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Gestational Diabetes, When women get pregnant
Gestational Diabetes
When women get pregnant for the first time, they can easily develop gestational diabetes. According to research, in America, in a population of 100 women who are pregnant, around three to eight of them are bound to have gestational diabetes. When women are pregnant, they are affected by factors such as weight gain and ever changing hormones. These changes prevent the insulin hormone to function as it is meant. According to the American Diabetes Association, the number of gestational diabetes cases is as high as 200,000. Unfortunately, this figure is escalating at an extremely high rate, and women ought to know how to prevent it. When a woman has gestational diabetes, it means that their insulin and hyperglycemia does not function well. This is due to problems concerning adaptation by beta cells and the latter can also become dysfunctional. Women who have gestational diabetes can have high blood pressure when giving birth. Moreover, the chances of them having caesarian sections are extremely high. Some of the factors, which make women likely to have gestational diabetes include; family history, obesity, as well as age. There is a need to know more about this deadly condition and how it manifests itself.
This paper seeks to give a critical analysis on gestational diabetes, concerning how it manifests itself in various instances. Furthermore, it seeks to discuss it how gestational diabetes affects nursing practices.
Annotated Bibliography
Ross, M. G. & Ervin, M. G. &Novak, D. (2007). Chapter 2 fetal physiology. In S. Gabbe, & J. Niebyl, & J. Simpson (Eds.), Obstetrics: Normal and problem pregnancies (pp. 26-33). Philadelphia, PA: Churchill Livingstone Elsevier.
According to this book, women giving birth for the first time are bound to develop gestational diabetes. The placenta plays an extremely vital role when a child is being formed in the mother’s womb. It has several functions such as providing the fetus with water, oxygen and even hormones. The latter is needed for the formation of healthy babies. Glucose is also vital, and it is needed for growth of the woman’s fetus. According to research done by the authors of the book, maternal glucose is needed by the placenta. The glucose that exists in the womb of the mother is at 70% and is used for various vital functions. In order for glucose to reach the fetus, it is transported by the GLUT 1. Thus, when a woman has gestational diabetes, the GLUT 1 does not function as it ought. In turn, it leads to extremely high levels of maternal glucose in the fetus. Insulin is then produced for the purpose of growth of the baby in the fetus. Moreover, levels of blood sugar in the mother are increased, and this has serious repercussions. The book seeks to show how pregnant women develop gestational diabetes depending on their neonates found in their system.
Barta, E. & Drugan, A. (2010). Glucose transport from mother to fetus— A theoretical study. Journal of Theoretical Biology, 263, 295-302. doi: 10.1016/j.jtbi.2009.12.010
According to the journal article by Drugan and Barta, they sort to find out how the fetus is provided with glucose. They found out that the GLUT 1 is responsible, and this is through a model that used mathematical equations. They believe that glucose is extremely vital in formation of the fetus, as well as that of the placenta. Without the presence of the GLUT 1, maternal glucose would not be transported. There are certain factors, which enable the maternal glucose to be transported. The most essential one is a concentration gradient that is used in the process of diffusion. This means that the fetus and the mother are well connected through the placenta. Their model provided crucial information regarding why the second trimester is the one when the pregnant woman is most vulnerable. They believe that their research needs further improvement especially in matters concerning insulin and hormones.
The HAPO Study Cooperative Research Group. (2008). Hyperglycemia and adverse pregnancy outcomes. The New England Journal of Medicine, 358(19), 1991-2002.
The article focuses on research by the HAPO Study Cooperative Research. It meant to find out the dangers, which are related with varying levels of maternal glucose intolerance. Their study was conducted on 25, 505 pregnant women. They used various mathematical methods in order to arrive at their conclusions. They made use of odd ratios and frequency, so as to determine levels of maternal glucose. When the levels of maternal glucose were high, the fetus had high chances of developing with defects. The standards deviation helped in knowing, which births were likely to be harmed. In some cases, those who had 1.07 to 1.09 SD levels were often admitted into intensive neonatal care. Furthermore, the women were likely to undergo cesarean sections. The authors want more research to be done in order to find out how hyperglycemia can be treated as well as diagnosed.
