Evidence-Based Strategies for Managing Gestational Diabetes in Women With Obesity

8/13/2019 Evidence-Based Strategies for Managing Gestational Diabetes in Women With Obesity

1/11


2/11

NEEvidence-Based

Strategies forManaging

GestationalDiabetes in

Women WithObesity

Donnay Elkins, MSN, RN, FNP-C

Julie Smith Taylor, PhD,

RN, WHNP-BC


3/11

INTRODUCTIONIn the United States, an estimated one-third of women of ages

20 to 39 are obese, with a body mass index (BMI) > 30 kg/m 2

(Nodine & Hastings-Tolsma, 2012). Pregnancy complications

related to obesity include, but are not limited to, gestational di-

abetes mellitus (GDM), gestational hypertension and cesarean

surgical birth (see Box 1; Nodine & Hastings-Tolsma). Moreo-

ver, pregnant women with obesity are 1.6 times more likely todevelop pre-eclampsia, 2.5 times more likely to develop gesta-

tional hypertension and more than 8.5 times more likely to de-

velop GDM when compared with pregnant women with BMIs

< 30 kg/m2(Shirazian & Raghavan, 2009).

Even in the absence of maternal obesity, GDM during

pregnancy is associated with fetal complications, such as mac-

rosomia, miscarriage, neonatal hypoglycemia, neural tube

defects and preterm delivery (Nielsen, deCourten, & Kapur,

2012; Reece, 2008; Reece, 2010; Schneiderman, 2010; see Box

2). However, when a pregnancy is complicated by both obe-

sity and GDM, each extra kg of body weight above a BMI of

30 kg/m2 increases the risk of adverse pregnancy outcomes by6.6 percent, and each increase of 10 mg/dL in fasting plasma

glucose levels above 95 mg/dL raises the adverse outcome risk

by another 15 percent (Langer, Yogev, Most, & Xenakis, 2005).

Because of the increased maternal and fetal risks associated

with maternal obesity and GDM, the development of evidence-

based strategies (see Figure 1) for screening and management

of GDM and for timing of birth in these women will provide

a comprehensive approach needed to optimize outcomes for

both women and newborns. us, the aim of this article is to

formulate best practice guidelines for the care of women with

obesity during pregnancies complicated by GDM to reduce ad-

verse maternal and fetal outcomes.

THEORETICAL FRAMEWORKAND LITERATURE REVIEWe Health Belief Model describes how personal perceptions

about a disease and the strategies available to decrease a disease

both impact the occurrence of a disease (Rosenstock, 1966).

e Health Belief Model revolves around four perceptions

that influence a persons health behaviors: perceived serious-

ness, perceived susceptibility, perceived benefits and perceived

422 2013, AWHONN http://nwh.awhonn.org

Donnay Elkins, MSN, RN, FNP-C, is a family nurse practitioner atChair City Family Medicine in omasville, NC. Julie Smith Taylor,PhD, RN, WHNP-BC, is an associate professor and graduate coordina-tor at the University of North Carolina Wilmington School of Nursingin Wilmington, NC. e authors and planners of this activity report noconflicts of interest or relevant financial relationships. No commercialsupport was received for this learning activity. Address correspondenceto: [email protected].

ObjectivesUpon completion of this activity, the learner will

be able to:

1. Describe risks associated with gestational

diabetes mellitus (GDM) and obesity in

pregnancy.

2. Describe methods to screen for GDM.

3. Describe evidence-based strategies for man-

aging GDM in women with obesity.

Continuing Nursing Education (CNE) Credit

A total of 1contact hour may be earned as CNE

credit for reading Evidence-based Strategies for

Managing Gestational Diabetes in Women With

Obesity and for completing an online post-test

and participant feedback form.

To take the test and complete the participant

feedback form, please visit http://JournalsCNE.

awhonn.org. Certificates of completion will be

issued on receipt of the completed participant

feedback form and processing fees.

Association of Womens Health, Obstetric and

Neonatal Nurses is accredited as a provider of

continuing nursing education by the American

Nurses Credentialing Centers Commission on

Accreditation.

Accredited status does not imply endorsement by

AWHONN or ANCC of any commercial products

displayed or discussed in conjunction with an

educational activity.

AWHONN is approved by the California Board of

Registered Nursing, provide #CEP580.

Abstract:Pregnancies complicated by both obesity and gestational diabe-tes mellitus (GDM) increase the risk of maternal and fetal complications,including but not limited to gestational hypertension, cesarean surgi-cal birth, fetal macrosomia and postpartum hemorrhage. Because of theincreased maternal and fetal risks associated with maternal obesity andGDM, the development of evidence-based strategies for screening for andmanagement of GDM and for timing of birth will provide a comprehensiveapproach needed to optimize outcomes for both women and newborns.DOI: 10.1111/1751-486X.12065

Keywords: gestational diabetes | maternal obesity | pregnancy | obesity


4/11

CNE

p//J

g

October November 2013 Nursing for Womens Health 423

barriers. Perceived seriousness indicates the belief about the

severity of a particular disease. Perceived susceptibility is how

likely a person believes she is to acquire a disease. Perceived

benefits explain how a health behavior will affect the chances of

developing a disease or experiencing sequelae from a disease.

