Evidence-Based Strategies for Managing Gestational Diabetes in Women With Obesity
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Transcript of Evidence-Based Strategies for Managing Gestational Diabetes in Women With Obesity
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NEEvidence-Based
Strategies forManaging
GestationalDiabetes in
Women WithObesity
Donnay Elkins, MSN, RN, FNP-C
Julie Smith Taylor, PhD,
RN, WHNP-BC
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INTRODUCTIONIn the United States, an estimated one-third of women of ages
20 to 39 are obese, with a body mass index (BMI) > 30 kg/m 2
(Nodine & Hastings-Tolsma, 2012). Pregnancy complications
related to obesity include, but are not limited to, gestational di-
abetes mellitus (GDM), gestational hypertension and cesarean
surgical birth (see Box 1; Nodine & Hastings-Tolsma). Moreo-
ver, pregnant women with obesity are 1.6 times more likely todevelop pre-eclampsia, 2.5 times more likely to develop gesta-
tional hypertension and more than 8.5 times more likely to de-
velop GDM when compared with pregnant women with BMIs
< 30 kg/m2(Shirazian & Raghavan, 2009).
Even in the absence of maternal obesity, GDM during
pregnancy is associated with fetal complications, such as mac-
rosomia, miscarriage, neonatal hypoglycemia, neural tube
defects and preterm delivery (Nielsen, deCourten, & Kapur,
2012; Reece, 2008; Reece, 2010; Schneiderman, 2010; see Box
2). However, when a pregnancy is complicated by both obe-
sity and GDM, each extra kg of body weight above a BMI of
30 kg/m2 increases the risk of adverse pregnancy outcomes by6.6 percent, and each increase of 10 mg/dL in fasting plasma
glucose levels above 95 mg/dL raises the adverse outcome risk
by another 15 percent (Langer, Yogev, Most, & Xenakis, 2005).
Because of the increased maternal and fetal risks associated
with maternal obesity and GDM, the development of evidence-
based strategies (see Figure 1) for screening and management
of GDM and for timing of birth in these women will provide
a comprehensive approach needed to optimize outcomes for
both women and newborns. us, the aim of this article is to
formulate best practice guidelines for the care of women with
obesity during pregnancies complicated by GDM to reduce ad-
verse maternal and fetal outcomes.
THEORETICAL FRAMEWORKAND LITERATURE REVIEWe Health Belief Model describes how personal perceptions
about a disease and the strategies available to decrease a disease
both impact the occurrence of a disease (Rosenstock, 1966).
e Health Belief Model revolves around four perceptions
that influence a persons health behaviors: perceived serious-
ness, perceived susceptibility, perceived benefits and perceived
422 2013, AWHONN http://nwh.awhonn.org
Donnay Elkins, MSN, RN, FNP-C, is a family nurse practitioner atChair City Family Medicine in omasville, NC. Julie Smith Taylor,PhD, RN, WHNP-BC, is an associate professor and graduate coordina-tor at the University of North Carolina Wilmington School of Nursingin Wilmington, NC. e authors and planners of this activity report noconflicts of interest or relevant financial relationships. No commercialsupport was received for this learning activity. Address correspondenceto: [email protected].
ObjectivesUpon completion of this activity, the learner will
be able to:
1. Describe risks associated with gestational
diabetes mellitus (GDM) and obesity in
pregnancy.
2. Describe methods to screen for GDM.
3. Describe evidence-based strategies for man-
aging GDM in women with obesity.
Continuing Nursing Education (CNE) Credit
A total of 1contact hour may be earned as CNE
credit for reading Evidence-based Strategies for
Managing Gestational Diabetes in Women With
Obesity and for completing an online post-test
and participant feedback form.
To take the test and complete the participant
feedback form, please visit http://JournalsCNE.
awhonn.org. Certificates of completion will be
issued on receipt of the completed participant
feedback form and processing fees.
Association of Womens Health, Obstetric and
Neonatal Nurses is accredited as a provider of
continuing nursing education by the American
Nurses Credentialing Centers Commission on
Accreditation.
Accredited status does not imply endorsement by
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educational activity.
