Case presentation

on
G P L A with POG 35+2 weeks with
5 3 2 2

gestational diabetes mellitus

SUBMITTED TO - Ms. Merlin A David
Tutor
Submitted by - Ms. Sneha Sehtrawat
MSc Nursing (OBG)
Rufaida College of Nursing

Submiited on - 20-09-2016

TOPICS COVERED-

1) BIOGRAPHIC DATA
2) INTRODUCTION OF PATIENT
3) SOCIOECONOMIC BACKGROUND
4) FAMILY HEALTH HISTORY
5) HISTORY OF PRESENT ILLNESS
6) HISTORY OF PAST ILLNESS
7) PERSONAL HISTORY
8) HEAD TO TOED EXAMINATION
9) INTRODUCTION OF THE DISEASE
10) DEFINITION OF THE DISEASE
11) ANATOMY OF THE ORGAN- PANCREASE
12) PHYSIOLOGY OF THE ORGAN
13) INCIDENCE
14) ETIOLOGY
15) RISK FACTORS
16) PATHOPHYSIOLOGY
17) CLINICAL MANIFESTATION
18) DIAGNOSTIC EVALUATION
19) MEDICAL MANAGEMENT OF GDM
20) NURSING MANAGEMENT
21) NURSING DIAGNOSES
22) COMPLICATIONS
23) NURSING CARE PLAN
24) RESEARCH EVIDENCES
25) SUMMARY
26) BIBLIOGRAPHY
I) BIOGRAPHIC DATA

 NAME Razia Begum

 AGE 27yrs
 SEX Female
 WARD NO. Gynae Ward
 MRD NO. IP0946723
 MARITAL STATUS Married
 EDUCATION Graduated
 OCCUPATION Housewife
 INCOME Rs. 35000/- per month
 RELIGION Muslim
 LANGUAGE KNOWN Hindi and english
 ADDRESS 12/9, Sangam Vihar, ND
 DIAGNOSIS G5P3L2A2 with POG 35+2 wks
& gestational diabetes mellitus

 DATE OF ADMISSION 21.8.2016

 DATE OF DISCHARGE not discharged yet
 DATE OF CARE STARTED 22.8.2016
 DATE OF CARE ENDED 26.8.2016
 INFORMANT Self and mother-in-law
II. INTRODUCTION OF PATIENT

My patient Razia Begum , a 27 yrs old female with POG

G5P3L2A2 with POG 35+2 wks & gestational diabetes mellitus
came to gynae OPD on 22.08.2016 with the complaints of deranged B.S. profile,
excessive thirst (polydypsia), increased volume of urine ( polyuria) , increased frequency of
micturation.

No C/o B.P.V, L.P.V, epigastric pain

C/o blurring vision (occasional),lathargy, restlessness, weakness, oedema (ankles).

Her general condition was poor. She looked not adequately hydrated.

On examination- T- 37.2°C
P- 88/ min
BP- 130/80 mm/Hg
 R- 20/min
RBS stat- 136mg/dl

On Fundal examination- Soft

Cephalic
NTNT ʘ ( non-tender, non-tensed)
Liquor adequate
FHS ＋/ R/ 144/min

A series of diagnostic tests were carried out and patient was diagnosed & admitted in Gynae
ward under Unit IV.

III. SOCIOECONOMIC BACKGROUND

 Mrs Razia Begum w/o Md. Alam lives in a city in her rented house. Water and
electricity facility is adequate and her house is well ventilated. Her house has toilet
constructed. Her husband is the one of earning member the family she live in a joint family.
No pet animals are there in her house.

IV. FAMILY HEALTH HISTORY

a) Family composition

S. Name Relations Age Sex Education Occup Health

No -hip with a-tion status
the
patient

1. Md. Alam Husband 33 M Post In Good

yrs graduated servic
e

2. Razia Self 27 F Graduated Tailor Poor

Begum yrs
3. Yasir Son 6 yrs M Primary - Good

4. Aliya Daughter 3 yrs F Preschoole - Healthy

r &
immuni
zed

There are three members in the family except the patient.

b) Family medical history

There is a history of diabetes in her family. Her mother had diabetes mellitus and her
sister also had developed gestational diabetes mellitus during her pregnancy.
There is so no other significant history of medical illness in the family.

V. HISTORY OF PRESENT ILLNESS

a) Present Obstetric History

Mrs. Razia Begum was admitted to HAH Centenary Hospital on 22nd August 2016 having
35 weeks +2 days of period of gestation(POG) with complaints of deranged B.S. profile,
excessive thirst (polydypsia), increased volume of urine ( polyuria) , increased frequency of
micturation.

1st Trimester
The mother had bouts of nausea and vomiting and food craving for fried foods and aversion
for milk and milk products. She had increased urination and fatigue. She also had
unexplained , unanticipated and significant weight loss despite pregnant state but she
ignored.

2nd Trimester

During the second trimester her nausea subsided but she started feeling pain in the lower
extremities and cramps too. She observed changes in urination pattern, leg cramps and
occasional dizziness. Quickening start at 5th month.