Lastly, perceived barriers are personal hindrances to adopting a

health behavior that will decrease disease (Rosenstock).

While these four perceptions influence an individuals be-

liefs about her health, these perceptions are influenced by mod-

ifying variables, cues to action and self-efficacy (Rosenstock,

1966). Variables such as culture, education, experiences and

motivation influence an individuals perceptions. Cues to ac-

tion from events or people also influence someones perception

of health beliefs. Self-efficacy determines peoples ability to do

something about their health despite their perceptions, vari-

ables or cues to action (Rosenstock).

PREVENTIONWhen preconception or early prenatal care is initiated, it may

be possible to prevent GDM completely. Exercise started be-

fore 20 weeks gestation reduces the risk of GDM development

by 46 percent (Weissgerber, Wolfe, Davies, & Mottola, 2006).

If physical activity is initiated a year before conception and is

continued consistently during the first 20 weeks of pregnancy,

the risk of developing GDM decreases by 60 percent (Weiss-

gerber et al.). Furthermore, introducing a walking regimen 3

to 4 days per week that reaches 30 percent of maximum age-

predicted heart rate for 30 minutes in conjunction with carbo-

hydrate restriction to 200 g/day has been shown to prevent the

development of GDM (Weissberger et al.).

SCREENINGScreening Schedule

Currently, there is no ideal approach to the best time to screen

for GDM (American College of Obstetricians and Gynecolo-

gists [ACOG], 2011). ACOG and the American Diabetes As-

sociation (ADA, 2011) recommend screening between 24 and

28 weeks gestation because evidence indicates that when treat-

ment is initiated at this gestational age, there are profound de-

creases in perinatal complications such as fetal death, shoulder

dystocia, bone fracture and nerve palsy (Hillier et al., 2008).

Also, physiologically this timing is most appropriate due to a

natural increase in insulin resistance starting in the second tri-

mester as a result of an increase in human placental lactogen

and other pregnancy hormones (Schneiderman, 2010). ese

higher physiologic levels of human placental lactogen result in

ever-increasing levels of insulin secretion. When the amount of

insulin secreted can no longer keep pace with the higher levels

of glucose, GDM develops.

GDM screening before 24 weeks gestation is associated

with early interventions, which decrease incidences of large-

for-gestational-age infants, APGAR scores < 7 at 5 minutes, in-

strumental vaginal deliveries and cesarean deliveries (P< 0.05;

Berg, Adlerberth, Sultan, Wennergren, & Wallin, 2006). How-

ever, the United States Preventive Services Task Force (USPSTF,

2008) reports limited evidence in the improvement of outcomes

when GDM treatment is initiated before 24 weeks gestation,

and recommends establishing decisions on a case-by-case basis,

When preconception or early prenatal

care is initiated, it may be possible toprevent GDM completely

BOX 1MATERNAL RISKS ASSOCIATEDWITH GDM AND OBESITY DURINGPREGNANCY

Gestational hypertension

Pre-eclampsia

Cesarean surgical birth

Wound infections

Thromboembolism

Source: Nodine and Hastings-Tolsma (2012).

BOX 2FETAL RISKS ASSOCIATED WITHGDM AND OBESITY DURING PREGNANCY

Neural tube defect

Heart defects

Macrosomia

Birth trauma

Preterm birth

Neonatal respiratory distress

MiscarriageIntrauterine fetal demise

Hypoglycemia

Hyperbilirubinemia

Jaundice

Sources: Kendrick (2011); Nielsen et al. (2012);

Reece (2008, 2010); Schneiderman (2010).


5/11

424 Nursing for Womens Health Volume 17 Issue 5

depending on the presence of risk factors such as increased ma-

ternal age or history of GDM in a previous pregnancy, for each

patient scenario (Scheneiderman, 2010; see Box 3). Further,

other research has demonstrated comparable outcomes when

screening occurred between 15 and 19 weeks or 24 and 28

weeks, with no differences in rates of cesarean, preterm birth,

5-minute APGAR < 7, macrosomia, presence of meconium or

neonatal intensive care unit (NICU) admissions (Kerr, 2008;

Hillier et al., 2008). In general, a possible management plan to

satisfy the spectrum is to screen all high-risk pregnant women

between 16 and 18 weeks gestation and if the

screen is negative, perform a follow-up screen-

ing at 28 weeks gestation (Serci, 2008).

Screening Method

A single, random glucose measurement should

not be used as a screening tool for GDM, because

of poor sensitivity and specificity (van Leeuwen et

al., 2011). Depending on gestation, a womans in-

sulin sensitivity naturally varies, making a random

glucose measurement unreliable (Hillier et al.,

2008). However, this screening tool can be useful

for early detection of undiagnosed type 2 diabetes

in high-risk gravida populations (Cundy, 2012).