Lawlor, D. A. & Fraser, A. & Lindsay, R.S.& Ness, A.& Dabelea, D.& Catalano, P. &Nelson, S. M. (2010). Association of existing diabetes, gestational diabetes and glycosuria in pregnancy with macrosomia and offspring body mass index, waist and fat mass in later childhood: Findings from a prospective pregnancy cohort. Diabetologia, 53, 89-97. doi: 10.1007/s00125-009-1560-z
Research was conducted by the various authors in order to find the relation, which exists between glycosuria and gestational diabetes during pregnancy. The variables used in the study were BMI of future offspring, macrosomia, as well as birth weight. The ages of those being measured were 9 to 11 years, through using their fat mass and waist circumference. The results show that women who had diabetes risk having their infants develop macrosomia. They also had high chances of being overweight, among others. The measurements used included the use of standard deviation. It is believed that the sample size used in the study was not enough. In the future, they recommend that the size be increased. According to their research, nursing practitioners should be able to diagnose gestational diabetes early enough. In turn, the infants will be saved from suffering in the future.
Hedderson, M. M. & Gunderson, E. P.& Ferrara, A. (2010). Gestational weight gain and risk of gestational diabetes mellitus. Obstetrics and Gynecology, 115(3), 597-604.
The authors of this journal article sort to carry out a study to find out about how gestational diabetes is related to weight gain. They sort to found this out through the use of the frequency method. Furthermore, the test included the use of a glucose tolerance test being administered to the pregnant women. According to their results, the chances of developing gestational diabetes are 2.3, when pregnant women gain weight. It is extremely dangerous as they have around an 80% chance of acquiring it and mostly in the first semester. There is a P<0.5 chance that even the pregnant woman’s BMI will increase. The study also found out that those likely to develop gestational diabetes were women not from the white race and those who were overweight. The authors suggest that there is a need to find out more about their study. In turn, clinical practitioners should inform pregnant women on the dangers of gaining unhealthy weight. They risk suffering from gestational diabetes as well as harming their unborn child.
Retnakaran, R., Qi, Y., Sermer, M., Connelly, P. W., Hanley, A. J. G., & Zinman, B. (2010). Beta-cell function declines within the first year postpartum in women with recent glucose intolerance in pregnancy. Diabetes Care, 33(8), 1798-1804. doi: 10.2337/dc10-0351
The study carried out by the various authors sort to find out about the gestational diabetic risk that pregnant women had. This is when they were subjected to postpartum conditions in their first years. Also, the study measured metabolic changes, which pregnant women undergo, due to high levels of maternal glucose. The results they found out were that P<0.0005 is the postpartum, when there is a decrease in the levels of beta cell and insulin sensitivity. These were measured after a period of three months. The figure kept on increasing as the months also did the same, in what is known as a dysglycemic state. Furthermore, depending on the extent of gestational dysglycemia, insulin sensitivity and beta cell dysfunction occurred. The pregnant woman also risks developing type 2 diabetes if the postpartum period increases. According to the researchers, during postpartum and pregnancy women can easily be victims of type two diabetes. Thus, clinicians should make women more aware about gestational diabetes.
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. The New England Journal of Medicine, 361(14), 1339-1348.
The researchers of this study used 1889 pregnant women as their subjects. There were certain conditions, which the women had to meet before they could take part. The study sort to found out if obstetrical conditions and perinatal conditions could be reduced by treatment administered for gestational diabetes. This means that there had to be a control and treatment group. The latter was administered with insulin, diet therapy, as well as having to go for counseling sessions. According to the results, those who received early treatment for gestational diabetes were likely to have healthy futures. An example is when the chances of having cesarean deliveries were reduced by 33.8%. The researchers want to ensure that clinicians find ways they can reduce the complications brought about by gestational diabetes.
Rowan, J. A. & Hague, W. M. & Gao, W. & Battin, M. R. & Moore, M. P. (2008). Metformin versus insulin for the treatment of gestational diabetes. The New England Journal of Medicine, 358(19), 2003-2015.
The researchers of this study sort to find out if gestational diabetes treatment is best given by insulin or Metformin. Furthermore, they wanted to found out if women treated with insulin, rather than Metformin, would have infants with disorders. The researchers used three different study populations, who were administered various treatments. It seems that the there is no difference in treatments, which are insulin or Metformin based. This means that complications that are neonatal were not likely to occur. The Metformin group is the one, which has a low frequency of neonatal hypoglycemia. They found out that the latter had a frequency level of P=0.008. Thus, it is better for clinicians to treat pregnant women who have gestational diabetes with insulin. The researchers are pensive about the results, as they believe that other crucial factors were not included. They still believe that metformin should be used in gestational diabetes treatment. They warn that caution must be taken when using metformin.
Work Cited
Barta, E. & Drugan, A. (2010). Glucose transport from mother to fetus— A theoretical study. Journal of Theoretical Biology, 263, 295-302. doi: 10.1016/j.jtbi.2009.12.010
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. The New England Journal of Medicine, 361(14), 1339-1348.
