Improving Outcomes for the Gestational Diabetic Patient

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    The intent of this article is to share suggestions to improve the quality and safety of care delivered to the GDM patient if she presents to your practice. This perspective is from my experience as a Maternal Fetal Medicine (MFM) Registered Nurse who collaborates with patients, doctors, dieticians and healthcare workers to implement best practice interventions. It is my hope that by sharing my experience I may help primary care AC nurses learn ways to enhance their skill when working with GDM patients.

    Improving Outcomes for the Gestational Diabetic Patient

    Improving Outcomes for the Gestational Diabetic Patient

    Gestational Diabetes Mellitus (GDM) is a disease that affects many women regardless of race, culture or background. The National Institute of Health states about 5 percent of all pregnancies (approximately 200,000 cases each year) are affected with GDM. GDM is defined as glucose intolerance of varying degrees detected during pregnancy. Women with GDM are at high risk for having or developing diabetes when they are not pregnant and experience severe adverse effects on fetal and neonatal outcomes resulting in abnormally high fetal and neonatal mortality. Infants born to GDM mothers have a significantly higher risk of Neonatal Intensive Care Unit (NICU) admission, longer hospital stay and higher rates of hypoglycemia (Al-Khalifah, Al-Subaihin,Al-Kharfi, Al-Alaiyan, Alfaleh, 2012). The diagnosis of GDM can be overwhelming causing feelings of uncertainty, confusion, fear and possibly anger.

    GDM is a Manageable Disease

    Diabetes self-management education is a collaborative process that will enable patients to learn the tools to successfully manage the disease (Burke, Sherr, Lipman, 2014). With ongoing contact between the GDM patient during pregnancy, the ambulatory care (AC) nurse has the opportunity to use critical thinking skills to assess and also guide the patient to implement self-management skills promoting the well-being of the mother and baby (Swan, Conway-Phillips, & Griffin, 2006).

    The intent of this article is to share suggestions to improve the quality and safety of care delivered to the GDM patient if she presents to your practice. This perspective is from my experience as a Maternal Fetal Medicine (MFM) Registered Nurse who collaborates with patients, doctors, dieticians and healthcare workers to implement best practice interventions. It is my hope that by sharing my experience I may help primary care AC nurses learn ways to enhance their skill when working with GDM patients.

    The Nursing Process

    Utilizing the nursing process of assessment, planning, implementing and evaluating is a good place to begin when you work with a GDM patient. Patient education empowers patients to take ownership of their disease process which leads to a positive outcome. (Burke, Sherr and Lipman, 2014). Components of education related to the GDM patient includes knowledge of the disease process, recognizing the need for careful monitoring and testing of glucose values, following important dietary recommendations, and the role medications offer in the plan of care.

    As the MFM RN, my role is to make initial contact with the GDM patient and identify where patient education should begin. Through conversation, I can identify their knowledge of GDM, discover if there has been a history of GDM in a past pregnancy and learn about the patient’s acceptance of this diagnosis. Then I can begin to explain the medical plan of care which includes testing and recording glucose levels 4 times a day, following dietary recommendations, and the importance of keeping prenatal care appointments. The need for possible ultrasounds and non-stress testing ( NST) as determined by the provider is also discussed. During the initial contact with the patient, there is a free booklet that can be downloaded from the CDC website covers key points about GDM (CDC, 2015), that I often provide as a resource.

    Patients continue routine prenatal care with their primary obstetrician (OB) and meet with a registered dietician for in-depth nutrition education. The MFM provider also follows the patient for the duration of the pregnancy and will evaluate the patient compliance with the plan of care by evaluating glucose values and the Hemoglobin A1c (HbA1c). A normal level for an HbA1c is 6% or less. Medication therapy such as insulin or oral agents are initiated only if blood glucose levels indicate the need.

