Research Paper on Gestational Diabetes Mellitus

Introduction

Gestational Diabetes Mellitus (GDM) refers to any degree of anomalies in the surge of glucose at the inception and during the period of pregnancy. Studies indicate that between 5 to 8 percent of pregnant women are highly susceptible to develop GDM which occurs around the 24th or 26th week of the prenatal period (Hartling et al., 2013). Diabetes may be described as a condition in which the cells of the body are unable to obtain glucose from the bloodstream efficiently. Glucose is essential for providing the body with energy that supports day to day activities. The hormone insulin is required for moving glucose from t blood into the blood cells where it is then converted into energy. Accordingly, when the movement of glucose into the cells is impeded, the blood glucose levels rises causing diabetes to develop.

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Screening and Diagnosis of GDM

During pregnancy, the placenta produces hormones which sustain the growth and development of a child. Some of the hormones may block the action of the mother's insulin, a condition that is otherwise referred to as insulin resistance. In a bid to maintain glucose levels at an optimum, the expectant mother requires double the amount of regular insulin due to the resistance. Hence, if the body is incapable of producing extra amounts of insulin, gestational diabetes is likely to develop. Once the infant is brought to life, the insulin requirements diminish, and the glucose limits return to within the recommended limits, and diabetes eventually disappears. The endocrine society (TES) and the U.S Preventive Service Task Force (USPSTF) agree that the ideal period for screening for GDM would be at 24-28 weeks while there exists insufficient evidence that supports the positive outcomes or harms of screening asymptomatic expectant women before 24 weeks (Buchanan, Xiang & Page, 2012). Conventionally, GDM has been diagnosed using a bi-lateral approach whereby the subject is given a 50-gram oral glucose solution which is subsequently followed by an hour of intravenous determination of glucose. Individuals who meet or exceed the screening threshold are then subjected to a 100 gram diagnostic OGTT (Oral Glucose Tolerance Test) that takes approximately 3-hour as the patient is requested to fast. On the other hand, screening and diagnosis of GDM may be conducted using a one-step approach where the individual is administered a 2-hour, 75-gram OGTT.

Etiology of GDM

GDM begins its manifestation during pregnancy without any substantiation of the pre-existing type 1 (TD1) or type 2 diabetes (T2D). The proliferation of gestational diabetes has demonstrated a steady surge in the past decade as it corresponds to the pervasiveness of the epidemic of T2D and obesity. In as much as GDM is expected to disappear afterwards, women who are identified to have GDM are highly susceptible to developing T2D in their latter stages of life and gestational diabetes in subsequent pregnancies. Moreover, the newborn children born of mothers determined to have GDM are at a higher danger of developing T2D in their adolescent or early childhood phase of life. Studies indicate that there are various grounds for insulin resistance and numerous metabolic anomalies are linked to the advent of different forms of diabetes. Perhaps the most reliable evidence is rooted in the fact that various kinds of diabetes share a mutual pathophysiological and pathogenesis dysregulation that is as a result of the progressive v-cell deterioration (Chen, Magliano & Zimmet, 2012). The effect of these interactions is the clinical manifestation of hyperglycemia. The monogenic type of diabetes may likewise happen at and amid the time of pregnancy while the normal variations in maturity-onset diabetes of the young (MODY) endorse the improvement of GDM. Basically, MODY alludes to any of the types of genetic diabetes that occurs because of transformations in an autosomal predominant quality which impacts insulin generation. Similarly, auto-resistant diabetes might be viewed as etiology of GDM as the auto-invulnerable markers of T1D is estimated to be in the region of 0.98 and 14 percent in ladies with GDM. Moreover, some unique factors such as race and ethnicity may contribute to the onset of GDM. Seminal studies indicate that individuals drawn from ethnic minority groups particularly those of South Asian descent present independent predictors for GDM. Further, the interaction between environmental risk and genetic factors may culminate in the development of GDM.

Antenatal, Intrapartum and Postpartum Care

The management of GDM aims at alleviating the devastating pregnancy outcomes which may ensue with the most common outcome being a cesarean section. Moreover, other consequences include preeclampsia which commonly occurs together proteinuria and gestational hypertension. Furthermore, GDM may culminate in the development of fetal complications such as fetal hypoglycemia which may be described as the condition where the glucose involvement from the mother is unsettled, and the newborn remains to be hyperinsulinaemic. Other outcomes include respiratory distress, hypocalcemia, stillbirth, and macrosomia (Ruchat & Mottola, 2013). Nonetheless, there exists limited knowledge on the quantifiable outcomes of pharmacological interventions including lifestyle outcomes against GDM using the novel benchmarks. This phenomenon may be attributed to the fact that most treatment approaches target blood glucose regulation independent from the etiology of GDM. Pregnancy-related hormonal alterations result in the augmentation of body weight and changes in fat distribution that is a typical after-pregnancy effect, and it occurs in both gestational diabetes and healthy pregnancies. This implies that fetal and placental factors cause stress on maternal metabolism due to the expected changes in mass and fat distribution. Fat deposits that may be linked to the factors above which result in gestational weight gain as evidenced by recent studies presumably due to the interactions between lifestyle behavioral patterns and environmental factors such as food quality, its availability and the impediments towards physical activity. As such, antenatal, intrapartum and postpartum care incorporates a multi-disciplinary approach that combines elements such dietary management, pharmacological interventions, blood glucose monitoring, glycemic reference targets, physical activities and self-administration of insulin.