3rd Trimester

During the third trimester she is having increased fatigue, constipation, increased frequency
of micturation and vomiting.She experienced excessive thirst, increased frequency and
volume of urine.

Labour Notes:
FTNVD with left mediolateral episiotomy
Under all aseptic precautions parts painted and draped. Patient given a lithotomy positioned
with good uterine contractions and good bearing efforts. Left mediolateral episiotomy given
under local anesthesia .

A single live female baby with 2.649 kg on 25/08/16 at 9:38 Pm delivered by cephalic
presentation no loop of cord around the neck, liquor clear cord clamped and cut . Placenta
delivered with complete membranes . No cotyledons missing in the placenta on examination.
Episiotomy stitched back in layers , No PPH . Vitals are checked and charted.

The client was having pain at suture line. Breast is secretory. Nipples are cracked and painful
while feeding. Baby given expressed milk. Baby is tolerating feeds well. The blood sugar is
under monitoring , edema has reduced considerably.

 Present Medical History:

Mrs Razia Begum developed high blood sugar profile, amkle edema , polyuria, polydypsia,
increased frequency of micturation for which she was admitted to the hospital.

 Present Surgical History:

No significant present surgical history.

 Menstrual history:

She has regular cycles with duration of 4-5 days. She had mild dysmenorrhea.
V. HISTORY OF PAST ILLNESS

a)PAST OBSTETRICAL HISTORY

Mrs. Razia Begum is a multigravida mother. Admitted with the complains 35wks+2days of
amenorrhea.

G1 - FTNVD, Male child, Active and healthy

G2 - 2½ month spontaneous abortion f/b D&C
G3\ - FTNVD, Female child, Active and Healthy
G4 - 2 months spontaneous abortion f/b D&C
G5 - Present pregnancy, spontaneous conception.
b)History of Past Medical Illness

No any significant history of past medical history.

c) History of Past Surgical Illness

No past surgical history

Personal history

Personal Habits - She is a non-smoker, non-alcoholic female.

Dietary Habits -She is a non-vegetarian.
Sleep and rest -She usually sleeps 8 hours a day which
demonstrates a normal sleeping pattern.
Activities of daily living -She faces difficulty in performing activities of
daily living because of increasing fetal weight,
POG and fatigue.
Elimination -Bowel evacuation once a day which is normal
but sometimes C/O constipation is present.
Bladder habits -She demonstrates abnormal bladder emptying
Pattern. She has C/O polyuria, nocturia, dysuria
and burning micturation.
Sexual History -No H/O any sexual assualt, sexually
Transmitted disease and sexually transmitted
infections.
Drug History -No H/O any previous ongoing treatment expect
Tab. Eltroxin 25µg BBF and
Tab. α - dopa 250mg TDS.
History of allergy - No significant previous known H/O any
Hypersensitivity reaction from any drug or
Eatables.
Menstrual history - Regular menstrual cycle of 29 days with 4-5
Days of bleeding, which is normal.
No H/O dysmenorrhea.
Psychiatry history -She is oriented to person, place and time.
Insight and thinking present. No
Significant H/O psychiatric illness given by the
Patient or informant.
Nutritional Status -Breakfast: Banana shake, apple , brown bread
Toast.
Lunch:2 chapatti, Dal, salad and a bowl of curd
Snacks: Tea and poha.
Dinner:One bowl porridge with milk and
an egg.

Head to toe examination

General Appearance
 Nourishment Moderately nourished
 Body built Thin
 Hygiene & grooming Poor personal hygiene
 Activity Partially active
 Posture Lethargic and curved posture
 Movement Subnormal activity level
Mental status Examination
 Consciousness Conscious
 Look Anxious and worried
 Attitude Cooperative but hesitating
 Affect and mood Sad
 Speech Appropriate, no stammering
 Orientation oriented to person,place and time

Vitals signs
 Temperature 98.9°F
 Pulse 88/min
 Respiration 22/min
 Blood pressure 130/86mm/Hg

Weight & Height

 Height 152cms
 Weight 136.6lbs
 BMI 24.84kg/cm2(Normal)

Head
 Shape Normal, cephalic
 Scalp Dandruff flakes present
 Face Acne & chloasma present
 Subjective symptoms She is very conscious about acne
marks on her face.

Hair
 Texture Dry hairs yet straight
 Colour Dark brown
 Grooming Clean & plaited
 Subjective feelings Patient has no complaints.