Lawlor, D. A. & Fraser, A. & Lindsay, R.S.& Ness, A.& Dabelea, D.& Catalano, P. &Nelson, S. M. (2010). Association of existing diabetes, gestational diabetes and glycosuria in pregnancy with macrosomia and offspring body mass index, waist and fat mass in later childhood: Findings from a prospective pregnancy cohort. Diabetologia, 53, 89-97. doi: 10.1007/s00125-009-1560-z
Hedderson, M. M. & Gunderson, E. P.& Ferrara, A. (2010). Gestational weight gain and risk of gestational diabetes mellitus. Obstetrics and Gynecology, 115(3), 597-604Retnakaran, R., Qi, Y., Sermer, M., Connelly, P. W., Hanley, A. J. G., & Zinman, B. (2010). Beta-cell function declines within the first year postpartum in women with recent glucose intolerance in pregnancy. Diabetes Care, 33(8), 1798-1804. doi: 10.2337/dc10-0351
Retnakaran, R., Qi, Y., Sermer, M., Connelly, P. W., Hanley, A. J. G., & Zinman, B. (2010). Beta-cell function declines within the first year postpartum in women with recent glucose intolerance in pregnancy. Diabetes Care, 33(8), 1798-1804. doi: 10.2337/dc10-0351
Ross, M. G. & Ervin, M. G. &Novak, D. (2007). Chapter 2 fetal physiology. In S. Gabbe, & J. Niebyl, & J. Simpson (Eds.), Obstetrics: Normal and problem pregnancies (pp. 26-33). Philadelphia, PA: Churchill Livingstone Elsevier.
Rowan, J. A. & Hague, W. M. & Gao, W. & Battin, M. R. & Moore, M. P. (2008). Metformin versus insulin for the treatment of gestational diabetes. The New England Journal of Medicine, 358(19), 2003-2015.
The HAPO Study Cooperative Research Group. (2008). Hyperglycemia and adverse pregnancy outcomes. The New England Journal of Medicine, 358(19), 1991-2002.
The Concept of Freedom
The Concept of Freedom
Name
Institution of Affiliation
Professor
Course
Date
The Concept of Freedom
In life’s history, Freedom has been so far the greatest cultural asset in the past. Freedom has slowed down with modernization, and citizens in various nations are fighting hard to restore it. Freedom is mainly defined as a person’s potential ability to freely choose an alternative, as an opportunity to think and act following ideas and desires, and not because of internal or external coercion, but because it gives the person the opportunity to be himself and exercise his rights.
Freedom of individuals is expressed through the media by leaders who practice politics either in their speeches or on duty, countries constitution, and church leaders. However, Freedom may bear or lack its meaning through the way different people view it. Therefore, philosophers have different views about Freedom with elaborate examples to make their opinions stand. Freedom is the only way to realize human potential, and it’s important to uphold it universally. I will explain Freedom’s concepts in Aristotle, Hospers, Skinner and Kant and identify the most convincing concept in my research.
Aristotle
Aristotle lacks a clear definition of Freedom in politics or Nicomachean Ethics. His idea was on self developments where he majored on three types of men, including the people who require only primitive resources and growth that’s the plant people. People-animals were described as influenced by what they felt and, finally, people-reasonable whose riddance was based on reasoning and decision making (Edelstein, 1944).
Theories based on Aristotle’s argument have been put into two categories; Effective agency and moral responsibility. The effective agency argues that humans tend to act according to their wishes with the view that whatever they anticipate in future might not be necessary (Eishtain, 2003). However, Aristotle’s refutes the argument by stating that the future is necessary, making human actions and deliberations futile.
Moral responsibility is the ability to be justifiably subject to praise and reward or blame and punishment based on our acts. He argues that human beings are responsible for their voluntary actions, which our desires and character traits might influence. Aristotle’s argument states that we are totally in control of our actions, an opposing idea to the causal determinism and Stoics belief that every action is according to the Act of God in line with his providence plans.
Hospers
John Hospers’ argument heavily lies on free will, which is almost closely attached to individuals’ voluntary actions. Hospers argues that the term voluntary is faced with ambiguity and asks for more clarity to stop its confusion for free will. He argues that some free will are free, and some are contrary to what most individuals think.
Moore, a scholar, indicates that people are free to carry on with tasks of their own will if they want to, and whatever the people can do is the definition of free will. Hospers bring out the psychological ID, ego, and superego as factors related to free will, emphasizing that unconsciousness is a factor in determining impulses and eventually free will. He adds to the distortion of Freedom in Moore’s criterion, expressing that a person is free concerning a given action if he can make it if he chooses to do it.
