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Gestational Diabetes

Gestational Diabetes. Adapted from: Turok DK, Ratcliff SD, Baxley EG. Management of Gestational Diabetes Mellitus. Am Fam Physician 2003; 68:1767-72. Gestational Diabetes. Defined as: Glucose intolerance that begins, or is first recognized, during pregnancy. Maternal Complications

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Gestational Diabetes

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  1. Gestational Diabetes Adapted from: Turok DK, Ratcliff SD, Baxley EG. Management of Gestational Diabetes Mellitus. Am Fam Physician 2003; 68:1767-72.

  2. Gestational Diabetes Defined as: • Glucose intolerance that begins, or is first recognized, during pregnancy

  3. Maternal Complications Increased risk of: Pre-eclampsia Cesarean delivery Future type 2 diabetes Fetal Complications Higher rates of: Perinatal mortality Macrosomia Birth trauma Hyperbilirubinemia Neonatal hypoglycemia Gestational Diabetes

  4. Gestational Diabetes Initial screening • 50g, 1 hr glucose challenge test • 24-28 weeks gestation Normal: <130mg/dL or <140mg/dL more sensitive & more false +’s

  5. If the screening test is abnormal… • 100g, 3 hr tolerance test • 3 days unrestricted diet • Overnight fast, 100g glucose load • Venous blood samples are taken (1, 2, and 3 hrs) *2 or more abnormal values = GD

  6. Gestational Diabetes Management • Blood glucose monitoring • Diet • Exercise • Insulin • Oral Hypoglycemic Medications

  7. Blood Glucose Monitoring • Diet-controlled diabetes • 4x per day, 2 days per week *If 2 values per week exceed limits, begin more intensive treatment (insulin)

  8. Diet • Ideal diet remains to be defined Current recommendations: • A diet that meets the needs of pregnancy but restricts CHO to 35-40% of daily calories

  9. Clinical Note • Elevated maternal serum ketone levels have been linked to reduced psychomotor development and IQ at 3-9 years (Rizzo, 1991 & 1995) Caloric restriction must be approached with caution!

  10. Exercise • Improves glycemic control *Has not been shown to affect perinatal outcomes

  11. Insulin >105mg/dL (fasting) and >120mg/dL (2hrs after meals) • Reduced incidence of: • Macrosomia Less evidence: • Operative delveries • Birth trauma

  12. Oral Hypoglycemic Medications glyburide (Micronase), metformin (Glucophage) • Not recommended • teratogenicity? • transport across the pacenta? • neonatal hypoglycemia More research is needed…

  13. Gestational Diabetes Antenatal Testing Recommended if: • blood glucose levels are not well controlled • required insulin therapy • concomitant hypertension • Nonstress test OR • Modified biophysical profile OR • nonstress test & amniotic fluid index • Full biophysical profile

  14. Gestational Diabetes Delivery • Most common complication = shoulder dystocia • 31% of neonates weighing >4,000g* • Data does not support the use of C-section to avoid birth trauma *13% error rate estimating fetal weight by untrasound

  15. What is a reasonable approach? Offer elective C-section • Estimated fetal weight >4,500g • Patient history and pelvimetry • Discuss risks and benefits

  16. No indications to pursue delivery before 40 weeks in patients with good glycemic control… *Unless other maternal or fetal indications are present

  17. Gestational Diabetes Postpartum Management • Insulin resistance resolves quickly • rarely require insulin in the postpartum period • Breastfeeding • improves glycemic control

  18. Postpartum Management (cont’d) • Higher risk for developing type 2 diabetes in the future • Should be tested 6 weeks after delivery • Screened annually thereafter • Should be counseled about diet and exercise

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