized in women with normal estimated fetal weight, good glycemic control, reassuring antenatal testing and normal amniotic fluid levels (Sela, Raz, & Elchalal, 2009). After 32 weeks gestation, non-reassuring antenatal testing or an abnormal fetal kick count as reported by the patient may indicate that delivery could be considered (Seri & Evan, 2008; Sugiyama, 2011). If preterm delivery is pursued, fetal lung maturity must be assessed first, since the pulmonary system is one of the last to complete development (Gillen-Goldstein, MacKenzie, & Funai, 2013).

IMPLICATIONS FOR NURSES

Within the framework of the Health Belief Model, nurses can help pregnant women with obesity understand and appreciate their increased likelihood of being diagnosed with GDM. Moreover, education and support provided by nurses during this very critical period may decrease or minimize any shortterm obstetric risk as well as further long-term risks, such as metabolic syndrome and type 2 diabetes mellitus (Dennedy et al., 2010; Kendrick, 2011). Nurses can counsel and motivate women through support, education and compassion, by explaining the benefits of adhering to evidence-based strategies to decrease the risk of complications. Nurses can address womens perceived barriers

BOX 5 FACTORS PREDICTING THE NEED FOR INSULIN IN WOMEN WITH GDM
POSITIVE INDICATORS Family history of diabetes mellitus Prepregnancy obesity Several (34) abnormal values on 3-hour 100-g OGTT Elevated HbA1c levels NEGATIVE INDICATORS Appropriate weight No family history of diabetes mellitus Only two abnormal values on 3-hour, 100-g OGTT
Source: Sapienza et al. (2010).

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BOX 6 INSTITUTE OF MEDICINE RECOMMENDATIONS FOR WEIGHT GAIN IN PREGNANCY

Prepregnancy BMI < 18.5 kg/m2 : 2840 pounds Prepregnancy BMI 18.524.9 kg/m2 : 2535 pounds Prepregnancy BMI 2529.9 kg/m : 1525 pounds
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pregnancy in women with polycystic ovary syndrome. Journal of Obstetric and Gynaecology Research, 35(2), 282286. Berg, M, Adlerberth, A., Sultan, B., Wennergren, M., & Wallin, G. (2006). Early random capillary glucose level screening and multidisciplinary antenatal teamwork to improve outcome in gestational diabetes mellitus. Acta Obstetricia et Gynecologica, 86, 283290. Catalano, P. (2013). Weight loss in overweight and obese pregnant women: What is the effect on fetal growth? American Journal of Obstetrics and Gynecology, 208(1), s155. doi:10.1016/j. ajog.2012.10.514 Clark, A. M., Thornley, B., Tomlinson, L., Galletley, C., & Norman, R. J. (1998). Weight loss in obese infertile women results in improvement in reproductive outcome for all forms of fertility treatment. Human Reproduction, 13, 15021505. doi:10.1093/ humrep/13.6.1502 Cosson, E., Benchimol, M., Carbillon, L., Pharisien, I., Paries, J., Valensi, P., Attali, J. R. (2006). Universal rather than selective screening for gestational diabetes mellitus may improve fetal outcomes. Diabetes Metabolism, 32, 140146. Cundy, T. (2012). Proposed new diagnostic criteria for gestational diabetes: A pause for thought? Diabetic Medicine, 29, 176180. doi:10.1111/j.1464-5491.2011.03407.x Davenport, M. H., Charlesworth, S., Vanderspank, D., Sopper, M. M., & Mottola, M. F. (2008). Development and validation of exercise target heart rate zones for overweight and obese pregnant women. Applied Physiology and Nutrition Metabolism, 33, 984 989. doi:10.1139/HO8-086 Davenport, M. H., Mottola, M. F., McManus, R., & Gratton, R. (2008). A walking intervention improves capillary glucose control in women with gestational diabetes mellitus: A pilot study. Applied Physiology, Nutrition and Metabolism, 33, 511517. Dennedy, M., OSullivan, E., & Dunne, F. (2010). Screening, complications and treatment of gestational diabetes. Diabetes and Primary Care, 12(6), 337342. DeSereday, M. S., Damiano, M. M., Gonzalez, C. D., & Bennet, P. H. (2003). Diagnostic criteria for gestational diabetes in relation to pregnancy outcome. Journal for Diabetes Complications, 17(3), 115119. Elnour, A. A., El Mugammar, I. T., Jaber, T., Revel, T., & McElnay, J. C. (2008). Pharmaceutical care of patients with gestational diabetes mellitus. Journal of Evaluation in Clinical Practice, 14, 131140. Gillen-Goldstein, J., MacKenzie, A. P., & Funai, E. F. (2013, January 22). Assessment of fetal lung maturity. Retrieved from www. uptodate.com/contents/assessment-of-fetal-lung-maturity Hillier, T., Vesco, K., Whitlock, E., Pettitt, D., Pedula, K., & Beil, T. (2008). Screening for gestational diabetes mellitus: Evidence synthesis no. 60. Rockville, MD: Agency for Healthcare Research and Quality. Institute of Medicine National Research Council. (2009). Weight gain during pregnancy: Reexamining the guidelines. Washington, DC: The National Academies Press. Kendrick, J. (2011). Screening and diagnosing gestational diabetes mellitus revisited. Journal of Perinatal and Neonatal Nursing, 25(3), 226232. doi:10.1097/JPN.0b013e318222dded