One standard procedure of GDM screening

includes an initial screening with a nonfasting,

1-hour 50-g oral glucose tolerance test (OGTT)

followed by a fasting, 3-hour 100-g OGTT if the

1-hour OGTT is elevated (ACOG, 2011). e

exact cutoff value considered elevated for the

1-hour OGTT remains elusive and under debate.

A diagnosis of GDM is made when at least twovalues are above the normative cutoffvalues for

the 3-hour OGTT (see Box 4).

A second screening option endorsed by the

International Association of Diabetes and Preg-

nancy Study Groups (IADSPG), National Insti-

tute for Clinical Excellence (NICE) and ADA

that emerged from the Hyperglycemia and Ad-

verse Pregnancy Outcomes (HAPO) study and

the Australian Carbohydrate Intolerance Study

in Pregnant Women (ACHOIS) is the single

2-hour 75-g OGTT (ADA, 2011; Cundy, 2012;

Dennedy, O-Sullivan, & Dunne, 2010). Diagno-sis of GDM can be made with only one abnor-

mal glucose level fasting (>92 mg/dL), at 1 hour

(>180 mg/dL) or at 2 hours (>153 mg/dL) (ADA,

2011). ACOG (2011) does not currently endorse

the 2-hour OGTT method as it would predict-

ably increase health care costs.

Studies comparing the screening methods in

more than 450 pregnant women between 26 and

30 weeks gestation using both screening methods have dem-

onstrated that the 2-hour 75-g OGTT has better sensitivity at

diagnosing GDM in women with obesity and can lead to de-

creased rates of macrosomia, hypoglycemia, hyperbilirubine-

mia and stillbirth by at least 10 percent (DeSereday, Damiano,

Gonzalez, & Bennett, 2003; Hillier et al., 2008). eoretically,

improved outcomes can be attributed to more patients receiving

treatment for GDM when screened with the 2-hour 75-g OGTT

due to the lower cutoffvalues and the requirement of only one

abnormal glucose measurement for diagnosis (Sinha, 2012).

FIGURE 1EVIDENCE-BASED STRATEGIES

FOR MANAGING GDM


6/11

CNE

p//J

g


Screening Population

Because of its better sensitivity and practicality, universal screen-

ing is recommended over selective screening based on risk fac-

tors (Kendrick, 2011). In an observational study (n = 1,600),

Cosson et al. (2006) found universal screening, as compared

to selective screening, decreased the prevalence of preterm

birth, large-for-gestational-age infants, neonatal hyperglycemia,

neonatal jaundice and NICU admissions (P< 0.05) while also

decreasing rates of shoulder dystocia (5 vs. 17), neonatal hypo-

glycemia (2 vs. 26) and neonatal respiratory distress syndrome

(3 vs. 14).

MANAGEMENT OF GDMHealth Education

Health education programs about GDM management, as brief

as 10 to 30 minutes, have shown to improve maternal and neo-

natal outcomes (Elnour, El Mugammar, Jaber, Revel, & McEl-

nay, 2008). Effective teaching programs include one-on-one

conversations about diet, exercise, normal blood sugar ranges,

timing and frequency of plasma glucose self-monitoring andtreatment of abnormal results, while also supplying an educa-

tional take-home booklet filled with information about diabe-

tes in general, GDM specifically, the role of diet and exercise in

treatment and actions to take in response to hypoglycemic or

hyperglycemic episodes (Elnour et al.).

In a randomized controlled trial (n = 165), researchers

found that participants in the structured educational pro-

gram experienced improved glycemic control and statistically

significant reductions (P< 0.05) in the incidence of cesarean

deliveries, preterm birth, shoulder dystocia, macrosomia in in-

fants, neonatal hypoglycemia, neonatal respiratory distress and

neonatal hyperbilirubinemia (Elnour et al., 2008). is study

shows that providing women with quality information about

their diagnosis and disease management increases the rate of

blood glucose self-monitoring and enables patients to readily

identify hyperglycemia and hypoglycemia, which positively

influences patients engagement in their own care (Elnour et

al.). e researchers concluded that this active participation by

women in the management of their GDM results in more fa-

vorable outcomes.

Home Blood Glucose Monitoring

A continuous glucose monitoring system is optimal for the

tighter glucose control recommended with GDM (Kestila, Ek-

blad, & Ronnemaa, 2007). In a randomized controlled trial of

73 patients, 31 percent of users were prompted to self-medi-

cate abnormal glucose levels, compared with only 8 percent

of participants using traditional monitoring with fasting and

2-hour postprandial readings (Kestila, Ekblad, & Ronnemaa).

However, the traditional approach has most oen been utilized

in current practice, as no significant improvements in mater-

nal or fetal outcomes have been demonstrated with the use of

continuous glucose monitoring compared to traditional glu-

cose monitoring (Kestila, Ekblad, & Ronnemaa).