Eyes
 Eyebrows Normal, symmetrical
 Eyelids Normal but dry
 Eyelashes Normal
 Pupil colour Hazel green
 Size ≈3mm
 Reaction to light Reactive pupils to light
 Corneal reflex Present
 Conjunctiva clear and pink
 Lens normal and transparent
 Pupil vision Bilaterally symetrical
 Extraocculor muscles Normal
 Subjective symptoms No subjective complaints

Ear
 Position Normal
 Cerumen cerumen present
 Otorrhoea Absent
 Subjective complaints No c/o hearing

Hearing
 Response to normal voice tone Normal
 Watch tick test Bilaterally ears responding to
Watch tick test
 Subjective complaints No subjective complaints

Nose
 External Symmetrical
 Nasal septum Midline; no deviation
 Patency of nasal cavity Air passes freely through both
Nostrils as the client was
Breathing.
 Frontal and maxillary sinuses Normal
 Olfaction Present

Mouth and larynx

 Outer lips Pink and moist
 Inner lips Pink, moist and smooth
 Teeth All present with 2 molar
Crowning

 gums Brown colored and healthy

 Tongue Hydrated and pink
 Palate Normal
 Uvula Normal, no inflammation.
 Odour of mouth No foul smell
 Subjective data No complaints

Neck
 Movement Range of motion present
 Trachea Midline
 Lymph nodes Not palpable
 Jugular vein Non-distended
 Carotid pulse Palpable
 Thyroid gland Normal

Chest
 Transverse diameter It is twice the anterior posterior
Diameter and symmetrical.
 Expansion of chest Symmetrical & palpable
 Auscultation No crackles
 Apical pulse Normal vascular sounds
 Breath sounds Normal
 Cough Absent
 Sputum Absent
 Heart S1 , S2 present
 Subjective symptoms No subjective symptoms of chest.

Breast & axilla

 Symmetry Bilaterally symmetrical.
 Areola amd nipples Montogomentory tubercles
Present.
 Hair distribution Uniform
 Discharge Scanty and viscous.
 Lesions and masses Absent
 Axillary nodes Not palpable.
 Condition of breast Normal and healthy.

Abdomen
 Appetite Normal
 Per-abdomen palpation All findings normal.
 Subjective symptoms No subjective symptoms

Skin
 Colour Pale in colour
 Texture Normal
 Temperature Warm to touch
 Lesions No skin lesions present
 Turgor Skin turgor normal
 Discoloration Striae gravidarum and linea nigra
present

Upper extremities
 Symmetry Bilaterally symmetrical
 Range of motion Range of motion normal
 Peripheral pulse Palpable and normal
 Reflexes Normal
 Edema/swelling Pedal edema present.
 Cyanosis Absent
 Joints Normal and flexible
 Deformity No deformity present.

Lower extremities
 Symmetry Bilaterally symmetrical
 Range of motion Range of motion normal
 Peripheral pulse Palpable and normal
 Reflexes Normal
 Edema/swelling Pedal edema present.
 Cyanosis Absent
 Joints Normal and flexible
 Deformity No deformity present.

Nails
 Shape Normal
 Texture Normal and smooth
 Nail bed colour Pink
 Tissue surrounding nails Healthy, no abrasions.
 Capillary refill time ≈3 secs( normal)

Genitals and rectum

 Hemorrhoids Absent
 Vaginal discharge No abnormal discharge.
 Labia majora and minora Healthy and normal.
About the disease

INTRODUCTION

Gestational diabetes mellitus (GDM), also known as type III diabetes mellitus, is one of the
most common type of diabetes mellitus and considered the most common complications of
pregnancy.

This health problem is like pregnancy-induced hypertension (PIH) that develops during
pregnancy and disappears after the delivery of the fetus, or as maternal body returns to its
pre-pregnant state.
Gestational diabetes mellitus may or may not with co-existing maternal diabetes. It heightens
the level of diabetes (if with previous diabetes) by a notch in response to the rise in fetal
carbohydrate demand. 40% of pregnant mothers who develops GDM will eventually develop
non-insulin-dependent diabetes mellitus (NIDDM or type II DM) within 5 years.

DEFINITION
GDM is defined as carbohydrate intolerance of variable severity with onset or first
recognition during the present pregnancy. The entity usually
presents in late second or during the third trimester. The definition applies
irrespective of whether or not insulin is used for treatment or
the condition persists after pregnancy.

Gestational diabetes mellitus (GDM) is defined as any degree of glucose intolerance with
onset or first recognition during pregnancy. The definition applies whether insulin or only
diet modification is used for treatment and whether or not the condition persists after
pregnancy.

It does not exclude the possibility that unrecognized glucose intolerance may have antedated
or begun concomitantly with the pregnancy.

About the organ - pancreas

The pancreas is an organ located in the abdomen. It plays an essential role in converting the
food we eat into fuel for the body's cells. The pancreas has two main functions: an exocrine
function that helps in digestion and an endocrine function that regulates blood sugar.

The pancreas is located behind the stomach in the upper left abdomen. It is surrounded by
other organs including the small intestine, liver, and spleen. It is spongy, about six to ten
inches long, and is shaped like a flat pear or a fish extended horizontally across the
abdomen.The wide part, called the head of the pancreas, is positioned toward the center of
the abdomen. The head of the pancreas is located at the juncture where the stomach meets
the first part of the small intestine. This is where the stomach empties partially digested food
into the intestine, and the pancreas releases digestive enzymes into these contents.

The central section of the pancreas is called the neck or body.

The thin end is called the tail and extends to the left side.
Several major blood vessels surround the pancreas, the superior mesenteric artery, the
superior mesenteric vein, the portal vein and the celiac axis, supplying blood to the pancreas
and other abdominal organs.
Almost all of the pancreas (95%) consists of exocrine tissue that produces pancreatic
enzymes for digestion. The remaining tissue consists of endocrine cells called islets of
Langerhans. These clusters of cells look like grapes and produce hormones that
regulate blood sugar and regulate
pancreatic secretions.

