gestational diabetes case study for nursing students

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Gestational Diabetes Mellitus Case Study

Gestational diabetes mellitus (GDM), also known as type III diabetes mellitus, is one of the most common types of diabetes mellitus and considered the most common complication 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 the 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 develop GDM will eventually develop non-insulin-dependent diabetes mellitus (NIDDM or type II DM) within 5 years.

FACTS ABOUT INSULIN

Knowing the facts about insulin facilitates the understanding of gestational diabetes mellitus. Or any form of diabetes for that matter. This creates/develops ideas on how and why such health problems occur.

• The insulin is a normal body hormone that is produced by the beta cells of the Islets of Langerhans in the pancreas.
• The release of insulin is regulated by negative feedback in response to high glucose levels. The high glucose level may come from excessive glucagon action or high carbohydrate intake.
• The insulin secretion of the pancreas and its action on the liver makes it maintain a normal value of 80-120 mg/dL.
• Carbohydrates— utilization of glucose by the cells
• Proteins— conversion of amino acids to replace muscle tissues
• Fats— conversion of excess glucose to fatty acids and store them to adipose tissues
• Endothelial and nerve cells are the only cells/tissues that can use glucose even without insulin.
• Low insulin level causes the rise in plasma glucose concentration and glycosuria.
• Diabetes mellitus develops as the body secretes a low amount or as body cells reject its utilization.

ANATOMY AND PHYSIOLOGY

A normal body uses insulin as a channel for glucose to enter the cells for utilization. This process is also applicable to the fetus (during pregnancy) for growth and development. As the fetus grows, the maternal body executes an automatic response by doubling the level of glucose level through lowering insulin secretion and with the aid of some gestational hormones that antagonize the effects of insulin, a process known as a 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), and 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 a protective mechanism that predisposes a pregnant mother in the triggering of her pre-diabetic state or heightens an existing diabetes mellitus.

The effects of pregnancy on diabetes mellitus are summarized as:

• The first trimester— glucose level is relatively stable or may decrease
• The second trimester— there is a rapid increase in glucose level
• The third trimester— there is a rapid decrease in glucose level and return to its pre-pregnant state.

CAUSES AND INCIDENCE

The primary cause is almost the same as the other types of diabetes . The inability of the body to produce or synthesize a sufficient amount of insulin in response to glucose level (as in type I DM), or the body’s rejection of insulin (as in type II DM) shows a significant relationship on the development of any form of diabetes. The existence of either of these problems, plus, the interaction of the protective mechanisms in pregnancy doubles the occurrence of GDM.

The incidence of gestational diabetes mellitus is almost 3% in all pregnancies and 2% in all women with diabetes before pregnancy.

GDM causes a high incidence of fetal morbidity and unwanted complications such as polyhydramnios and macrosomia in fetus.

RISK FACTORS

For some clear and unclear pathological reasons, the following are considered the risk factors in the occurrence/development of GDM:

• Family history of DM
• Age of 45 or older (when got pregnant)
• Previous delivery of a 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

SIGNS AND SYMPTOMS

The clinical manifestations of gestational diabetes mellitus coincide with the signs and symptoms of the other types of diabetes mellitus. These are popularly known as the “3 P’s” or polydipsia (excessive thirst), polyphagia (excessive hunger), and polyuria (frequent urination). Aside from these manifestations, there are also other signs and symptoms that are general manifestations and pregnancy-specific manifestations.

PATHOPHYSIOLOGY

COMPLICATIONS

The chronic effects or the uncontrolled glucose level during pregnancy would lead to the development of the following complications:

• Urinary tract infection (UTI)
• Infertility
• Preterm labor and delivery
• Pregnancy-induced hypertension (PIH)- pre-eclampsia and eclampsia
• Congenital anomalies
• Spontaneous abortion

Also, a woman who developed or experienced gestational diabetes mellitus is expected to have type II diabetes mellitus within 5 years for the rest of her life.

The prognosis or the chance of the mother and/or fetus for survival depends on the maternal ability to tolerate and adjust to high glucose levels, medical management, and obedience to the treatment regimen. This means that the more cooperative and responsive the mother to the treatment regimen is, the better chances of both maternal and fetal well being are.

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.

• 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.
• Glucose tolerance test (GTT)— to evaluate the response of insulin to loading glucose.
• Glycated hemoglobin (Glycohemoglobin)— measures glycemic control by evaluating the attachment of glucose to freely permeable erythrocytes during their whole life cycle.
• C-peptide Assay (connecting peptide assay)— useful when the presence of insulin antibodies interferes with direct insulin assay.
• Fructosamine assay— is much more useful than glycosylated hemoglobin tests in cases of hemoglobin variants.
• Urine glucose and ketone monitoring— may be performed in cases where blood glucose monitoring is not available, but, is not as accurate as of the former.
• Amniocentesis
• Non-stress test

NURSING DIAGNOSES

• Altered nutrition, more or less than body requirements related to weight gain.
• High-risk pregnancy: high risk for infection, ketosis, fetal demise, cephalopelvic disproportion, polyhydramnios, congenital anomalies, preterm labor.
• Knowledge deficit related to disease and insulin use and interaction.

The overall goal of management for gestational diabetes mellitus is the control of the maternal glucose level and keep it on a 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 (hypoglycemia) 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 health education.

Along with this, health promotion and disease prevention activities like diet, exercise, and fetal monitoring are of great importance.

NURSING MANAGEMENTS

History taking on:

• First presentation of the manifestations of diabetes (3 P’s)
• First diagnosis of DM
• Family members with DM

Review of systems:

• Weight gain, increasing fatigue/weakness/tiredness
• Skin lesions, infections, hydration, signs of poor wound healing
• Changes in vision—floaters, halos, blurred vision, dry/burning eyes, cataract, glaucoma
• Gingivitis, periodontal disease
• Orthostatic hypotension, cold extremities, weak pedal pulses
• Diarrhea, constipation, early satiety, bloating, flatulence, hunger and thirst
• Frequent urination, nocturia, vaginal discharge
• Numbness and tingling of the extremities, decrease pain and temperature sensation

Intervention

1. Nutrition

• Assess the 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 the client to do self-administration
• Review mastery of the whole process

3.   Injury from hypoglycemia

• Monitor maternal blood glucose level
• Instruct on insulin-activity-diet interaction
• Teach on the signs and symptoms of hypoglycemia
• Teach/present list of things/foods that need to be available at all times (in cases of hypoglycaemic attacks)
• Have an 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
• Advice 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  
• Bodyweight is within the normal range for the age of gestation.
• Demonstrates proper technique in self-administration of insulin
• No episodes of hypoglycemia as claimed by the client
• No skin problems/lesions
• Verbalizes readiness on the possible fetal defects.
•   Stable fetal heart rate

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Mastering Gestational Diabetes - A Must-Read for Nursing Students and NCLEX Prep

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Understanding Gestational Diabetes is Crucial for Nursing Students

Understanding gestational diabetes is crucial for nursing students preparing for the NCLEX exam for several reasons: Maternal and Fetal Health: Gestational diabetes poses risks to both the pregnant individual and the developing fetus. It increases the risk of maternal complications such as preeclampsia, cesarean delivery, and type 2 diabetes later in life. Additionally, it can lead to fetal macrosomia (large baby), birth trauma, and neonatal hypoglycemia. Screening and Diagnosis: Nurses play a significant role in identifying pregnant individuals at risk for gestational diabetes through routine screening tests. Understanding the criteria and process for screening helps nurses identify those who need further evaluation. Patient Education: Nurses educate pregnant individuals about gestational diabetes risk factors, preventive measures, and management strategies. Providing clear instructions on glucose monitoring, dietary modifications, and exercise can positively impact maternal and fetal outcomes. Medication Management: In some cases, pregnant individuals with gestational diabetes may require insulin or oral antidiabetic medications to manage their blood glucose levels. Nurses need to understand the administration, monitoring, and potential side effects of these medications.

Monitoring and Assessment: Regular monitoring of blood glucose levels, fetal well-being, and maternal health status is essential. Nurses must be knowledgeable about interpreting results, recognizing signs of complications, and reporting concerns promptly. Labor and Delivery Considerations: Nurses need to understand how gestational diabetes can impact labor and delivery. Close monitoring of blood glucose levels during labor, potential adjustments to insulin dosages, and the risk of fetal macrosomia are important considerations. Postpartum Care: Nurses play a role in educating postpartum individuals about their increased risk for type 2 diabetes and the importance of ongoing glucose monitoring, lifestyle modifications, and follow-up care. Patient Advocacy: Understanding gestational diabetes empowers nurses to advocate for pregnant individuals by ensuring appropriate screening, diagnosis, and management. NCLEX Preparation: The NCLEX exam may include questions about gestational diabetes, its assessment, management, and potential complications. A strong grasp of this topic is essential for answering these questions accurately. Understanding gestational diabetes prepares nursing students to provide safe, competent, and compassionate care to pregnant individuals, promoting positive outcomes for both mothers and babies. It aligns with the nursing profession's commitment to holistic and patient-centered care.

Gestational Diabetes Overview

1. Pregnancy can cause insulin resistance because increased weight and hormones cause higher blood sugars 2. but needs a source for glucose. 3. If the mother has high blood sugar, the glucose will cross the placenta. a. In response to the mother’s hyperglycemia, the fetus’s body produces more insulin causing excessive growth. b. Maternal insulin will not cross the placenta, only the glucose.

Nursing Assessment for Gestational Diabetes

Therapeutic management for gestational diabetes.

1. Ideal to control with diet and exercise 2. Monitor for typical DM complications (signs of infection, HTN, edema, proteinuria)

Nursing Case Study for Gestational Diabetes

Patient: Hannah

Assessment: Identify risk factors for gestational diabetes, such as obesity, family history of diabetes, and advanced maternal age. Monitor blood glucose levels regularly using a glucometer and record the results. Assess dietary habits and physical activity level to determine the need for modifications. Evaluate the patient's understanding of gestational diabetes, its management, and potential complications.

Nursing Diagnoses:

Risk for Maternal and Fetal Injury related to uncontrolled blood glucose levels during pregnancy. Deficient Knowledge regarding self-care measures and management of gestational diabetes. Alteration in Nutrition: More than Body Requirements related to elevated blood glucose levels.

Goals: The patient will achieve and maintain target blood glucose levels within the recommended range. The patient will demonstrate an understanding of self-care measures and management strategies for gestational diabetes. The patient's nutritional intake will align with the recommended dietary plan for gestational diabetes.

Interventions: 1. Blood Glucose Monitoring: Educate the patient on proper technique for blood glucose monitoring. Encourage the patient to monitor blood glucose levels as per the healthcare provider's recommendations. Collaborate with the healthcare team to adjust insulin or oral antidiabetic medication dosages based on monitoring results.

2. Dietary Management: Collaborate with a registered dietitian to develop a personalized meal plan that promotes stable blood glucose levels. Educate the patient about carbohydrate counting, portion control, and the importance of balanced meals. Emphasize the need for regular meals and snacks to prevent blood glucose fluctuations.