Blood Glucose Control

Literature review indicates that the risk of macrosomia is directly proportional to rise in maternal glycemia. More specifically, the risk of macrosomia seems to increase in postprandial glucose levels. The association has been confirmed by others; this led to the recommendation by American Diabetes Association to monitor pregnancies that are complicated by diabetes. However, controversy has been brought up concerning the sole role maternal glucose in the etiology of macrosomia. Reports, however, indicate that there can be a manifestation of macrosomia despite "normoglycemia" The median blood glucose (MBG) may be obtained from not less than three preprandial and three postprandial measurements. Nonetheless, one must take into consideration the experience with blood glucose measurements which could be limited at the commencement so the findings should not serve as the singular reference for recommending therapeutic interventions (Moyer, 2014). This notion is mostly applicable in instances of insulin therapy where the glucose goals may be modified in accordance with: higher levels for fetal intrauterine growth retardation (IUGR); lower levels for disproportional fetal growth in favor of the abdomen according to the findings of the ultrasound; higher values for maternal propensity to hypoglycaemia during insulin therapy. The measurement timetable at the start involves a 4 point glucose profile where an individual is required to fast in the morning and 1-2 hours before consuming every meal. Following the diagnosis for GDM, two weeks should elapse before biometric data and measurement results are reviewed to determine whether GDM therapy should only be sustained with diet therapy or whether insulin therapy will be necessitated. If the measurements surge beyond the 50th percentile, then insulin therapy should be considered.

Glycemic Reference Targets

The primary objective of the treatment of GDM is directed towards diminishing the related risks of gestational diabetes for both the mother and the infant through the regulation of high maternal blood glucose concentrations. Conventionally, glycemic control is measure through monitoring the capillary blood glucose concentrations with the aim of ensuring that the levels are maintained within the pre-defined limits. This process may be achieved through the incorporation of lifestyle and diet modifications or pharmacological intervention such as subcutaneous insulin or hypoglycemic medication when it is deemed necessary (Bain et al., 2015). Glycemic reference target is based on the persistent relationship between the augmentation of maternal blood glucose concentration which causes injurious fetal and maternal outcomes. Hence, the treatment of GDM focuses on the maintenance of maternal blood glucose concentration by ensuring that glycaemic target thresholds are observed. Indeed, evidence-based research indicates that the reduction of the physiological response of the fetus to the surge in maternal blood glucose concentration has demonstrated its benefits in curtailing perinatal morbidity.

Dietary Management of GDM

The most crucial part of treatment for GDM may be associated with food intake and an individual's eating pattern. Diet is essential in the sense that it helps in meeting the nutritional needs of the expectant mother and the baby while also keeping the blood glucose levels within the recommended limits. Equally important is the fact that eating the right types of food is more crucial that the quantity of food consumed hence the insistence on taking a balanced diet. For instance, iron, folate, protein, and calcium are examples of nutrients which are essential during pregnancy. Moreover, the Australian Guide to Healthy Eating divides diets into five food groups namely fruit; low-fat milk products; whole grain foods; vegetables and proteins such as legumes and meat products. This implies that any foods that exist outside the categories above are not essential to the body hence such foods should be limited or avoided entirely (Brokaw et al., 2017). When GDM is diagnosed, the consumption of large amounts of carbohydrates eaten at the same time may lead to high blood glucose levels. Hence, the prevention of high blood glucose levels will necessitate the need to satisfy one's hunger while maintaining a healthy weigh through consumption of small amounts at scheduled times. Additionally, an expectant mother is required to spread her food intake evenly throughout the day. For example, a clinician may recommend that it would be advisable to have three small meals and three snacks than consuming three large meals.

Physical Activity and GDM

Physical activity has been primarily incorporated as a therapeutic tool during pregnancy based on the notion that exercise enhances good health and prevents miscarriage. Early studies also indicate that prenatal exercise programs assist in the easing of labor, augmentation in fetal oxygenation, improving muscle tone and facilitating post-partum weight loss. As a result, exercise has been certified as being safe and expedient for glucose regulation for women who are diagnosed with GDM. Moreover, multiple studies have indicated positive effects of exercising which leads to decreased lower back pain in women while other cases there has been an improvement in cardiovascular f...