PUBHLTH 3124 Health Promotion III

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PUBHLTH 3124 Health Promotion III

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PUBHLTH 3124 Health Promotion III

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Course Code: PUBHLTH 3124
University: The University Of Adelaide

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Country: Australia

Question:
Discuss about management of gestational diabetes during pregnancy
Answer:

Introduction
Gestational diabetes is the type of diabetes that occurs during pregnancy. At the time of the pregnancy the hormones secreted by the placenta builds up glucose in the blood which generally disappears after the baby is born. The focus of the report would be the management of gestational diabetes during pregnancy.
Description of the tissue
Gestational diabetes is one of the common types of diabetes occurring in Australia affecting many pregnant women. According to studies about 12% and 14% of women who are pregnant have been found to be developing gestational diabetes (Moses et al. 2015).  A large population based study in Canada have demonstrated that between the years 2012- 2017, the incidence of both GDM and PGDM has doubled from 2.7% to 5.8%. When the diabetic women are compared to the non-diabetic pregnant women, the risk of both the perinatal mortality and congenital anomaly have been found to be higher. Before that the rate of the gestational diabetes in Canada was 54.5 (95% CI: 53.6–55.4) per 1,000 deliveries (Government of Canada. 2015). Rates of the GDM have been found to be increasing with age probably due to the increase of the weight and the body mass index. The highest rate was found to be in British Columbia and the lowest in Nunavut. The women vulnerable to the risk of developing gestational diabetes are those who are aged over 40 years, those who have a family history of type 2 diabetes, those who are above the healthy weight range, those who had gestational diabetes in the previous pregnancy, women having polycystic ovarian syndrome, those mothers who are under antipsychotic medications. Gestational diabetes have been found to be high among the aboriginals and the ethnic groups of Melanesian, Chinese, South Asian and the Middle Eastern women (Chamberlain et al. 2013).  The major predictive factors that has been identified are recurrent, insulin use and a high 1-h glucose level on the glucose tolerance test are those who have had GDM in their first pregnancy (Zhu and Zhang 2016). Studies says that women with undiagnosed hyperglycemia in many pregnancies is associated with higher rate of fetal loss and malformation in the infants. Such fetal abnormalities can be identified by the identification of the diabetes and effective control of the blood glucose level prior to the conception (Ae et al. 2013). Risk of cardiovascular diseases has been found to higher in women with prior GDM. Studies related to women with prior GDM has suggested that the chronic inflammatory response can be present which represents cluster of cardiovascular risk factors (Buckley et al. 2012).
Due to the widespread prevalence of the GDM and the cluster of risk factors associated to this, health promotion strategies should be taken to mitigate the risk factors of the condition.
Discussion
Health promotion program should be set in every clinical settings or communities that would provide free checkups to the would be mothers and suggest with suitable recommendations. A health promotion program for managing GDM should consist of a general practitioner, a nutritionist, a physiotherapist and a community nurse (Gabbe et al. 2012).  The health promotion program would mainly focus on the following interventions:-
Life style changes for delaying the onset of the gestational diabetes
Nutrition therapy
A nutritional assessment should be done by a nutritionist present in a health promotion program. Medical nutrition therapy (MNT) recommended by a registered dietician taking part in health promotion program should be the first line of treatment of maternal diabetes, due to the impact on the maternal and infant outcomes, when initiated early in pregnancy (McCance 2015).  An integral part of the diabetes management includes the exclusion of calorigenic diets. The total fat should be 25% to 35% of the total calories and saturated fat less than 7% (Gabbe et al. 2012). Some of the essential food that should be especially chosen during pregnancy are foods that contain calcium, milk, iron, folic acid and leafy vegetables.
Physical activity
A pregnant women should get minimum 30 minutes of moderate physical activities 5 days a week suitable to the time of the pregnancy. A physiotherapist demonstrate the suitable exercises that are to be carried out by the women. Education about special tools should be given for monitoring their track of the daily food, fat intake as well as the physical activity (Moses et al. 2015). Proper guidelines for the weight gain should be given to the women with maternal diabetes in compliance with the Institute of Medicine (IOM). A systematic review examining the recommendation of the IOM guidelines showed that the ones who followed the guidelines are more likely to have better infant birth weight and fetal growth. It decreased the amount of the weight loss required in the postpartum period (McCance 2015).
According to McCance (2015), glycemic control, prepregnancy BMI and CWG can have additive impact on the fetal growth and hence education and management of the nutrition for these group of women are necessary. The nutritionist should educate the target group of people about the disadvantages of obesity in women with GDM. Cohort studies of various body mass index have found that excessive gestational weight is related to higher birth weight infants’ independent of the pre-pregnancy BMI and the glycemic control.   Cohort studies of various body mass index have found that excessive gestational weight is related to higher birth weight infants independent of the pre-pregnancy BMI and the glycemic control.   
Glucose monitoring
Frequent monitoring of the blood glucose level in pregnant women with gestational diabetes is essential for achieving the glycemic control. Preprandial testing and post prandial testing has been associated with reduced preeclampsia and low macrosomia. Pregnant women possess higher risk of nocturnal hypoglycemia and frequent self-monitoring of the blood glucose level at night is also necessary for women with GDM. Self-monitoring can help to identify the periods of the hyperglycemia or hypoglycemia in women.