3. Physical Activity: Assess the patient's physical activity level and develop an appropriate exercise plan. Educate the patient about the benefits of regular physical activity in managing blood glucose levels. Emphasize safe exercises that are suitable for pregnant individuals.

4. Medication Administration: If insulin or oral antidiabetic medications are prescribed, educate the patient about administration techniques and potential side effects. Emphasize the importance of adherence to the medication regimen.

5. Patient Education: Provide comprehensive education about gestational diabetes, its risks, and the potential impact on the mother and baby. Teach the patient how to recognize signs of hypoglycemia and hyperglycemia and how to respond appropriately. Discharge Planning: Provide written instructions on blood glucose monitoring, medication administration (if applicable), meal planning, and exercise guidelines. Schedule follow-up appointments with the healthcare provider to monitor progress and adjust the care plan as needed.

Conclusion and Free Download

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The 3 P's of Diabetes Mellitus (DM) and why you should know them for your NCLEX Exam

• Open access
• Published: 11 January 2024

Experiences and self-care of pregnant nurses with gestational diabetes mellitus: a qualitative study

• Jing He   ORCID: orcid.org/0000-0001-7654-1872 1 , 2 , 3 ,
• Hui Wang 1 &
• Xiaoli Chen 3  

BMC Nursing volume  23 , Article number:  33 ( 2024 ) Cite this article

1199 Accesses

Metrics details

Pregnant nurses are at high risk of developing gestational diabetes mellitus (GDM), and nurses diagnosed with GDM face challenges in balancing disease management and work, which affects maternal and child health and the quality of care. GDM requires significant changes to lifestyle and physical activity to control blood glucose levels, which is key to reducing adverse pregnancy outcomes. However, few studies have focused on the experiences of pregnant nurses with GDM. This study aimed to gain insight into the experiences of pregnant nurses with GDM in China in terms of their illness, work burdens, and self-care.

This qualitative study used an interpretative phenomenological analysis. Face-to-face semi-structured in-depth interviews were conducted with pregnant nurses with GDM to investigate their experiences and self-care. The study was performed at Chongqing’s maternal and child health hospital in China. A purposive sampling was used. Nine pregnant nurses diagnosed with GDM were recruited and interviewed.

The interview data generated four themes and 11 sub-themes. The four themes were ‘the perceptions and feelings of GDM’, ‘experiences of lifestyle changes’, ‘social support needs’, and ‘health expectations and risk perception.’

Many factors such as the unique occupational environment, overwork, occupational pressure, shift work, family status, and education level may lead to difficulties in managing blood glucose in nurses with GDM. These findings suggest that managers should pay more attention to nurses with GDM and develop personalized medical care and work arrangements. These measures can improve the self-care and well-being of nurses with GDM and promote the health of nurses and their offspring.

Peer Review reports

Introduction

According to Chinese health statistics, there were approximately 5.02 million registered nursing staff in the country in 2021. Women accounted for 96.7% of these, and 85% of female nurses were of childbearing age between the ages of 18 to 44 years [ 1 ]. There were 8.47 billion visits to medical and health institutions in China in 2021 while the proportion of registered nurses per 1,000 population was 3.56, indicating a high demand on nursing teams and nursing service quality [ 1 ]. Shen et al. observed that the status quo of nurses’ clinical work represented continuous busyness with regular overtime involving shift relief and the writing up of nursing records and quality control information) [ 2 ]. Occupational challenges, as well as the physical and mental changes occurring during pregnancy, make it difficult for nurses to maintain a healthy lifestyle; these challenges include long working hours, night work, stress, and working in a COVID-19 background, amongst others [ 3 , 4 ].

Studies have shown that specific aspects of nursing work, such as long shifts, can worsen insulin resistance during pregnancy [ 5 ]. Shan et al. and Pan et al. found that night shifts and job-related psychosocial stress were independent risk factors for type 2 diabetes mellitus (T2DM) in nurses [ 6 , 7 ]. In addition, sleep disturbances and stress may lead to insulin resistance, impaired glucose regulation, and the development of T2DM [ 8 , 9 ]. The pathological mechanism of gestational diabetes mellitus (GDM) is similar to that of T2DM and is associated with insulin resistance and islet cell dysfunction [ 10 ]. The results of these studies suggest that pregnant nurses are likely to be at high risk of developing GDM; however, there is little information on the occurrence of GDM in nurses.

Once a pregnant nurse is diagnosed with GDM, daily work tasks and blood glucose management during pregnancy become more challenging. These complex scenarios during pregnancy can exacerbate burnout and job dissatisfaction, as well as limiting effective glycemic management and self-care during pregnancy [ 4 , 11 ]. Weschenfelder et al. found that poor sleep status in women with GDM was independently related to the need to use long-acting insulin at night [ 12 ]. Circadian disruption in shift work can impair blood glucose regulation [ 13 ], and a study from China found that reduced durations of nighttime sleep were associated with poor blood sugar control in women with GDM [ 14 ]. Moreover, GDM increases the risk of short-term adverse perinatal outcomes and long-term metabolic diseases [ 15 , 16 ].

Guidelines from the American Diabetes Association (ADA) recommend that adopting a healthy lifestyle during GDM significantly reduces the risk of adverse outcomes, indicating the importance of blood sugar control and management [ 17 ]. Unfortunately, although nurses with GDM may understand the importance of such requirements, they may not be able to obtain regular exercise, adequate stress management sleep, or eat a healthy diet [ 18 ]. Nurses may also consider it too difficult to balance busy work schedules with regular self-care behaviors during pregnancy [ 4 ]. In addition, nurses with GDM need to practice proper blood glucose management and the self-care of a healthy lifestyle during pregnancy to ensure the health and well-being of both themselves and the fetus [ 4 ]. However, there are no current studies addressing the work experience, blood glucose management, and self-care of pregnant nurses with GDM.

It is thus important to investigate the experiences of nurses with GDM to determine the problems they face and their ability to manage both the disease and self-care during pregnancy to identify and mitigate the possible risks and problems in this field. This study aimed to investigate and analyze the experiences of pregnant nurses with GDM. The findings can provide a comprehensive understanding of the needs and difficulties of nurses with GDM, help to develop personalized nursing management plans, reduce the risk of metabolic diseases caused by GDM, and promote the health of nurses and their offspring.

Study design

This study was undertaken as an interpretative phenomenological analysis (IPA) of qualitative research to explore the experiences and feelings of pregnant nurses with GDM. The purpose of an IPA is to explore how participants understand their own personal and social worlds [ 19 ]. This method can be used to elaborate on the interviewee’s personal views and understanding of the object or events in a specific life experience. Our view of the world consists of the interaction between the raw material of the world and the complex mental framework developed by personal backgrounds and life experiences [ 20 ]. This interaction helps us construct unique interpretations of the world. Researchers need to identify how participants try to make sense of their personal and social worlds in a particular cultural context. The researcher (JH) who conducted the interviews was a female nursing postgraduate student and qualified Psychological Consultant with expert psychological knowledge and interview experience.

This study was approved by the Ethics Committee of the Chongqing Health Center for Women and Children (Number: 2020-022), and participants provided signed informed consent to participate in the study before taking part. The Consolidated Criteria for Reporting Qualitative Studies (COREQ) checklist was used in the study [ 21 ].

Sampling and participants

The study participants were selected using the purposive sampling approach combined with maximum variation (in terms of age, parity, pre-pregnancy body mass index, educational background, and clinical department) [ 22 ]. The pregnant nurses with GDM were interviewed and information was collected. The study used Information Power to determine the sample size; this includes four specifications, namely, a narrow study aim, dense sample specificity, strong dialogue quality, and case strategy [ 23 ]. The obstetrics GDM specialist outpatient nurse was responsible for recruiting participants who met the criteria at Chongqing Health Center for Women and Children. One researcher (JH) was responsible for contacting and identifying participants willing to participate in the study and making a telephone appointment to be interviewed at the next outpatient obstetric visit after the diagnosis of GDM.

The inclusion criteria were as follows; pregnant nurses with professional qualifications, and patients using the 75-gram Oral Glucose Tolerance Test (OGTT) who met the diagnostic criteria of the International Association of Diabetes in Pregnancy Study Group (IADPSG). Any abnormalities in these indicators were diagnosed as GDM. The exclusion criteria were patients with other pregnancy complications or other underlying medical conditions.

Data collection

The data were collected through personal face-to-face semi-structured interviews using the Chinese language. Before the research interview, we introduced the purpose, significance, methods and content of the research to the participants and established a familiar relationship. Written informed consent was obtained from the participants for the recording and taking of notes. The collection site was a quiet office with only one participant and one researcher (JH) in the clinic. The subjects were anonymized with letters and numbers (e.g., G1 = Participant 1).

A total of 20 eligible participants were recruited and 11 nurses declined to participate. Nine pregnant nurses did not have time for the interview and two pregnant nurses did not want to talk about GDM. Each participant was interviewed only once. The interviews were completed from May to October 2020 and lasted on average 41.2 min. The nurses were asked to describe their experiences and feelings after being diagnosed with GDM. The interview questions are shown in Table  1 . All information relating to the interview was kept on secure computers and password protected by two researchers (JH and XC). One researcher translated the Chinese quotations into English while another, a Chinese person living in an English-speaking country, translated them back to ensure that the original meaning was preserved.

Data analysis

The analysis followed the procedures outlined by the IPA [ 24 ]. The specific steps of analysis were: (1) Repeated reading of the transcribed text; (2) Analysis of each code line by line, looking for descriptive, linguistic, and conceptual points of interest, and forming preliminary comments and analysis; (3) Transformation of the initial notes into emerging emotional themes that capture the core of the participants’ experience, leading to the proposal of themes; (4) Cases are collected and converted into a separate topic table, and correlations between the topics are identified; (5) Analysis of subsequent cases, grouping and converting each case into a separate topic table; (6) Comparison of the topics by searching for convergence and divergence, that is, looking for thematic patterns between individual cases. The IPA endorses a two-stage interpretive process, implying that researchers are required to construct meaning by understanding participants [ 24 ].

NVivo12 (QSR International Pty Ltd. Version 10, 2014) was used in the management, shaping, and analysis of the text of qualitative data. The results of data transcription and analysis were returned to the interview subject for confirmation and questions or ambiguities were clarified. Two researchers (JH and XC) acquired, analyzed, summarized, and supplemented the recording materials and field notes within 24 h. The recorded material was transcribed verbatim into text. The participants listened to the recorded material, compared the transcribed material, and added and recorded nonverbal information. Three researchers (JH, HW, and XC) were involved in the coding of the data. HW and XC are nursing professors working in a hospital and university, respectively, with rich experience in nursing management and obstetric care. Different analyses by different researchers could potentially extract different elements from the participants’ accounts. Therefore, a collaborative approach to analysis ensures the comprehensiveness and credibility of the final report [ 25 ].

