Gestational Diabetes and Pre-eclampsia - Case Study Example

Case study on maternal health Introduction:  Judith is a case of gestational diabetes (GDM) with associated mild- preeclampsia. GDM does not occur in all women; its incident is around 4%. GDM develops as a result of over production of placental hormones. These hormones make insulin resistant to glucose. As a result symptoms of type 2 diabetes develop (Yu et al , 2004). The implication of GDM and associated pre-eclampsia are discussed in Judith’s case. The discussion begins with an overview of GDM and preeclampsia and proceeds to analysis of Judith’s case. An overview of Gestational diabetes and Pre-eclampsia: The GDM may manifest itself in following outcomes (Yu et al , 2004) : Macrosomia: The foetus gets its nutrition from mother’s blood. If it has more glucose the foetal pancreas produces large quantity of insulin to use it up. While mother may be deficient in glucose utilization, foetal insulin is normally produced. As a result it grows in size beyond the normal. The excess glucose is stored as fat. The delivery of a big baby becomes difficult and in some cases the baby has to be delivered early (preterm) Pre-eclampsia: Gestational diabetes also induces hypertension in some women. It results in swelling in feet and lower limbs or whole body and leaking of proteins in urine. There are also incidents of headaches, nausea, vomiting, abdominal pain and blurry vision. Pre-eclampsia is detected by blood pressure checks or urinalysis. Pre-eclampsia confines the women to bed rest but delivery is only solution to this problem. Hypoglycemia: The baby may become hypoglycemic immediately after birth. Since mother’s blood was high in glucose so the baby produced high levels of insulin. The levels still remain high but glucose is no longer available to use. The new born uses glucose available in the body causing hypoglycemia. Jaundice: Baby may develop jaundice if delivered preterm with immature liver. Since the bilirubin produced by breakdown of RBCs is not processed by an immature liver. Tests for gestational diabetes are OGTT or oral glucose tolerance test, a syrupy sweet liquid is to be swallowed by the patient and after that if blood glucose level is higher than normal GDM may be suspected. 150 g carbohydrates are eaten for three days and for 14 h, thereafter nothing is eaten. The blood drawn is tested for fasting glucose level. . Then 100g glucose is given to the pregnant woman and at every hour for three hours blood glucose is monitored. The blood glucose levels are high initially but as the time passes the sugar is broken down by insulin. But person deficient in insulin activity does not reduce blood glucose levels to normal (Diagnosing Diabetes, 2009). Besides GDM, Judith also needs to be monitored for prevention of severe pre-eclampsia. Women with preeclampsia develop high blood pressure, protein in the urine and swelling of the legs, hands and sometimes the entire body. There are also headaches and blurred vision. Judith has swelling or oedema in her ankles and feet. According to DeCherney (2002) lower extremity oedema is natural effect of hydrostatic compromise of lower body circulation. Upper body oedema of face, hand etc indicates first signs of preeclampsia followed by moderate rise in BP and excessive fluid retention. Others, as indicated above, relate lower body oedema also to pre-emplasia. Some women may develop swelling, headaches, blurry vision or abdominal pain if they have preeclampsia. But many women don't develop symptoms at all. That's why it's so important that pregnant women get regular prenatal care and have their blood pressure checked throughout their pregnancy. Women at upper extreme of reproductive age, obese women and those with family history are at greater risk. Other causes are multiple pregnancies and type 2 diabetes as stated earlier (Woldeselassie , 2005). Preeclampsia occurs in presence of placenta and it is resolves when placenta is removed. It is as a result of oxidative stress and giving vitamins and other anti oxidants reduce incidents of preeclampsia. The diagnosis is based on blood pressure values and protein in urine (proteinuria) Proteinuria is a late sign of pregnancy-induced hypertensive disorders but HELLP {Haemolysis, Elevated Liver enzyme levels, Low Platelet count} syndrome and eclampsia could occur in the absence of proteinuria (Woldeselassie , 2005 ) My Nursing interventions in Judith’s case: 1. Observation of Judith’s particulars and her history to assess the risk Rationale: Judith’s history to be consulted in the light of her present condition. She had multiple pregnancies children, whether she is at the upper extreme of reproductive age, obese had family history of hyper tension and diabetes. If so she is in high risk group and should be admitted in the hospital to keep her under supervision. 