Discussion Postings on Universal Screening for GDM

I have listed four discussion postings regarding Universal Screening for Gestational Diabetes Mellitus and i need you to look at each posting and individually state whether you agree or disagree and why you agree or disagree. Please number your response to each. Choose two with opposing viewpoints and respectfully defend your stance until you either agree or agree to disagree. Remember to justify your stance with facts. 1)At the present time I would have to say that I am not for universal screening for GDM. The tests are not 100% accurate and I believe this can lead to unnecessary treatment for the mother and possibly harm the infant. Other issues can include more cost to the mother for prenatal care because she will be considered high risk. If she is considered to have GDM she will most likely be subjected to early induction, aggressive management protocols and more c-sections that may not be necessary and could possibly put her and the baby's life at risk. The RN's role is keep her personal opinion to herself and explain the facts to the patient. You can give the pros and cons and what the test will include and what the follow up would be if it came back high. If the patient decides to be tested then the nurse will make sure she comes in at the correct time in her pregnancy to be tested. Pros "Some women may be undiagnosed diabetics or have been tipped into true diabetes by the extra demands of pregnancy (about 1 in 1,000 pregnant women). Screening will reveal this. Developing gestational diabetes in pregnancy indicates higher risk for developing true diabetes later in life. This may provide greater motivation to lose weight and exercise regularly, which may reduce this risk.(1) Cons "Neither the OGTT nor the screening test are reliable tests in that they give different results when repeated in the same person. In addition, blood glucose values rise as pregnancy advances, but no adjustments are made for this. This means you could “fail” a test in week 28 that you would have “passed” had you taken it in week 24. The various thresholds used to diagnose GD are purely arbitrary. None of them correlate with the appearance of or a marked increase in complications. Studies fail to show that treatment reduces adverse outcomes such as overlarge babies. However, being identified as a gestational diabetic greatly increases the chance of having a cesarean simply because of the diagnosis, not because of problems such as overlarge baby. For these reasons, several organizational bodies have opposed GD testing. A Guide to Effective Care in Pregnancy and Childbirth, the bible of evidence-based care, relegates screening, diet, and diet plus insulin to “Forms of Care Unlikely to be Beneficial.” The American College of Obstetricians and Gynecologists says no data support the benefits of screening. The U.S. Preventative Services Task Force and the Canadian Task Force on the Periodic Health Examination both conclude that there is insufficient evidence to justify universal GD screening."(2) (1,2)Quoted from: http://www(dot)plus-size-pregnancy(dot)org/gd/gdinsulin.htm#The Debate About Stricter Treatment Protocols: A Brief Overview Ethical Issues "Proponents would also claim that simply by lowering the rate of macrosomia, they have probably prevented a whole host of problems for the child as it grows. In reality, there is no way to know if that is true yet. There are no studies showing this conclusively; in fact, there is VERY little long-term follow-up of gd children at all, let alone comparing the long-term outcome between modes of treatment. This raises one of the most troubling questions of all: what is the long-term effect on the children given this extremely aggressive insulin treatment? Most of the time, researchers simply note that the babies turned out smaller, congratulate themselves, and pat themselves on the back in the journals. But is this REALLY better for the babies? Are there any consequences to using large amounts of exogenous insulin during pregnancy, at levels mostly unexperienced by the majority of women? Is it proven to be SAFE to use such aggressive treatment?(3) Another troubling question is whether it is healthy to try to alter a baby's birth weight. Henci Goer, a strong critic of traditional gd treatment protocols, says "The price of reducing macrosomia is the manipulation of the primary growth mechanism of infants, roughly 80% of whom would not be LGA if they were left alone. And this, like GD itself, presumes without evidence that this physiologic variation in birth weight is pathological." In other words, artificially reducing the natural birth weight of a baby may be dangerous. Nine pound babies may just be a variation of normal, not necessarily an indication of abnormality, disease, or macrosomia caused by excessive blood sugar and hyperinsulinemia. Genetics may play a role as well, and what will using unneeded insulin do to babies that nature intended to be larger anyhow? (4) Numerous studies have shown that low-birthweight babies are at especially high risk for diabetes, heart problems, and other health difficulties later in life, and other studies have shown that *extremely* tight diabetic protocols have caused an increase in the number of SGA [Small-for-Gestational-Age] babies. What if extreme treatment to bring a normally 9 lb. baby down to an 'acceptable' level of 7.5 lbs. actually exposes him to this same type of risk? In essence, a baby who is genetically supposed to be 9 lbs. but whose birthweight is reduced through aggressive treatment is being born 'underweight'. Is that baby's health going to be improved or vastly put at risk? Do these aggressive protocols to reduce the size of 'macrosomic' babies really improve the baby's health in the long run by preventing a 'misprogramming' of its metabolism, or does it skew its metabolism by trying to alter its primary growth rate? These are very troubling and confusing questions, but the most troubling problem of all is that THESE QUESTIONS ARE NOT EVEN BEING ASKED BY RESEARCHERS."