Participant characteristics

Nine pregnant nurses that had been diagnosed with GDM were interviewed. The participants were between 25 and 33 years old with an average age of 29 years. The interviewees were included five primiparas and four multiparas with pre-pregnancy body mass index (BMI) of 19.5–28.9 kg/m 2 . Three pregnant nurses were educated to junior college level and six nurses were educated to undergraduate level. The characteristics of the participants are summarized in Table  2 .

In-depth interviews were conducted on the experiences and self-care of nine pregnant nurses diagnosed with GDM, and the interview data comprising 571 nodes were analysed and coded. In addition, the interview data formed 11 sub-themes and four themes. The findings were presented as four core themes: the perception and feelings of GDM, experiences of lifestyle changes, social support needs, and health expectations and risk perception (Table  3 ).

Fasting, fasting plasma glucose of oral glucose tolerance test (OGTT); 1-h, OGTT 1-h plasma glucose; 2-h, OGTT 2-h plasma glucose (mmol/L); Pre-BMI, Pre-pregnant body mass index.

The perceptions and feelings of GDM

The first topic of the study was the perception and feelings associated with GDM. Pregnant nurses reported emotional shock at the diagnosis of GDM, which caused them to question their health status. Pregnant nurses with GDM immediately reflected on the influence of diet and exercise on their blood glucose levels based on their medical knowledge. In addition, nurses also expressed perceptions of GDM, including issues such as controllability and disease stigma. Three sub-themes were identified in relation to this topic.

Emotional response to the diagnosis

Pregnant nurses with GDM were interviewed for this study. The pregnant nurses with GDM were psychologically shocked, amazed, lost, and sad when they became aware of their blood glucose results. However, as nurses, as they had medical knowledge and understood that GDM was controllable, these adverse emotional reactions were rapidly alleviated. At this stage, the nurses considered that excessive anxiety over the controllability of blood glucose was unnecessary and that maintaining a good state of mind was important for fetal health. In addition, some nurses said a diagnosis of GDM was a “wake-up call” to past unhealthy eating habits. Typical statements conveying their emotions are shown below.

“My OGTT results were only 0.2 (mmol/l) above the diagnostic criteria 2-h plasma glucose. However, the doctor said it was GDM, although I was reluctant to accept the result… (sighs).” (G1) . “When I got the OGTT results, I was so upset. I couldn’t control my emotions and cried for a while. I began to resist anything sweet and dared not eat fruit.” (G5) .

Self-reflection

Pregnant nurses reported self-reflection on the possible causes of the abnormal OGTT results immediately after the diagnosis, reflecting their professional knowledge and understanding of health. They considered the risk factors for GDM in a medical context, including overindulgence in fruit and sweets, drinking soft drinks, insufficient exercise, obesity, and eating takeaways.

“I know that my pre-pregnancy weight (overweight) and PCOS (polycystic ovary syndrome) are high-risk factors for GDM. I need to stay in a good mood and control my diet, including limiting anything too sweet or salty.” (G3) . “I order takeout at work. I know takeout is unhealthy (a GDM risk), but I was so busy at work that I didn’t have time to choose other healthy foods.” (G5) .

Attitudes and perceptions of GDM

All pregnant nurses with GDM in the study described GDM as a controllable disease, and understood that adverse effects on the fetus could be reduced if the blood glucose is controlled. Several nurses said that GDM is a widespread condition and they should not worry about adverse pregnancy outcomes. Other nurses were reluctant to talk about GDM and felt guilty and stigmatized for their poor blood glucose control. Some nurses interpreted GDM as a threat to their health and wanted to maintain a healthy lifestyle during pregnancy and the postpartum period.

“It (diet management of GDM) is excruciating. I always say, after delivery, I want to eat cake and fruit. I try to control myself deliberately at present.” (G5) .

Experiences of lifestyle changes

The second theme of this study was the indication by pregnant nurses with GDM that lifestyle changes based on existing medical knowledge could help them cope with the complex glycemic management of GDM. Nevertheless, they described the significant challenges involved in maintaining a healthy lifestyle and the difficulty in balancing their busy clinical work and self-care. Regular blood glucose monitoring was unsatisfactory in terms of time and brought emotional turmoil and self-reproach due to pain and abnormal blood glucose levels. Three sub-themes were identified under this theme.

Conflict between diet management and clinical work

We found that pregnant nurses with GDM could appreciate the relationship between the blood glucose results and daily diet and could actively change and adjust their diets. However, many nurses said that that the adjustment to the GDM lifestyle required significant effort especially as they had to balance the proper diet with busy clinical work and shift work. They had to give up dietary management during working hours because strategies to reduce the amount and portion size of meals are difficult to implement. The pregnant nurses with GDM also reported guilt, anxiety, and frustration about the health of the fetus when the lack of dietary management resulted in abnormal blood glucose levels.

“I’m always busy with clinical work and don’t have time to stop. There’s no way to get much time to eat (sigh of resignation). So, I need to eat quickly and eat filling food every time I eat.” (G8) .

Fatigue from physical labor

In this study, pregnant nurses with GDM reported significant levels of fatigue resulting in physical and emotional labor, shift work, and the intense pace of their daily clinical work, with no extra time for physical activity. At the same time, they also indicated that the physical labor of clinical work was heavy, and that the amount of walking done was more than 10,000 steps per day, which they believed met the energy consumption required for GDM. Exhausted from nursing work, nurses described going home and wanting to lie and rest or sleep. In addition, nurses with specific pregnancy conditions, such as artificial insemination or pregnant women with scars for a short time, were cautious and worried about clinical work and exercise.

“I am busy at work (as a nurse). I do approximately 15,000 steps per day. I rarely schedule a time to exercise alone anymore. I am tired, mentally and physically.” (G6) .

Blood glucose monitoring and emotional shock

Pregnant nurses with GDM reported understanding the importance of self-monitoring blood glucose as they were caregivers for others, as well as having a clear understanding of the impact of a healthy lifestyle. Some nurses said blood glucose measurement was convenient in hospital work. At the same time, they hoped to get help from colleagues but did not want to increase the burden on colleagues.

Furthermore, all pregnant nurses with GDM reported that their daily emotions, sleep patterns, and lifestyles were affected by the blood glucose-monitoring results. Meanwhile, the nurses also described guilt and remorse when their blood glucose was abnormal, and they were at a loss. We also found that nurses were resistant to the use of insulin. Even though endocrinologists emphasized the safety of the drug’s use, they were still worried and fearful about possible side effects of the drug on fetal health. This corresponds to the Chinese proverb that drugs are seven parts effective and three parts toxic.

“The doctor advised me to be hospitalized and injected insulin to adjust my blood glucose. I’m scared. But then I got my blood glucose under control with diet and physical activity, and I was so glad.” (G7) . “It’s hard for me to find time to test blood glucose in my clinical work. I occasionally measure my blood glucose and find it extremely high, leaving me devastated and overwhelmed.” (G9) .

Social support needs

The third theme of this study was the stated need by pregnant nurses with GDM for social support and the observation that clinical work stress, such as overburdening with work and specific shift systems, conflicted with the lifestyle management required. Nurses have subject to high levels of expectation for humanistic care from leaders. However, most of the time, family and professional support could help them cope with a complex condition. Three sub-themes were identified under this theme.

Humanistic care needs

Nurses expressed concern that overcrowded working conditions and the need to deal with emergencies resulted in high levels of mental stress, especially during COVID-19, with little energy left over to pay attention to pregnancy status and blood glucose. At the same time, they were also concerned that the working hours of the shift system, especially the night shift, could harm the health of both themselves and the fetus. Most of the nurses in the study said they received care and help from the nursing managers to reduce their work burden as much as possible. For example, nursing managers would reduce clinical work schedules, reduce night shifts, arrange easy administrative work, and other ways to take humanistic care of nurses with GDM.

“We must work until 37 weeks before we can take maternity leave, and most jobs involve lifting patients. So, my nursing work is very stressful and busy. I can’t feel like a pregnant woman, and it was hard (crying). I also didn’t take the time to manage my blood glucose.” (G1) . “Working night shifts during pregnancy was tiring, and the disturbed sleep was terrible for my blood glucose. After work, I want to sleep and do nothing. I am worried about my baby’s health, but in this profession, there is no other way (helpless sigh).” (G9) .

Family support needs

The pregnant nurses with GDM agreed that family support helped with pregnancy and blood glucose management and eased their anxiety. They reported that care and encouragement from their partners provided both emotional support and assistance or participation in encouraging blood glucose management behaviors among nurses. Some pregnant nurses with GDM described feeling happy to be recognized for sharing a healthy lifestyle with family members.

“He (husband) encouraged me to control it (blood glucose).” (G8) . “I share healthy eating ways with my family. They recognize my expertise and eat the same food as I do.” (G6) .

Some pregnant nurses with GDM expressed that ingrained traditional dietary beliefs affected the relationships between the participants and their mothers-in-law. For example, conventional cultural habits believe that eating rich food (such as high carbohydrate foods and the soup of the day) and more fruit is necessary during pregnancy to promote fetal development. The nurses said they understood the elders’ concerns, but that the recommendations would result in overnourishment. Nurses are knowledgeable about nutrition and can adequately self-care in this area.

“I don’t like hearing my mother-in-law’s lessons, such as eating more (high-fat) soup, rice, and fruit, which can promote foetal development. I think these perceptions are problematic. However, they are concerned and ask me to do what they want (helpless smile, sigh).” (G7) .

Available professional support

The pregnant nurses with GDM had a different willingness to learn new GDM knowledge. All nurses were self-rated that they had a basic knowledge of GDM, blood glucose control, and its adverse effects on the fetus and themselves. Most pregnant nurses were not willing to participate in or occasionally participate in the GDM courses offered by the hospital. They explained that they were too busy at work and believed that their medical knowledge was sufficient. However, the study found that pregnant nurses were not sufficiently clear about their knowledge of GDM and were not enthusiastic about professional support. Other nurses stated that it was easier to get help from obstetricians in the hospital, which reduced negative emotions about adverse fetal outcomes. In addition, they could share their blood glucose status with colleagues at any time to get encouragement and comfort.

“I occasionally attend classes at the diabetes day clinic, and also dos online study on GDM. I think that I have adequate knowledge on blood glucose control so this does not need to be learned.” (G7) .

A few other pregnant nurses with GDM actively acquired knowledge of GDM and had good medical knowledge. These nurses felt reassured that enough professional information could help manage the illness and maintain good mental equilibrium. In addition, two nurses expressed horror because they were well aware of the adverse risks of GDM to the fetus and their own high risk of diabetes.

“Although I am a nurse, I do not work in endocrinology or obstetrics and thus I don’t have specific knowledge of GDM. I have taken online courses to learn about GDM. This information and understanding eased my anxiety.” (G4) .

Health expectations and risk perception

The fourth theme identified in this study was the nurses’ perception of the threat of GDM to their own health and that of the fetus. They stated that blood glucose management was the responsibility of the mother and the health of the fetus was the driver of lifestyle change. In addition, pregnant nurses with GDM had concerns and fears about weight, shame, and future health risks. Two sub-themes were identified under this theme.