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Abstract:Pregnancies complicated by both obesity and gestational diabe-tes mellitus (GDM) increase the risk of maternal and fetal complications,including but not limited to gestational hypertension, cesarean surgi-cal birth, fetal macrosomia and postpartum hemorrhage. Because of theincreased maternal and fetal risks associated with maternal obesity andGDM, the development of evidence-based strategies for screening for andmanagement of GDM and for timing of birth will provide a comprehensiveapproach needed to optimize outcomes for both women and newborns.DOI: 10.1111/1751-486X.12065
Keywords: gestational diabetes | maternal obesity | pregnancy | obesity
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barriers. Perceived seriousness indicates the belief about the
severity of a particular disease. Perceived susceptibility is how
likely a person believes she is to acquire a disease. Perceived
benefits explain how a health behavior will affect the chances of
developing a disease or experiencing sequelae from a disease.
Lastly, perceived barriers are personal hindrances to adopting a
health behavior that will decrease disease (Rosenstock).
While these four perceptions influence an individuals be-
liefs about her health, these perceptions are influenced by mod-
ifying variables, cues to action and self-efficacy (Rosenstock,
1966). Variables such as culture, education, experiences and
motivation influence an individuals perceptions. Cues to ac-
tion from events or people also influence someones perception
of health beliefs. Self-efficacy determines peoples ability to do
something about their health despite their perceptions, vari-
ables or cues to action (Rosenstock).
PREVENTIONWhen preconception or early prenatal care is initiated, it may
be possible to prevent GDM completely. Exercise started be-
fore 20 weeks gestation reduces the risk of GDM development
by 46 percent (Weissgerber, Wolfe, Davies, & Mottola, 2006).
If physical activity is initiated a year before conception and is
continued consistently during the first 20 weeks of pregnancy,
the risk of developing GDM decreases by 60 percent (Weiss-
gerber et al.). Furthermore, introducing a walking regimen 3
to 4 days per week that reaches 30 percent of maximum age-
predicted heart rate for 30 minutes in conjunction with carbo-
hydrate restriction to 200 g/day has been shown to prevent the
development of GDM (Weissberger et al.).
SCREENINGScreening Schedule
Currently, there is no ideal approach to the best time to screen
for GDM (American College of Obstetricians and Gynecolo-
gists [ACOG], 2011). ACOG and the American Diabetes As-
sociation (ADA, 2011) recommend screening between 24 and
28 weeks gestation because evidence indicates that when treat-
ment is initiated at this gestational age, there are profound de-
creases in perinatal complications such as fetal death, shoulder
dystocia, bone fracture and nerve palsy (Hillier et al., 2008).
Also, physiologically this timing is most appropriate due to a
natural increase in insulin resistance starting in the second tri-
mester as a result of an increase in human placental lactogen
and other pregnancy hormones (Schneiderman, 2010). ese
higher physiologic levels of human placental lactogen result in
ever-increasing levels of insulin secretion. When the amount of
insulin secreted can no longer keep pace with the higher levels
of glucose, GDM develops.
GDM screening before 24 weeks gestation is associated
with early interventions, which decrease incidences of large-
for-gestational-age infants, APGAR scores < 7 at 5 minutes, in-
strumental vaginal deliveries and cesarean deliveries (P< 0.05;
Berg, Adlerberth, Sultan, Wennergren, & Wallin, 2006). How-
ever, the United States Preventive Services Task Force (USPSTF,
2008) reports limited evidence in the improvement of outcomes
when GDM treatment is initiated before 24 weeks gestation,
and recommends establishing decisions on a case-by-case basis,
When preconception or early prenatal
care is initiated, it may be possible toprevent GDM completely
BOX 1MATERNAL RISKS ASSOCIATEDWITH GDM AND OBESITY DURINGPREGNANCY
Gestational hypertension
Pre-eclampsia
Cesarean surgical birth
Wound infections
Thromboembolism
Source: Nodine and Hastings-Tolsma (2012).
BOX 2FETAL RISKS ASSOCIATED WITHGDM AND OBESITY DURING PREGNANCY
Neural tube defect
Heart defects
Macrosomia
Birth trauma
Preterm birth
Neonatal respiratory distress
MiscarriageIntrauterine fetal demise
Hypoglycemia
Hyperbilirubinemia
Jaundice
Sources: Kendrick (2011); Nielsen et al. (2012);
Reece (2008, 2010); Schneiderman (2010).
