School of Nursing and Midwifery Nuritinga

School of Nursing and Midwifery www.utas.edu.au/nursing-midwifery Nuritinga ELECTRONIC JOURNAL OF NURSING EDITION 12, 2013

The impact of gestational diabetes mellitus on the pregnant woman, her infant(s) and family, midwifery practice and the health care system, Graduate Diploma of Midwifery, First year School of Nursing and Midwifery University of Tasmania Abstract The incidence of gestational diabetes mellitus (GDM) is on the rise due to significant changes in demographics including maternal age, obesity and ethnicity. These changes have led to a cascade of negative short and long term impacts that affect not only the woman diagnosed with GDM, but her infant(s), family, midwifery practice and the health care system. This paper examines the impact of GDM on each of the affected parties using latest evidence based literature and research. It further looks at the affects of universal screening versus selective screening and issues surrounding non-compliance. There are many challenges that may present during pregnancy. For most women however, pregnancy progresses without complication and the woman and her unborn child remain well (Thorogood and Donaldson 2010, p. 754). The Australian Health Ministers Conference (AHMC) explain that birth is a normal but significant physiological event, and that different women have different needs in relation to pregnancy and childbirth (Australian Health Ministers Conference (AHMC) 2010, p. 13). For some women preceding issues, challenges or complications that may occur during pregnancy put the woman and her baby at risk of adverse outcomes. Thorogood and Donaldson (2010, p. 754) explain that these complications may lead to serious illness, trauma, and even death of the woman, her baby or both if not managed accordingly. It is therefore imperative that midwives are able to recognise such complications, and through working in partnership with these women, apply their knowledge and skills to help manage these challenges in accordance with hospital policy, evidence based practice, and research. Midwives have a professional, legal and ethical responsibility to act on their findings. Thorogood and Donaldson (2010, p. 754) point out that when these findings fall outside the scope of midwifery practice, midwives, still working in Nuritinga Issue 12, 2013 Page 12

partnership with the women, must consult other colleagues such as obstetricians and liaison officers, in a timely manner and work collaboratively with them to ensure that all women receive the safest quality of care. Alwan, Tuffnell and West (2011, p. 5) define GDM as any degree of glucose intolerance with onset or first recognition during pregnancy. They explain that this definition applies even if the condition continues post pregnancy and regardless of whether insulin or only diet modification is required for treatment (Alwan, Tuffnell & West 2011, p. 5). Thorogood and Donaldson (2010, p. 776) further outline that GDM encompasses any type of diabetes first diagnosed in pregnancy. For example, type one or type two diabetes recognised for the first time during antenatal screening. GDM is characterised by pancreatic b-cell function that is insufficient to meet the body s needs (Thorogood & Donaldson 2010, p. 777) and is diagnosed by routine glucose tolerance screening. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) and the Australian Diabetes in Pregnancy Society (ADIPS) suggest that screening for GDM occur as part of antenatal care between 26 and 28 weeks of gestation (Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) 2011 & Nankervis et al. 2012). Where a glucose challenge test (GCT) is performed, plasma glucose is measured one hour after either a 50g or 75g oral glucose load has been administered in a non-fasting state. RANZCOG (2011) explain that plasma levels greater than or equal to 7.8mmol/l after the 50g oral load, and greater than or equal to 8.0 mmol/l after the 75g load, are regarded as positive and the woman should undergo a full glucose tolerance test (GTT). The diagnosis of GDM is made following the GTT where a fasting plasma level is greater than or equal to 5.5mmol/l, and a two hour GTT plasma level post a 75g oral glucose load is greater than or equal to 8.0mmol/l. However, more recently research published by ADIPS suggests a slightly different criterion: with a diagnosis of GDM made following a fasting glucose of greater than or equal to 5.1mmol/l and a two hour GTT post glucose load of greater than or equal to 8.5mmol/l (Nankervis et al. 2012). Both ADIPS (Nankervis et al. 2012) and RANZCOG (2011) further recommend that women at high risk of GDM, for example Nuritinga Issue 12, 2013 Page 13