The responsibilities and expectations of motherhood

Successful behavioral change depends on many factors, and the fetus is the most crucial factor in blood glucose management. The pregnant nurses with GDM expressed responsibility for the health of their babies. We found that pregnant women with GDM had more had an increased knowledge of the adverse pregnancy outcomes that added to their worries concerning their children’s health.

“When I feel terrible about my diet and lack of exercise, I’m very scared. Because I underwent IVF (In-vitro fertilization) many times. Now I have GDM, which makes me even more worried about the effect on the baby.” (G4) . “I’m a little worried, worried… polyhydramnios, macrosomia, miscarriage, premature delivery. Hypoglycaemia after birth… I’m mainly worried about my baby.” (G9) .

Awareness of self-health and image

Most nurses with GDM said they were mainly worried about the baby’s health not themselves. They generally believed that the blood glucose levels would naturally return to normal after childbirth. In addition, some nurses with GDM were well aware that a history of GDM carries a high risk of developing T2DM and felt afraid of financial burden of diabetes. Some GDM nurses also expressed dissatisfaction and anxiety about the impact of excessive weight gain during pregnancy on their self-image, and there was weight shame.

“I’m afraid I will get diabetes. People with diabetes have daily blood glucose tests and insulin injections, and there is no cure.” (G5) . “I’m worried I’ll still be this fat postpartum.” (G2) .

This study explored the experiences and feelings of pregnant nurses in China after a diagnosis of GDM. The results showed that pregnant nurses with GDM have medical knowledge to help them understand the disease and blood glucose management. Most nurses said they understood the importance of a healthy lifestyle for blood glucose but found balancing busy clinical work with blood glucose management challenging. In addition, as nurses take care of others, they spend most of their time taking care of patients, so they often lack the ability or motivation to care for themselves. At the same time, nurses felt helpless about the adverse effects of work overload, especially the demanding working conditions, long working hours, and shift work, on managing GDM and the fetus. Pregnant nurses with GDM expressed their desire to receive more care and special care from nursing managers to minimize adverse pregnancy outcomes.

Pregnant nurses experienced strong feelings of shock, fear, sadness, guilt, and anxiety when diagnosed with GDM. In a review study, women were found to suffer from emotional disorders [ 15 ], and some women experienced excessive fear, helplessness, stigma, and self-blame due to information gaps after a GDM diagnosis [ 26 ]. In this study, patients with medical knowledge of GDM were more inclined to evaluate and analyze their physical condition based on diagnostic criteria and blood glucose levels. Compared to pregnant women with less knowledge of GDM, women with a medical background had a shorter interval between the shock of diagnosis and emotional plateau and had confidence in proper glycaemic control.

Pregnant nurses with GDM face many challenges in learning to adjust their diet and exercise habits. Social and cultural backgrounds also influence eating habits. For example, rice and pasta are the main meals in China, so it is difficult to adjust the intake of staple foods [ 27 ]. However, it was found to be often difficult for nurses with GDM to balance dietary management and demanding clinical work during pregnancy. Failure to manage blood glucose levels adequately can significantly increase the anxiety and stress during pregnancy [ 15 , 28 ].

Physical activity is another crucial factor in controlling blood glucose levels. The nurses said they took over 10,000 steps daily during their clinical work. Most nurses with GDM stated that they were physically and mentally exhausted due to the high work load and long-term mental stress and were not able to arrange extra time for physical activities [ 5 ]. Moreover, all pregnant nurses with GDM recognized the importance and convenience of monitoring blood glucose. However, only a few nurses with GDM conducted regular blood glucose monitoring, and the busy work pace was an obstacle to blood glucose monitoring. However, women with GDM found that abnormal blood glucose readings increased their feelings of guilt and self-blame [ 29 ]. Both nurses and women in general with GDM were found to poor compliance with routine monitoring, which is significant for neonatal outcomes [ 30 ].

In the study, all nurses with GDM used lifestyle changes to control blood glucose, and expressed rejection, worry, and fear about the use of insulin. The pros, cons, and importance of drug therapy and blood glucose management should be emphasized and refined in GDM health guidance [ 15 , 31 ]. Furthermore, nurses with GDM experience pregnancy stress and emotional stress in addition to their demanding clinical work and shift-work loads, which can further worsen their islet function [ 12 ]. Pregnant nurses experience various difficulties due to the physical and mental changes occurring during pregnancy, and the demanding clinical working environment requires greater humanistic care [ 3 ]. Support from partners and other family members can ease a woman’s anxiety during pregnancy and increase her confidence and enthusiasm in managing GDM [ 32 ].

Studies have shown that educational courses about GDM were considered feasible for learning about glycemic management and risk perception [ 15 , 33 ]. While the nurses with GDM lacked precise relevant knowledge, the study found that they took the initiative to acquire knowledge about GDM when needed and could easily understand it. Poor management of GDM in women in general is associated with a lack of adequate and understandable health education [ 34 ]. In addition, Dayyani et al. emphasized that a false sense of security should not arise by informing the offspring of the possibility of blood glucose recovery after birth [ 26 ].

We found that women’s focus and concern for fetal health is the key promoter of glucose management, which agrees with many previous studies [ 35 , 36 ]. However, some nurses with GDM described fear and stigma associated with the possibility of adverse risk outcomes, and expressed guilt or anxiety about poor glycemic management behavior [ 37 , 38 ]. The stigma associated with body image resulting from excess weight gain during pregnancy and obesity is also widely recognized [ 39 ]. During the interview, we learned that most women with GDM are aware of the risk of type 2 diabetes, but the risk awareness is related to education level and medical background. In general, health awareness and risk consciousness are related to the level of knowledge of GDM [ 15 ].

Pregnancy and GDM experienced by nurses, who are core providers of health services, should not be seen as problems that individuals suffer in isolation [ 18 ]. Pregnant nurses with GDM should receive care from nursing managers, active improvements to their working environment, and encouragement for self-care and the promotion of their well-being experience and the ability of nurses with GDM to self-care, we can lay a foundation for providing accurate and personalized medical services and management measures.

Study limitations

Our study had several limitations. Although the researchers and participants were in a quiet and undisturbed office during the interview, it was inevitable that participants would be interrupted by calls they needed to answer, which may have impacted their thinking during the interview. As with all qualitative studies, the intent of these results is not to generalize, as they are specific to the participants’ experiences, which were those of a relatively small number of nurses with GDM. The physical and mental burdens of pregnant nurses with GDM increased during COVID-19 with the additional tasks of nucleic acid testing and high levels of patient management. The findings provide an understanding of the experiences of pregnant nurses during that disastrous era.

Conclusions

The study’s results provide information on nurses’ emotional responses, disease experiences, and self-care abilities after being diagnosed with GDM. In addition, many factors, such as unique occupational environment, demanding and pressured work often leading to overwork, long hours and shift work, family status, and education level may lead to difficulties in the management of blood glucose levels in nurses with GDM. Based on these findings, we strongly encourage nurses and healthcare managers to pay more attention to pregnant nurses with GDM and develop personalized medical care and work arrangements. These measures could improve self-care and well-being in nurses with GDM and promote the health of both the nurses and their offspring.

Data availability

All data generated or analyzed during this study are included in this published article.

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Acknowledgements

We thank all pregnant nurses for participating and sharing their experiences.

This work was supported by the Wuhan Nursing Association in China (Number WHHL202201) and the Research Major Project for Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology (Number 2022C06).

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J.H. drafted the manuscript. J.H., X.C., and H.W. contributed to the concept and design of the study. J.H., H.W., and X.C. have contributed to the acquisition, analysis, or interpretation of data. X.C. provided research supervision. H.W. critically modified the content of the manuscript. They have complete access to all the data of the study, and the patients are responsible for the integrity of the data and the accuracy of the data analysis.

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All procedures involving human participants in this study comply with institutional and national Research Council ethical standards and the Declaration of the Helsinki Medical Society. This study involves human participants and was approved by the Ethics Committee of Chongqing Health Center for Women and Children (Number: 2020-022). Participants gave informed consent and signature to participate in the study before taking part.

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He, J., Wang, H. & Chen, X. Experiences and self-care of pregnant nurses with gestational diabetes mellitus: a qualitative study. BMC Nurs 23 , 33 (2024). https://doi.org/10.1186/s12912-023-01679-x

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A: How do you ASSESS a patient with gestational diabetes?

Two key assessments for a patient with gestational diabetes are to monitor for signs of hypoglycemia and hyperglycemia. Hypoglycemia is a risk for anyone taking glucose lowering medications and often manifests as s hakiness, irritability or confusion, sweating, cool skin, palpitations, headache, dizziness, and hunger. When severe, hypoglycemia can cause a decreased level of consciousness.

Common signs of hyperglycemia include increased urination, thirst and hunger. Other signs include blurred vision, nausea, and vomiting. If the hyperglycemia progresses to diabetic ketoacidosis, the hallmark signs are fruity smelling breath, Kussmaul respirations (which are rapid and deep) and altered or decreased LOC.

T: What TESTS will be conducted for gestational diabetes?  

Screening for gestational diabetes is conducted on all pregnant individuals between their 24th and 28th week, though early screening may be warranted for those at high risk. There are two types of tests – the glucose challenge test and the glucose tolerance test. 

Glucose challenge test – This test is conducted as a routine part of prenatal care and is the first test done to evaluate the patient for gestational diabetes. In this test, the patient drinks a solution containing 50 gram glucose and has their blood sugar tested in one hour. If the blood glucose level is abnormal, then a glucose tolerance test is conducted.

Glucose tolerance test – In this test, the patient fasts prior to the exam and a baseline glucose level is measured prior to the ingestion of a solution containing 75 grams glucose. Blood is drawn after one hour and then again at the two hour mark. A third sample may be taken at the three hour mark if needed.

Diagnostic criteria for gestational diabetes:

• 180 mg/dL or higher at the one hour mark 
• 153 mg/dL or higher at the two hour mark 
• 140 mg/dL or higher at the three hour mark

During pregnancy and labor

Throughout pregnancy, the patient will have frequent prenatal visits as gestational diabetes places them into the high-risk category. At these visits the patient will have their blood glucose , blood pressure, and dipstick urine protein assessed (remember, these patients are at higher risk for preeclampsia!). The baby’s growth and development will also be carefully monitored via ultrasound and nonstress testing. The non-stress test (NST) involves the patient wearing a monitor to assess fetal heart rate while at rest for a period of 20 – 30 minutes (longer assessment periods may be utilized if the patient has been involved in a trauma, is bleeding, or has experienced decreased fetal movement.)

During active labor or with an epidural, blood sugar levels are often tested hourly due to the risk for both hypoglycemia and hyperglycemia.

After delivery

Since 15 to 60% of individuals with gestational diabetes develop type 2 DM, blood glucose levels are also evaluated after delivery and again six to twelve weeks later. 

T: What TREATMENTS are provided for gestational diabetes?

The evidence shows that outcomes for both mom and baby are significantly improved when gestational diabetes is detected and treated in a timely manner. Treatments for gestational diabetes include diet, exercise, and medication when needed. 