    While assisting the patient to manage their GDM, it is important to provide ongoing support. Newly diagnosed GDM patients may be fearful of the diagnosis, testing, injecting themselves, following dietary recommendations and possible outcomes of their pregnancy. Support can be provided with telephone contact, classes and during prenatal visits. Patients can have entirely different outcomes based on their participation and compliance with GDM self-management.

    Case Studies

    Patient 1 was a 34 year old African American (AA) female, Gravida 11 Para 8 who presented early in her pregnancy to her primary OB with an elevated Body Mass Index (BMI) above 25. A 1 hour glucose tolerance test (Gtt) performed during this initial visit was elevated as was the subsequent 3 hour Gtt., thus the provider recommended enrolling Patient I in the GDM program. The primary care AC nurse contacted the patient to schedule appointments with the dietician and the MFM nurse and ordered diabetic supplies (DM supplies).

    The purpose of my initial visit with the patient is to assess and review the GDM plan of care. This includes checking blood sugars 4 times a day; a fasting upon arising, and the others performed 2 hours after breakfast, lunch and dinner. I also reinforce dietary recommendations and need for consistent prenatal care. The MFM provider recommends a fasting blood sugar range of 60-95mg/dl and a range of 95-120 mg/dl two hours after meals. Although the patient had been shown how to use the DM supplies by the AC nurse, she failed to keep her scheduled appointment with MFM or dietician and was not sharing blood sugar results. Upon contacting Patient 1 by phone, I identified fear was an impediment. She verbalized she was afraid to use the lancets to obtain blood specimens and reluctant to participate with the GDM appointments. The patient eventually agreed to a nurse visit. During the visit, I reviewed the risks associated with uncontrolled glucose levels to her and her baby, and reinforced technique for checking glucose levels. While offering her support, she was able to perform and record finger sticks that she subsequently reported for the MFM provider to review every week. She became more compliant in disease management as evidenced by an HbA1c of 5.4% prior to delivery. The efforts of the patient and her obstetrical team contributed to delivery of a viable infant.

    Patient 2 experienced a different outcome. Patient 2 was a 27 year old AA female, Gravid 6 Para 2, who also presented to her initial prenatal visit with an elevated BMI. The results of a 1 hour GTT was elevated at 257mg/dl. This value immediately identified patient as a GDM patient. She was contacted by phone and enrolled in the GDM management program. Patient 2‘s plan of care was similar to Patient 1, including need for consistent prenatal care with her primary OB, glucose monitoring 4 times a day, dietician consult, MFM consult, and would be scheduled for Non-Stress Tests (NST) after 32 weeks gestation. Patient 2 was reluctant from the beginning, did not obtain DM supplies until 1-2 weeks after first contact, and initially missed both the MFM provider and MFM nurse consult appointments. She attended her primary OB prenatal care visits and the AC nurse was able to reschedule her visit to meet with me. At her visit with me, we discussed GDM in detail. As she began to test blood glucose, the values were elevated in 400 mg/dL range and insulin administration was initiated by the MFM provider. The AC nurse continued to attempt to engage patient with creative ways to monitor and submit glucose results such as e-mail/fax call or sending through electronic medical records (EMR) with no success. Patient 2 would not report her weekly glucose levels and did not return repeated phone calls made by the AC nurse, nor did she respond to letters that were sent to her. Patient 2 failed to attend the scheduled NST’s and her routine prenatal care visits became infrequent. When she eventually presented for a routine prenatal visit at approximately 36 weeks gestation, an intrauterine fetal death was discovered). The failure of patient 2 to participate in plan of care may have contributed to the unfortunate outcome.

    GDM is Serious

    GDM is a serious diagnosis which can be managed more safely if the patient partners with the health care team. Nurses working in a variety of AC settings have the privilege and responsibility of assisting the patient with managing their diagnosis to achieve a healthy baby and pregnancy. The additional support and education offered through the duration of the pregnancy improve the confidence and skill which empowers the GDM patient to self –manage this condition. The ultimate goal is to have a healthy pregnancy and healthy baby. My hope is that this discussion will assist AC nurses to deliver safer care with the best outcome possible to the GDM patient.