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424 Nursing for Womens Health Volume 17 Issue 5
depending on the presence of risk factors such as increased ma-
ternal age or history of GDM in a previous pregnancy, for each
patient scenario (Scheneiderman, 2010; see Box 3). Further,
other research has demonstrated comparable outcomes when
screening occurred between 15 and 19 weeks or 24 and 28
weeks, with no differences in rates of cesarean, preterm birth,
5-minute APGAR < 7, macrosomia, presence of meconium or
neonatal intensive care unit (NICU) admissions (Kerr, 2008;
Hillier et al., 2008). In general, a possible management plan to
satisfy the spectrum is to screen all high-risk pregnant women
between 16 and 18 weeks gestation and if the
screen is negative, perform a follow-up screen-
ing at 28 weeks gestation (Serci, 2008).
Screening Method
A single, random glucose measurement should
not be used as a screening tool for GDM, because
of poor sensitivity and specificity (van Leeuwen et
al., 2011). Depending on gestation, a womans in-
sulin sensitivity naturally varies, making a random
glucose measurement unreliable (Hillier et al.,
2008). However, this screening tool can be useful
for early detection of undiagnosed type 2 diabetes
in high-risk gravida populations (Cundy, 2012).
One standard procedure of GDM screening
includes an initial screening with a nonfasting,
1-hour 50-g oral glucose tolerance test (OGTT)
followed by a fasting, 3-hour 100-g OGTT if the
1-hour OGTT is elevated (ACOG, 2011). e
exact cutoff value considered elevated for the
1-hour OGTT remains elusive and under debate.
A diagnosis of GDM is made when at least twovalues are above the normative cutoffvalues for
the 3-hour OGTT (see Box 4).
A second screening option endorsed by the
International Association of Diabetes and Preg-
nancy Study Groups (IADSPG), National Insti-
tute for Clinical Excellence (NICE) and ADA
that emerged from the Hyperglycemia and Ad-
verse Pregnancy Outcomes (HAPO) study and
the Australian Carbohydrate Intolerance Study
in Pregnant Women (ACHOIS) is the single
2-hour 75-g OGTT (ADA, 2011; Cundy, 2012;
Dennedy, O-Sullivan, & Dunne, 2010). Diagno-sis of GDM can be made with only one abnor-
mal glucose level fasting (>92 mg/dL), at 1 hour
(>180 mg/dL) or at 2 hours (>153 mg/dL) (ADA,
2011). ACOG (2011) does not currently endorse
the 2-hour OGTT method as it would predict-
ably increase health care costs.
Studies comparing the screening methods in
more than 450 pregnant women between 26 and
30 weeks gestation using both screening methods have dem-
onstrated that the 2-hour 75-g OGTT has better sensitivity at
diagnosing GDM in women with obesity and can lead to de-
creased rates of macrosomia, hypoglycemia, hyperbilirubine-
mia and stillbirth by at least 10 percent (DeSereday, Damiano,
Gonzalez, & Bennett, 2003; Hillier et al., 2008). eoretically,
improved outcomes can be attributed to more patients receiving
treatment for GDM when screened with the 2-hour 75-g OGTT
due to the lower cutoffvalues and the requirement of only one
abnormal glucose measurement for diagnosis (Sinha, 2012).
FIGURE 1EVIDENCE-BASED STRATEGIES
FOR MANAGING GDM
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October November 2013 Nursing for Womens Health 425
Screening Population
Because of its better sensitivity and practicality, universal screen-
ing is recommended over selective screening based on risk fac-
tors (Kendrick, 2011). In an observational study (n = 1,600),
Cosson et al. (2006) found universal screening, as compared
to selective screening, decreased the prevalence of preterm
birth, large-for-gestational-age infants, neonatal hyperglycemia,
neonatal jaundice and NICU admissions (P< 0.05) while also
decreasing rates of shoulder dystocia (5 vs. 17), neonatal hypo-
glycemia (2 vs. 26) and neonatal respiratory distress syndrome
(3 vs. 14).
