Chapter 13 Gestational Diabetes Student Copy

Gestational Diabetes (GD) Case Study 13 Margaret Margaret is admitted to the high-risk perinatal unit for adjustment of her insulin. She is a gestational diabetic for the first time. Her obstetrical history includes two previous infants both over 9 pounds. She is 36 years old and is 32 weeks’ pregnant. She was placed on insulin therapy at 26 weeks’ gestation. eResource 13-1: To read the recommended guidelines for screening and care go to the National Guidelines Clearinghouse (NGC) [Pathway: guideline.gov enter “gestational diabetes” into search field.] For screening guidelines, tap to select the guideline “Screening for Gestational diabetes. . . .” or the most current listed screening guideline.] For care guidelines: tap to select the guideline “Gestational diabetes mellitus (GDM). Evidence-based nutrition practice guideline” or the most current listed guideline. Open a browser on your mobile device and go to: nlm.nih.gov to access MedlinePlus [Pathway: nlm.nih.gov select “MedlinePlus” enter “gestational hypertension” into the search field scroll down and select “gestational hypertension.”] Exercise 13-1: Multiple Choice Question Gestational diabetes was diagnosed at 24 weeks after a routine screening 1-hour glucose tolerance test (GTT) revealed a blood glucose level above: A. 130 mg/dL B. 135 mg/dL C. 140 mg/dL D. 150 mg/dL eResource 13-2: To learn more about the GTT, go to MerckMedicus on your mobile device and open the Pocket Guide to Diagnostic Tests [Pathway: Pocket Guide enter “GTT” into the search field select “GTT” to review information. Note: be sure to look at “Comments.”] Answer. Exercise 13-2: Matching Match the terms to the condition. __________ Absolute insulin deficiency that usually appears before age 30. __________ Glucose intolerance during pregnancy. __________ Hyperglycemia at levels lower than what qualifies for gestational diabetes (GD). __________ Insulin resistance or deficiency usually diagnosed after age 30. A. Type I diabetes B. Type II diabetes C. Impaired glucose tolerance D. Gestational diabetes mellitus Answer. Exercise 13-3: Multiple Choice Question Margaret’s diabetes was not noticed in her first trimester because: A. Her glucose was not routinely checked. B. She fasted before she came for her office visit. C. There was physiologically less insulin resistance. D. She consumed less glucose. Answer. Exercise 13-4: Multiple Choice Question The placental hormones in pregnancy that cause insulin resistance are: A. Human placental lactogen (hPL) and estriol. B. Progesterone and estriol. C. Progesterone and somatotropin. D. Human placental lactogen and somatotropin. Answer. Exercise 13-5: Fill-in Glucose intolerance in pregnancy is most likely to occur after the __________ week of gestation. Answer. Exercise 13-6: Multiple Choice Question eResource 13-3: To supplement patient teaching, You can provide Margaret a pamphlet from American Congress of Obstetrics and Gynecologists (ACOG) [Pathway: www.acog.org select “ACOG Patient Page” select “patient education pamphlets” enter “Diabetes and Pregnancy” select “Diabetes and Pregnancy.”] In addition, you may opt to show Margaret the March of Dimes video about gestational diabetes: bcove.me/xhnth2js The nurse understands which of the following blood glucose levels indicates an abnormal value for a 3-hour glucose tolerance test (GTT)? A. Fasting glucose of 104 B. A 1-hour glucose of 188 C. A 2-hour glucose of 163 D. A 3-hour glucose of 148 Margaret knows that regulating her insulin is of utmost importance because of the risks to herself and the fetus. Answer. Exercise 13-7: Select All That Apply Known maternal and fetal risks exposed to glucose intolerance are: Hydramnios Small for gestation age (SGA) Postdate deliveries Hypertension Fetal death Cord prolapsed Urinary tract infections (UTis) Vomiting Vaginal yeast infections Precipitous labors Neonatal respiratory distress syndrome Neonatal hyperglycemia Neonatal polycythemia Margaret’s glycosylated hemoglobin (HbA1C) level was 15% and therefore her glucose controls need to be readjusted. Answer. Exercise 13-8: Fill-in HbA1C is an average measurement of glucose over the past __________ days. eResource 13-4: To learn more about the HbA1C, Go to MerckMedicus on your mobile device and open the Pocket Guide to Diagnostic Tests [Pathway: Pocket Guide enter “HbA1C” into the search field select “HbA1C” to review information tap on the drop-down menu in the upper right corner to view content sections. Note: be sure to look at “Comments.”] Go to LabsOnline [Pathway: labtestsonline.org enter “HbA1C” into the search field select “A1c and eAG: At a Glance” to review material.] Most women such as Margaret are not candidates for oral hypoglycemics since many have teratogen effects. Insulin is usually used to maintain GD. Glyburide (Diabeta) is an antidiabetic oral medication that is sometimes used because it is a category B drug while most of the others are category C drugs. Glyburide does not cross the placenta. Not only does Margaret’s glucose need to be better controlled but a fetal surveillance schedule is set up to maintain the health of her fetus. eResource 13-5: To learn more about Diabeta, go to Epocrates online [Pathway: online.epocrates.com tap on the “Drugs” tab [Pathway: Epocrates enter “Diabeta” into the search field tap on “Diabeta” to view content scroll down to view “Adverse Reactions” and to view indications “Safety and Monitoring” as well