Module 5 Unit A Flashcards
What patients are eligible for selective GDM screening?
Women who are considered to be at low risk for GDM.
> 25
Not Hispanic, African American, Native American, South
or East Asian, or Pacific Islander
BMI 25 or less
No hx of abnormal glucose tolerance
No hx of adverse OB outcomes
No first degree relative with DM
What is the rationale for universal GDM screening?
90% of the population have risk factors and trying to identify 10% of women without screening is unnecessarily complex
Will identify women w/ previously undetected diabetes
When is the 50 g 1‐hour test screening test used?
It is used in early pregnancy with high risk patients.
If the results are negative, then it is repeated between 24 -28 weeks.
The test is used to test all pregnant women between 24 -28 weeks.
When is the 100 g GDM screening used?
The 3‐hour, 100 g OGTT is the common diagnostic test used in the United States when a 1‐hour screen is positive. The test is administered in the morning after an overnight fast.
When is the 75 g GDM screening used?
The one‐step method combines screening and diagnosis in one test. A 75 g oral glucose load is administered and plasma glucose levels are evaluated after 1 and 2 hours. Only one abnormal value is required for a diagnosis of GDM.
What is the GDM2 step testing approach?
The two‐step method, commonly known as the 1‐hour oral glucose tolerance test (OGTT), starts with a 50 g oral glucose load administered with plasma glucose levels evaluated after 1 hour. A positive screening result is then followed up with a 3‐hour oral glucose tolerance test for diagnosis. Screening and diagnosis occur in two separate steps. The 1‐hour OGGT is considered positive at levels exceeding 130–140 mg/dL
What is the GTM 1 step testing approach?
The one‐step method combines screening and diagnosis in one test. A 75 g oral glucose load is administered and plasma glucose levels are evaluated after 1 and 2 hours. Only one abnormal value is required for a diagnosis of GDM.
What is the threshold value for the one hour, 50 g gdm screening?
The 1‐hour OGGT is considered positive at levels exceeding 130–140 mg/dL.
What are the threshold values for a 3 hour, 100 g gdm screening?
Blood Sample National Diabetes Carpenter &
Data Group Coustan
Fasting 105 mg/dL 95 mg/dL
(5.8 mmol/L) (5.3 mmol/L)
1 hour 190 mg/dL 180 mg/dL
(10.5 mmol/L) (10.0 mmol/L)
2 hour 165 mg/dL 155 mg/dL
(9.2 mmol/L) (8.6 mmol/L)
3 hour 145 mg/dL 140 mg/dL
(8.0 mmol/L) (7.8 mmol/L)
What is the NDDG scale?
100gm glucose load
Fasting >/= 105
Postprandial 1hr >/= 190
Pp 2 hr >/= 165
Pp 3 hr >/= 145
Dx >/= 2 abnormal values
Diagnoses 3.3 %
What is the Carpenter/Coustan scale?
100gm glucose load
Fasting >/= 95
Postprandial 1hr >/= 180
Pp 2 hr >/= 155
Pp 3 hr >/= 140
Dx >/= 2 abnormal values
Diagnoses 5.1%
Why does ACOG support a 2 step testing versus one step testing?
It would increase (around 3x) the number diagnosed w/GDM w/o proven improvement in outcomes
How is GDM diagnosed in the pregnant patient?
A positive diagnosis of GDM traditionally has required that two or more threshold glucose levels on the 3‐hour test be met or exceeded. However, ACOG (2017) now states that one elevated value may be used to establish the diagnosis of GDM, noting that research evidence has demonstrated an increased risk for adverse perinatal outcomes with even one abnormal value.
What is the 1st line management of GDM?
Diet and exercise
When are diet and exercise indicated in GDM management?
If there are no OB contraindications to exercise.
When is blood sugar monitoring indicated in GDM management?
Diet diary for several weeks after dx to help assess dietary control - in conjunction w/ dietician
Fasting and 1 or 2 hour postprandial levels daily.
Record in logbook and review at prenatal visits
Fasting =95
Postprandial 1 hour =140
Postprandial 2 hour (more commonly used) =120
How many times a day should a patient monitor their blood sugar?