Physical Activity

In a review of the literature, Weissgerber et al. (2006) report

findings from an earlier study (Clark, ornley, Tomlinson,

Galletley, & Norman, 1998) that demonstrated a decrease in

the rate of miscarriage from 75 percent to 18 percent in obese,

previously infertile, women who participated in a 6-month

physical activity intervention. Physical activity during preg-

nancy can decrease the rate of miscarriage from 75 percent

to 18 percent in certain populations of pregnant women with

obesity (Weissgerber et al., 2006). Walking, stationary bikes,

aquatic exercise and low-impact aerobics are the activities most

recommended during pregnancy (Mottola, 2009). Davenport,Mottola, McManus, and Gratton (2008) found through a case-

control study of 30 overweight, pregnant women with GDM

that low-intensity walking 3 to 4 days per week for at least 6

weeks starting at 25 minutes/day and working up to 40 minutes/

BOX 3RISK FACTORS TO INFLUENCETIME OF GDM SCREENING

Family history of mother with diabetes mellitus

Hispanic, Asian, Native American, African Ameri-can or Pacific Islander ethnicity

History of GDM in a previous pregnancy

Hypertensive disorders in current pregnancy

Multiple gestation

Prior birth of infant weighing > 9lbs

Polycystic ovary syndrome

Source: Schneiderman (2012).

BOX 4ORAL GLUCOSE TOLERANCE TESTDIAGNOSTIC CRITERIA

Fasting > 105 mg/dL

After 1hour > 190mg/dL

After 2hours > 165mg/dL

After 3hours > 140mg/dL

Note: Two values above these cutoffs

are needed to diagnose GDM.

Source: ACOG (2011).


7/11


day lowered mean glucose levels by 11 mg/dL for the morning

fasting level, about 9 mg/dL aer breakfast, about 13 mg/dL

aer lunch and about 7 mg/dL aer dinner, with an average of

10 mg/dL throughout the four blood glucose checks per day

(P< 0.05). Walking also decreased frequency and amount of

insulin treatment, with injections only needed at breakfast and

bedtime. In a study of women ages 20 to 39, researchers deter-

mined that during any exercise program, target heart rate levels

for overweight and obese pregnant women should be 102 to

124 beats per minute (bpm) for ages 20 to 29 and 101 to 120bpm for ages 30 to 39 (Davenport, Charlesworth, Vanderspank,

Sopper, & Mottola, 2008)

Diet Modification and Education

Referral to a registered dietitian should occur simultaneously

with GDM diagnosis and, ideally, women should meet with a

registered dietitian within a week of diagnosis (National Guide-

line Clearinghouse, 2010). is early referral can prevent the

need for pharmacotherapy as treatment, and at least three visits

throughout the pregnancy can improve maternal and neona-

tal outcomes (National Guideline Clearinghouse; Rugge, King,Davis, & Schechtel, 2009). Medical nutrition therapy (MNT)

guided by an experienced registered dietitian should be a first-

line treatment for GDM because of the impact on maternal and

neonatal outcomes when initiated early in pregnancy (National

Guideline Clearinghouse; Serlin & Lash, 2009). Providing in-

dividualized MNT following the ADAs Nutrition Practice

Guidelines for GDM decreases the need for insulin, the rates of

cesarean deliveries and prevalence of large-for-gestational-age

infants (Singh & Rastogi, 2008). Guidance with regard to food

choices and nutrition appears to have a significant impact on

the overall course of disease in many patients.

Following diabetes nutrition guidelines should be recom-

mended for overweight and obese pregnant women with GDM

(Serci, 2008). However, severe caloric restrictions should be

avoided due to the higher prevalence and risk of intrauterine

growth restriction (IUGR) as well as small-for-gestational-age

infants (Catalano, 2013; Serci, 2008). At least 175 g/day of car-bohydrates should be consumed to enhance fetal brain devel-

opment and prevent maternal ketosis, but these carbohydrates

should comprise


8/11

CNE

p//J

g


In creating plans of care based on estimated fetal weight by

ultrasound, it is important to remember this method has a mar-

gin of error between 10 percent and 15 percent (Lalys, Pineau,

& Guihard-Costa, 2010). However, if macrosomia with estimat-

ed fetal weight > 4,000 g via ultrasound is suspected, delivery

should be considered between 38 and 39 weeks to reduce the

risk of shoulder dystocia from 10 percent to 1.4 percent (Me-

nato et al., 2008). If estimated fetal weight is > 4,250 g, cesarean

should be considered to decrease the likelihood of shoulderdystocia, postpartum hemorrhage, third- and fourth-degree

lacerations and maternal infections (Sela et al., 2009). Cur-

rently, research is ongoing to compare maternal and neonatal

outcomes in scheduled inductions between 38 and 39 weeks

gestation and expectant management for women with GDM

(Maso et al., 2011).