MANAGEMENT OF GDMHealth Education
Health education programs about GDM management, as brief
as 10 to 30 minutes, have shown to improve maternal and neo-
natal outcomes (Elnour, El Mugammar, Jaber, Revel, & McEl-
nay, 2008). Effective teaching programs include one-on-one
conversations about diet, exercise, normal blood sugar ranges,
timing and frequency of plasma glucose self-monitoring andtreatment of abnormal results, while also supplying an educa-
tional take-home booklet filled with information about diabe-
tes in general, GDM specifically, the role of diet and exercise in
treatment and actions to take in response to hypoglycemic or
hyperglycemic episodes (Elnour et al.).
In a randomized controlled trial (n = 165), researchers
found that participants in the structured educational pro-
gram experienced improved glycemic control and statistically
significant reductions (P< 0.05) in the incidence of cesarean
deliveries, preterm birth, shoulder dystocia, macrosomia in in-
fants, neonatal hypoglycemia, neonatal respiratory distress and
neonatal hyperbilirubinemia (Elnour et al., 2008). is study
shows that providing women with quality information about
their diagnosis and disease management increases the rate of
blood glucose self-monitoring and enables patients to readily
identify hyperglycemia and hypoglycemia, which positively
influences patients engagement in their own care (Elnour et
al.). e researchers concluded that this active participation by
women in the management of their GDM results in more fa-
vorable outcomes.
Home Blood Glucose Monitoring
A continuous glucose monitoring system is optimal for the
tighter glucose control recommended with GDM (Kestila, Ek-
blad, & Ronnemaa, 2007). In a randomized controlled trial of
73 patients, 31 percent of users were prompted to self-medi-
cate abnormal glucose levels, compared with only 8 percent
of participants using traditional monitoring with fasting and
2-hour postprandial readings (Kestila, Ekblad, & Ronnemaa).
However, the traditional approach has most oen been utilized
in current practice, as no significant improvements in mater-
nal or fetal outcomes have been demonstrated with the use of
continuous glucose monitoring compared to traditional glu-
cose monitoring (Kestila, Ekblad, & Ronnemaa).
Physical Activity
In a review of the literature, Weissgerber et al. (2006) report
findings from an earlier study (Clark, ornley, Tomlinson,
Galletley, & Norman, 1998) that demonstrated a decrease in
the rate of miscarriage from 75 percent to 18 percent in obese,
previously infertile, women who participated in a 6-month
physical activity intervention. Physical activity during preg-
nancy can decrease the rate of miscarriage from 75 percent
to 18 percent in certain populations of pregnant women with
obesity (Weissgerber et al., 2006). Walking, stationary bikes,
aquatic exercise and low-impact aerobics are the activities most
recommended during pregnancy (Mottola, 2009). Davenport,Mottola, McManus, and Gratton (2008) found through a case-
control study of 30 overweight, pregnant women with GDM
that low-intensity walking 3 to 4 days per week for at least 6
weeks starting at 25 minutes/day and working up to 40 minutes/
BOX 3RISK FACTORS TO INFLUENCETIME OF GDM SCREENING
Family history of mother with diabetes mellitus
Hispanic, Asian, Native American, African Ameri-can or Pacific Islander ethnicity
History of GDM in a previous pregnancy
Hypertensive disorders in current pregnancy
Multiple gestation
Prior birth of infant weighing > 9lbs
Polycystic ovary syndrome
Source: Schneiderman (2012).
BOX 4ORAL GLUCOSE TOLERANCE TESTDIAGNOSTIC CRITERIA
Fasting > 105 mg/dL
After 1hour > 190mg/dL
After 2hours > 165mg/dL
After 3hours > 140mg/dL
Note: Two values above these cutoffs
are needed to diagnose GDM.
Source: ACOG (2011).