The blood glucose should be kept at the target range. A diabetes educator in the health promotion program can explain the importance of monitoring of the blood glucose level and demonstrate the ways   to monitor the blood glucose level and understand the pattern of the blood glucose level (Buchanan et al. 2012). An HbA1c ≥ 6.5% (48 mmol/mol) 14, 15 was regarded diagnostic of diabetes.
Antepartum assessment of the fetus
Data on GDM and fetal demise are conflicting and there had been less evidence to determine the optimal antepartum testing regimen in the women. Antenatal assessment is required in people with people who have no control over the blood glucose level or those who have concomitant hypertension (Buchanan et al. 2012).
In women with GDM, shoulder dystocia is a clinical condition that takes place at the time of the delivery (Allen and Allen 2017). Studies have found that about 31 % of the women with GDM has given birth to overweight babies.  A reasonable approach is to offer a caesarian delivery to those suffering from GDM.
Apart from the strategies taken in the health promotion program, certain interventions also have to be taken in the intrapartum period and the post partum period (Buchanan et al. 2012).
The goal of the intrapartum management should be to maintain a normal glucose level in order to prevent neonatal hypoglycemia. Mothers having diet controlled diabetes do not need intrapartum insulin and only requires regular monitoring of the blood glucose level.
Pharmacologic management
Another topic of education and the self-management of gestational diabetes is the pharmacologic management of the diabetes. When physical activities and the dietary glycemic control cannot provide adequate glycemic control, short acting insulin therapy is the primary line of the treatment (Elkins and Taylor 2013). The GP in charge of the educational program can prescribe appropriate dosage for the patients. It has to be remembered that the education given in the health promotion program are for the all the patients and hence any medication that should be taken has to be prescribed by a registered GP. Oral anti-hyperglycemic agent can also be recommended for those who cannot afford the cost of the insulin therapy or cannot stick to the insulin regimen (Elkins and Taylor 2013). These agents have been found to be best in controlling GDM in patients who’s GDM has been diagnosed in the first trimester.
Behavioral therapy
Behavioral therapies may include adoption of the new dietary changes. Pregnant women often suffer from psychological stresses due to the array of physiological changes occurring in the body of the women and also due to GDM developed (Moses et al. 2015). A counselor can help a pregnant women in self-monitoring, problem solving, cognitive structuring, self-directed goal setting and social support.
Regular follow up and the referrals
In compliance with the health belief model the nurses and the health care professionals in charge of a health promotion program can assist the pregnant women to understand the the increased likelihood of being diagnosed with GDM.
The nurse practitioners and the GPs should provide information about important referrals such as referrals to the community weight control clinic and registered dieticians can be given. The nurse practitioners can also arrange for the regular follow ups.
Conclusion
In conclusion it can be said that proper education about diet, physical exercise and glucose monitoring can successfully mitigate the risk factors of the GDM. The interventions mainly emphasize on regular monitoring of glucose, controlling diet and exercise. The diagnosis for the GDM should start a long time family intervention involving the primary care providers, obstetrician-gynecologists, physicians, pediatricians and the nurse practitioners for screening diabetes as early as possible and to ensure a healthy development of the child.
References
Ae, J., Ranasinha, S., Zoungas, S. and Hj, T., 2014. Gestational diabetes and type 2 diabetes in reproductive-aged women with polycystic ovary syndrome.
Allen, E.G. and Allen, R.H., 2017. Management of Shoulder Dystocia. In Management and Therapy of Late Pregnancy Complications (pp. 167-178). Springer, Cham.
Buchanan, T.A., Xiang, A.H. and Page, K.A., 2012. Gestational diabetes mellitus: risks and management during and after pregnancy. Nature Reviews Endocrinology, 8(11), p.639.
Buckley, B.S., Harreiter, J., Damm, P., Corcoy, R., Chico, A., Simmons, D., Vellinga, A. and Dunne, F., 2012. Gestational diabetes mellitus in Europe: prevalence, current screening practice and barriers to screening. A review. Diabetic medicine, 29(7), pp.844-854.
Chamberlain, C., Banks, E., Joshy, G., Diouf, I., Oats, J.J., Gubhaju, L. and Eades, S., 2014. Prevalence of gestational diabetes mellitus among Indigenous women and comparison with non?Indigenous Australian women: 1990–2009. Australian and New Zealand Journal of Obstetrics and Gynaecology, 54(5), pp.433-440.
Elkins, D. and Taylor, J.S., 2013. Evidence?Based Strategies for Managing Gestational Diabetes in Women With Obesity. Nursing for women’s health, 17(5), pp.420-430.
Gabbe, S. G., Landon, M., Warren-Boulton, E., and  Fradkin, J. 2012. Promoting Health After Gestational Diabetes: A National Diabetes Education Program Call to Action. Obstetrics and Gynecology, 119(1), 171–176.
Government of Canada., 2015.Maternal diabetes in Canada. Access date: 12.8.2018. Retrieved from: https://www.canada.ca/en/public-health/services/publications/healthy-living/maternal-diabetes-canada.html
McCance, D.R., 2015. Diabetes in pregnancy. Best Practice & Research Clinical Obstetrics & Gynaecology, 29(5), pp.685-699.
Moses, R. G., Goluza, I., Borchard, J. P., Harman, A., Dunning, A., & Milosavljevic, M. (2017). The prevalence of diabetes after gestational diabetes–An Australian perspective. Australian and New Zealand Journal of Obstetrics and Gynaecology, 57(2), 157-161.
Zhu, Y. and Zhang, C., 2016. Prevalence of gestational diabetes and risk of progression to type 2 diabetes: a global perspective. Current diabetes reports, 16(1), p.7.

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