IMPLICATIONS FOR NURSESWithin the framework of the Health Belief Model, nurses can

help pregnant women with obesity understand and appreci-

ate their increased likelihood of being diagnosed with GDM.

Moreover, education and support provided by nurses duringthis very critical period may decrease or minimize any short-

term obstetric risk as well as further long-term risks, such as

metabolic syndrome and type 2 diabetes mellitus (Dennedy et

al., 2010; Kendrick, 2011).

Nurses can counsel and motivate women through sup-

port, education and compassion, by explaining the benefits of

adhering to evidence-based strategies to decrease the risk of

complications. Nurses can address womens perceived barriers

Metformin appears to be more useful than glyburide, as

metformin use is associated with fewer cesarean deliveries,

large-for-gestational-age infants and macrosomia (Silva et al.,

2010). Metformin is also associated with an increase in APGAR

scores and a decrease in premature deliveries, neonatal jaun-

dice, NICU admissions and macrosomic infants (Balani, Hyer,

Rodin, & Shehata, 2009; Begum et al., 2008).

COMBINING MODALITIESTO MANAGE GDMDietary modifications and physical activity are the mainstays

of GDM treatment for women with obesity, with the addition

of self-monitoring of glucose levels, insulin therapy and oral

antihyperglycemic agents when necessary (Landon et al., 2009;

Rugge et al., 2009). In a randomized controlled trial of 958

women, combination therapy including nutrition counseling,

dietary modifications, physical activity, self-glucose monitor-

ing, insulin therapy and oral antihyperglycemic agents pro-

duced statistically significant decreases in the prevalence of

large-for-gestational-age infants, macrosomia, shoulder dysto-cia, cesarean delivery, preterm delivery, NICU admission and

hyperbilirubinemia (Landon et al.).

BIRTH TIMINGIf a pregnant woman with GDM and obesity has experienced

good glycemic control throughout her pregnancy, there is in-

sufficient evidence and no medical indication to contradict the

recommendation against elective induction of labor before 39

weeks gestation (ACOG Committee on Practice Bulletins

Obstetrics, 2009; March of Dimes, n.d.). Expectant manage-

ment should be utilized in women with normal estimated fetal

weight, good glycemic control, reassuring antenatal testing andnormal amniotic fluid levels (Sela, Raz, & Elchalal, 2009). Aer

32 weeks gestation, non-reassuring antenatal testing or an ab-

normal fetal kick count as reported by the patient may indicate

that delivery could be considered (Seri & Evan, 2008; Sugiy-

ama, 2011). If preterm delivery is pursued, fetal lung maturity

must be assessed first, since the pulmonary system is one of the

last to complete development (Gillen-Goldstein, MacKenzie, &

Funai, 2013).

Nurses can counsel and motivate

women through support, education and

compassion, by explaining the benefits of

adhering to evidence-based strategies to

decrease the risk of complications

BOX 5FACTORS PREDICTING THE NEED FOR INSULIN IN WOMEN WITH GDM

POSITIVE INDICATORS

Family history of diabetes mellitus

Prepregnancy obesity

Several (34) abnormal values on 3-hour 100-g OGTT

Elevated HbA1c levels

NEGATIVE INDICATORS

Appropriate weight

No family history of diabetes mellitus

Only two abnormal values on 3-hour, 100-g OGTT

Source: Sapienza et al. (2010).


9/11


pregnancy in women with polycystic ovary syndrome.Journal ofObstetric and Gynaecology Research, 35(2),282286.

Berg, M, Adlerberth, A., Sultan, B., Wennergren, M., & Wallin, G.(2006). Early random capillary glucose level screening and mul-tidisciplinary antenatal teamwork to improve outcome in ges-tational diabetes mellitus. Acta Obstetricia et Gynecologica, 86,283290.

Catalano, P. (2013). Weight loss in overweight and obese preg-nant women: What is the effect on fetal growth?American Jour-nal of Obstetrics and Gynecology, 208(1), s155. doi:10.1016/j.ajog.2012.10.514

Clark, A. M., ornley, B., Tomlinson, L., Galletley, C., & Nor-man, R. J. (1998). Weight loss in obese infertile women resultsin improvement in reproductive outcome for all forms of fertil-ity treatment. Human Reproduction,13,15021505. doi:10.1093/humrep/13.6.1502

Cosson, E., Benchimol, M., Carbillon, L., Pharisien, I., Paries, J.,Valensi, P., Attali, J. R. (2006). Universal rather than selec-tive screening for gestational diabetes mellitus may improve fetaloutcomes. Diabetes Metabolism, 32, 140146.