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426 Nursing for Womens Health Volume 17 Issue 5
day lowered mean glucose levels by 11 mg/dL for the morning
fasting level, about 9 mg/dL aer breakfast, about 13 mg/dL
aer lunch and about 7 mg/dL aer dinner, with an average of
10 mg/dL throughout the four blood glucose checks per day
(P< 0.05). Walking also decreased frequency and amount of
insulin treatment, with injections only needed at breakfast and
bedtime. In a study of women ages 20 to 39, researchers deter-
mined that during any exercise program, target heart rate levels
for overweight and obese pregnant women should be 102 to
124 beats per minute (bpm) for ages 20 to 29 and 101 to 120bpm for ages 30 to 39 (Davenport, Charlesworth, Vanderspank,
Sopper, & Mottola, 2008)
Diet Modification and Education
Referral to a registered dietitian should occur simultaneously
with GDM diagnosis and, ideally, women should meet with a
registered dietitian within a week of diagnosis (National Guide-
line Clearinghouse, 2010). is early referral can prevent the
need for pharmacotherapy as treatment, and at least three visits
throughout the pregnancy can improve maternal and neona-
tal outcomes (National Guideline Clearinghouse; Rugge, King,Davis, & Schechtel, 2009). Medical nutrition therapy (MNT)
guided by an experienced registered dietitian should be a first-
line treatment for GDM because of the impact on maternal and
neonatal outcomes when initiated early in pregnancy (National
Guideline Clearinghouse; Serlin & Lash, 2009). Providing in-
dividualized MNT following the ADAs Nutrition Practice
Guidelines for GDM decreases the need for insulin, the rates of
cesarean deliveries and prevalence of large-for-gestational-age
infants (Singh & Rastogi, 2008). Guidance with regard to food
choices and nutrition appears to have a significant impact on
the overall course of disease in many patients.
Following diabetes nutrition guidelines should be recom-
mended for overweight and obese pregnant women with GDM
(Serci, 2008). However, severe caloric restrictions should be
avoided due to the higher prevalence and risk of intrauterine
growth restriction (IUGR) as well as small-for-gestational-age
infants (Catalano, 2013; Serci, 2008). At least 175 g/day of car-bohydrates should be consumed to enhance fetal brain devel-
opment and prevent maternal ketosis, but these carbohydrates
should comprise
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In creating plans of care based on estimated fetal weight by
ultrasound, it is important to remember this method has a mar-
gin of error between 10 percent and 15 percent (Lalys, Pineau,
& Guihard-Costa, 2010). However, if macrosomia with estimat-
ed fetal weight > 4,000 g via ultrasound is suspected, delivery
should be considered between 38 and 39 weeks to reduce the
risk of shoulder dystocia from 10 percent to 1.4 percent (Me-
nato et al., 2008). If estimated fetal weight is > 4,250 g, cesarean
should be considered to decrease the likelihood of shoulderdystocia, postpartum hemorrhage, third- and fourth-degree
lacerations and maternal infections (Sela et al., 2009). Cur-
rently, research is ongoing to compare maternal and neonatal
outcomes in scheduled inductions between 38 and 39 weeks
gestation and expectant management for women with GDM
(Maso et al., 2011).
IMPLICATIONS FOR NURSESWithin the framework of the Health Belief Model, nurses can
help pregnant women with obesity understand and appreci-
ate their increased likelihood of being diagnosed with GDM.
Moreover, education and support provided by nurses duringthis very critical period may decrease or minimize any short-
term obstetric risk as well as further long-term risks, such as
metabolic syndrome and type 2 diabetes mellitus (Dennedy et
al., 2010; Kendrick, 2011).
Nurses can counsel and motivate women through sup-
port, education and compassion, by explaining the benefits of
adhering to evidence-based strategies to decrease the risk of
complications. Nurses can address womens perceived barriers
Metformin appears to be more useful than glyburide, as
metformin use is associated with fewer cesarean deliveries,
large-for-gestational-age infants and macrosomia (Silva et al.,
2010). Metformin is also associated with an increase in APGAR
scores and a decrease in premature deliveries, neonatal jaun-
dice, NICU admissions and macrosomic infants (Balani, Hyer,
Rodin, & Shehata, 2009; Begum et al., 2008).
COMBINING MODALITIESTO MANAGE GDMDietary modifications and physical activity are the mainstays
of GDM treatment for women with obesity, with the addition
of self-monitoring of glucose levels, insulin therapy and oral
antihyperglycemic agents when necessary (Landon et al., 2009;
Rugge et al., 2009). In a randomized controlled trial of 958
women, combination therapy including nutrition counseling,
dietary modifications, physical activity, self-glucose monitor-
ing, insulin therapy and oral antihyperglycemic agents pro-
duced statistically significant decreases in the prevalence of
large-for-gestational-age infants, macrosomia, shoulder dysto-cia, cesarean delivery, preterm delivery, NICU admission and
hyperbilirubinemia (Landon et al.).