previous GDM, current obesity, or a family history of type two diabetes, be screened earlier and then repeated at 26-28 weeks gestation if the results are negative. Universal versus selective screening will be discussed in more detail once the reader is familiar with the impact GDM has on women, infants, midwives and the health care system. The Australian Institute of Health and Welfare (AIHW) report that in 2007-2008 approximately 5% (14, 400) of females aged 15-49 years who gave birth in an Australian hospital setting had been diagnosed with GDM, with more than one third of these women aged 35 years and older (Australian Institute of Health and Welfare (AIHW) 2008, p. 11). In combination with an older maternal age, Carolan (2012, p. 1) further identifies obesity and non-caucasian ethnicity as key risk factors influencing the growing prevalence of GDM in Australia. A Cochrane Systematic Review by Tieu et al. (2011) reports that other risk factors linked to GDM include the previous birth of a large baby, a family history of diabetes mellitus, weight gain and cigarette smoking. The AIHW (2010) support these findings reporting that current figures are likely to increase rapidly as obesity, ethnic diversity and older maternal age become more wide spread within the Australian population. This increase is of concern due to the adverse effects this illness has on women and their babies during pregnancy, labour, delivery and following birth which can have both short and long term consequences. GDM has a profound impact on the health and wellbeing of pregnant women. In the short term, women s health concerns associated with GDM include higher rates of hypertension (AIHW 2010, p. 15), pre-eclampsia (Coghill, Hansen & Littman 2011), preterm labour, induced labour, and an increased need for intervention at birth (AIHW 2010, p. 15 & Bewley 2011, p. 780). The long term effects include a higher risk of recurrent GDM in subsequent pregnancies and an increased risk of developing type two diabetes post pregnancy. A study by Bellamy et al. (2009) shows that women who acquire GDM in pregnancy are six times more likely to develop type 2 diabetes than women with a normoglycaemic pregnancy. Lee et al. (2007) further point out that in Australia alone, 17% of women diagnosed with GDM develop type two diabetes within ten years and up to 50% within 30 years. Stables and Rankin (2011, p. 473) discuss the seriousness of this prognosis, explaining Nuritinga Issue 12, 2013 Page 14

that deaths from cardiovascular, renal, and neuropathic diseases are much more common among those women diagnosed with type 2 diabetes. As the diagnosis of GDM is linked to many life altering health consequences it is not surprising that women affected by the illness are impacted by many changes and new responsibilities that present during the antenatal period of their pregnancy. These include treatments such as learning to manage GDM through dietary and exercise modifications, self-monitoring of blood glucose levels and the possible use of hypoglycaemic therapies (metformin) or insulin and/or rapid acting insulin analogues (Tieu et al. 2011 & National Institute for Health and Clinical Excellence (NICE) 2008). Thorogood and Donaldson (2010, p. 783) point out that a woman with GDM must become the most active member of her health care team, calling on other members, such as midwives and diabetic educators, for specific guidance and expertise to help her achieve a healthy pregnancy, labour, birth and baby. If a woman has previously had GDM in an earlier pregnancy it is essential for the midwife and health care team to ensure care begins pre conception for subsequent pregnancies (McIntyre & Flack 2004). Good glycaemic control pre-pregnancy can reduce the risks of miscarriage, congenital malformation, stillbirth and neonatal death (Bewley 2011, p. 780). Weight control is also important and women with a body mass index (BMI) greater than 35 kg/m2 should be encouraged to lose weight (Nankervis et al. 2012). However, the National Institute for Health and Clinical Excellence (NICE) recommend that women exhibiting key risk factors associated with GDM be offered advice on weight management if their BMI is greater than 27 kg/m2 (NICE 2006 & NICE 2008). Due to the large variance in recommended figures, and sensitivity of the issue, advice should only be given after contemplating each individual s circumstance. Although somewhat dated, ADIPS 1998 guidelines discuss the importance of nutrition therapy in the treatment of GDM focusing on the management of carbohydrate intake for blood glucose maintenance (Hoffman et al. 1998). These guidelines are further supported by up to date research by Tieu, Crowther and Middleton (2011, p. 4) who explain that the purpose of dietary advice is to prevent maternal hyperglycaemia when Nuritinga Issue 12, 2013 Page 15