PHYSIOLOGY of the Pancreas

A healthy pancreas produces the correct chemicals in the proper quantities, at the right times,
to digest the foods we eat.
Exocrine Function:

The pancreas contains exocrine glands that produce enzymes important to digestion. These
enzymes include trypsin and chymotrypsin to digest proteins; amylase for the digestion of
carbohydrates; and lipase to break down fats. When food enters the stomach, these
pancreatic juices are released into a system of ducts that culminate in the main pancreatic
duct. The pancreatic duct joins the common bile duct to form the ampulla of Vater which is
located at the first portion of the small intestine, called the duodenum. The common bile duct
originates in the liver and the gallbladder and produces another important digestive juice
called bile. The pancreatic juices and bile that are released into the duodenum, help the body
to digest fats, carbohydrates, and proteins.

Endocrine Function:

The endocrine component of the pancreas consists of islet cells (islets of Langerhans) that
create and release important hormones directly into the bloodstream. Two of the main
pancreatic hormones are insulin, which acts to lower blood sugar, and glucagon, which acts
to raise blood sugar. Maintaining proper blood sugar levels is crucial to the functioning of
key organs including the brain, liver, and kidneys.
 Incidence

Recent data show that gestational diabetes mellitus (GDM) prevalence has increased by
∼10–100% in several race/ethnicity groups during the past 20 years.

A true increase in the prevalence of GDM, aside from its adverse consequences for infants in
the newborn period, might also reflect or contribute to the current patterns of increasing
diabetes and obesity, especially in the offspring. Therefore, the public health aspects of
increasing GDM need more attention.

Diabetes is a major public health problem in India with prevalence rates reported to be
between 4.6% and 14% in urban areas, and 1.7% and 13.2% in rural areas.India has an
estimated 12 million people with Gestational diabetes mellitus (GDM); this number is
expected to go up to 29.4 million by 2025.

The prevalence of gestational diabetes has been reported to range from 3.8% in Kashmir, to
6.2% in Mysore, 9.5% in Western India and 17.9% in Tamil Nadu. In more recent studies,
using different criteria, prevalence rates as high as 35% from Punjab and 41% from
Lucknow have been reported.

The incidence of gestational diabetes mellitus is almost 3% in all pregnancies and 2% in all
women with diabetes before pregnancy.
GDM causes high incidence of fetal morbidity and unwanted complications such as
polyhydramnios and macrosomia in fetus.
Etiology of gestational diABETES MELLITUS

Your body digests the food you eat to produce sugar (glucose) that enters your bloodstream.
In response, your pancreas — a large gland behind your stomach — produces insulin. Insulin
is a hormone that helps glucose move from your bloodstream into your body's cells, where
it's used as energy.

During pregnancy, the placenta, which connects your baby to your blood supply, produces
high levels of various other hormones. Almost all of them impair the action of insulin in your
cells, raising your blood sugar. Modest elevation of blood sugar after meals is normal during
pregnancy.
As your baby grows, the placenta produces more and more insulin-blocking hormones. In
gestational diabetes, the placental hormones provoke a rise in blood sugar to a level that can
affect the growth and welfare of your baby.

Gestational diabetes usually develops during the last half of pregnancy — sometimes as
early as the 20th week, but generally not until later.
A normal body uses insulin as a channel for glucose to enter the cells for utilization. This
process is also applicable with the fetus (during pregnancy) for growth and development.

As the fetus grows, the maternal body executes automatic response by doubling the level of
glucose level through lowering insulin secretion and with the aid of some gestational
hormones that antagonizes the effects of insulin, a process known as protective mechanism.
Along with this, this mechanism causes the rise of placental lactogen, estrogen, and
progesterone to cause the following effects:

1.antagonizes the effects of insulin,

2.prolong the elevation of stress hormones (cortisol, epinephrine, and glucagon).
3.degradation of insulin by the placenta.
The total effect of these mechanisms raises the maternal glucose level for fetal usage.
Hyperglycemia normally occurs with protective mechanism that predisposes a pregnant
mother in the triggering of her pre-diabetic state or heighten an existing diabetes mellitus.