BIRTH TIMINGIf a pregnant woman with GDM and obesity has experienced
good glycemic control throughout her pregnancy, there is in-
sufficient evidence and no medical indication to contradict the
recommendation against elective induction of labor before 39
weeks gestation (ACOG Committee on Practice Bulletins
Obstetrics, 2009; March of Dimes, n.d.). Expectant manage-
ment should be utilized in women with normal estimated fetal
weight, good glycemic control, reassuring antenatal testing andnormal amniotic fluid levels (Sela, Raz, & Elchalal, 2009). Aer
32 weeks gestation, non-reassuring antenatal testing or an ab-
normal fetal kick count as reported by the patient may indicate
that delivery could be considered (Seri & Evan, 2008; Sugiy-
ama, 2011). If preterm delivery is pursued, fetal lung maturity
must be assessed first, since the pulmonary system is one of the
last to complete development (Gillen-Goldstein, MacKenzie, &
Funai, 2013).
Nurses can counsel and motivate
women through support, education and
compassion, by explaining the benefits of
adhering to evidence-based strategies to
decrease the risk of complications
BOX 5FACTORS PREDICTING THE NEED FOR INSULIN IN WOMEN WITH GDM
POSITIVE INDICATORS
Family history of diabetes mellitus
Prepregnancy obesity
Several (34) abnormal values on 3-hour 100-g OGTT
Elevated HbA1c levels
NEGATIVE INDICATORS
Appropriate weight
No family history of diabetes mellitus
Only two abnormal values on 3-hour, 100-g OGTT
Source: Sapienza et al. (2010).
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pregnancy in women with polycystic ovary syndrome.Journal ofObstetric and Gynaecology Research, 35(2),282286.
Berg, M, Adlerberth, A., Sultan, B., Wennergren, M., & Wallin, G.(2006). Early random capillary glucose level screening and mul-tidisciplinary antenatal teamwork to improve outcome in ges-tational diabetes mellitus. Acta Obstetricia et Gynecologica, 86,283290.
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Kendrick, J. (2011). Screening and diagnosing gestational diabe-tes mellitus revisited.Journal of Perinatal and Neonatal Nursing,25(3), 226232. doi:10.1097/JPN.0b013e318222dded
to adopting these evidence-based strategies. Nurses connect
women with appropriate resources and provide vital support
to women as they modify their behaviors in efforts to decrease
adverse maternal and fetal outcomes associated with GDM.
CONCLUSIONPreventing the development of GDM in pregnant women with
obesity is the ideal scenario, and could potentially decrease the
development of adverse maternal and fetal outcomes. Targeted
interventions to increase physical activity, implement dietary
modifications and maintain appropriate pregnancy weight gain
(Institute of Medicine National Research Council, 2009; see
Box 6) would be the best strategy to decrease the likelihood of
complications. Nurses play an integral role in helping pregnant
women with obesity reduce their risk for maternal and fetal
complications of GDM.!"#
REFERENCESAkinci, B., Celtik, A., Yener, S., & Yesil, S. (2008). Is fasting glucose
level during oral glucose tolerance test an indicator of the insulinneed in gestation diabetes? Diabetes Research and Clinical Prac-tice, 82, 219225.
American College of Obstetricians and Gynecologists. (2011).Screening and diagnosis of gestational diabetes mellitus. Com-mittee Opinion No. 504. Obstetrics & Gynecology, 118, 751753.
American College of Obstetricians and Gynecologists Committeeon Practice BulletinsObstetrics. (2009). ACOG Practice Bul-letin No. 107: Induction of labor. Obstetrics & Gynecology, 114,386397.
