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Case Study Gestational DM Lucy You are working as a registered nurse (RN) in a large women's clinic. Lucy, a 28-year-old Asian woman, arrives for her regularly scheduled obstetric appointment. She is in her 26th week of pregnancy and is a primigravida. After examining the patient, the nurse-midwife tells you to schedule Y.L. for a glucose challenge test. You review Y.L.'s chart and note she is 5 feet, 3 inches tall and weighs 143 pounds; her pre-pregnancy body mass index (BMI) was 25. Her father has type 2 diabetes mellitus (DM), and both paternal grandparents had type 2 DM. You enter the room to talk to Y.L. 

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What is the purpose of a glucose challenge test?  The glucose challenge test is done during pregnancy to screen for gestational diabetes — diabetes that develops during pregnancy. The glucose challenge test is done in two steps. First you drink a sugary solution. One hour later, your blood sugar level is measured. An oral glucose tolerance test can be used as the initial test if a women is at high risk for GDM, but the test is more likely to be used for diagnosis following abnormally high GCT results. When is a glucose challenge test performed?  Fasting is not necessary for a glucose challenge test, but if the concentration is really high then you do have to fast to do a oral glucose tolerance test. You have to fast from midnight on the day of the test. Once fasting plasma glucose level is determined, the woman should ingest 100g of oral glucose solution and then the levels are determined at 1, 2, and 3 hours. Interpret the results of Lucy's test.  After running these tests, it shows that Lucy does had gestational diabetes. Her results are all higher than normal which also shows that she is at higher risk for gestational diabetes. Lucy is diagnosed with gestational diabetes mellitus (GDM). What is GDM?  Gestational diabetes mellitus is a carbohydrate intolerance of variable severity that develops or is first recognized during pregnancy. Some women diagnosed with gestational diabetes may actually have unrecognized type 2 diabetes. GDM is also an added risk factor that a woman will develop type 2 diabetes later in life, often well after she has finished bearing children List five risk factors for GDM. Check the box next to those risk factors that Lucy has.  Overweight (BMI≥25 to 25.9) or obesity (BMI≥30) or morbidly obese (BMI≥40 or higher)-RISK FACTOR OF LUCY  Maternal age older than 25 years-RISK FACTOR OF LUCY  Previous birth outcome often associated with GDM (neonatal macrosomia, maternal hypertension, infant with unexplained congenital anomalies, previous fetal death); gestational diabetes in previous pregnancy d. History of abnormal glucose tolerance; history of diabetes in a close (firstdegree) relativeRISK FACTOR OF LUCY  Member of a high-risk ethnic group (African-American, Hispanic, or Latino, American Indian, Asian American, or Pacific Islanders)-RISK FACTOR OF LUCY What is the goal of medical nutrition therapy?  The diet should provide the calories and nutrients needed for maternal and fetal health, result in euglycemia, avoid ketosis, and promote appropriate weight gain. The goal is to promote optimal blood glucose control. Describe the usual diet used in treating GDM  Calories should be distributed in a way similar to that for preexisting diabetes. Simple sugars, found in concentrated sweets , should be eliminated from the diet. Based on a non obese pre pregnancy weight,

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an average of 30 kcal/kg/day is recommended. Calorie restriction to 25 kcal/kg each day may be recommended for women who are obese. These may be prescribed a diet with a smaller percentage of carbohydrates then that for women of normal weight to limit hyperglycemia. Carbohydrates at breakfast may be limited to 30 g during pregnancy because of increased levels of cortisol and growth hormones at that time of day. Protein foods at breakfast help satisfy early morning hunger. An evening snack is usually needed to prevent ketosis at night. Calories should be divided among three meals and at least three snacks. Why is medical nutrition therapy for a woman with GDM higher in fat and protein than for a woman who is not pregnant?  Fats provide the essential fatty acids needed for fetal brain development. Fats should be distributed as less than 33% from saturated, less than 33% from polyunsaturated, and the balance from monounsaturated sources. The normal recommended protein allowance for a woman is 0.8 g/kg of body weight/day. During pregnancy, an additional 10 g/day of protein is required for adequate fetal growth and to support metabolic changes in the mother Women with GDM cannot metabolize concentrated simple sugars without a sharp rise in blood glucose. Name five examples of simple sugars you would teach Y.L. to limit.  1. regular soda, milk  2. Candy, cake, cookies-all’s desserts in general  3. Whole-wheat pasta, beans, sweet potatoes, jams or jellies, syrup  4. Glucose, honey, fructose, corn syrup, molasses, sucrose  5. fruit, fruit juice Complex carbohydrates (CHOs) do not cause a rapid rise in blood glucose when eaten in small amounts. Identify five foods from this group.  1. Whole oats, kidney beans, black beans, wheat tortilla, lentils  2. Apples, oranges, carrots  3. Skim milk, cashews, peanuts,  4. Pearled barley, black beans, chickpeas, soy beans, peanuts  5. Grapefruit, pear, prunes Is it important that Y.L. take a calcium supplement along with her prenatal vitamins?  Adequate amounts of calcium during pregnancy are necessary to calcify fetal bones and teeth. Women of Y.L.'s age normally need 1000 mg/day of dietary calcium intake. Being pregnant does not increase the need for calcium. The dietitian will evaluate Y.L.'s normal diet. If it provides less than 1000 mg/day, the dietitian might recommend either a change in foods that Y.L. eats or a calcium supplement, whichever best suits Y.L.'s needs. Calcium can also help with her lactose intolerance and it can also help with the Ca+ loss in ketoacidosis. . Lucy is instructed to monitor her fasting blood glucose first thing in the morning and 2 hours after every meal. What are the purposes of this request?  The purpose of monitoring her fasting blood glucose first thing in the morning and 2 hours after every meal is to mainly make sure that her sugar is under control and doesn’t go abnormally higher or lower than she wants to or her body desires. If it does go abnormally higher or lower than her normal, then she would have to intervene with either medications or having something to eat. Y.L. is instructed to complete ketone testing using the first-voided urine in the morning. What is the rationale for this request?  The presence of urine ketones indicates nocturnal starvation because of inadequate food intake as a bedtime snack but can also signify the need for bedtime insulin. During pregnancy, there is an increased tendency to catabolize fat and spare amino acids and glucose for the developing fetus. There is evidence

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to suggest that elevated ketone levels might decrease psychomotor skills and lower IQ scores in the fetus. Lucy asks whether having gestational diabetes will hurt her baby. How would you respond?  The accelerated protein synthesis and the deposit of fat and glycogen in fetal tissues result in macrosomia in as many of 20% of infants of mother’s wing gestational diabetes. Strict control of mother’s blood glucose level, especially during the 3rd trimester, reduces risk of macrosomia. Infants with macrosomia are at risk for trauma during birth, including fractures of the clavicle from shoulder sytocia, cephalhematoma, and facial nerve and brachial plexus injury. The babies can have lower blood sugar and mineral levels when they are born and have jaundice when they are born. They are also at higher risk for being born prematurely and can have temporary breathing problems (RDS) because increased levels of insulin block the effect of cortisol on stimulation of lung maturation. Answer: c. “I need to stop exercising because I will need more carbohydrates.” D. “There is a risk for recurrence of GDM in the next pregnancy. Let your health care provider know that you had GDM with this pregnancy.”...