Prepregnancy BMI 30 kg/m2 : 1120 pounds

Source: IOM (2009).

to adopting these evidence-based strategies. Nurses connect women with appropriate resources and provide vital support to women as they modify their behaviors in efforts to decrease adverse maternal and fetal outcomes associated with GDM.

CONCLUSION
Preventing the development of GDM in pregnant women with obesity is the ideal scenario, and could potentially decrease the development of adverse maternal and fetal outcomes. Targeted interventions to increase physical activity, implement dietary modifications and maintain appropriate pregnancy weight gain (Institute of Medicine National Research Council, 2009; see Box 6) would be the best strategy to decrease the likelihood of complications. Nurses play an integral role in helping pregnant women with obesity reduce their risk for maternal and fetal complications of GDM. !"#

REFERENCES
Akinci, B., Celtik, A., Yener, S., & Yesil, S. (2008). Is fasting glucose level during oral glucose tolerance test an indicator of the insulin need in gestation diabetes? Diabetes Research and Clinical Practice, 82, 219225. American College of Obstetricians and Gynecologists. (2011). Screening and diagnosis of gestational diabetes mellitus. Committee Opinion No. 504. Obstetrics & Gynecology, 118, 751753. American College of Obstetricians and Gynecologists Committee on Practice BulletinsObstetrics. (2009). ACOG Practice Bulletin No. 107: Induction of labor. Obstetrics & Gynecology, 114, 386397. American Diabetes Association. (2011). Standards of medical care in diabetes. Retrieved from http://care.diabetesjournals.org/content/34/Supplement_1/S11.full Balani, J., Hyer, S. L., Rodin, D. A., & Shehata, H. (2009). Pregnancy outcomes in women with gestational diabetes treated with metformin or insulin: A case-control study. Diabetic Medicine, 26, 798802. doi:10.1111/j.1464-5491.2009.02780.x Begum, M. R., Khanam, N. N., Quadir, E., Ferdous, J., Begum, M. S., Khan, F., & Begum, A. (2008). Prevention of gestational diabetes mellitus by continuing metformin therapy throughout