• Diet – Diet is first line therapy for women with gestational diabetes. A dietician helps the patient develop an eating plan that accommodates food preferences, weight, and blood glucose levels. Studies show that about 75% of pregnant women with gestational diabetes can positively impact their blood glucose levels with diet and exercise.
• Physical activity – The American Diabetes Association recommends pregnant individuals aim for at least 20 minutes of physical activity per day or 150 active minutes per week.
• Medication – When needed, the most commonly prescribed medication for gestational diabetes is insulin since most types do not cross the placenta. 

E: How do you EDUCATE the patient about gestational diabetes?

Just like with type 1 and type 2 diabetes, gestational diabetes requires a lot of patient education around blood glucose monitoring, lifestyle modifications and follow up care. Note that not only is the goal to manage blood glucose during pregnancy but to also decrease the individual’s risk for developing type 2 diabetes after pregnancy.

Blood glucose monitoring – Ensure the patient understands how and when to measure their blood glucose. Initially, most patients will be advised to check their blood sugar four times per day – before breakfast and one to two hours after each meal. If taking insulin, blood sugar may be measured prior to eating and again at bedtime.

Nutrition – Teach patients that nutrition plays the most important role in managing gestational diabetes. If they do not have a personalized meal plan designed by a dietician, some general nutritional guidelines are: 

• Choose foods high in fiber and low in fat and calories. The American Diabetes Association recommends half the plate consist of non-starchy vegetables, one quarter of the plate dedicated to complex carbohydrates, and one quarter of the plate for protein foods.
• Avoid sweetened foods such as desserts and sodas. If desired, alternative sweeteners such as stevia may be utilized.
• Eat three small meals and three to four healthy snacks per day.

Physical activity – Teach patients that regular physical activity can improve glucose tolerance and reduce insulin needs. The ADA recommends at least 20 minutes of activity a day, which can include a mix of aerobic and strength activities.

Weight management – Prior to becoming pregnant, teach the patient about the importance of maintaining a healthy weight as a way to reduce the risk for gestational diabetes. If already pregnant, active weight loss efforts are not advised. Instead, ensure the patient understands the benefits of a healthy diet and physical activity as well as how much weight gain is recommended. For example, a woman of normal weight should gain between 25 and 35 pounds, while a woman with a BMI greater than 30 should gain between 11 and 20 pounds. In the postpartum period, teach the patient that weight loss can reduce the risk of developing type 2 diabetes.

Insulin – Approximately 15% of women with gestational diabetes require insulin. Ensure the patient understands when and how to take their insulin.  It’s also important they understand how to recognize the signs of hypoglycemia and how to treat it. Typically this involves ingesting 15 grams carbohydrate (such as 4 oz juice) and rechecking blood glucose in 15 minutes.

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• Diabetes & Primary Care
• Vol:25 | No:02

Interactive case study: Gestational diabetes

• 10 May 2023

Share this article + Add to reading list – Remove from reading list ↓ Download pdf

Diabetes & Primary Care ’s series of interactive case studies is aimed at all healthcare professionals in primary and community care who would like to broaden their understanding of diabetes.

These two cases provide an overview of gestational diabetes (GDM). The scenarios cover the screening, identification and management of GDM, as well as the steps that should be taken to screen for, and ideally prevent, development of type 2 diabetes in the long term post-pregnancy.

The format uses typical clinical scenarios as tools for learning. Information is provided in short sections, with most ending in a question to answer before moving on to the next section.

Working through the case studies will improve our knowledge and problem-solving skills in diabetes care by encouraging us to make evidence-based decisions in the context of individual cases.

Readers are invited to respond to the questions by typing in their answers. In this way, we are actively involved in the learning process, which is hopefully a much more effective way to learn.

By actively engaging with these case histories, I hope you will feel more confident and empowered to manage such presentations effectively in the future.

Holly is a 31-year-old lady who is now 26 weeks into her first pregnancy. She sees you with a 3-day history of dysuria and frequency of micturition. There is no history of abdominal pain or fever.

A urine dipstick reveals a positive test for nitrites and the presence of white cells. It also shows glycosuria ++.

What is your assessment of Holly’s situation?

Nadia is a 34-year-old lady of Indian ethnic origin who is now 24 weeks into her second pregnancy, her last pregnancy being 7 years ago. Nadia’s BMI is 32.4 kg/m 2 and her father has type 2 diabetes. GDM was not, however, diagnosed during her first pregnancy and her first baby was born at term weighing 3.8 kg.

How would you assess Nadia’s risk of acquiring gestational diabetes?

By working through this interactive case study, we will consider the following issues and more:

• The risk factors for developing gestational diabetes.
• Investigations and how to interpret them.
• Effects of gestational diabetes on outcomes for the mother and offspring.
• Which treatments for diabetes are considered safe and effective in gestational diabetes.
• What arrangements should be set in place for future screening of diabetes post-pregnancy.

Click here to access the case study .

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Gestational Diabetes Nursing Diagnosis and Nursing Care Plans

Last updated on May 16th, 2022 at 12:47 pm

Gestational Diabetes Nursing Care Plans Diagnosis and Interventions

Gestational Diabetes NCLEX Review and Nursing Care Plans

       Gestational Diabetes is a pregnancy-related type of diabetes. It causes elevated blood sugar level which can be detrimental to both the mother and baby’s health during pregnancy.

Like any other complications of pregnancy, gestational diabetes is seemingly alarming but risks may be reduced by controlling the blood sugar level of the mother.

This can be achieved by modifying diet and appropriate exercise.

Medications are likely needed if these interventions are not enough. It is essential to keep blood sugar at normal level to ensure healthy pregnancy and safe delivery.

Gestational diabetes usually disappears after giving birth. However, women who have had gestational diabetes are at risk for recurrence in next pregnancies and even developing Type 2 diabetes in the near future.

A regular blood sugar level check is necessary to note any changes.

Signs and Symptoms of Gestational Diabetes

• Polydipsia – increased thirst
• Polyuria – increased urinary frequency
• mouth dryness
• fatigue or tiredness

The mother can be asymptomatic and the condition can only be diagnosed when she goes to her prenatal visits.

Causes of Gestational Diabetes

The exact cause of gestations diabetes is still unknown.

However, the risk factors that contribute to its development include: being overweight or obese , previous gestational diabetes or prediabetes, a lack of physical activity, diabetes in an immediate family member,  polycystic ovary syndrome (PCOS), and previously delivering a baby weighing more than 9 pounds (4.1 kilograms).

In addition to these, women who are Black, Hispanic, American Indian and Asian American have a higher risk of developing gestational diabetes.

Complications of Gestational Diabetes

Failure to manage gestational diabetes may cause elevation in blood sugar levels which can greatly affect the mother and her baby.

It may also increase the likelihood of delivering thru Cesarean section .

The fetus may be at risk for having the following conditions:

• Fetal macrosomia. This term used for excessive birth weight, typically weighs 9 pounds or more which makes them at risk for birth injuries. It also increases the need for surgical delivery
• Early preterm birth. High blood sugar level may precipitate early labor and delivery prior to the expected delivery date
• Serious breathing disorders such as newborn respiratory distress syndrome (NRDS) which are common in preterm newborns
• Hypoglycemia . Low blood sugar after birth and risk for having type 2 diabetes and obesity later in life
• Stillbirth or fetal death before or shortly after delivery

The mother may be at risk for having the following conditions:

• Hypertension . Elevated blood pressure can lead to a serious complication such as preeclampsia that may put the mother and the baby’s life at risk.
• Delivery via C-Section. Macrosomia can cause the baby to become wedged in the birth canal causing difficulty in vaginal delivery.
• Diabetes. It can be either developed on the next pregnancy or as the mother gets older.

Diagnosis of Gestational Diabetes

• Screening tests – usually done during the second trimester which is between 24- and 28-weeks of pregnancy and during the prenatal visit for those who are at high risk.
• Initial glucose challenge test- a blood sugar below 140 mg/dL (7.8 mmol/L) can be considered normal
• Follow-up glucose tolerance testing

Treatment of Gestational Diabetes

The following may help in prevention and treatment of gestational diabetes:

• Blood sugar monitoring. Gestational diabetes can be treated through lifestyle modification. Blood sugar monitoring (one in the morning and after meals) also helps in managing blood sugar levels. An individual’s lifestyle plays an important role in maintaining their blood sugar at a normal level. The mother’s food choices and daily activities can improve or negatively affect her blood sugar. It’s important to set a pregnancy weight gain goal with the dietitian.
• Proper Nutrition. It’s important to get the daily nutrition by consuming foods that are high in nutrients such as fruits, vegetables, whole grains and lean protein. Foods that are high in fat and highly refined sugars should be avoided. A meal plan based on one’s preference, food habits and blood sugar can be of great help.
• Regular Exercise. Exercise not only relieves pregnancy discomfort but also helps a lot in lowering blood sugar. Everyday activities such as walking, doing household chores and gardening are also beneficial.
• Insulin administration. If the lifestyle modifications are inadequate then insulin injections may be incorporated in the management. Close monitoring of the baby’s condition thru ultrasounds and other diagnostics will be done throughout the pregnancy.

Nursing Care Plans for Gestational Diabetes

Diabetes is a medical condition that involves excessive glucose (sugar) levels in the blood due to the little or no production of the hormone insulin, or the presence of insulin resistance.

Despite not having a cure, diabetes can be controlled by effective medical and nursing management, as well as the patient’s strict adherence to prescribed medication, lifestyle changes, and blood sugar monitoring.

The following nursing care plans can be used to assess, plan, manage, and monitor the symptoms and effects of diabetes to a patient.

Gestational Diabetes Nursing Care Plan 1

Nursing Diagnosis: Deficient Knowledge related to new diagnosis of gestational diabetes as evidenced by patient’s verbalization of “I want to know more about my new diagnosis and care”

Desired Outcome: At the end of the health teaching session, the patient will be able to demonstrate sufficient knowledge of gestational diabetes and its management.

Gestational Diabetes Nursing Care Plan 2

Nursing Diagnosis: Fatigue related to decreased metabolic energy production as evidenced by overwhelming lack of energy, verbalization of tiredness, generalized weakness, blood sugar level of  210 mg/dL, and shortness of breath upon exertion

Desired Outcome : The patient will demonstration active participation in necessary and desired activities and demonstrate increase in activity levels.

Gestational Diabetes Nursing Care Plan 3

Risk for Imbalanced Nutrition: Less than Body Requirements

Nursing Diagnosis: Risk for Imbalanced Nutrition: Less than Body Requirements related to lack of ability to make use of nutrients appropriately secondary to gestational diabetes.

Desired Outcomes:

• The patient will express an understanding of the treatment management process and the necessity of regular self-assessment.
• The patient will attain the required fasting blood sugar levels, between 60 to 100 mg/dl, and no higher than 140 mg/dl after meals.
• The patient will increase body weight by at least 24 to 30 pounds prenatally or according to the recommended pre-pregnancy weight.
• The patient will not develop diabetic ketoacidosis and signs and symptoms such as weakness, fruity-scented breath, excessive thirst, frequent urination, confusion , and complications.