4
What is the fasting threshold value in patients with GDM?
95
What is the 2 hour postprandial threshold value in a patient with GDM?
120
When are medications indicated in GDM management?
When target can’t be consistently reached w/ diet and exercise
What medication is 1st line in GDM management?
Insulin
When can oral medications be used in GDM management?
If insulin cannot be safely injected or cannot be afforded.
What oral medication is preferred in GD management?
Metformin
When is fetal antenatal surveillance required in GDM management?
At 32 weeks if
On insulin – NST 2x/week
Pregestational diabetes
GDM and poor glycemic control
Pharm therapies - usually offered testing 2x/week starting at 32 wks w/ daily fetal movement counts
Diet controlled - 40 weeks
Ultrasounds 28 - 32 weeks
What are the maternal and fetal indications for induction of labor?
Diet/exercise controlled - expectant mgmt up to 40 6/7 weeks
Good control on meds - 39 0/7 - 39 6/7 weeks
What is the primary intra partum risk for a patient with GDM?
Neonatal hypoglycemia
How does the nurse midwife manage a patient with GDM during the intrapartum period?
Prolonged labor women with T1DM - often require glucose and insulin to prevent ketosis
GDM and T2DM - labor insulin requirements vary, depending on the length of maternal disease, stage of labor, antepartum glycemic control and baseline insulin resistance
The use of various insulin/glucose protocols for diet and exercise controlled GDM is controversial and lacks strong research evidence
Some recommend using ACOG’s pregestational diabetes use of IV D5W w/ insulin drip to maintain serum glucose levels of 100 mg/dL or <110 mg/dL w/ hourly blood glucose checks
ACOGs GDM 2013, 2017 and 2018 bulletins do not discuss intrapartum management of GDM
According to the Fifth International Workshop Conference on GDM - most common practice has been to monitor and treat only those GDM women who received insulin therapy antenatally
How does the nurse midwife manage a patient with TDM during the post partum period?
Not a contraindication to breastfeeding
Follow-up to assess for type 2 diabetes at 6-12 wks pp
Lifelong screening for DM recommended every 3 years
Typically, will not require any follow up in the immediate postpartum period
Once the placenta is delivered, euglycemia and resolution of the disease occurs
Optimal time to discuss reduction strategies to minimize the risk of T2DM
ADA and ACOG (2018) recommend repeat testing every 1- 3 years for women with a history of GDM.
4-12 weeks postpartum - 75g 2-hour OGTT to determine resolution
2-hour 75g OGTT postpartum results interpretation according to American Diabetic Association
*Must be confirmed by testing on a subsequent day
What are the signs and symptoms of newborn hypoglycemia?
Can be asymptomatic, especially at first
Often vague and nonspecific
Jitteriness
Cyanosis
Apnea
Weak cry, can be high-pitched
Lethargy
Limpness
Refusal to feed
What newborns are at risk for hypoglycemia?
SGA/FGR
Preterm infants
Post-term infants
Newborns who have experienced some form of distress prior to birth are at particular risk for hypoglycemia in the newborn period
Infants with mothers who have DM or GDM or received steroids
LGA
Due to a different mechanism which involves increased calorie consumption to maintain body temperature. This occurs in LGA infants whether or not the mother had DM, with the newborn’s risk increasing as birth weight increases
Sepsis, hypothermia, inborn errors of metabolism
What are the optimal timing and intervals for glucose screening in the newborn?
Feed w/in 1 hr of birth and check BG 30 min after first feed
If refeed required, recheck 1 hr later
If BG good, feed on demand at least every 2-3 hr and recheck before feeds
Blood glucose levels initially fall to a nadir approx 1-2 hrs after birth.
The physiologic low occurs approx 1-1.5 hrs after birth
Levels stabilizing at 3-4 hrs
Routine blood glucose testing of term newborns after an uncomplicated birth is not recommended
Plasma or blood glucose concentration should be measured as soon as possible (minutes, not hours) in any infant who manifests clinical signs (see “Clinical Signs”) compatible with a low blood glucose concentration (ie, the symptomatic infant).
What level of interprofessional collaboration is warranted for a newborn with hypoglycemia?
Refer to pediatrician
