Gestational Diabetes Mellitus (GDM): Diagnosis and Patient Education (Nursing)

00:01 So we talked about how things go up and down, so let's summarize that a little bit, make it easier to remember.

00:07 So with polycythemia, we have an increase in red blood cells, so that's in response to perhaps some of that respiratory depression and needing more oxygen.

00:16 Hypoglycemia, remember, blood sugar goes down after birth, so that happens.

00:23 We can also have a change in the temperature.

00:26 Remember that as the baby gets cold and the temperature drops because of that hypoglycemia, then we want to pay attention to what that vital sign might be.

00:37 And, finally, hypocalcemia can also result as the changes in the respiratory effort and also some of the other changes that happened during this period.

00:47 So make sure you have all those arrows going in the right direction.

00:50 So the stage has been set for all the bad things that can happen as a result of gestational diabetes, so let's think about how we make the diagnosis.

01:01 So there's actually a 2-step process to diagnose saying gestational diabetes.

01:06 So there's a screening and there's a diagnosing.

01:10 So let's start with the screening which is Step 1.

01:13 So we do this with an Oral Glucose Tolerance Test or OGTT.

01:18 It's a one hour non-fasting, so that means the person can eat pretty much their normal diet and then come in to be tested. They're given a 50 gram load of sugar.

01:29 Now, we have a standardized dosing that comes in this really not very good tasting, very sugary drink, that comes in a variety of flavors, but still not very good.

01:38 We can give the client a 50 gram load of glucose and then draw their blood an hour later.

01:44 The test is considered a positive screen if the value is above 140 mg/dL, so that's a positive screen, not a diagnosis, and this will actually identify about 80% of the clients who have gestational diabetes.

02:00 So remember that means that there can be a false-positive and a false-negative, also that happens with this test, so that's why it's called a screen.

02:09 Now if someone has a positive one hour test, then we move on to step two, to make a diagnosis.

02:17 And, this time, it's not one, it's not two, but it's a three hour test.

02:22 And it's not a 50 gram load, it's a 100 gram load. And this time the client is fasting.

02:29 So that means that the night before the test, after midnight, they shouldn't have anything to either drink expect water, and when they get up in the morning, they really shouldn't brush their teeth because there's sugar in the toothpaste, and they shouldn't have a cup of coffee; they shouldn't do anything instead come to the clinic that morning and then have a fasting blood sugar and then they will have a serum draw at hour one, at hour two, and hour three.

02:54 And if two out of those four blood draws are elevated, then that's considered diagnostic for gestational diabetes.

03:03 So how about we try an example to see if we can put that together.

03:08 So we're going to look at Mary.

03:10 So Mary presents for her 3-hour glucose tolerance test because Mary had a positive screen, so let's look at her results.

03:19 So Mary's fasting blood sugar was 110.

03:22 The one hour was 165, the two hour was 160, and the three hour was 120.

03:32 So let's look at the reference range.

03:34 Now, remember, a positive 3-hour test would mean that two of the four tests are above the normal limits, so what do you think? Is Mary positive for gestational diabetes or not? Exactly, Mary's fasting sugar is 110 which is well above the reference range of 95 and also Mary's two hour is 160 which is also above the ref range of 155.

04:07 Now the one hour was okay and the three hour was okay, but we have two values that are abnormal, so this would be considered a positive diagnostic test. Great job.

04:19 In addition to the step one and step two, we can look at what someone's blood sugar has been over the last three months.

04:27 Maybe you remember this test from your discussion of diabetes type 1 and type 2, it's called a hemoglobin A1c.

04:34 So the glucose actually sticks to the hemoglobin in the body.

04:39 It actually does this over a period of about three months, so we can actually look at the amount of glucose that's stuck to the hemoglobin and make some determinations about an average blood sugar.

04:51 So, once we measure that blood sugar, we get an A1c test result.

04:56 So you can see from this graph, we can get a percentage, 4 through 14, and it coincides with an average blood sugar, so you see those numbers on the bottom.

05:06 So someone who has an A1c of six has an average blood sugar of about 126, so see how that works? Perfect.

05:15 Okay, so we want the pregnant person's blood sugar to be around an average of a 120, we don't really want it to be higher than that, so if we look at our chart, then we can look at the A1c and figure out over the last three months has this person's blood sugar been around an average of 120 or less, or has it been more? So when you look at this chart, someone who has an A1c, that's between 5 and 6 would be desirable. See how that works? So in addition to how we screen and make a diagnosis, what else do we want to talk to the client about? Now, remember, the client is going to be pretty important in this process, because if we're able to keep that blood sugar in euglycemic state, which means a normal blood sugar, then their outcomes can be almost the same as someone who doesn't have gestational diabetes.

06:09 So we would talk to them about diagnosing and the risks, so the things we've talked about already.

06:15 We would also talk about diet and nutrition, because diet and nutrition may be all the alterations needed in order for someone to achieve that euglycemic state.

06:26 We also want to talk to them potentially about medication, so if we've tried diet and exercise and we're still having an issue with keeping that blood sugar under control, then we need to move on to medication.

06:39 And we need to talk about what could potentially happen postpartum.

06:43 If we're able to keep someone in good control during their pregnancy, there's a very good chance we can alleviate some of the risk factors for postpartum complications, and then once they're aware of their potential for developing type 2 diabetes later, then they may make some modifications even after pregnancy, to decrease those risks as well.

07:04 Now, so, if I'm a client, I want to know how I'm going to know if my blood sugar is high or low aside from just sticking my finger.

07:12 So some of these will be a review, but it's important that we talk about it again.

07:16 So feeling nervous or having a headache, feeling weak or feeling irritable.

07:22 I'm feeling irritable so maybe it's time for a little snack for me, I could be hypoglycemic.

07:28 Now, they could also feel hungry or have blurry vision or tingling extremities.

07:36 So if you've ever talked to a diabetic, sometimes they know, just because they're feeling some of these symptoms.

07:42 So those are the signs of a low blood sugar.

07:45 Let's talk about what happens when the blood sugar is elevated.

07:49 See if you remember these, polydipsia, polyphagia, polyuria, the 3Ps, they come back.

07:58 We can also add to that abdominal pain.

08:01 So, sometimes, we get all of these symptoms, sometimes it's just one, it doesn't matter, but if you've got someone with gestational diabetes and they present with any of these symptoms, we need to know what their blood sugar is, okay? Think about nausea, think about flushed, dry skin.

08:17 Think about fruity breath, so, sometimes these are going to be things that you notice when you see the client as well.