    References

    Al-Khalifah, R., Al-Subaihin, T., Al-Alaiyan, S., AlFaleh, K.M. (2012). Neonatal short term
    outcomes of gestational diabetes mellitus in Saudi mothers: A retrospective cohort study.
    Journal of Clinical Neonatology, 1(1), 29-33 .

    Burke,S.D.,Sherr,D.,Lipman,R.D. (2014). Partnering with diabetes educators to improve patient
    outcomes. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy. (10)7:45-33.

    Center for Disease Control and Prevention, Diabetes and pregnancy: Gestational diabetes. Atlanta, 2015,
    September, 16. Retrieved November 10, 2015 from
    http://www.cdc.gov/pregnancy/documents/Diabetes_and_Pregnancy508.pdf

    Swan, B.A., Conway-Phillips, R. and Griffin, K.F. (2006) Demonstrating the value of the RN in
    ambulatory care. Nursing Economics, 24, 315-322.
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    About mseh1

    Mary Echols,RN,BSN,MSN Maternal Fetal Medicine Nurse Coordinator/Women's Health/Labor and Delivery

    Joined Dec '15; Posts: 2; Likes: 5.

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    5 Comments

  3. by   traumaRUs
    Very interesting topic and one of interest to reducing pre-term births which in turn reduces healthcare costs
  4. by   klone
    Great article. Another thing that I wished would be emphasized with patients in the outpatient setting is the importance of good glycemic control BEFORE conception. So many women do not realize how devastating uncontrolled DM is to a pregnancy. High blood sugar is a teratogen, same as drugs, heavy metals and some viral infections. If a woman has an A1c of greater than 11 during organogenesis, I think it's something like a 65% likelihood that her baby will have major malformations and/or miscarriage.

    I found it curious that you would call a 1-hour glucose challenge of >200 as DM - do you not follow up with a 3-hour GTT or even an A1c before calling it? What if she just had pancakes and syrup immediately before coming in and drinking 50g of glucose?

    I believe the current literature does not support doing an early 1-hour glucose challenge, but rather an A1c at entry to prenatal care as being a better diagnostic tool for identifying women who have underlying undiagnosed DM in early pregnancy.
  5. by   LibraSunCNM
    Our population of patients has such a high rate of GDM that we don't do a GCT (not sure why you are calling the 1 hour test a GTT), we do an A1C with intake labs, and then a 2 hour GTT for all patients around 25-28 weeks. For patients at high risk for GDM (BMI>30, prior hx of GDM, strong family hx of DM), we do a fasting glucose with the A1C with the intake labs. Our MFMs consider a fasting >200 or an A1C >6.7 overt, pre gestational diabetes.
  6. by   klone
    Quote from LibraSunCNM
    Our population of patients has such a high rate of GDM that we don't do a GCT (not sure why you are calling the 1 hour test a GTT), we do an A1C with intake labs, and then a 2 hour GTT for all patients around 25-28 weeks. For patients at high risk for GDM (BMI>30, prior hx of GDM, strong family hx of DM), we do a fasting glucose with the A1C with the intake labs. Our MFMs consider a fasting >200 or an A1C >6.7 overt, pre gestational diabetes.
    That's very similar to what we do. We used to do a 1-hour challenge at entry to care for "high risk" groups (which was pretty much everyone), but it was determined that there was little evidence behind this, so now we do an A1c on ALL patients at entry to care, then follow up with a 3-hour GTT if the A1c is 5.9 or greater. If it comes back 6.5 or greater, she receives a diagnosis of pre-existing DM.
  7. by   mseh1
    Thank you everyone for the responses. It's great to hear everyone is committed in their practice to providing the best delivery of care. This commitment to continue to improve the process for GDM patients will improve patient outcomes by increasing the number of healthy pregnancies and babies--something we all strive for.

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