Cundy, T. (2012). Proposed new diagnostic criteria for gestational

diabetes: A pause for thought? Diabetic Medicine, 29, 176180.doi:10.1111/j.1464-5491.2011.03407.x

Davenport, M. H., Charlesworth, S., Vanderspank, D., Sopper, M.M., & Mottola, M. F. (2008). Development and validation of ex-ercise target heart rate zones for overweight and obese pregnantwomen.Applied Physiology and Nutrition Metabolism, 33, 984989. doi:10.1139/HO8-086

Davenport, M. H., Mottola, M. F., McManus, R., & Gratton, R.(2008). A walking intervention improves capillary glucose con-trol in women with gestational diabetes mellitus: A pilot study.Applied Physiology, Nutrition and Metabolism, 33, 511517.

Dennedy, M., OSullivan, E., & Dunne, F. (2010). Screening, com-plications and treatment of gestational diabetes. Diabetes and

Primary Care, 12(6),337342.

DeSereday, M. S., Damiano, M. M., Gonzalez, C. D., & Bennet, P.H. (2003). Diagnostic criteria for gestational diabetes in relationto pregnancy outcome.Journal for Diabetes Complications, 17(3),115119.

Elnour, A. A., El Mugammar, I. T., Jaber, T., Revel, T., & McEl-nay, J. C. (2008). Pharmaceutical care of patients with gestationaldiabetes mellitus. Journal of Evaluation in Clinical Practice, 14 ,131140.

Gillen-Goldstein, J., MacKenzie, A. P., & Funai, E. F. (2013, Janu-ary 22).Assessment of fetal lung maturity. Retrieved from www.uptodate.com/contents/assessment-of-fetal-lung-maturity

Hillier, T., Vesco, K., Whitlock, E., Pettitt, D., Pedula, K., & Beil,T. (2008). Screening for gestational diabetes mellitus: Evidencesynthesis no. 60. Rockville, MD: Agency for Healthcare Researchand Quality.

Institute of Medicine National Research Council. (2009). Weightgain during pregnancy: Reexamining the guidelines. Washington,DC: e National Academies Press.

Kendrick, J. (2011). Screening and diagnosing gestational diabe-tes mellitus revisited.Journal of Perinatal and Neonatal Nursing,25(3), 226232. doi:10.1097/JPN.0b013e318222dded

to adopting these evidence-based strategies. Nurses connect

women with appropriate resources and provide vital support

to women as they modify their behaviors in efforts to decrease

adverse maternal and fetal outcomes associated with GDM.

CONCLUSIONPreventing the development of GDM in pregnant women with

obesity is the ideal scenario, and could potentially decrease the

development of adverse maternal and fetal outcomes. Targeted

interventions to increase physical activity, implement dietary

modifications and maintain appropriate pregnancy weight gain

(Institute of Medicine National Research Council, 2009; see

Box 6) would be the best strategy to decrease the likelihood of

complications. Nurses play an integral role in helping pregnant

women with obesity reduce their risk for maternal and fetal

complications of GDM.!"#

REFERENCESAkinci, B., Celtik, A., Yener, S., & Yesil, S. (2008). Is fasting glucose

level during oral glucose tolerance test an indicator of the insulinneed in gestation diabetes? Diabetes Research and Clinical Prac-tice, 82, 219225.

American College of Obstetricians and Gynecologists. (2011).Screening and diagnosis of gestational diabetes mellitus. Com-mittee Opinion No. 504. Obstetrics & Gynecology, 118, 751753.

American College of Obstetricians and Gynecologists Committeeon Practice BulletinsObstetrics. (2009). ACOG Practice Bul-letin No. 107: Induction of labor. Obstetrics & Gynecology, 114,386397.

American Diabetes Association. (2011). Standards of medical carein diabetes.Retrieved from http://care.diabetesjournals.org/con-tent/34/Supplement_1/S11.full

Balani, J., Hyer, S. L., Rodin, D. A., & Shehata, H. (2009). Preg-nancy outcomes in women with gestational diabetes treated withmetformin or insulin: A case-control study. Diabetic Medicine,26, 798802. doi:10.1111/j.1464-5491.2009.02780.x

Begum, M. R., Khanam, N. N., Quadir, E., Ferdous, J., Begum,M. S., Khan, F., & Begum, A. (2008). Prevention of gestationaldiabetes mellitus by continuing metformin therapy throughout

BOX 6INSTITUTE OF MEDICINERECOMMENDATIONS FORWEIGHT GAIN IN PREGNANCY

Prepregnancy BMI < 18.5kg/m2 : 2840pounds

Prepregnancy BMI 18.524.9kg/m2 : 2535pounds

Prepregnancy BMI 2529.9kg/m2

: 1525poundsPrepregnancy BMI 30kg/m2 : 1120pounds

Source: IOM (2009).


10/11

CNE

p//J

g


Rosenstock, I. M. (1966). Why people use health services.MilbankMemorial Fund Quarterly, 83(4), 132.

Rugge, B., King, V., Davis, E., & Schechtel, M. (2009). Gestationaldiabetes: Caring for women during and aer pregnancy. Rockville,MD: Agency for Healthcare Research and Quality.