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Kerr, M. (2008, May 13). American College of Obstetricians and Gynecologists: Early screening of women at high risk for gestational diabetes recommended. Retrieved from www.medscape.com/ viewarticle/574407 Kestila, K. K., Ekblad, U. U., & Ronnemaa, T. (2007). Continuous glucose monitoring versus self-monitoring of blood glucose in the treatment of gestational diabetes mellitus. Diabetes Research and Clinical Practice, 77, 174179. Lalys, L., Pineau, J. C., & Guihard-Costa, A. M. (2010). Small and large fetuses: Identification and estimation of foetal weight at delivery from third-trimester ultrasound data. Early Human Development, 86, 753757. doi:10.1016/j.earthumdev.2010.07.014 Landon, M. B., Spong, C. Y., Thom. E., Carpenter, M. W., Ramin, S. M., Casey, B., Anderson, G. B. (2009). A multicenter, randomized trial of treatment for mild gestational diabetes. New England Journal of Medicine, 316(14), 13391348. Langer, O., Yogev, Y., Most, O., & Xenakis, E. M. (2005). Gestational diabetes: The consequence of not treating. American Journal of Obstetrics and Gynecology, 192, 989997. Langer, O., Yogev, Y., Xenakis, E. M., & Brustman, L. (2005). Overweight and obese in gestational diabetes: The impact on pregnancy outcome. American Journal of Obstetrics and Gynecology, 192, 17681776. March of Dimes. (n.d.) Less than 39 weeks toolkit. White Plains, NY: Author. Retrieved from www.marchofdimes.com/professionals/less-than-39-weeks-toolkit.aspx Maso, G., Alberico, S., Wiesenfield, U., Ronfani, L., Erenbourg, A., Hadar, E., Hod, M. (2011). GINEXMAL RCT: Induction of labour versus expectant management in gestational diabetes pregnancies. BMC Pregnancy and Childbirth, 11(1), 3137. Menato, G., Bo, S., Signorile, A., Gallo, M. L., Cotrino, I., Poala, C. B., & Massobrio, M. (2008). Current management of gestational diabetes mellitus. Expert Review of Obstetrics and Gynecology, 3(1), 7391. Retrieved from www.medscape.com/viewarticle/568728_6 Mottola, M. F. (2009). Exercise prescription for overweight and obese women: Pregnancy and postpartum. Obstetrics and Gynecology Clinics of North America, 36, 301316. National Guideline Clearinghouse. (2010, March 9). Gestational diabetes mellitus: Evidence-based nutrition practice guidelines. Retrieved from www.guideline.gov/content.aspx?id=14888 Nielsen, K., de Courten, M., & Kapur, A. (2012). The urgent need for universally applicable simple screening procedures and diagnostic criteria for gestational diabetes mellitus: Lessons from projects funded by the World Diabetes Foundation. Global Health Action, 5, 112. Nodine, P., & Hastings-Tolsma, M. (2012). Maternal obesity: Improving pregnancy outcomes. American Journal of Maternal Child Nursing, 37(2), 110115. Reece, E. A. (2008). Obesity, diabetes, and links to congenital defects: A review of evidence and recommendation for intervention. Journal of Maternal-Fetal and Neonatal Medicine, 21(3), 173180. Reece, E. A. (2010). The fetal and maternal consequences of gestational diabetes mellitus. Journal of Maternal-Fetal and Neonatal Medicine, 23(3), 199203.

Rosenstock, I. M. (1966). Why people use health services. Milbank Memorial Fund Quarterly, 83(4), 132. Rugge, B., King, V., Davis, E., & Schechtel, M. (2009). Gestational diabetes: Caring for women during and after pregnancy. Rockville, MD: Agency for Healthcare Research and Quality. Sapienza, A. D., Francisco, R. P., Trindale, T. C., & Zugaib, M. (2010). Factors predicting the need for insulin therapy in patients with gestation diabetes mellitus. Diabetes Research and Clinical Practice, 88, 8186. Schneiderman, E. (2010). Gestational diabetes: An overview of a growing health concern for women. Journal of Infusion Nursing, 33(1), 4854. Sela, H. Y., Raz, I., & Elchalal, U. (2009). Managing labor and delivery of the diabetic mother. Expert Review of Obstetrics and Gynecology, 4(5), 547554. Retrieved from www.medscape.com/ viewarticle/712289_4 Serci, I. (2008). Diabetes in pregnancy: Dietary management. Practicing Midwife, 11(6), 4351. Seri, I., & Evans, J. (2008). Limits of viability: Definition of the gray zone. Journal of Perinatology, 28, 48. doi:10.1038/jp.2008.42 Serlin, D. C., & Lash, R. W. (2009). Diagnosis and management of gestational diabetes mellitus. American Family Physician, 80(1), 5762. Retrieved from www.aafp.org/afp/2009/0701/p57.html Shirazian, T., & Raghavan, S. (2009). Obesity and pregnancy: Implications and management strategies for providers. Mount Sinai Journal of Medicine, 76, 539545. Silva, J. C., Pacheco, C., Bizato, J., Souza, B. V., Ribeiro, T. E., & Bertini, A. M. (2010). Metformin compared with glyburide for the management of gestational diabetes. International Journal of Gynecology and Obstetrics, 111, 3740. Singh, S. K., & Rastogi, A. (2008). Gestational diabetes mellitus. Diabetes and Metabolic Syndrome: Clinical Research and Reviews, 2, 227234. Sinha, S. (2012, September 13). Gestational diabetes: Impact and screening. Retrieved from www.medpagetoday.com/resourcecenter/glp1-type-2-diabetes/gestational-diabetes/a/34743 Sugiyama, T. (2011). Management of gestational diabetes mellitus. Journal of the Japan Medical Association, 139(10), 20892094. United States Preventive Services Task Force (USPSTF). (2008). Screening for gestational diabetes mellitus: U.S. preventive services task force recommendation statement. Annals of Internal Medicine, 148(10), 759765. van Leeuwen, M., Opmeer, B. C., Yilmaz, Y., Limpens, J., Serlie, M. J., & Mol, B. M. (2011). Accuracy of the random glucose test as screening test for gestational diabetes mellitus: A systematic review. European Journal of Obstetrics and Gynecology and Reproductive Biology, 154, 130135. Weissgerber, T. L., Wolfe, L. A., Davies, G. A. L., & Mottola, M. F. (2006). Exercise in the prevention and treatment of maternalfetal disease: A review of literature. Applied Physiology, Nutrition and Metabolism, 31, 661674.