Hospers concludes that an act is free if it’s not compelled or coerced, which is nearly impossible for such occurrences to happen because individuals are mostly caught up in the stream of determinism with the unconscious forces driving them into wanting or defying the action in question.
Skinner
Skinners contribution to Freedom came in 1971 by writing a book Beyond Freedom and dignity (Skinner, 1971). In the book, Skinner denied intentions, purposes, aims, goals and other internal psychological states. In his work, he touched on various themes and questioned existing perceptions about man’s Freedom.
He questioned the control exercised by autonomous man and demonstrated the control exercised by the environment., a science of behaviour that seemed to question dignity or worth (Boguslaw & Skinner, 1972). He argued that an individual should be responsible for his behaviour by receiving punishment or criticism in wrongdoing and receiving rewards and credits for the achievements. Still, both blame and credit are shifted towards the environments in the modern world.
Skimmer, in his book, elaborated that man’s Freedom is not a result of free will but behavioural processes that contribute to dodging of aversive environment features. He further mentions that literature has been a force to define Freedom as a state of mind and feelings without considering the social environment that humans are exposed. In his concept, the information philosopher shifts his analysis of Freedom from autonomous man to the environment (Skinner & Taylor, 1973).
Kant
Kant started his work early by looking out for ways to overcome the limitation of vies of Freedom as independence from one thinking to other people’s inclinations. He formulated the positive conception of Freedom as the capacity for choice, asserting Freedom’s unconditional value to set one owns ends (Westphal, 2017). In his philosophy, Kant paid attention to autonomy and morality, stating that morality and right are intrinsically related. He also criticized moral utilitarianism as related to servility and political paternalism, leading to unfreedom.
The philosophers heavily contributed to Freedom’s understanding and nature depending on what their objectives were geared to achieve. Immanuel Kant remains the most convincing philosopher of Freedom since he believed in limited government and maximum Freedom in a based moral society, basing his arguments on the goodwill and moral law, the categorical imperative, rights and Freedom and Kantian liberalism elements (Halldenius, 2011).
References
Boguslaw, R., & Skinner, B. F. (1972). Beyond Freedom and Dignity. Contemporary Sociology, 1(1), 23. https://doi.org/10.2307/2063899
Edelstein, L. (1944). Aristotle and the Concept of Evolution. The Classical Weekly, 37(13), 148. https://doi.org/10.2307/4341872
Eishtain, J. B. (2003). Aristotle and Augustine on Freedom. International Studies in Philosophy, 35(4), 193–194. https://doi.org/10.5840/intstudphil200335449
Halldenius, L. (2011). Kant on Freedom and Obligation Under Law. Constellations, 18(2), 170–189. https://doi.org/10.1111/j.1467-8675.2011.00638.x
Hospers, J. (1955). XIV.—The Concept of Artistic Expression. Proceedings of the Aristotelian Society, 55(1), 313–344. https://doi.org/10.1093/aristotelian/55.1.313
Skinner, B. F. (1971). Beyond Freedom and dignity. Knopf.
Skinner, B. F., & Taylor, F. K. (1973). Beyond Freedom and Dignity. By B. F. Skinner. London: Jonathan Gape. 1972. Pp. 225. Price $2.25. British Journal of Psychiatry, 122(566), 99–100. https://doi.org/10.1192/bjp.122.1.99-a
Westphal, K. R. (2017). How Kant Justifies Freedom of Agency (without Transcendental Idealism). European Journal of Philosophy, 25(4), 1695–1717. https://doi.org/10.1111/ejop.12264
Gestational Diabetes Mellitus, N 560 Advanced Concepts in Physiology and Pathophysiology annotated Bibliography
Gestational Diabetes Mellitus, N 560 Advanced Concepts in Physiology and Pathophysiology annotated Bibliography
28 October 2010
Box 363
Gestational Diabetes Mellitus
There are approximately 200,000 cases of gestational diabetes mellitus diagnosed per year, and it continues to increase (American Diabetes Association, 2010). Gestational Diabetes Mellitus (GDM) is a subgroup of diabetes mellitus and is defined as “any degree of glucose intolerance with onset or first recognition during pregnancy” (American Diabetes Association, 2010, p. S65). Gestational diabetes manifests as hyperglycemia and insulin resistance caused by dysfunctional beta cells and decreased beta cell adaptation (Pridjian & Benjamin, 2010). There are several risk factors including age, obesity, current glycosuria, history of glucose intolerance, and family history of diabetes (Serlin & Lash, 2009). The symptoms of GDM normally include polydipsia, polyuria, and sometimes polyphagia (American Diabetes Association, 2010). Gestational diabetes has been known to cause complications in both the mother and the fetus. Some complications to the fetus include birth trauma, macrosomia, hyperinsulinism, hypoglycemia, hyperbilirubinemia (The HAPO Cooperative Study Research Group, 2008). This paper will discuss the normal physiology of the placenta, pathophysiology and clinical manifestations of gestational diabetes, treatments, and implications for advanced practice nurses.