Gestational Diabetes Nursing Care Plan 4

Risk for Maternal Injury

Nursing Diagnosis: Risk for Maternal Injury related to changes in diabetic control secondary to gestational diabetes.

• The patient will maintain a normal blood sugar level.
• The patient will be free of signs and symptoms of maternal injury related to gestational diabetes.

Gestational Diabetes Nursing Care Plan 5

Risk for Fetal Injury

Nursing Diagnosis: Risk for Fetal Injury related to elevated maternal serum blood glucose levels secondary to gestational diabetes.

• The fetus will remain safe and pregnancy is maintained until it reaches maturity.
• The fetus will display a reactive normal stress test, a negative result in OCT and CST.

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020).  Nursing diagnoses handbook: An evidence-based guide to planning care . St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2022).  Nursing care plans: Diagnoses, interventions, & outcomes . St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018).  Medical-surgical nursing: Concepts for interprofessional collaborative care . St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020).  Saunders comprehensive review for the NCLEX-RN examination . St. Louis, MO: Elsevier.  Buy on Amazon

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Case study: a patient with uncontrolled type 2 diabetes and complex comorbidities whose diabetes care is managed by an advanced practice nurse.

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Geralyn Spollett; Case Study: A Patient With Uncontrolled Type 2 Diabetes and Complex Comorbidities Whose Diabetes Care Is Managed by an Advanced Practice Nurse. Diabetes Spectr 1 January 2003; 16 (1): 32–36. https://doi.org/10.2337/diaspect.16.1.32

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The specialized role of nursing in the care and education of people with diabetes has been in existence for more than 30 years. Diabetes education carried out by nurses has moved beyond the hospital bedside into a variety of health care settings. Among the disciplines involved in diabetes education, nursing has played a pivotal role in the diabetes team management concept. This was well illustrated in the Diabetes Control and Complications Trial (DCCT) by the effectiveness of nurse managers in coordinating and delivering diabetes self-management education. These nurse managers not only performed administrative tasks crucial to the outcomes of the DCCT, but also participated directly in patient care. 1  

The emergence and subsequent growth of advanced practice in nursing during the past 20 years has expanded the direct care component, incorporating aspects of both nursing and medical care while maintaining the teaching and counseling roles. Both the clinical nurse specialist (CNS) and nurse practitioner (NP) models, when applied to chronic disease management, create enhanced patient-provider relationships in which self-care education and counseling is provided within the context of disease state management. Clement 2 commented in a review of diabetes self-management education issues that unless ongoing management is part of an education program, knowledge may increase but most clinical outcomes only minimally improve. Advanced practice nurses by the very nature of their scope of practice effectively combine both education and management into their delivery of care.

Operating beyond the role of educator, advanced practice nurses holistically assess patients’ needs with the understanding of patients’ primary role in the improvement and maintenance of their own health and wellness. In conducting assessments, advanced practice nurses carefully explore patients’ medical history and perform focused physical exams. At the completion of assessments, advanced practice nurses, in conjunction with patients, identify management goals and determine appropriate plans of care. A review of patients’ self-care management skills and application/adaptation to lifestyle is incorporated in initial histories, physical exams, and plans of care.

Many advanced practice nurses (NPs, CNSs, nurse midwives, and nurse anesthetists) may prescribe and adjust medication through prescriptive authority granted to them by their state nursing regulatory body. Currently, all 50 states have some form of prescriptive authority for advanced practice nurses. 3 The ability to prescribe and adjust medication is a valuable asset in caring for individuals with diabetes. It is a crucial component in the care of people with type 1 diabetes, and it becomes increasingly important in the care of patients with type 2 diabetes who have a constellation of comorbidities, all of which must be managed for successful disease outcomes.

Many studies have documented the effectiveness of advanced practice nurses in managing common primary care issues. 4 NP care has been associated with a high level of satisfaction among health services consumers. In diabetes, the role of advanced practice nurses has significantly contributed to improved outcomes in the management of type 2 diabetes, 5 in specialized diabetes foot care programs, 6 in the management of diabetes in pregnancy, 7 and in the care of pediatric type 1 diabetic patients and their parents. 8 , 9 Furthermore, NPs have also been effective providers of diabetes care among disadvantaged urban African-American patients. 10 Primary management of these patients by NPs led to improved metabolic control regardless of whether weight loss was achieved.

The following case study illustrates the clinical role of advanced practice nurses in the management of a patient with type 2 diabetes.

A.B. is a retired 69-year-old man with a 5-year history of type 2 diabetes. Although he was diagnosed in 1997, he had symptoms indicating hyperglycemia for 2 years before diagnosis. He had fasting blood glucose records indicating values of 118–127 mg/dl, which were described to him as indicative of “borderline diabetes.” He also remembered past episodes of nocturia associated with large pasta meals and Italian pastries. At the time of initial diagnosis, he was advised to lose weight (“at least 10 lb.”), but no further action was taken.

Referred by his family physician to the diabetes specialty clinic, A.B. presents with recent weight gain, suboptimal diabetes control, and foot pain. He has been trying to lose weight and increase his exercise for the past 6 months without success. He had been started on glyburide (Diabeta), 2.5 mg every morning, but had stopped taking it because of dizziness, often accompanied by sweating and a feeling of mild agitation, in the late afternoon.

A.B. also takes atorvastatin (Lipitor), 10 mg daily, for hypercholesterolemia (elevated LDL cholesterol, low HDL cholesterol, and elevated triglycerides). He has tolerated this medication and adheres to the daily schedule. During the past 6 months, he has also taken chromium picolinate, gymnema sylvestre, and a “pancreas elixir” in an attempt to improve his diabetes control. He stopped these supplements when he did not see any positive results.

He does not test his blood glucose levels at home and expresses doubt that this procedure would help him improve his diabetes control. “What would knowing the numbers do for me?,” he asks. “The doctor already knows the sugars are high.”

A.B. states that he has “never been sick a day in my life.” He recently sold his business and has become very active in a variety of volunteer organizations. He lives with his wife of 48 years and has two married children. Although both his mother and father had type 2 diabetes, A.B. has limited knowledge regarding diabetes self-care management and states that he does not understand why he has diabetes since he never eats sugar. In the past, his wife has encouraged him to treat his diabetes with herbal remedies and weight-loss supplements, and she frequently scans the Internet for the latest diabetes remedies.

During the past year, A.B. has gained 22 lb. Since retiring, he has been more physically active, playing golf once a week and gardening, but he has been unable to lose more than 2–3 lb. He has never seen a dietitian and has not been instructed in self-monitoring of blood glucose (SMBG).

A.B.’s diet history reveals excessive carbohydrate intake in the form of bread and pasta. His normal dinners consist of 2 cups of cooked pasta with homemade sauce and three to four slices of Italian bread. During the day, he often has “a slice or two” of bread with butter or olive oil. He also eats eight to ten pieces of fresh fruit per day at meals and as snacks. He prefers chicken and fish, but it is usually served with a tomato or cream sauce accompanied by pasta. His wife has offered to make him plain grilled meats, but he finds them “tasteless.” He drinks 8 oz. of red wine with dinner each evening. He stopped smoking more than 10 years ago, he reports, “when the cost of cigarettes topped a buck-fifty.”

The medical documents that A.B. brings to this appointment indicate that his hemoglobin A 1c (A1C) has never been <8%. His blood pressure has been measured at 150/70, 148/92, and 166/88 mmHg on separate occasions during the past year at the local senior center screening clinic. Although he was told that his blood pressure was “up a little,” he was not aware of the need to keep his blood pressure ≤130/80 mmHg for both cardiovascular and renal health. 11  

A.B. has never had a foot exam as part of his primary care exams, nor has he been instructed in preventive foot care. However, his medical records also indicate that he has had no surgeries or hospitalizations, his immunizations are up to date, and, in general, he has been remarkably healthy for many years.

Physical Exam

A physical examination reveals the following:

Weight: 178 lb; height: 5′2″; body mass index (BMI): 32.6 kg/m 2

Fasting capillary glucose: 166 mg/dl

Blood pressure: lying, right arm 154/96 mmHg; sitting, right arm 140/90 mmHg

Pulse: 88 bpm; respirations 20 per minute

Eyes: corrective lenses, pupils equal and reactive to light and accommodation, Fundi-clear, no arteriolovenous nicking, no retinopathy

Thyroid: nonpalpable

Lungs: clear to auscultation

Heart: Rate and rhythm regular, no murmurs or gallops

Vascular assessment: no carotid bruits; femoral, popliteal, and dorsalis pedis pulses 2+ bilaterally

Neurological assessment: diminished vibratory sense to the forefoot, absent ankle reflexes, monofilament (5.07 Semmes-Weinstein) felt only above the ankle

Lab Results

Results of laboratory tests (drawn 5 days before the office visit) are as follows:

Glucose (fasting): 178 mg/dl (normal range: 65–109 mg/dl)

Creatinine: 1.0 mg/dl (normal range: 0.5–1.4 mg/dl)

Blood urea nitrogen: 18 mg/dl (normal range: 7–30 mg/dl)

Sodium: 141 mg/dl (normal range: 135–146 mg/dl)

Potassium: 4.3 mg/dl (normal range: 3.5–5.3 mg/dl)

Lipid panel

    • Total cholesterol: 162 mg/dl (normal: <200 mg/dl)

    • HDL cholesterol: 43 mg/dl (normal: ≥40 mg/dl)

    • LDL cholesterol (calculated): 84 mg/dl (normal: <100 mg/dl)

    • Triglycerides: 177 mg/dl (normal: <150 mg/dl)

    • Cholesterol-to-HDL ratio: 3.8 (normal: <5.0)

AST: 14 IU/l (normal: 0–40 IU/l)

ALT: 19 IU/l (normal: 5–40 IU/l)

Alkaline phosphotase: 56 IU/l (normal: 35–125 IU/l)

A1C: 8.1% (normal: 4–6%)

Urine microalbumin: 45 mg (normal: <30 mg)

Based on A.B.’s medical history, records, physical exam, and lab results, he is assessed as follows:

Uncontrolled type 2 diabetes (A1C >7%)

Obesity (BMI 32.4 kg/m 2 )

Hyperlipidemia (controlled with atorvastatin)

Peripheral neuropathy (distal and symmetrical by exam)

Hypertension (by previous chart data and exam)

Elevated urine microalbumin level

Self-care management/lifestyle deficits

    • Limited exercise

    • High carbohydrate intake

    • No SMBG program

Poor understanding of diabetes

A.B. presented with uncontrolled type 2 diabetes and a complex set of comorbidities, all of which needed treatment. The first task of the NP who provided his care was to select the most pressing health care issues and prioritize his medical care to address them. Although A.B. stated that his need to lose weight was his chief reason for seeking diabetes specialty care, his elevated glucose levels and his hypertension also needed to be addressed at the initial visit.