Sapienza, A. D., Francisco, R. P., Trindale, T. C., & Zugaib, M.(2010). Factors predicting the need for insulin therapy in pa-tients with gestation diabetes mellitus. Diabetes Research andClinical Practice, 88, 8186.

Schneiderman, E. (2010). Gestational diabetes: An overview of agrowing health concern for women. Journal of Infusion Nursing,33(1), 4854.

Sela, H. Y., Raz, I., & Elchalal, U. (2009). Managing labor and de-livery of the diabetic mother. Expert Review of Obstetrics andGynecology, 4(5), 547554. Retrieved from www.medscape.com/viewarticle/712289_4

Serci, I. (2008). Diabetes in pregnancy: Dietary management.Prac-ticing Midwife, 11(6), 4351.

Seri, I., & Evans, J. (2008). Limits of viability: Definition of the grayzone.Journal of Perinatology, 28, 48. doi:10.1038/jp.2008.42

Serlin, D. C., & Lash, R. W. (2009). Diagnosis and management ofgestational diabetes mellitus.American Family Physician, 80(1),5762. Retrieved from www.aafp.org/afp/2009/0701/p57.html

Shirazian, T., & Raghavan, S. (2009). Obesity and pregnancy: Im-plications and management strategies for providers.Mount SinaiJournal of Medicine, 76, 539545.

Silva, J. C., Pacheco, C., Bizato, J., Souza, B. V., Ribeiro, T. E., &Bertini, A. M. (2010). Metformin compared with glyburide forthe management of gestational diabetes. International Journal ofGynecology and Obstetrics, 111, 3740.

Singh, S. K., & Rastogi, A. (2008). Gestational diabetes mellitus.Diabetes and Metabolic Syndrome: Clinical Research and Reviews,2, 227234.

Sinha, S. (2012, September 13). Gestational diabetes: Impact andscreening. Retrieved from www.medpagetoday.com/resource-center/glp1-type-2-diabetes/gestational-diabetes/a/34743

Sugiyama, T. (2011). Management of gestational diabetes mellitus.Journal of the Japan Medical Association, 139(10), 20892094.

United States Preventive Services Task Force (USPSTF). (2008).Screening for gestational diabetes mellitus: U.S. preventive ser-vices task force recommendation statement.Annals of InternalMedicine, 148(10), 759765.

van Leeuwen, M., Opmeer, B. C., Yilmaz, Y., Limpens, J., Serlie,M. J., & Mol, B. M. (2011). Accuracy of the random glucose testas screening test for gestational diabetes mellitus: A systematic

review. European Journal of Obstetrics and Gynecology and Re-productive Biology, 154, 130135.

Weissgerber, T. L., Wolfe, L. A., Davies, G. A. L., & Mottola, M. F.(2006). Exercise in the prevention and treatment of maternal-fetal disease: A review of literature.Applied Physiology, Nutritionand Metabolism, 31, 661674.

Kerr, M. (2008, May 13).American College of Obstetricians and Gy-necologists: Early screening of women at high risk for gestationaldiabetes recommended. Retrieved from www.medscape.com/viewarticle/574407

Kestila, K. K., Ekblad, U. U., & Ronnemaa, T. (2007). Continuousglucose monitoring versus self-monitoring of blood glucose inthe treatment of gestational diabetes mellitus. Diabetes Researchand Clinical Practice, 77, 174179.

Lalys, L., Pineau, J. C., & Guihard-Costa, A. M. (2010). Small andlarge fetuses: Identification and estimation of foetal weight atdelivery from third-trimester ultrasound data. Early Human De-velopment, 86, 753757. doi:10.1016/j.earthumdev.2010.07.014

Landon, M. B., Spong, C. Y., om. E., Carpenter, M. W., Ramin,S. M., Casey, B., Anderson, G. B. (2009). A multicenter, rand-omized trial of treatment for mild gestational diabetes. New Eng-land Journal of Medicine, 316(14),13391348.

Langer, O., Yogev, Y., Most, O., & Xenakis, E. M. (2005). Gestation-al diabetes:e consequence of not treating.American Journal ofObstetrics and Gynecology, 192, 989997.

Langer, O., Yogev, Y., Xenakis, E. M., & Brustman, L. (2005). Over-weight and obese in gestational diabetes: e impact on preg-

nancy outcome.American Journal of Obstetrics and Gynecology,192, 17681776.

March of Dimes. (n.d.) Less than 39 weeks toolkit. White Plains,NY: Author. Retrieved from www.marchofdimes.com/profes-sionals/less-than-39-weeks-toolkit.aspx

Maso, G., Alberico, S., Wiesenfield, U., Ronfani, L., Erenbourg,A., Hadar, E., Hod, M. (2011). GINEXMAL RCT: Inductionof labour versus expectant management in gestational diabetespregnancies. BMC Pregnancy and Childbirth, 11(1), 3137.