The effects of pregnancy on diabetes mellitus are summarized as:

1.First trimester—glucose level is relatively stable or may decrease

2.Second trimester—there is rapid increase in glucose level

3.Third trimester—there is rapid decrease in glucose level and return to its pre-pregnant
state.
Risk factors that causes gdm

Any woman can develop gestational diabetes, but some women are at greater risk. Risk
factors for gestational diabetes include:

 Age greater than 30. Women older than age 30 are more likely to develop gestational
diabetes.
 You're also more likely to develop gestational diabetes if you had it during a previous
pregnancy, if you delivered a baby who weighed more than 9 pounds (4.1 kilograms), or
if you had an unexplained stillbirth.
 Obesity : Excess weight. You're more likely to develop gestational diabetes if you're
significantly overweight with a body mass index (BMI) of 30 or higher.
 Nonwhite race. For reasons that aren't clear, women who are black, Hispanic, American
Indian or Asian are more likely to develop gestational diabetes.
 Positive Family history of DM( parents or sibling) : Family or personal health history.
Your risk of developing gestational diabetes increases if you
have pre diabetes — slightly elevated blood sugar that may be a precursor to type 2
diabetes — or if a close family member, such as a parent or sibling, has type 2 diabetes
 Previous delivery of baby weighing 9 lbs or more
 History of any autoimmune disease
 Belonging to/with ethnic background from African Americans, Latino, and native
Americans
 History of previous GDM
 With any level of hypertension
 With elevated high-density lipoprotein

Pathophysiology of gdm

The pathophysiology of gestational diabetes mellitus includes increase in maternal insulin

resistance, autoimmune β-cell dysfunction and genetic abnormalities which causing impaired
insulin secretion.
Progression of insulin resistance normally starts near the mid-pregnancy throughout the third
trimester and progresses to resistance level seen in Type II diabetes.

There are two type of insulin resistance namely physiological insulin resistant and chronic
insulin resistant with β-cell dysfunction. It has been suggested that physiological insulin
resistance is contributed by combination of increased maternal adiposity and effects of
placental growth hormones. The defects of postreceptor in the insulin-signalling pathway of
skeletal muscle and adipose tissue has caused the insulin sensitivity reduction in pregnancy.
The alterations in the pathway reduce the insulin-mediated glucose uptake in skeletal muscle
which is a major tissue for glucose disposal. The increase in physiological insulin resistance
and alterations in glucose metabolism are believed been influenced by placental growth
hormones. This is proven when resistance abates soon after labouring in women with normal
glucose tolerance. Chronic insulin resistance is a condition where patients have β-cell
dysfunction which is presented before pregnancy and exacerbated during pregnancy due to
some physiological changes. Chronic insulin resistance occurred mostly in women with
GDM and this had been demonstrated in a study where normal women have higher insulin
sensitivity than those with GDM after physiological insulin resistance abates. It is also
believed that obesity play a role in developing insulin resistance since GDM women tend to
be obese.
Pathophysiology of gdm
CLINICAL MANIFESTATION

GESTATIONAL DIABETES MELLITUS IN BOOK

1.Higher glucose level (20-30 mg/dL) than the pre-pregnant level

2.Very rapid weight gain
3.Polyhydramnios
4.Recurrent monilial infections
5.Glycosuria
6.Nocturia
7.Large for gestational age (LGA) or small for gestational age (SGA) fetus
8.More severe state of edema

GESTATIONAL DIABETES MELLITUS IN PATIENT

1. Pre pregnant state- RBS: 89mg/dl , Pregnancy- RBS: 136mg/dl

2. Pre pregnant state- 53kgs, Pregnancy-62kgs
3. Polyhydramnios absent
4. Monilial infection absent
5. Glycosuria present
6. Nocturia present
7. Large for gestational age (LGA) present
8. Pedal edema present

ABDOMINAL EXAMINATION
BOOK PICTURE PATIENT PICTURE

ABDOMINAL EXAMINATION
Inspection:

 may reveal evidences of chronic placental Absent

insufficiency scanty liquor or growth
retardation of the fetus

Palpation:

 Term abdomen. 35wks 3 days

 Girth of the abdomen round the umbilicus is 75cm
less than the gestation period
 Diagnostic evaluation and
investigations

DIAGNOSTIC EVALUATION

The performance of the following diagnostic tests aims to determine the level of diabetes
present in the pregnant mother and determine its extent of damage or impending effects. This
serves as the basis for the plan of care for the mother and the fetus.

1.Blood glucose monitoring—this can either be done through fasting blood sugar (FBS) or
randomly. This reveals the glucose level and indicates the plan of care needed.
2.Glucose tolerance test (GTT)—to evaluate the response of insulin to loading glucose.
3.Glycated haemoglobin (Glycohemoglobin)—measures glycemic control byy evaluating the
attachment of glucose to freely permeable erythrocytes during their whole life cycle.
4.C-peptide Assay (connecting peptide assay)—useful when the presence of insulin
antibodies interferes with direct insulin assay.
5.Fructosamine assay—is much more useful than glycosylated haemoglobin tests in cases of
haemoglobin variants.
6.Urine glucose and ketone monitoring—may be performed in cases where blood glucose
monitoring is not available, but, is not as accurate as the former.
7.Amniocentesis
8.Non-stress test
9.Sonography
SNO TEST NAME RESULT NORMAL RANGE

1) HAEMATOLOGY
1. Haemoglobin 11.7gm/dl 13-18gm/dl
2. Total leukocyte count 10800/cumm 4000-11000
3. Neutrophils 69% 45-70
4. Lymphocytes 30% 20-45
5. Eosinophils 01% Upto 6
6. Monocytes 02% 2-10
7. RBC 4.4mill/cumm 4.5-5.4
8. Haematocrit 28.9% 40-54
9. Platelet count 2.66lacs/cumm 1.5-4