The patient and his wife agreed that a referral to a dietitian was their first priority. A.B. acknowledged that he had little dietary information to help him achieve weight loss and that his current weight was unhealthy and “embarrassing.” He recognized that his glucose control was affected by large portions of bread and pasta and agreed to start improving dietary control by reducing his portion size by one-third during the week before his dietary consultation. Weight loss would also be an important first step in reducing his blood pressure.

The NP contacted the registered dietitian (RD) by telephone and referred the patient for a medical nutrition therapy assessment with a focus on weight loss and improved diabetes control. A.B.’s appointment was scheduled for the following week. The RD requested that during the intervening week, the patient keep a food journal recording his food intake at meals and snacks. She asked that the patient also try to estimate portion sizes.

Although his physical activity had increased since his retirement, it was fairly sporadic and weather-dependent. After further discussion, he realized that a week or more would often pass without any significant form of exercise and that most of his exercise was seasonal. Whatever weight he had lost during the summer was regained in the winter, when he was again quite sedentary.

A.B.’s wife suggested that the two of them could walk each morning after breakfast. She also felt that a treadmill at home would be the best solution for getting sufficient exercise in inclement weather. After a short discussion about the positive effect exercise can have on glucose control, the patient and his wife agreed to walk 15–20 minutes each day between 9:00 and 10:00 a.m.

A first-line medication for this patient had to be targeted to improving glucose control without contributing to weight gain. Thiazolidinediones (i.e., rosiglitizone [Avandia] or pioglitizone [Actos]) effectively address insulin resistance but have been associated with weight gain. 12 A sulfonylurea or meglitinide (i.e., repaglinide [Prandin]) can reduce postprandial elevations caused by increased carbohydrate intake, but they are also associated with some weight gain. 12 When glyburide was previously prescribed, the patient exhibited signs and symptoms of hypoglycemia (unconfirmed by SMBG). α-Glucosidase inhibitors (i.e., acarbose [Precose]) can help with postprandial hyperglycemia rise by blunting the effect of the entry of carbohydrate-related glucose into the system. However, acarbose requires slow titration, has multiple gastrointestinal (GI) side effects, and reduces A1C by only 0.5–0.9%. 13 Acarbose may be considered as a second-line therapy for A.B. but would not fully address his elevated A1C results. Metformin (Glucophage), which reduces hepatic glucose production and improves insulin resistance, is not associated with hypoglycemia and can lower A1C results by 1%. Although GI side effects can occur, they are usually self-limiting and can be further reduced by slow titration to dose efficacy. 14  

After reviewing these options and discussing the need for improved glycemic control, the NP prescribed metformin, 500 mg twice a day. Possible GI side effects and the need to avoid alcohol were of concern to A.B., but he agreed that medication was necessary and that metformin was his best option. The NP advised him to take the medication with food to reduce GI side effects.

The NP also discussed with the patient a titration schedule that increased the dosage to 1,000 mg twice a day over a 4-week period. She wrote out this plan, including a date and time for telephone contact and medication evaluation, and gave it to the patient.

During the visit, A.B. and his wife learned to use a glucose meter that features a simple two-step procedure. The patient agreed to use the meter twice a day, at breakfast and dinner, while the metformin dose was being titrated. He understood the need for glucose readings to guide the choice of medication and to evaluate the effects of his dietary changes, but he felt that it would not be “a forever thing.”

The NP reviewed glycemic goals with the patient and his wife and assisted them in deciding on initial short-term goals for weight loss, exercise, and medication. Glucose monitoring would serve as a guide and assist the patient in modifying his lifestyle.

A.B. drew the line at starting an antihypertensive medication—the angiotensin-converting enzyme (ACE) inhibitor enalapril (Vasotec), 5 mg daily. He stated that one new medication at a time was enough and that “too many medications would make a sick man out of me.” His perception of the state of his health as being represented by the number of medications prescribed for him gave the advanced practice nurse an important insight into the patient’s health belief system. The patient’s wife also believed that a “natural solution” was better than medication for treating blood pressure.

Although the use of an ACE inhibitor was indicated both by the level of hypertension and by the presence of microalbuminuria, the decision to wait until the next office visit to further evaluate the need for antihypertensive medication afforded the patient and his wife time to consider the importance of adding this pharmacotherapy. They were quite willing to read any materials that addressed the prevention of diabetes complications. However, both the patient and his wife voiced a strong desire to focus their energies on changes in food and physical activity. The NP expressed support for their decision. Because A.B. was obese, weight loss would be beneficial for many of his health issues.

Because he has a sedentary lifestyle, is >35 years old, has hypertension and peripheral neuropathy, and is being treated for hypercholestrolemia, the NP performed an electrocardiogram in the office and referred the patient for an exercise tolerance test. 11 In doing this, the NP acknowledged and respected the mutually set goals, but also provided appropriate pre-exercise screening for the patient’s protection and safety.

In her role as diabetes educator, the NP taught A.B. and his wife the importance of foot care, demonstrating to the patient his inability to feel the light touch of the monofilament. She explained that the loss of protective sensation from peripheral neuropathy means that he will need to be more vigilant in checking his feet for any skin lesions caused by poorly fitting footwear worn during exercise.

At the conclusion of the visit, the NP assured A.B. that she would share the plan of care they had developed with his primary care physician, collaborating with him and discussing the findings of any diagnostic tests and procedures. She would also work in partnership with the RD to reinforce medical nutrition therapies and improve his glucose control. In this way, the NP would facilitate the continuity of care and keep vital pathways of communication open.

Advanced practice nurses are ideally suited to play an integral role in the education and medical management of people with diabetes. 15 The combination of clinical skills and expertise in teaching and counseling enhances the delivery of care in a manner that is both cost-reducing and effective. Inherent in the role of advanced practice nurses is the understanding of shared responsibility for health care outcomes. This partnering of nurse with patient not only improves care but strengthens the patient’s role as self-manager.

Geralyn Spollett, MSN, C-ANP, CDE, is associate director and an adult nurse practitioner at the Yale Diabetes Center, Department of Endocrinology and Metabolism, at Yale University in New Haven, Conn. She is an associate editor of Diabetes Spectrum.

Note of disclosure: Ms. Spollett has received honoraria for speaking engagements from Novo Nordisk Pharmaceuticals, Inc., and Aventis and has been a paid consultant for Aventis. Both companies produce products and devices for the treatment of diabetes.

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• Published: 19 April 2024

Maternal and foetal complications of pregestational and gestational diabetes: a descriptive, retrospective cohort study

• Miriam Oros Ruiz 1 ,
• Daniel Perejón López 1 ,
• Catalina Serna Arnaiz 1 ,
• Júlia Siscart Viladegut 1 ,
• Joan Àngel Baldó 1 &
• Joaquim Sol 1  

Scientific Reports volume  14 , Article number:  9017 ( 2024 ) Cite this article

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• Endocrinology
• Health care

Gestational diabetes is characterized by hyperglycaemia diagnosed during pregnancy. Gestational and pregestational diabetes can have deleterious effects during pregnancy and perinatally. The baby's weight is frequently above average and might reach macrosomia (≥ 4 kg), which can reduce pregnancy time causing preterm births, and increase foetal-pelvic disproportion which often requires delivery by caesarean section. Foetal-pelvic disproportion due to the baby’s weight can also cause foetal distress resulting in lower Apgar scores. To analyse the association between pregestational and gestational diabetes with maternal and foetal risk. We conducted a retrospective cohort study in women pregnant between 2012 and 2018 in the region of Lleida. Regression coefficients and 95% confidence intervals (CI) were used. The multivariate analysis showed statistically significant associations between pregestational diabetes and: prematurity (OR 2.4); caesarean section (OR 1.4); moderate (OR 1.3), high (OR 3.3) and very high (OR 1.7) risk pregnancies; and birth weight ≥ 4000 g (macrosomia) (OR 1.7). In getational diabetes the multivariate analysis show significant association with: caesarean section (OR 1.5); moderate (OR 1.7), high (OR 1.7) and very high (OR 1.8) risk pregnancies and lower 1-minuto Apgar score (OR 1.5). Pregestational and gestational diabetes increase: pregnancy risk, caesarean sections, prematurity, low Apgar scores, and macrosomia.

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Introduction.

Gestational diabetes (GD) is defined by hyperglycaemia diagnosed during pregnancy 1 . Maternal factors associated with gestational diabetes are increasing, mainly: the rise of overweight and obesity in women, risks factors to develop type 2 diabetes and gestational diabetes; and the older average age of the mothers in the pregnancy of their first child.

GD is the most common pregnancy-associated disorder, with potential obstetric and perinatal consequences. Therefore, antenatal care in women with GD require hospital specialists instead of primary care health checks.

A study published in 2021 by Wdowiak et al. 2 showed that overweight of the mother before pregnancy correlates with high birth weight of the baby. This was confirmed in the review by Catalano et al. 3 . A study on hyperglycaemia and adverse pregnancy outcomes by Metzger et al., 4 which comprised data from over 23,000 women, found that the prevalence of macrosomia was 6.7%, 10.2% and 20.2% in 17,244 non-obese women without GD, 2,791 non-obese women with GD, and 935 obese women with GD, respectively. Women with obesity without GD had a 13.6% higher risk of macrosomia (defined as a birth weight of 4000 g and over) than non-obese women. Adverse pregnancy outcomes are more common in women with pregestational diabetes compared to GD, according to a systematic review by Malaza et al. Complications include cesarean section, preterm birth, congenital anomalies, pre-eclampsia, neonatal hypoglycemia, macrosomia, neonatal intensive care unit admission, stillbirth, Apgar score, large for gestational age, induction of labor, respiratory distress syndrome, and miscarriages 5 .

Insulin is an anabolic hormone that regulates foetal growth 6 , 7 . Maternal hyperglycaemia induces hyperglycaemia and hyperinsulinemia in the foetus. This stimulates anabolism and consequently the development of muscle, adipose, and connective tissue. The combination of hyperglycaemia and hyperinsulinemia cause an increase in storage of foetal fat and protein which results in macrosomia 6 .

Macrosomia is defined by a foetal weight by gestational age above the 90th percentile, or equal/over 4000 g 8 . This weight can shorten pregnancy time causing prematurity. It can also cause foetal-pelvic disproportion, which requires more caesarean sections and can result in lower Apgar scores.

The common etiological mechanism in pregestational and gestational diabetes is insulin resistance. Both cause hyperglycaemia in pregnancy and both have been associated with adverse effects in pregnancy. With this study conducted in the health region of Lleida, we aim to analyse the prevalence of pregestational and gestational diabetes, of high-risk pregnancies and of complications in the baby.

Methodology

Design and data collection.

Retrospective, cohort observational study in pregnant women between 2012 and 2018 in the health region of Lleida.

Data from women who had delivered at the hospital Arnau de Vilanova between 1-1-2012 and 31-12-2018 were obtained through the CMBD database (Minimum Data Set) of the electronic medical records database e-CAP, and from electronic prescriptions of the Catalan Health Service.