Menato, G., Bo, S., Signorile, A., Gallo, M. L., Cotrino, I., Poala,C. B., & Massobrio, M. (2008). Current management of gesta-tional diabetes mellitus. Expert Review of Obstetrics and Gynecol-ogy, 3(1), 7391. Retrieved from www.medscape.com/viewarti-

cle/568728_6

Mottola, M. F. (2009). Exercise prescription for overweight andobese women: Pregnancy and postpartum. Obstetrics and Gyne-cology Clinics of North America, 36, 301316.

National Guideline Clearinghouse. (2010, March 9). Gestationaldiabetes mellitus: Evidence-based nutrition practice guidelines.Retrieved from www.guideline.gov/content.aspx?id=14888

Nielsen, K., de Courten, M., & Kapur, A. (2012). e urgent needfor universally applicable simple screening procedures and di-agnostic criteria for gestational diabetes mellitus: Lessons fromprojects funded by the World Diabetes Foundation. GlobalHealth Action, 5, 112.

Nodine, P., & Hastings-Tolsma, M. (2012). Maternal obesity: Im-proving pregnancy outcomes. American Journal of MaternalChild Nursing, 37(2), 110115.

Reece, E. A. (2008). Obesity, diabetes, and links to congenital de-fects: A review of evidence and recommendation for interven-tion. Journal of Maternal-Fetal and Neonatal Medicine, 21(3),173180.

Reece, E. A. (2010). e fetal and maternal consequences of gesta-tional diabetes mellitus. Journal of Maternal-Fetal and NeonatalMedicine, 23(3), 199203.


11/11

CNE

http://JournalsCNEawhonnorg


Post-Test QuestionsInstructions:To receive contact hours for this learningactivity, please complete the online post-test and participant

feedback form at http://JournalsCNE.awhonn.org. CNEfor this activity is available online only; written tests submit-ted to AWHONN will notbe accepted.

1. Which of the following are the four perceptions describedby the Health Belief Model?

a. Barriers, challenges, benefits and seriousness

b. Seriousness, susceptibility, benefits and barriers

c. Susceptibility, usefulness, ability and motivation

2. When a pregnancy is complicated by both obesity andGDM, each extra kg of body weight over a BMI of 30kg/m2increases the risk of adverse pregnancy outcomes by howmuch?

a. 4.5percent

b. 6.6percent

c. 15percent

3. The risk of developing GDM decreases by how much ifphysical activity is initiated a year before conception andis consistently continued during the first 20 weeks of preg-nancy?

a. 20percent

b. 40percent

c. 60percent

4. The American College of Obstetricians and Gynecolo-gists and the American Diabetes Association recommendscreening for GDM at what point?

a. Between 20and 24weeks gestationb. Between 24and 28weeks gestation

c. Once symptoms develop

5. During the second trimester of pregnancy, levels of placen-tal lactogen increase, causing

a. A decrease in insulin resistance

b. An increase in insulin resistance

c. Stable levels of insulin secretion

6. In studies comparing GDM screening methods in morethan 450pregnant women between 26and 30weeks gesta-tion, which test was found to have better sensitivity fordiagnosing GDM in women with obesity?

a. 1-hour 50-g OGTTb. 2-hour 75-g OGTT

c. 3-hour 100-g OGTT

7. When GDM is diagnosed with the 2-hour, 75-g OGTTrather than the 3-hour 100-g OGTT, research has found:

a. Decreased rates of macrosomia and stillbirth

b. Improved glycemic control during pregnancy

c. Improved ability to predict which women will develop

type 2diabetes later in life

8. Which type of home glucose monitoring has been deter-mined by research to have the best maternal and fetaloutcomes?

a. Continuous monitoring

b. No differences in outcomes have been demonstratedin research

c. Traditional monitoring

9. Why should referral to a registered dietitian be made atthe time of GDM diagnosis?

a. It can help the woman improve her cooking skills.

b. It can help the woman lose weight.

c. It can reduce the womans risk for needing diabetesmedication as the pregnancy progresses.

10. In a 2008 case-control study of 30 overweight pregnantwomen, what exercise regimen lowered the womens meanglucose levels and decreased the frequency and amount ofinsulin needed?

a. Cycling 3to 4days per week for at least 6weeks

b. Swimming 3to 4days per week for at least 6weeks

c. Walking 3to 4days per week for at least 6weeks

11. Which of the following is true of birth timing for womenwith obesity and GDM?

a. If a woman has experienced good glycemic control

throughout her pregnancy and has no medical indica-tions, there is insufficient evidence to support induc-ing labor before 39weeks.

b. Regardless of glycemic control, inducing labor early isgenerally recommended to reduce risk for complica-tions such as shoulder dystocia.

c. Women with GDM and obesity should never beinduced because of risk of complications associatedwith induction.

12. When lifestyle modifications do not achieve desired glyce-mic control, which pharmacologic agent is the preferredfirst-line treatment for GDM in women with obesity?

a. Glyburide

b. Metformin

c. Short-acting insulin

Documents

Evidence-Based Strategies for Managing Gestational Diabetes in Women With Obesity