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Post-Test Questions
Instructions: To receive contact hours for this learning
activity, please complete the online post-test and participant feedback form at http://JournalsCNE.awhonn.org. CNE for this activity is available online only; written tests submitted to AWHONN will not be accepted.
1. Which of the following are the four perceptions described by the Health Belief Model? a. Barriers, challenges, benets and seriousness b. Seriousness, susceptibility, benets and barriers c. Susceptibility, usefulness, ability and motivation When a pregnancy is complicated by both obesity and GDM, each extra kg of body weight over a BMI of 30 kg/m2 increases the risk of adverse pregnancy outcomes by how much? a. 4.5 percent b. 6.6 percent c. 15 percent The risk of developing GDM decreases by how much if physical activity is initiated a year before conception and is consistently continued during the rst 20 weeks of pregnancy? a. 20 percent b. 40 percent c. 60 percent The American College of Obstetricians and Gynecologists and the American Diabetes Association recommend screening for GDM at what point? a. Between 20 and 24 weeks gestation b. Between 24 and 28 weeks gestation c. Once symptoms develop During the second trimester of pregnancy, levels of placental lactogen increase, causing a. A decrease in insulin resistance b. An increase in insulin resistance c. Stable levels of insulin secretion In studies comparing GDM screening methods in more than 450 pregnant women between 26 and 30 weeks gestation, which test was found to have better sensitivity for diagnosing GDM in women with obesity? a. 1-hour 50-g OGTT b. 2-hour 75-g OGTT c. 3-hour 100-g OGTT 7. When GDM is diagnosed with the 2-hour, 75-g OGTT rather than the 3-hour 100-g OGTT, research has found: a. Decreased rates of macrosomia and stillbirth b. Improved glycemic control during pregnancy c. Improved ability to predict which women will develop type 2 diabetes later in life Which type of home glucose monitoring has been determined by research to have the best maternal and fetal outcomes? a. Continuous monitoring b. No differences in outcomes have been demonstrated in research c. Traditional monitoring Why should referral to a registered dietitian be made at the time of GDM diagnosis? a. It can help the woman improve her cooking skills. b. It can help the woman lose weight. c. It can reduce the womans risk for needing diabetes medication as the pregnancy progresses.

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10. In a 2008 case-control study of 30 overweight pregnant women, what exercise regimen lowered the womens mean glucose levels and decreased the frequency and amount of insulin needed? a. Cycling 3 to 4 days per week for at least 6 weeks b. Swimming 3 to 4 days per week for at least 6 weeks c. Walking 3 to 4 days per week for at least 6 weeks 11. Which of the following is true of birth timing for women with obesity and GDM? a. If a woman has experienced good glycemic control throughout her pregnancy and has no medical indications, there is insufcient evidence to support inducing labor before 39 weeks. b. Regardless of glycemic control, inducing labor early is generally recommended to reduce risk for complications such as shoulder dystocia. c. Women with GDM and obesity should never be induced because of risk of complications associated with induction. 12. When lifestyle modications do not achieve desired glycemic control, which pharmacologic agent is the preferred rst-line treatment for GDM in women with obesity? a. Glyburide b. Metformin c. Short-acting insulin

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