challenged by glucose loads by re-establishing the balance between insulin secreted and the insulin resistance created through the action of placental hormones. Research by Brankston, Mitchell and Ryan (2004) and Symons and Ulbrecht (2006) show that in combination with moderate exercise, dietary modification has been found to improve blood glucose control in women with GDM. Tieu et al. (2011) explains that blood glucose monitoring is recommended to women with GDM to provide not only the health care team with a representation of glycaemic control, but to provide the woman with feedback on her progress or regression. They further discuss that where maternal hyperglycaemia cannot be controlled through dietary and exercise modifications, and blood glucose levels remain elevated, insulin is added for greater control (Tieu et al. 2011, p. 4). A Cochrane Systematic Review by Farrar, Tuffnell and West (2007) looks at continuous insulin infusions versus multiple daily injections of insulin, as well the use of oral hypoglycaemic medication such as metformin for treatment as an alternative to insulin, which showed no significant difference in primary outcomes. The woman in consultation with her obstetrician would need to discuss the best option for her based on her own personal circumstances and what hospital policy and evidence based research recommends at the time. The women s family is also greatly impacted by GDM. A study by Carolan (2012) shows that a woman relies greatly on her family, in particular, her partner to help cope with the shock of the diagnosis, come to terms with the illness, and when learning to manage GDM. This study points out that husbands and partners offered the most support by eating the same food as the woman, encouraging them to avoid overeating and by accompanying them during exercise (Carolan 2012, p. 6). Women in the study further pointed out that they relied heavily on their mothers and other family members to support them by listening and offering advice in times of confusion and uncertainty (Carolan 2012, p. 7). The study concluded that self-management of GDM was largely facilitated by the support of family members, meaning that family members must adapt to lifestyle changes and emotional challenges in order to lessen the impact of GDM on the family unit. Nuritinga Issue 12, 2013 Page 16

Langer et al. (2005, p. 1) point out that when inadequately managed, GDM results in a two to three times higher morbidity rate for women and infants. It is therefore imperative that women and their partners are educated on the short and long term impacts GDM may have on their infant. The AIHW (2010, p. 15) and Tieu et al. (2011) report that the short-term adverse effects for babies born to mothers with GDM include: increased risk of stillbirth, caesarean section, macrosomia, shoulder dystocia, respiratory distress syndrome, neonatal hypoglycaemia, jaundice, polycythaemia and hypocalcaemia. Alwan, Tuffnell and West (2011, p.6) support these findings and show evidence that macrosomia, a baby born with a birth weight greater than 4000 grams, is the most frequently reported complication of an infant affected by GDM. Further studies have shown that macrosomia alone increases the risk of caesarean section, shoulder dystocia, nerve palsies, birth trauma to the baby and even death (NICE 2008; Tieu, Crowther & Middleton 2011; Tieu et al. 2011 & Mohsin, Bauman & Jalaludin 2006). Each of these complications increases the likelihood that mother and baby will be separated at birth. Research by Alwan, Tuffnell and West (2011, p.7) confirms this, explaining that GDM infant admissions to neonatal intensive care or special care nursery settings are increasing. The AIHW (2010, p. 15) further report the longer-term effects of maternal diabetes on babies including; living with congenital anomalies arising from exposure to maternal diabetes, being at an increased risk of obesity, impaired glucose tolerance, and type two diabetes in early adulthood. A review by Fetita et al. (2007) concludes that fetal exposure to maternal diabetes will contribute significantly to the worldwide diabetes epidemic. This conclusion emphasizes the immense impact GDM has and will continue to have on not only midwives but the health care system in Australia. With a dramatic increase in key risk factors contributing to the diagnosis of GDM it is essential for health services, in particular maternity services, to develop policies that aide in the reduction of GDM and its associated complications (Carolan 2012, p. 8). GDM presents health professionals, such as midwives and diabetic educators, with distinct opportunities for education and intervention as women with GDM are closely monitored and have repeated contact with the health care system Nuritinga Issue 12, 2013 Page 17