2) LFT

10. S. Bil(/total) 0.7mg/dl 0.2-1.0

11. S. Bil (Direct) 0.3mg/dl 0.0-0.2
12. S. Bil(Indirect) 0.4mg/dl 0.2-0.8
13. SGOT 20 IU/L 5-40
14. SGPT 26 IU/L 5-40
15. S. Alk Phosphatase 110 IU/L 25-90
16. AST 32 IU/L 11-30(IU/L)
17. ALT 34 IU/L 6-32(IU/L)
3) KFT

18 Blood urea 48mg/dl 15-45

19. S. Creatinine 1.8mg/dl 0.5-1.4
20. S. Protein 7mg/dl 6-8
21. S. Albumin 2.9mg/dl 3.7-5
22. S. Globulin 3.5mg/dl 1.5-3.0
23. S. Na 148meq/L 136-145
24. S. K 4.1meq/L 3.5-5.4
25. S. C 114meq/L 98-108
26. TSH 1.2Miu/l 0.3-3.04 mIU/L
27. VDRL negative negative
28. HIV negative negative
29. Hbs Ag negative negative
 4) URINE:
 color: yellowish light yellow
 ph 5.6 4.5-7.2
 reaction acidic acidic
 pus cells 6-7 pus cells nil
 RBCs 2-3 0-3
 epithelial cells trace 0-trace
75-76 >80
 urine protein
trace negative
 urine ketone
+1 negative

 TSH (0.19 ) normal range (0.35-4.49)

 hgbAC1 (6.2) normal range (3.9-6.1)

 SONOGRAPHY:
A single live intrauterine pregnancy,
The internal os is closed. The cervical length is normal. Liquor is adequate.
Cardiac activity and fetal movement are present. The FHR is 148 bpm.
The placenta is posteriorly placed. 3.4 cms away from the internal os, Gr 3 maturity. No
incidence of retro/ intra placental bleed is seen. Placental blood flow is reduced and weighs
approx 540gms.
No ROC. Fetal ascities absent.

Impression: Mild placental insufficiency present.

MEDICAL MANAGEMENT OF GDM

When diet, exercise and maintaining a healthy weight aren’t enough, you may need the help
of medication. Medications used to treat diabetes include insulin. Everyone with type 1
diabetes and some people with type 2 diabetes must take insulin every day to replace what
their pancreas is unable to produce. Unfortunately, insulin can’t be taken in pill form because
enzymes in your stomach break it down so that it becomes ineffective. For that reason, many
people inject themselves with insulin using a syringe or an insulin pen injector,a device that
looks like a pen, except the cartridge is filled with insulin. Others may use an insulin pump,
which provides a continuous supply of insulin, eliminating the need for daily shots.
The most widely used form of insulin is synthetic human insulin, which is chemically
identical to human insulin but manufactured in a laboratory. Unfortunately, synthetic human
insulin isn’t perfect. One of its chief failings is that it doesn’t mimic the way natural insulin
is secreted. But newer types of insulin, known as insulin analogs, more closely resemble the
way natural insulin acts in your body. Among these are lispro (Humalog), insulin aspart
(NovoLog) and glargine (Lantus).

1) PHARMACOLOGY

 Sulfonylurea drugs. These medications stimulate your pancreas to produce and release
more insulin. For them to be effective, your pancreas must produce some insulin on its
own. Second-generation sulfonylureas such as glipizide (Glucotrol, Glucotrol XL),
glyburide (DiaBeta, Glynase PresTab, Micronase) and glimepiride (Amaryl) are
prescribed most often. The most common side effect of sulfonylureas is low blood sugar,
especially during the first four months of therapy.
 Meglitinides. These medications, such as repaglinide (Prandin), have effects similar to
sulfonylureas, but you’re not as likely to develop low blood sugar. Meglitinides work
quickly, and the results fade rapidly.
 Biguanides. Metformin (Glucophage, Glucophage XR) is the only drug in this class
available in the United States. do other diabetes medications. Possible side effects
include a metallic taste in your mouth, loss of appetite, nausea or vomiting, abdominal
bloating, or pain, gas and diarrhea.

 Alpha-glucosidase inhibitors. These drugs block the action of enzymes in your digestive
tract that break down carbohydrates. That means sugar is absorbed into your bloodstream
more slowly, which helps prevent the rapid rise in blood sugar that usually occurs right
after a meal. Drugs in this class include acarbose (Precose) and miglitol (Glyset).
Although safe and effective, alpha-glucosidase inhibitors can cause abdominal bloating,
gas and diarrhea. If taken in high doses, they may also cause reversible liver damage.

 Thiazolidinediones. These drugs make your body tissues more sensitive to insulin and
keep your liver from overproducing glucose. Side effects of thiazolidinediones, such as
 rosiglitazone (Avandia) and pioglitazone hydrochloride (Actos), include swelling, weight
gain and fatigue. A far more serious potential side effect is liver damage.
 Drug combinations. By combining drugs from different classes, you may be able to
control your blood sugar in several different ways. Each class of oral medication can be
combined with drugs from any other class. Most doctors prescribe two drugs in
combination, although sometimes three drugs may be prescribed. Newer medications,
such as Glucovance, which contains both glyburide and metformin, combine different
oral drugs in a single tablet.