(5) 2) The pros for universal screening of GMD are first of all that EBP shows that a successful treatment GMD will decrease the chance of fetal or maternal fatalities. Problems that can arise for a fetus increase in size (LGA) and weight in which can be problematic for the neo natal and mother. Furthermore, this can cause hypoglycemia and breathing difficulties for the baby. It has been found that children who have been born with LGA can develop diabetes and possibly become obese. For the mother the birthing of the baby can be very complicated and may result in c- section. The mother could also have long term effects and develop diabetes after pregnancy. The cons Screening all patients for GMD may give a large amount of false positives, thereby wasting resources, causing worries for the patient, to counter this some studies therefore suggest limiting screening to women displaying risk factors like obesity, family history and ethnicity. As a nurse it is essential that we recognize our role as advocates for women and thereby support and encourage. Other nursing implications that are important in this scenario is healthy diet, moderate exercise and monitoring blood glucose. The legal and/or ethical implications, including the patient's right to refuse care “Pregnant women's autonomous decisions should be respected. Concerns about the impact of maternal decisions on fetal well-being should be discussed in the context of medical evidence and understood within the context of each woman's broad social network, cultural beliefs, and values. In the absence of extraordinary circumstances, circumstances that, in fact, the Committee on Ethics cannot currently imagine, judicial authority should not be used to implement treatment regimens aimed at protecting the fetus, for such actions violate the pregnant woman's autonomy.” The role of the registered professional nurse is to give informed EBP education to the patient , the nurse must also use critical thinking while assessing the patient to create a care plan that has realistic, safe outcomes. However, Drs orders may be to test all pregnant patients this in turn creates a sticky situation. 3)Gestational diabetes mellitus, or GDM, is a carbohydrate intolerance that begins or is recognized during pregnancy. The Committee on Obstetric Practice recommends that all pregnant women be screened for GDM by patient history, clinical risk factors or a 1- hour glucose test at 24-28 weeks of gestation. The American Diabetes Association also recommends that pregnant women who have risk factors be tested at their first prenatal visit. GDM has risks to the fetus and infant as well as the mother. It can cause oversized infant, which can lead to trauma at birth. It can also cause hypoglycemia at birth, premature birth, jaundice, and type 2 diabetes later in life. There are also risks to the mother. These include greater risk of caesarian section, preeclampsia, and later development of type 2 diabetes. The pros of universal screening include possible diagnosis prior to development of complications. If the patient is aware of the presence of GDM, lifestyle changes can be made to decrease chances of developing preeclampsia during pregnancy or type 2 diabetes after pregnancy. It can also decrease risks to the newborn. The increasing occurrence of GDM in the United States may be curtailed by the implementation of universal screening. The healthcare cost is a con to universal screening. There is some disparity as to when and what method of screening should be done. By screening at the first prenatal visit, there may be an increase of diagnoses of GDM, which may actually be an undiagnosed type 2 diabetes. There is also the emotional affect to be considered to the patient and family. Screening for GDM may cause additional anxiety to the patient, due to the testing process and the possibility of negative results. The patient always has the right to refuse any treatment or testing. Legally, this needs to be respected. It is an ethical issue to a healthcare provider if there is a strong possibility of the patient having GDM and not being screened. This leaves the fetus at risk. The legal and ethical issues deal with the fact that there are two patients receiving care. The rights and concerns of the fetus need to be considered. The professional nurse has a duty to educate the patient on all possible outcomes of any decision of care. In this case, the risks associated with GDM to both the patient and her growing fetus. The nurse in this situation should thoroughly explain the testing procedure. By being screened, the patient increases her chance of an uncomplicated pregnancy and delivery. 4)Even mild hyperglycemia during pregnancy can have negative outcomes for the developing fetus such as cardiac and respiratory conditions, hypoglycemia and other metabolic abnormalities, and even still birth. Gestational diabetes mellitus (GDM) also has maternal risks such as higher incidence of pre-eclampsia and surgical intervention for delivery, and excessive amniotic fluid. In cases of GDM there is also the risk of insulin resistance which predisposes the mother to other possible complications such as cardiac disease and vascular accidents (Kendrick, 2011). Patients with GDM also have an increased risk for obesity (Kendrick, 2011). Their offspring carries this same risk which could be contributing to the prevalence of obesity in our country. Just knowing about the risks involved with GDM, I believe that universal screening is important. There are too many complications that could be prevented with universal testing. Pros would include early detection and treatment with possible avoidance of complications, decreased costs if complications can be successfully avoided, and empowerment for the patient to make healthy choices that could impact both herself and her child. Cons for the International Association of Diabetes in pregnancy Study Groups (IADPSG) recommended standards include financial implications, burden on clinics due to early morning appointments for fasting tests, increased number of GDM diagnosis with increased need for nutritionists, testing supplies, and further burden on the system related to increased monitoring of this condition, possible unnecessary treatment/testing related to inaccurate test results, burden on patients to comply with early appointments for testing. For legal/ethical implications I would agree that the patient has a right to refuse treatment but what about the proven medical implications refusing treatment could have on the fetus? If this patient has risk factors then the decisions they make do not just affect them as they could potentially have GDM. This would be one for the ethics department for sure, and if I was one of the nurses caring for this patient I would ask to be a part of that discussion.