2. Educating for Glucose monitoring and placental disruption Rationale: Judith is to be tested for gestational diabetes by OGTT since she is suffering from ‘pin and needle’ sensation, fatigue and frequent urination. She should also be cautioned for vaginal bleeding and urinary tract infections. A diet and, exercise plan if possible should be strictly followed in her case. 3. To monitor foetal growth and maternal safety Rationale: The Doppler and AF volume tests should also be conducted on her since no one or two tests are absolute certain indicators of a condition. Though an abnormal CTG or ultrasound does indicate a cause of worry but a normal test does not always signify that every thing is fine. DeCherney & DeCherney (1999) also suggest that in cases of gestational diabetes fetal growth and assessment of AF volume is to be done. Abnormal uterine artery Doppler results increase the likelihood of pre-eclampsia six-fold despite of the limited ability to screen for pre-eclampsia (Dekker & Sibai , 2001). 4. Prepare the mother mentally for premature birth in case condition warrants so Severe pre-eclampsia may be rapidly progressive resulting in sudden deterioration in the status of both mother and foetus, so that prompt delivery is recommended regardless of the duration of gestation. Prompt delivery is clearly indicated when there is imminent eclampsia, multiorgan dysfunction, or foetal distress or when severe pre-eclampsia develops after 34 weeks ( Sibai 1996; Walling 2004). So as soon as the condition of mother is favourable for delivery, the baby should be delivered. Explanation of Interventions given in the case study: 1. DeCherney & DeCherney (1999) suggested that patients with pre-eclampsia should be admitted in the hospital. CTGs are taken twice weekly from 32-24 wks unless foetal growth restriction and maternal hypertension requires these to be taken more frequently as in Judith’s case prescribed by the obstrecian . Besides, CTGs, daily testing of foetal movements are also required in these conditions (Woldeselassie , 2005) . James et al (1999) report that a 20-40 min CTG is used for fetal surveillance. CTG with normal baseline (120-160bpm) and normal variability,>10 – 15 bpm with two or more accelerations is reassuring. One with low baseline variability and/or decelerations is abnormal as it is non- reactive. Pre-eclampsia accounts for more than 40% of pre-mature deliveries and substantially increases the risk of low birth weight. A study conducted by Xiong et al. revealed that gestation was 0.6 weeks shorter in women with severe pre-eclampsia than in normotensive women . Their study showed that preeclampsia and severe pre-eclampsia increased the risks of intra uterine growth restriction (IUGR) and low birth weight. The bloods drawn in the first interruption would be used to detect fasting and three hour glucose tests. The value of these tests for normal people are fasting sugar levels that generally run between 70-110 mg/dl. A woman has gestational diabetes when she is pregnant and has any two of these, a fasting plasma glucose of more than 105 mg/dl, a 1-hour glucose level of more than 190 mg/dl, a 2-hour glucose level of more than 165 mg/dl, or a 3-hour glucose level of more than 145 mg/dl (Diagnosing Diabetes, 2009) The blood tests are also to be conducted to find out progression of preeclampsia shown by multiorgan dysfunctions and foetal distress. The tests necessary are: Uric acid: The normotensive pregnant women show uric acid levels in the range,285± 72 micromole/L was while those with gestational hypertension (341+ 83 micro mole/l) and the pre-eclampsia (384+ 93 micro mol/L) show highly elevated levels. Xio et al., associated hyper-uricaemia and proteinuria with a higher incidents of foetal and maternal complications (as in Woldeselassie , 2005 ) Haemoglobin The maternal haemoglobin {HB} concentration and haematocrit are necessary in case of Judith as it is associated with low birth and placental weight. It may also increase frequency of prematurity and perinatal mortality besides maternal hypertension. Serial measurement of HB and hematocrit are used to monitor pregnancy at high risk of utero-placental