Annotated Bibliography
Ross, M. G., Ervin, M. G., Novak, D. (2007). Chapter 2 fetal physiology. In S. Gabbe, J. Niebyl, & J. Simpson (Eds.), Obstetrics: Normal and problem pregnancies (pp. 26-33). Philadelphia, PA: Churchill Livingstone Elsevier.
The placenta is an organ with high metabolic demands, providing nutrients, oxygen, water, immunologic protection, and hormones to the fetus; glucose is the primary solute essential for fetal growth. It is estimated the placenta metabolically uses 70% of the maternal glucose, and the remainder is for fetal growth. The microvillus plasma membrane on the maternal side is the transport mechanism through the placental plasma membrane to the basal membrane on the fetal side. GLUT 1 transports glucose to the fetus. In normal pregnancy, the transfer rate of glucose to the fetus decreases as maternal glucose concentration increases. Maternal diabetes may alter the GLUT 1 transporter, causing the fetus to receive higher concentrations of maternal glucose. The fetus produces insulin to transport glucose for growth, thus it increases in response to elevated levels of blood glucose. This phenomenon explains why the neonates of diabetic mothers are macrosomic, or large bodied.
Barta, E., & Drugan, A. (2010). Glucose transport from mother to fetus— A theoretical study. Journal of Theoretical Biology, 263, 295-302. doi: 10.1016/j.jtbi.2009.12.010
The authors used mathematical equations to form a model explaining the transport process of glucose via GLUT 1 through the placenta to the fetus. Glucose is essential for metabolic consumption of the placenta and the development of the fetus. The researchers found that GLUT 1 is the glucose transporter that transfers maternal glucose to the fetus. The glucose supply to the fetus depends on the concentration gradient between mother to the fetus in a process that includes diffusion. Through the model, it becomes clearer why the GLUT 1 transporter doubles in the late part of the second trimester; therefore, allowing the fetus to grow 20-fold between 16 weeks gestation and term. The placenta aids in buffering the glucose supply to the fetus in order to keep the glucose levels normal when hyperglycemia occurs. Barta and Drugan recommend improving their model by forming a three-dimensional model that reveals a more geometrical or morphologic situation. They also recommend a study of the effects of hormones and insulin on glucose transport, leading to implications for clinical settings.
The HAPO Study Cooperative Research Group. (2008). Hyperglycemia and adverse pregnancy outcomes. The New England Journal of Medicine, 358(19), 1991-2002.
The HAPO Study Cooperative Research Group performed a study on 25,505 pregnant women to clarify the risks of adverse outcomes associated with various degrees of maternal glucose intolerance. The frequency of each adverse outcome increased with increasing maternal glucose levels. The odds ratios for an increase in the glucose level by one standard deviation (SD) were highest for birth weight greater than ninetieth percentile and cord-blood serum C-peptide level above the ninetieth percentile. Shoulder dystocia or birth injury occurred more often in relation to increasing maternal blood glucose with an SD of 1.20. The 1 hr and 2 hr plasma glucose tests were significantly related to premature delivery with an SD level of 1.18 and 1.16, intensive neonatal care admissions with an SD level of 1.07 and 1.09, and hyperbilirubinemia with an SD level of 1.11 and 1.08. The significant quadratic associations were the fasting plasma glucose level in relation to primary cesarean delivery (P < 0.001), and the neonate’s age with the fasting, 1 hour, and 2 hour plasma glucose levels were associated with clinical neonatal hypoglycemia (P = 0.05, P = 0.03, P = 0.001). The authors suggest the current criteria for diagnosing and treating hyperglycemia in pregnancy needs to be reevaluated.