This study is part of the ILERPREGNANT project. The main objective of ILERPREGNANT is to analyse the prevalence of different conditions, therapeutic prescription and pharmacological adherence during pregnancy 9 .

Participants

Women who had delivered between 1-1-2012 and 31-12-2018. Pregnancy data are included from the date of the last period until the date of birth. As such, data from 2011 were taken into account for pregnant women with a birth date in 2012 but with a last period date in 2011. Pregnant women who do not belong to the health region of Lleida were excluded. To verify the representativity of the sample, the percentage of births studied (births registered at the University Hospital Arnau de Vilanova in Lleida) was calculated with respect to the total number of births in the health region of Lleida according to the data obtained from the Statistical Institute of Catalonia (Idescat) database (Table 1 ).

The main variable recorded was presence of gestational diabetes or previous diabetes, a dichotomous qualitative variable defined by an abnormal O'Sullivan test at weeks 24 and 28 of pregnancy (according to GEDE, 2014), verified by an Oral Glucose Tolerance test (OGT). Extraction of medical records in e-CAP with the code for gestational diabetes (ICD-10 code O24.9).

Other variables taken into account were: risk of the pregnancy; duration of the pregnancy (miscarriage, preterm, term, prolonged); caesarean section; birth weight (< 2500 g = underweight, between 2500 g and 3999 g = normal weight, and ≥ 4000 g = macrosomia), 1-minute and 5-minute Apgar score; and preeclampsia 9 .

This study was approved by the Clinical Research Ethics Committee (CREC) of the Institut de Recerca IDIAP Jordi Gol (code 19/194-P). It follows the tenets of the Declaration of Helsinki. The information was extracted from centralized medical files in the e-CAP database by the Health Research and Assessment Management Department. Informed consent from participants was not needed. The variables in the e-CAP database were processed anonymously and with all the guarantees of confidentiality established by the National Law and Regulation 2016/679 of the European Parliament and Council on the protection of individuals with regard to the use of personal information. The need of Informed consent was waived by “Idiap Jordi Gol i Gurina comitè”.

Human and animal rights

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008.

Informed consent

The databases from which the data were obtained are based on opt-out presumed consent and data are anonymized. If a patient decides to opt out, their data is excluded from the database. The need of Informed consent was waived by the Clinical Research Ethics Committee (CREC) of the Institut de Recerca IDIAP Jordi Gol.

Study population

The sample consisted of 21,375 pregnant women who had given birth at the Hospital Arnau de Vilanova in Lleida between 2012 and 2018 (both included). Women who did not have a personal identification code (CIP) (n = 1625) were excluded from the group, as well as women with insufficient data in the clinical record. The final sample consisted of 17,177 patients (Fig.  1 ).

Selection process of participating pregnant women.

Characteristics of the study population

The prevalence of pregnant women with diabetes was 8.2%, 1.6% pregestational (diabetes mellitus type 1 N = 4, diabetes mellitus type 2 N = 271) and 6.6% gestational (N = 1123). A total of 87.2% pregnancies ended in term deliveries, 5.9% were preterm infants, 2.5%, prolonged pregnancies, and 4.4% ended in miscarriage. Preeclampsia occurred in 0.9% of pregnancies. Caesarean section was performed in 17.3% deliveries. Most babies (87.2%) had a normal weight at birth (2500–4000 g), 6% had low weight (< 2500 g), and 6.8% had macrosomia (> 4000 g). Low 1-min and 5-min Apgar scores (< 7) were found in 2.5% and 0.8% infants, respectively (Table 2 ).

Factors associated with diabetes during pregnancy

The following factors were associated with diabetes during pregnancy:

The proportion of caesarean sections was higher in women with gestational diabetes 25.6%) or pregestational diabetes (24%) than in women with no diabetes (16.6%). Preterm pregnancies were 7.7% in women with gestational diabetes, 12.8% in pregestational diabetes compared to 5.7% in women with no diabetes. A larger proportion of babies with a birth weight over 4000 g (macrosomia) had mothers with diabetes (8.4% gestational diabetes and 11.8% pregetational diabetes), compared to mothers with no diabetes (6.5%). The prevalence of 1-min Apgar < 7 was of 3.9% in case of mothers with gestational diabetes, 4.1% in case of pregestational diabetes and 2.4% in case of mothers without diabetes (Table 3 ).

The multivariate analysis showed statistically significant associations between pregestational diabetes and: prematurity (OR 2.4); caesarean section (OR 1.4); moderate (OR 1.3), high (OR 3.3) and very high (OR 1.7) risk pregnancies; and birth weight ≥ 4000 g (macrosomia) (OR 1.7) (Fig.  2 ). In gestational diabetes the multivariate analysis show significant association with: caesarean section (OR 1.5); moderate (OR 1.7), high (OR 1.7) and very high (OR 1.8) risk pregnancies and lower 1-minuto Apgar score (OR 1.5) (Fig.  3 ).

Multivariate analysis of pregestational diabetes and outcomes in the mother and baby.

Multivariate analysis of gestational diabetes and outcomes in the mother and baby.

In this retrospective study, prevalence of gestational and pregestational diabetes were 6.6% and 1.6%, respectively. Pregestational diabetes in pregnancy is associated with higher rates of prematurity, caesarean section and macrosomia, and gestational diabetes is associated with caesarean section, lower 1-min Apgar scores and risk of pregnancy (moderate, high and very high).

Preterm births account for 75% of neonatal mortality and almost 50% of long-term neurological morbidity 10 , 11 , 12 , 13 . In this study, the prevalence of preterm births was 8.6% in patients with diabetes compared to 5.7% in patients without diabetes. Similarly, a case–control study found a higher incidence of foetal distress, macrosomia, small for gestational age and preterm infants in mothers with GD compared to the control group 14 .

Furthermore, a meta-analysis that evaluated the effects of glucose intolerance (GI) that does not reach the criteria for gestational diabetes, observed an increase in caesarean sections, babies large for gestational age (LGA), preeclampsia, preterm births and low Apgar scores in women with GI 15 .

Regarding the increased risk of caesarean section, the Hyperglycaemia and Adverse Pregnancy Outcome (HAPO) study reported an increased risk in women with elevated glucose concentrations 4 . Analysing the characteristics and outcomes of pregnant women with gestational diabetes according to insulin sensitivity, Benhalima et al. 16 observed that patients with gestational and insulin-resistant diabetes presented higher rates of preterm births (8.5% vs. 4.7%, p = 0.030), need for induction of labour (42.7% vs. 28.1%, p < 0.001), total caesarean sections (28.7% vs. 19.4%, p = 0.00) and emergency caesarean sections (16.0% vs. 9.7%, p = 0.010) compared with women without diabetes. In the current study, the proportion of caesarean sections was also higher in women with than without diabetes (25.4% vs. 16.6%, p < 0.001).

Our data agree with the literature, although the percentage of caesarean sections varies in different studies. Moore et al. 17 analyse the cultural perception of the caesarean section and suggest that it is possible to reduce its rates. Powe et al. 18 analyse gestational diabetes in relation to insulin sensitivity, reporting a higher number of caesarean sections (33.3% vs 15.2%) in patients with impaired insulin sensitivity, even after adjusting for BMI.

Regarding Apgar scores < 7, they have been associated with gestational and pregestational diabetes 5 , 19 , 20 in various studies, and with higher rates of respiratory distress and admission to neonatal intensive care units. Preda et al. 18 reports a 1-min Apgar < 7 in 7.8% of mothers with GD compared to 0% in mothers without GD.

Other studies have also shown macrosomia as a significant adverse effect in gestational and pregestational diabetes 21 , 22 , 23 , 24 . The longitudinal Lawlor study associated diabetes with macrosomia 25 . Zeng et al. 26 corroborated the association between gestational and pregestational diabetes with macrosomia. Since they found a significant association between glycaemia one year before pregnancy and macrosomia, they proposed to perform a rapid glucose test during check-ups in women before they become pregnant. Other factors also associated with macrosomia are obesity, age of the pregnant mother, body mass index, hypertension, and smoking 8 , 27 .

Limitations

We believe that the sample obtained from a large population database has avoided a possible selection bias in this observational study. Since this is a retrospective study, some variables might not be well recorded in the medical history, i.e., socio-demographic data, and data regarding control of diabetes during pregnancy which can be related to complications, such as HbA1c or glycaemic control. It is currently unclear if current GD treatment guidelines can completely prevent long-term adverse effects. However, some studies have shown that treatment of GD based on different thresholds can reduce the incidence of macrosomia and other unfavourable perinatal outcomes 28 , 29 , 30 , 31 .

In our study, we have not differentiated the different subtypes of gestational diabetes. This is relevant, since we observe that women with high insulin resistance show worse metabolic parameters during complications of pregnancy, while the phenotype and outcomes of women with insulin-sensitive gestational diabetes are more similar to women without diabetes 16 . We believe that these clinical phenotypes may also be associated with the complications of gestational diabetes.

We have analysed the outcomes in relation to diabetes during pregnancy, however undertaking subgroup analyses, considering factors such as BMI, age, and ethnicity, could provide more detailed insights into the risks linked with gestational and pregestational diabetes.

Despite these limitations, since we have extracted a large sample from a universal health system, we believe that our data reliably reflect the complications of diabetes in our environment.

Conclusions

In conclusion, screening and diagnosis of diabetes mellitus during and before pregnancy is crucial for an appropriate management that prevents maternal and neonatal complications and reduces the chronic cardio-metabolic risk of mother and child.

Our study shows that pregestational and gestational diabetes correlate with a larger incidence of prematurity, caesarean sections, worse 1-min Apgar scores, and macrosomia.

Obesity and diabetes continue a global upward trend with negative effects on patients and society. Adhering to clinical guidelines holds significant importance for clinicians, facilitating early counseling to pregnant women concerning risk factors and requisite interventions in diabetes mellitus 32 .

Data availability

The data used in this study are only available for the participating researchers, in accordance with current European and national laws. Thus, the distribution of the data is not allowed. However, researchers from public institutions can request data from SIDIAP. Further information is available online ( https://www.sidiap.org/index.php/en/solicituds-en ).

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Acknowledgements

The authors would like to acknowledge Dr. Miquel Butí for his valuable contribution and support to design and create the data base.

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Miriam Oros Ruiz, Daniel Perejón López, Catalina Serna Arnaiz, Júlia Siscart Viladegut, Joan Àngel Baldó & Joaquim Sol

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J.S and M.S. conducted the data analysis, J.A and D.P. developed the study protocol and contributed to discussion. M.O. and M.S. wrote and edited the final manuscript.

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Correspondence to Catalina Serna Arnaiz .

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Oros Ruiz, M., Perejón López, D., Serna Arnaiz, C. et al. Maternal and foetal complications of pregestational and gestational diabetes: a descriptive, retrospective cohort study. Sci Rep 14 , 9017 (2024). https://doi.org/10.1038/s41598-024-59465-x

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Received : 11 December 2023

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Published : 19 April 2024

DOI : https://doi.org/10.1038/s41598-024-59465-x

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