(Carolan 2012, p. 8). Thorogood and Donaldson (2010, p. 783) explain that each woman requires regular antenatal assessment, including a GDM management plan. They further report that if the diabetes is well controlled the pregnancy should be treated as normal however, if poorly controlled and from the third trimester when women with GDM are more at risk of complication, the number of antenatal visits should increase (Thorogood & Donaldson 2010, p. 783). This in turn increases the demand for skilled midwives, requiring them to be adequately trained and up to date on best practice guidelines concerning the management and treatment of GDM. It also increases the demand on the health care system as a greater provision must also be made to accommodate for the increasing number of women with GDM and women and infants affected by long term consequences of the disease (Carolan 2012, p. 8). With this increase in demand on services, the health care system is required to respond by providing adequate trained staff, undergraduate and post graduate training, prevention programs such as public awareness campaigns, and services including space to accompany mothers and infants who present in either the antenatal or postnatal periods with GDM complications. The AIHW (2010) report that public health programs to promote awareness of risk factors and the uptake of universal screening programs can affect the number of women being diagnosed with GDM. This increasing demand costs the health care system and community an exponential amount of money. A study by Kolu et al. (2012) shows that the total mean health care costs adjusted for age, body mass index and education were 25.1% higher among women diagnosed with GDM than among women without GDM. They further explained that the cost of inpatient visits was 44% higher and neonatal intensive care unit use was 49% higher in the GDM group than among women without GDM. In a bid to reduce these costs Kolu et al. (2012) recommend that effective lifestyle counselling by primary health care providers, such as midwives, be offered as a means to reduce the increasing costs of secondary care. Midwives should also provide women with information regarding the benefits of antenatal expressing which are discussed in greater detail in literature provided by Cox (2006) and Forster et al. (2011). Nuritinga Issue 12, 2013 Page 18

For the reader to fully grasp the impact GDM has on women, infants, midwives and the health care system legal and ethical issues concerning GDM including implications of universal versus selective screening and issues around non-compliance and the effects this has on the unborn child, must also be examined. Thorogood and Donaldson (2010, p. 783) discuss the first issue of whether all pregnant women should be offered universal screening for GDM or whether selective screening should only be offered to those at high risk. Thorogood and Donaldson (2010, p. 783) question whether the cost of GDM screening outweighs its benefits? When reviewing the literature, it would appear that the benefits associated with early identification and treatment of GDM would, in the long term far out way that of the screening costs. Crowther et al. (2005), Nankervis (2012) and the International Association of Diabetes and Pregnancy Study Group (IADPSG 2010) demonstrate the efficiency of screening all pregnant women for GDM. The AIHW (2010) explain that although universal screening for GDM is recommended in Australia, no national data sources are currently available to assess the proportion of pregnant women who are being screened. They further report that changes to the diagnostic thresholds and the screening and diagnostic process may be introduced at a national level in Australia in the near future, in accordance with the published recommendations from the IADPSG (2010) (AIHW 2010). It is important to recognise that although testing for GDM is currently offered during weeks 24-28 weeks gestation, it is ultimately the woman s decision whether she wishes to be screened. If a woman chooses not to be screened, or is non-compliant in the treatment of GDM post diagnosis, then it is essential for midwives and other health care professionals to provide the mother with education and counseling on the maternal and neonatal impacts of the illness. Carolan (2012, p. 8) reports that women with GDM are likely to be receptive to counseling and interventions provided by midwives as they are generally highly motivated to behave in the fetus best interest. Once again though, it is important to acknowledge that it is the woman s decision to treat or not treat the illness. By empowering the woman with knowledge and best practice concerning her Nuritinga Issue 12, 2013 Page 19

baby s health, as well as her own health, one should see positive outcomes. If however, the woman chooses not to treat she must be made aware of the health consequences. It is important for the woman to make an informed decision based off best practice guidelines, research and studies. As population trends of older maternal age, obesity and migration from areas with higher risks of GDM increase, the number of women diagnosed with GDM in Australia is set to increase. The maternal and neonatal health impacts are critical and indicate both short and long term consequences. All women should be encouraged to test for GDM at 24-28 weeks gestation and earlier if key risk factors are identified. Husbands, partners and families play a vital role in ensuring women with GDM comply with treatment, it is therefore important that they too adapt their lifestyles to provide greater support within their family unit. As GDM has shown to significantly increase total health care costs it is imperative that midwives are up skilled to provide the best quality of care and latest knowledge concerning the illness. To further ensure the best outcome for women with GDM, it is paramount that midwives work collaboratively with other health care professionals. By empowering women with best practice knowledge, research and studies women diagnosed with GDM are able to make better informed health care decisions. Nuritinga Issue 12, 2013 Page 20

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