Lawlor, D. A., Fraser, A., Lindsay, R.S., Ness, A., Dabelea, D., Catalano, P., . . . Nelson, S. M. (2010). Association of existing diabetes, gestational diabetes and glycosuria in pregnancy with macrosomia and offspring body mass index, waist and fat mass in later childhood: Findings from a prospective pregnancy cohort. Diabetologia, 53, 89-97. doi: 10.1007/s00125-009-1560-z
Lawlor et al. examined 10,591 mother-offspring pairs for the association of existing diabetes, gestational diabetes, and glycosuria in pregnancy with birthweight, macrosomia, and future offspring BMI, waist circumference and fat mass at ages 9-11 years. Of the infants born of these pairs, 1,426 (10-16%) were born macrosomic, 1,570 (23%) were overweight at 9-11 years, 2,614 (38%) were centrally obese at 9-11 years, and 13 were on insulin treatment for diabetes. Overweight or obesity was more common in females than males (25% vs. 21%) with a P < 0.0001. Infants of diabetic mothers had a 4.3-8.5 fold increased risk of macrosomia. The authors also found that offspring of gestational diabetic mothers were more likely to be overweight, have higher BMI (SD 0.302) and waist circumference (SD 0.038).
The researchers recommend that the study be replicated with a larger sample size with more detailed measurements of gestational glycaemia. This study reflects the importance of monitoring and controlling blood glucose levels in those with gestational diabetes and existing diabetes in order to prevent the long-term effects in the offspring.
Hedderson, M. M., Gunderson, E. P., & Ferrara, A. (2010). Gestational weight gain and risk of gestational diabetes mellitus. Obstetrics and Gynecology, 115(3), 597-604.
The goal was to assess the frequency of which gestational diabetes occurs in relation to the rate of weight gain during pregnancy prior to the 50 g 1 hour oral glucose tolerance test. Hedderson et al. found that the women who were in the highest class for weight gain in the first trimester had an 80% significant increased risk of GDM, with an odds ratio of 2.3. They also found that women who exceeded the Institute of Medicine’s (IOM) guidelines for weight gain during pregnancy had a 50% increase in the risk for GDM. The woman’s pregravid BMI and the rate of gestational weight gain up to the time of GDM screening was statistically significant with a P < 0.5. Overweight women in the greater class for weight gain and women of non-white ethnicity were twice as likely to develop gestational diabetes with odd ratios of 2.1 and 2.66.
Hedderson et al. recommend more studies to assess if the findings of this study can be replicated. Clinicians must be aware that greater weight gain during pregnancy may lead to the diagnosis of gestational diabetes and education should be given to higher risk individuals.
Retnakaran, R., Qi, Y., Sermer, M., Connelly, P. W., Hanley, A. J. G., & Zinman, B. (2010). Beta-cell function declines within the first year postpartum in women with recent glucose intolerance in pregnancy. Diabetes Care, 33(8), 1798-1804. doi: 10.2337/dc10-0351
The aim of this study was to evaluate the metabolic changes that occur in the first year postpartum to assess for future diabetic risk. Both insulin sensitivity and beta-cell function decreased from the normal glucose tolerance group to the gestational diabetes group at 3 months postpartum (P < 0.0005), and there was an increase in the occurrence of dysglycemic states after 12 months postpartum. The findings showed that beta-cell dysfunction occurs very early without insulin sensitivity and varies according to the severity of gestational dysglycemia. In the study, gestational diabetes emerged as a negative independent predictor of the change in beta cell function with a P of 0.0006 within 3-12 months postpartum, which may contribute to the development of type 2 diabetes.
The researchers propose that health care providers identify women at risk for gestational diabetes. Women at risk should be educated on lifestyle modification during pregnancy and postpartum to prevent the development of type 2 diabetes.
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. The New England Journal of Medicine, 361(14), 1339-1348.
This study was performed on 1,889 women who were in their twenty-fourth to thirty-first week of gestation and diagnosed with gestational diabetes, to assess if treatment for GDM would reduce perinatal and obstetrical complications. The treatment group received formal nutritional counseling and diet therapy, along with insulin, if required. The study found that birth weight (3302 g vs. 3408 g, P < 0.001), neonatal fat mass (427g vs. 464 g, P = 0.003), as well as the occurrence of large-for-gestational-age infants (7.1% vs. 14.5%, P < 0.001) were considerably reduced in those being treated for gestational diabetes. The rate of cesarean section delivery (29% vs. 33.8%), shoulder dystocia (1.5% vs. 4%, P = 0.02), preeclampsia (8.6% vs. 13.6%, P = 0.01), maternal weight gain (P < 0.001), and body-mass index levels (P < 0.001) were greatly reduced in the treatment group than the control group. The authors encourage health care providers to treat and educate their patients in order to reduce complications.
Rowan, J. A., Hague, W. M., Gao, W., Battin, M. R., & Moore, M. P. (2008). Metformin versus insulin for the treatment of gestational diabetes. The New England Journal of Medicine, 358(19), 2003-2015.