insufficiency (Dekker & Sibai , 2001). Judith also has not got any weight in past four weeks and is hypertensive also. Platelet count: The platelet count does fall below 200x109 counts / L because of the normal maternal blood volume expansion during pregnancy. In pre-eclampsia, the platelet count falls further resulting from increased consumption and intravascular destruction (Walker, 2001). Liver enzyme: Estimation of AminTransferase (ALT) and Aspartate Amino Transferase (AST) can assess liver involvement in serum; they increase in pre-eclampsia as a result of leakage across the cell membrane (Dekker & Sibai , 2001). If liver enzymes are elevated, i.e., if the ALT >35 u/L, AST> 30 u/L and LDH (lactose dehydrogenase) is > 670 u/L a diagnosis of severe pre-eclampsia or HELLP syndrome can be concluded. Maternal blood is checked weekly for platelet count, hepatic enzymes and serum creatinin levels (Woldeselassie , 2005 ) 2. James et al (1999) emphasized a regular kick chart to be filled by the mother. The Foetal Kick chart is used to monitor foetal health. Foetus is expected to move 10 times in a 12 hr period on a ‘count to ten chart’ most mothers find it reassuring. However, sometimes these make a mother anxious since movements are difficult to feel. Fetal movements correlate well with baby’s health, how ever, these are not ultimate basis to assure child’s safety. These do not provide evidence that it reduces incident of still birth in late pregnancy 3. DeCherney et al (2002) in the third trimester BP in Supine position is higher than in recumbent position which indicates hypertension. Normal patient shows a significant drop when in supine position. It is corrected when patient is in left lateral position. 4.The midwife tells Judith to visit the unit sooner if she gets vaginal bleeding, swelling in upper part of body, face hands and also, if she is not satisfied with foetal movement as suggested to her. The reasons may be progression of preeclampsia to severe levels causing placental disruption and foetal morbidity. Conclusion: The case of Judith puts her in the category of complicated pregnancy. About her the only detail available is that she had multiple pregnancies with same partner. Whether she is obese and at late end of her reproductive cycle and whether there is any family history of hypertension and diabetes is not known. She is in her 32nd week and showing signs of GDM induced pre-emplasia which is being monitored strictly by serial blood pressure checks. She is being educated about her complications by the nurse/ midwife. She has not gained weight for past four weeks and low birth weight is an implication of pre-emplasia. She is also undergoing tests for foetal safety by CTG and kick chart. The Doppler and Amniotic Fluid (AF) volume tests should also be performed for placental health. Besides she should be put on a diet specially planned for her condition. She may have to take bed rest in case her pre-emplasia worsens. I n such cases a preterm delivery is only option for safety of baby and mother. References  DeCherney, AH, Pernoll, ML & Nathan, L 2002. Current Obstetric & Gynecologic Diagnosis & Treatment: 9th Ed, McGraw-Hill Professional DeCherney, CH & DeCherney, MJ 1999. Fetal Medicine: Basic Science and Clinical Practice, Elsevier Health Sciences Dekker G, Sibai BM. 2001. ‘Primary, Secondary and tertiary prevention of preeclampsia’. Lance, vol.; 357, pp, 209-15. Diagnosing Diabetes 2009. ‘The two primary tests and their results which combine to make the diagnosis of diabetes’ from http://www.endocrineweb.com/diabetes/diagnosis.html, [18 Mar 2009] James , M, Dracott, T, Fox, R & Read, M 1999. Obstetrics and Gynaecology: A Problem-solving Approach, by Elsevier Health Sciences Sibai BM. 1996. ‘Treatment of Hypertension in Pregnancy’. The New England Journal of Medicine. Vol. 335, no.4, pp. 257-265 Yu, W, Stjernholm, M & Munier, A 2004. What to Do When the Doctor Says It's Diabetes: The Most Important Things You Need to Know about Blood Sugar, Diet, and Exercise for Type I and Type II Diabetes, Fair Winds Walker JJ. 2000. Pre-eclampsia. Lancet, vol. 356, pp.1260-65 Walling AD 2004. ‘Management of Gestational hypertension- Pre-eclampsia’. American Family Physician. Vol.69, no.4, pp. 979-980 Woldeselassie , BH 2005. ‘Pre-eclampsia and its outcome (Maternal and Neonatal Morbidity and Mortality) in the two Referral Hospitals (Windhoek Central and Katutura), Namibia’ , MPH thesis, School of Public Health, University of the Western Cape Read More