American Diabetes Association. (2011). Standards of medical carein diabetes.Retrieved from http://care.diabetesjournals.org/con-tent/34/Supplement_1/S11.full
Balani, J., Hyer, S. L., Rodin, D. A., & Shehata, H. (2009). Preg-nancy outcomes in women with gestational diabetes treated withmetformin or insulin: A case-control study. Diabetic Medicine,26, 798802. doi:10.1111/j.1464-5491.2009.02780.x
Begum, M. R., Khanam, N. N., Quadir, E., Ferdous, J., Begum,M. S., Khan, F., & Begum, A. (2008). Prevention of gestationaldiabetes mellitus by continuing metformin therapy throughout
BOX 6INSTITUTE OF MEDICINERECOMMENDATIONS FORWEIGHT GAIN IN PREGNANCY
Prepregnancy BMI < 18.5kg/m2 : 2840pounds
Prepregnancy BMI 18.524.9kg/m2 : 2535pounds
Prepregnancy BMI 2529.9kg/m2
: 1525poundsPrepregnancy BMI 30kg/m2 : 1120pounds
Source: IOM (2009).
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8/13/2019 Evidence-Based Strategies for Managing Gestational Diabetes in Women With Obesity
11/11
CNE
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430 Nursing for Womens Health Volume 17 Issue 5
Post-Test QuestionsInstructions:To receive contact hours for this learningactivity, please complete the online post-test and participant
feedback form at http://JournalsCNE.awhonn.org. CNEfor this activity is available online only; written tests submit-ted to AWHONN will notbe accepted.
1. Which of the following are the four perceptions describedby the Health Belief Model?
a. Barriers, challenges, benefits and seriousness
b. Seriousness, susceptibility, benefits and barriers
c. Susceptibility, usefulness, ability and motivation
2. When a pregnancy is complicated by both obesity andGDM, each extra kg of body weight over a BMI of 30kg/m2increases the risk of adverse pregnancy outcomes by howmuch?
a. 4.5percent
b. 6.6percent
c. 15percent
3. The risk of developing GDM decreases by how much ifphysical activity is initiated a year before conception andis consistently continued during the first 20 weeks of preg-nancy?
a. 20percent
b. 40percent
c. 60percent
4. The American College of Obstetricians and Gynecolo-gists and the American Diabetes Association recommendscreening for GDM at what point?
a. Between 20and 24weeks gestationb. Between 24and 28weeks gestation
c. Once symptoms develop
5. During the second trimester of pregnancy, levels of placen-tal lactogen increase, causing
a. A decrease in insulin resistance
b. An increase in insulin resistance
c. Stable levels of insulin secretion
6. In studies comparing GDM screening methods in morethan 450pregnant women between 26and 30weeks gesta-tion, which test was found to have better sensitivity fordiagnosing GDM in women with obesity?
a. 1-hour 50-g OGTTb. 2-hour 75-g OGTT
c. 3-hour 100-g OGTT
7. When GDM is diagnosed with the 2-hour, 75-g OGTTrather than the 3-hour 100-g OGTT, research has found:
a. Decreased rates of macrosomia and stillbirth
b. Improved glycemic control during pregnancy
c. Improved ability to predict which women will develop
type 2diabetes later in life
8. Which type of home glucose monitoring has been deter-mined by research to have the best maternal and fetaloutcomes?
a. Continuous monitoring
b. No differences in outcomes have been demonstratedin research
c. Traditional monitoring
9. Why should referral to a registered dietitian be made atthe time of GDM diagnosis?
a. It can help the woman improve her cooking skills.
b. It can help the woman lose weight.
c. It can reduce the womans risk for needing diabetesmedication as the pregnancy progresses.
10. In a 2008 case-control study of 30 overweight pregnantwomen, what exercise regimen lowered the womens meanglucose levels and decreased the frequency and amount ofinsulin needed?
a. Cycling 3to 4days per week for at least 6weeks
b. Swimming 3to 4days per week for at least 6weeks
c. Walking 3to 4days per week for at least 6weeks
11. Which of the following is true of birth timing for womenwith obesity and GDM?
a. If a woman has experienced good glycemic control
throughout her pregnancy and has no medical indica-tions, there is insufficient evidence to support induc-ing labor before 39weeks.
b. Regardless of glycemic control, inducing labor early isgenerally recommended to reduce risk for complica-tions such as shoulder dystocia.
c. Women with GDM and obesity should never beinduced because of risk of complications associatedwith induction.
12. When lifestyle modifications do not achieve desired glyce-mic control, which pharmacologic agent is the preferredfirst-line treatment for GDM in women with obesity?
a. Glyburide
b. Metformin
c. Short-acting insulin