This study was conducted to determine whether an increase in a number of perinatal complications in infants of women treated with metformin as compared with insulin treatment. The three participant groups were treated with only metformin, only insulin, or both. They did not find a substantial increase of neonatal complications between those treated with metformin versus insulin. Neonatal hypoglycemia occurred less often (P = 0.008) in the metformin group. The overall mean maternal 2 hour postprandial glucose levels were slightly lower in the metformin group (P = 0.003, P = 0.006, P = 0.19), meaning the goal glucose levels were reached sooner in women treated with metformin than those treated with insulin. The adverse effect more common in the metformin group was the increased incidence of preterm birth (P = 0.04), but the authors stated it could be due to chance or an unrecognized effect of metformin on the labor process.
Metformin is a beneficial and safe treatment for gestational diabetes, but further studies are needed to assess the long-term effects and safety of metformin.
Chertok, I. R. A., Raz, I., Shoham, I., Haddad, H., & Wiznitzer, A. (2009). Effects of early breastfeeding on neonatal glucose levels of term infants born to women with gestational diabetes. Journal of Human Nutrition and Dietetics, 22, 166-169. doi: 10.1111/j.1365-277X.2008.00921.x
This study was performed to compare the blood glucose levels of infants of diabetic mothers, who received early breastfeeding to those who did not, or those who were given formula for the first feeding. Among the 84 infants in this study, those who received breast milk within 30 minutes to 1.5 hours after birth had less occurrence of hypoglycemia than those who were not fed early (P = 0.05). The breastfed infants also had much higher plasma glucose levels (3.2 mmol L) than those who were formula fed (2.68 mmol L) within 3 hours postpartum (P = 0.002).
The results indicate that breast-feeding is the preferred method of feeding and treatment for hypoglycemia in infants of diabetic mothers. They suggest more studies be conducted with more control over the timing of when the infants are fed, and to continue exploring the physiological outcomes associated with feeding infants of diabetic women.
Ozcimen, E. E., Uckuyu, A., Ciftci, F. C., Yanik, F. F., & Bakar, C. (2008). Diagnosis of gestational diabetes mellitus by use of the homeostasis model assessment-insulin resistance index in the first trimester. Gynecological Endocrinology, 24(4), 224-229. doi: 10.1080/09513590801948416
The study was performed to predict gestational diabetes prior to the twenty-fourth week of gestation by using the homeostasis model assessment insulin resistance index (HOMA-IR) to measure insulin sensitivity in the first trimester. Participants with a HOMA-IR score above 2.38 were more likely to have higher fasting glucose levels, insulin levels, and BMI (P < 0.05). Women with gestational diabetes were found to have higher HOMA-IR levels than those without GDM (P = 0.0001).
The limitations include that the lack of a cut-off value for the HOMA-IR, so the researchers determined their own value for insulin resistance. They suggest performing larger randomized control studies, and others that look at BMI as it relates to GDM in the first trimester. The researchers conclude that using the HOMA-IR test during the first trimester is a reliable way of diagnosing GDM. They recommend screening patients at risk in the first trimester to prevent adverse maternal and perinatal outcomes.
International Association of Diabetes and Pregnancy Study Groups Consensus Panel. (2010). International association of diabetes and pregnancy study groups recommendations of the diagnosis and classification of hyperglycemia in pregnancy. Diabetes Care, 33(3), 676-682. doi: 10.2337/dc09-1848
The International Association of Diabetes and Pregnancy Study Groups (IADPSG) Consensus Panel met in 2008 to develop criteria for the diagnosis and classification of diabetes in pregnancy to be used internationally. This group used the results from the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study to develop new diagnostic criteria for GDM. The IADPSG panel decided that at least one of these thresholds must be met to be classifed as GDM: Fasting plasma glucose level about 92 mg/dl, 1 hour plasma glucose above 180 mg/dl, and 2 hour plasma glucose level above 153 mg/dl. The following results would be considered overt diabetes in pregnancy: Fasting plasma glucose greater than 126 mg/dl, hemoglobin A1C greater than 6.5%, and random plasma glucose level greater than 200 mg/dl and confirmations. It was also decided that all clinics would use a 75 g glucose oral glucose tolerance test to diagnose diabetes. The group suggests that these new approaches will increase the number of hyperglycemic disorders in pregnancy.