as “Patient Education” to view precautions] or open Epocrates on your mobile device [Pathway: Epocrates enter “Diabeta” into the search field tap on “Diabeta” to view content scroll down to view “Adverse Reactions” and to view indications “Safety and Monitoring.”] Answer. Exercise 13-9: Fill-in Daily fetal movement counts are to be done now every day. Margaret should feel __________ fetal movements in 2 hours. Weekly nonstress tests (NSTs) are also scheduled to make sure there is no fetal hypoxia. eResource 13-6: Prior to setting Margaret up with the NST, you decide to provide some patient education by showing a brief video tutorial regarding NST: youtu.be/DvcDXvlCXAE Answer. Exercise 13-10: Exhibit Question The current NST done on Margaret is below. How many fetal heart accelerations are there? eResource 13-7: Let’s review how to interpret a fetal heart rate strip, Go to Fetalmonitorstrips.com [Pathway: fetalmonitorstrips.com click on “Learn more about monitor patterns and fetal distress” located at the top of the screen] or Go to Monitorart.org [Pathway: monitorart.org scroll down and select “How to interpret the fetal heart monitor tracing” from the menu on the left.] At home, blood glucose monitoring is reviewed with Margaret. Answer. Exercise 13-11: Multiple Choice Question The nurse understands that further teaching is needed when the patient states: A. “I should wash my hands before I handle the strips.” B. “I should check my glucose before I eat if I feel weak.” C. “I should keep concentrated glucose in my purse.” D. “I should wear my alert band all the time.” Margaret takes Humalog and Lantus in the morning and Humulin N at night. She rotates her injection sites and is fine with giving herself insulin. The next day before discharge the registered dietician visits Margaret and explains about carbohydrate counting. She tells Margaret to take in two to four carbohydrates per meal. eResource 13-8: To learn more about these medications, go to Epocrates online [Pathway: online.epocrates.com tap on the “Drugs” tab enter “Humalog”, and “Lantus” and “Humulin N” in the search field one at a time to view content tap on “Adult dosing” to view indications “Safety and Monitoring”, as well as “Patient Education” to view precautions.] Answer. Exercise 13-12: Multiple Choice Question Two to four carbohydrates per meal are how many grams of carbohydrate? A. 15–30 g B. 25–50 g C. 30–60 g D. 45–90 g Because Margaret’s fetus needs glucose 24/7, she needs to consume two snacks a day that are one to two carbohydrate choices. One of the most difficult times to regulate glucose is after breakfast, so Margaret is told to monitor her glucose one hour after breakfast. If it is high she should decrease her intake by one carb and increase protein. Margaret is given a diet history tool so she can record her intake and glucose levels. Margaret is discharged with a return prenatal appointment in a week. eResource 13-9: To locate more dietary teaching information for Margaret, go to the CDC [Pathway: cdc.gov enter “Gestational Nutrition Guidelines” into the search field and tap on the link to view guidelines] or University of Wisconsin Department of Medicine [Pathway: www2.medicine.wisc.edu enter “Diabetes Management Assist” into the search field tap on “Diabetes Management Assist” to view content.] Answer. Exercise 13-13: Exhibit Question In 1 week, the patient’s diet history looks like the following. Circle the meal that requires modification. The primary care practitioner (PCP) keeps a close watch on Margaret’s glucose and provides her with fetal surveillance. At 37 weeks the estimated fetal weight is approaching 10 pounds. A Cesarean birth is scheduled pending an amniocentesis for fetal lung maturity. eResource 13-10: This short video presents an overview of the process of performing and amniocentesis using ultrasound guidance: youtu.be/fvqJ4lX5I8o Answer. Exercise 13-14: Multiple Choice Question The Lecithin-sphingomyelin ratio, which indicates fetal lung maturity, is: A. 1:1 B. 1:2 C. 2:1 D. 2:3 eResource 13-11: Go to MerckMedicus on your mobile device and open the Pocket Guide to Diagnostic Tests [Pathway: Pocket Guide enter “Lecithin” into the search field select “Lecithin-sphingomyelin ratio” to review information tap on the drop-down menu in the upper right corner to view content sections. Note: be sure to look at “Comments.”] Answer. Exercise 13-15: True/False Phosphatidylglycerol (PG) presence in amniotic fluid indicates fetal lung maturity. True/False The fetal tests indicate that Margaret’s infant is mature and a Cesarean is done. The infant is 9 pounds and 13 ounces and is taken to the newborn nursery for assessment. Margaret does well postoperatively and is taken to the postpartum unit. Her glucose levels are checked for the first two days and are within normal range. No further insulin or glucose monitoring is ordered. Answer. Exercise 13-16: Multiple Choice Question The patient asks the nurse if her diabetes will return. The best answer is: A. “You are at high risk for insulin-dependent diabetes.” B. “Probably not, since you are not having more kids.” C. “Yes, in a year or so it is likely.” D. “You are high risk for latent diabetes.” eResource 13-12: To supplement patient teaching regarding prognosis, go to Epocrates online [Pathway: online.epocrates.com tap on the “Diseases” tab enter “gestational” in the search field to view content select “gestational diabetes” tap on “Followup” to view prognosis.] Answer.