2)Medical Nutrition Therapy (MNT) and physical activity

 Women with GDM should receive a nutritional counselling by a registered dietician or

qualified individuals who are experienced in managing patients with GDM22. The food
plan that is designed for a particular individual not only needs to fulfil the minimum
nutrient requirement for pregnancy but also being able to maintain glycaemic target that
have been established.
The individualised food plan is designed based on patient's body habitus, pre-pregnancy
weights and physical activities. The food planning should emphasise on moderate
carbohydrate restriction in order to prevent ketosis and may not always emphasise on low-fat
foods since foetus needs cholesterol.
Self monitoring of blood glucose is performed during pregnancy by using a glucose meter
and testing strips. It is well-tolerated by most women and is useful to evaluate and adjust
patients' therapy such as medical nutritional therapy and insulin therapy. SMDG is crucial to
check for asymptomatic hyperglycaemia as well as hypoglycaemia. Pregnant

 Medical nutritional therapy is considered as the primary therapy for 30-90% of women
with GDM since studies have proved that GDM women who have undergone MNT had
infants with lower birth weight, less macrosomia, and reduced perinatal complications.
Physical activities should also be encouraged since it is adjuvant in maintaining
glycaemic target. Regular aerobic exercises also demonstrated to lower the fasting and
postprandial glucose in women who previously diagnosed with GDM

3)Self-monitoring blood glucose (SMBG)

Women with GDM should check their blood glucose three or more times each day
throughout their pregnancies.
Nocturnal hypoglycaemia has been an issue during pregnancy for those who are on insulin
therapy. Therefore, self testing during the night is necessary.

4)Prenatal Surveillance
In order to optimise the outcomes for pregnant women with gestational diabetes, prenatal
surveillance is necessary. Women with GDM should monitor foetal movements at 28 weeks
of pregnancy and should report immediately if there is any reduction in foetal movements.
Prenatal surveillance can be delayed until weeks 40 if the hyperglycaemic is controlled using
MNT . For women who are on pharmacological treatment such as insulin therapy, non-stress
testing should be encouraged after week 32 of the pregnancy. Ultrasound can be used to
detect abnormalities or macrosomia in foetus.

5)Labour and Delivery Management

Women with gestational diabetes are found to have greater risk of giving birth to excessive
grown babies and may be complicated by shoulder dystocia30. Therefore, ultrasound can be
used within 2 weeks of delivery to estimate the foetal weight and decide whether a caesarean
delivery option is better in order to prevent shoulder dystocia. A study has been performed
where caesarean delivery was recommended if the estimated foetal weight (EFW) was above
4250g and labour induction was recommended if the EFW is 90th percentile.

6)Postpartum follow-up
All women with prior gestational diabetes have an approximately 50% risk of developing
type II diabetes within the next 10 years. Their chances of developing type II diabetes even
have increased up to 80% if impaired glucose tolerance was developed after delivery. Hence,
appropriate counselling and follow up are important after delivery. Breastfeeding should be
encouraged due to the fact that it may minimise the insulin resistance and decrease maternal
progression to diabetes .

Women who gain much weight during pregnancy are advised to keep fit and if possible
maintain to their pre-pregnancy weight. Glucose tolerance testing should be performed at
week 6-12 on women who do not develop diabetes immediately after delivery. Furthermore,
infants of women with gestational diabetes also associated with higher risk of obesity and
subsequently to diabetes thus counsel on healthy lifestyle is crucial for them.

Nursing MANAGEMENT

The overall goal of management for gestational diabetes mellitus is the control of the
maternal glucose level and keep it on normal or near-normal level to prevent the
development of complications that might compromise both the mother and the fetus. The
most significant of these managements is the use of insulin. This is the most potent, yet,
requires accuracy and monitoring of its unwanted effect (hypoglycaemia) that brings
immediate danger to both the mother and the fetus. Proper timing, dosage, and knowledge on
counteractions of its over-reaction are vital concepts to be incorporated in the health
education.
Along with this, health promotion and disease prevention activities like diet, exercise, and
fetal monitoring are of great importance.

NURSING MANAGEMENT OF GDM

 Assessment
History taking on:

a.First presentation of the manifestations of diabetes (3 P’s)

b.First diagnosis of DM
c.Family members with DM

Review of systems:

1.Weight gain, increasing fatigue/weakness/tiredness

2.Skin lesions, infections, hydration, signs of poor wound healing
3.Changes in vision—floaters, halos, blurred vision, dry/burning eyes, cataract, glaucoma
4.Gingivitis, periodontal disease
5.Orthostatic hypotension, cold extremities, weak pedal pulses
6.Diarrhea, constipation, early satiety, bloating, flatulence, hunger and thirst
7.Frequent urination, nocturia, vaginal discharge
8.Numbness and tingling of the extremities, decrease pain and temperature sensation