Summary
Glucose is necessary for fetal development during pregnancy. During normal pregnancy, there is a decrease insulin sensitivity to allow for increased transport of glucose to the fetus. According to Pridijian and Benjamin (2010, p. 255), “pregnancy is characterized by increased and adaptive pancreatic beta-cell function to compensate for decreased insulin sensitivity and increased requirements”. However, women with gestational diabetes have beta cell dysfunction that results in insulin resistance (Pridijian & Benjamin, 2010).
Gestational diabetes mellitus (GDM) is a damaging disease that has many adverse effects on the mother and fetus. The maternal adverse effects include increased cesarean sections, preeclampsia, and impaired beta cell function leading to development type 2 diabetes mellitus after birth, along with many others (The HAPO Study Cooperatie Researc Group, 2008; Hedderson et al., 2010; Retnakaran et al., 2010). GDM has many perinatal complications including macrosomnia, birth weight above ninetieth percentile, fetal hyperinsulinemia, neonatal hypoglycemia, hyperbilirubinemia, premature delivery, shoulder dystocia or birth injury, and increased occurrences of intensive care unit admissions (The HAPO Study Cooperative Research Group, 2008; Lawlor et al., 2010). Lawlor et al. (2010) found that children born to diabetic women were more likely to be overweight or centrally obese, and some were classified as diabetic and on insulin treatment by 9 years old. These results reveal that the effect of gestational diabetes has a long-term effect on the health of the mother and infant.
Advanced practice nurses must be aware of the increased occurrence of gestational diabetes and screen women early in pregnancy. Ozcimen et al. (2008) and IADPSG Consensus Panel (2010) recommend identifying and screening women early during pregnancy, preferably at the first prenatal visit, to reduce perinatal adverse outcomes. A 75 g oral glucose tolerance test (OGTT) should be performed on all patients, who are not already diagnosed with overt diabetes or GDM, at 24-28 weeks gestation. A diagnosis of GDM includes one or more of the following values: fasting plasma glucose greater than 92 mg/dl, plasma glucose greater than 180 mg/dl at the 1 hour mark, and a level greater than 153 at the 2 hour mark (International Association of Diabetes and Pregnancy Study Groups Consensus Panel, 2010).
A woman diagnosed with gestational diabetes be informed on the management of the disease to prevent adverse effects. Follow up appointments are made every 1-2 weeks to monitor the effects of treatment and for complications. The health care provider should provide the patient with information on nutritional therapy, exercise and weight management, and medication treatment. Nutritional therapy and monitoring blood glucose 3-4 times daily is started first (Pridijian & Benjamin, 2010). A dietitian should be consulted for dietary management, and the woman may be placed on a 1,900-2,400 k calorie diet with a 30-40% carbohydrate restriction (Pridijian & Benjamin, 2010). Because exercise aids with glycemic control, women with GDM should be encouraged to do light exercise at least three times per week. If nutritional therapy and exercise do not reduce blood glucose levels, health care professionals should prescribe either oral glycemic medications, such as metformin or subcutaneous insulin, or both. The patient should be informed of the side effects, drug and food interactions associated with the medication. She should also be informed that metformin and insulin are safe to the fetus (Landon et al., 2009; Rowan et al., 2008).
Most health care providers will induce labor for women with GDM in order to prevent birth complications due to macrosomia of the infant. During labor, women who were treated with glycemic medications might require an intravenous (IV) insulin drip and their blood glucose monitored closely (Pridijian & Benjamin, 2010). It is necessary that both the mother and fetus be monitored closely for birthing complications and perform a cesarean section if needed.
Because GDM women are more likely to develop type 2 diabetes postpartum, they should have their blood glucose monitored. Therefore, a 75 g OGTT should be done at their 6 week postpartum visit, and they should continue to have it monitored three times per year (Pridijian & Benjamin, 2010). They should also be informed of lifestyle modifications that may be needed to prevent the development of type 2 diabetes.
The infant of a GDM mother should be monitored very closely after birth for complications. Healthcare providers should monitor the infant for hypoglycemia and initiate breast or bottle feeding within the first 30 minutes after birth, and check their blood glucose levels closely (Barnes-Powell, 2007; Chertok et al., 2009). If the infant is symptomatic and the blood glucose level is below 47 mg/dl, then IV dextrose must be initiated immediately. The infant may also present with hyperbilirubinemia due to the increased breakdown of red blood cells, and may need to be placed under phototherapy and have exchange transfusions (Barnes-Powell, 2007).
Gestational diabetes has many hazardous effects on the mother and fetus. Therefore, it is necessary to keep her blood glucose under control through nutritional management, exercise, and medical management. The frequency of gestational diabetes mellitus will continue to increase if it is not diagnosed early in pregnancy.
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