 Intervention
1. Nutrition
Assess timing and content of meals
Instruct on importance of a well-balanced diet
Explain the importance of exercise
Plan for a weight reduction course

2. Insulin use
Encourage verbalization of feelings
Demonstrate and explain insulin therapy
Allow client to do self-administration
Review mastery of the whole process

3. Injury from hypoglycaemia

Monitor maternal blood glucose level
Instruct on insulin-activity-diet interaction
Teach on the signs and symptoms of hypoglycaemia
Teach/present list of things/foods that need to be available at all times (in cases of
hypoglycaemic attacks)
Have identification band indicating the health condition (DM) for fainting instances

4. Activity tolerance
Plan for regular exercise
Increase carbohydrate intake before exercise
Instruct to avoid exercise if blood glucose level exceeds 250 mg/dL and urine ketones are
present
Advise to use abdomen for insulin injection if arms and legs are used for exercise
5. Skin integrity
Avoid alcohol use, instead, lotion
Teach on proper foot care
Advise to stop smoking and alcohol use

6. Fetal well-being
Continuous monitoring of fetal activities and fetal heart tone
Monitor fetal activities during maternal activities
Monitor early signs of labor
Advice to report of any discharge coming from the vagina
Monitor daily weight and advice to report on rapid weight gain.

7. Educative
Teach on lifestyle modifications
Advice to see psychologists with other family members for therapy on the possibilities
of fetal abnormalities
Advice to call emergency response team in cases of emergency
Advise to religiously follow health instructions
 EVALUATION

1.Body weight is within the normal range for the age of gestation.
2.Demonstrates proper technique in self-administration of insulin
3.No episodes of hypoglycemia as claimed by the client
4.No skin problems/lesions
5.Verbalizes readiness on the possible fetal defects.
6. Stable fetal heart rate

NURSING DIAGNOSES

1.Altered body nutrition less than body requirement r/t insufficiency of insulin as evidenced
by decreased oral input.
2.High risk pregnancy: high risk for infection, ketosis, fetal demise, cephalopelvic
disproportion, polyhydramnios, congenital anomalies, preterm labor .
3.Knowledge deficit related to disease and insulin use and interaction lack of exposure and
information as evidenced by frequent questions and expression of concern.
4.Self care deficit related to pain over episiotomy site as evidenced by poor personal
hygiene, unability to perform ADLs, take care of the newborn.
Complications

Most women who have gestational diabetes deliver healthy babies. However, gestational
diabetes that's not carefully managed can lead to uncontrolled blood sugar levels and cause
problems for you and your baby, including an increased likelihood of needing a C-section to
deliver.

Complications that may affect your baby

If you have gestational diabetes, your baby may be at increased risk of:

 Excessive birth weight. Extra glucose in your bloodstream crosses the placenta,
which triggers your baby's pancreas to make extra insulin. This can cause your baby to
grow too large (macrosomia). Very large babies — those that weigh 9 pounds or more —
are more likely to become wedged in the birth canal, sustain birth injuries or require a
C-section birth.

 Early (preterm) birth and respiratory distress syndrome. A mother's high blood
sugar may increase her risk of early labor and delivering her baby before its due date. Or
her doctor may recommend early delivery because the baby is large.
 Babies born early may experience respiratory distress syndrome- A condition that
makes breathing difficult. Babies with this syndrome may need help breathing until their
lungs mature and become stronger. Babies of mothers with gestational diabetes may
experience respiratory distress syndrome even if they're not born early.
 Low blood sugar (hypoglycemia). Sometimes babies of mothers with gestational
diabetes develop low blood sugar (hypoglycemia) shortly after birth because their own
insulin production is high. Severe episodes of hypoglycemia may provoke seizures in the
baby. Prompt feedings and sometimes an intravenous glucose solution can return the
baby's blood sugar level to normal.

 Type 2 diabetes later in life. Babies of mothers who have gestational diabetes have a
higher risk of developing obesity and type 2 diabetes later in life.

 Untreated gestational diabetes can result in a baby's death either before or shortly after
birth.

Gestational diabetes may also increase the mother's risk of:

 High blood pressure and preeclampsia. Gestational diabetes raises your risk of high
blood pressure, as well as, preeclampsia — a serious complication of pregnancy that
causes high blood pressure and other symptoms that can threaten the lives of both mother
and baby.
 Future diabetes. If you have gestational diabetes, you're more likely to get it again
during a future pregnancy. You're also more likely to develop type 2 diabetes as you get
older. However, making healthy lifestyle choices such as eating healthy foods and
exercising can help reduce the risk of future type 2 diabetes.

 Of those women with a history of gestational diabetes who reach their ideal body
weight after delivery, fewer than 1 in 4 eventually develops type 2 diabetes
BIBLIOGRAPHY

1.Dutta .D.C. Textbook of Obstetrics. Sixth edition. 2004. Pg no221-230

2.Marie Elizabeth ,Midwifery for nurses ,2nd edition .2013.pg no. 206-215
3.Diagnosis and management of GDM: an update Judi A Turner Published online 2010 Sep
30. doi: 10.2147/IJWH.S8550 PMCID: PMC2990902.