GESTATIONAL DIABETES

What is gestational diabetes? Is a condition in which women without previously diagnosed diabetes exhibit high blood glucose levels during pregnancy. "Gestational" diabetes implies that this disorder is induced by pregnancy, perhaps due to exaggerated physiological changes in glucose metabolism is formally defined as "any degree of glucose intolerance with onset or first recognition during pregnancy" Its medical name is gestational diabetes mellitus or GDM different with OVERT DIABETES patients known to have diabetes even before pregnancy prevalence may range from 1 to 14% of all pregnancies, and more than 200.000 cases annually What causes gestational diabetes? No specific cause has been identified, but it is believed that the hormones produced during pregnancy reduce a woman's sensitivity to insulin, resulting in high blood sugar levels. Why do some women develop gestational diabetes? Our body normally makes a hormone called insulin that moves glucose out of the blood and into the cells of the body. Women with gestational diabetes develop resistance to insulin and cannot move glucose into the cells. This causes the blood sugar level remain too high Almost all women have some degree of impaired glucose intolerance during pregnancy as a result of hormonal changes that occur during pregnancy. That means that their blood sugar may be higher than normal, but not high enough to have diabetes. During the later part of pregnancy (the third trimester), these hormonal changes place pregnant woman at risk for gestational diabetes. The placenta is a system of vessels that passes nutrients, blood, and water from mother to fetus. The placenta makes certain hormones that may prevent insulin from working the way that it should. When this condition happens, it is referred to as insulin resistance. In order to keep metabolism normal during pregnancy, the body has to make three times more insulin than normal to offset the hormones made by the placenta. For most women, the bodys extra insulin is enough to keep their blood sugar levels in the healthy range. But, for about 5% of pregnant women, even the extra insulin is not enough to keep blood sugar levels normal. These women end up with high blood sugar or gestational diabetes at around the 20th to 24th week of pregnancy Whos at risk for gestational diabetes? A previous diagnosis of gestational diabetes or prediabetes, impaired glucose tolerance, or impaired fasting glycaemia [H] A family history revealing a first degree relative with type 2 diabetes [H] Maternal age - a woman's risk factor increases the older she is (especially if older than 35 years of age) Ethnic background (those with higher risk factors include African-Americans, North American native peoples and Hispanics) Being overweight, obese or severely [H] Previous pregnancy which resulted in a child with a high birth weight (>90th centile, or >4000g) [H] 1

 Previous poor obstetric history Diagnosis of polycystic ovarian syndrome [H] Presence of glycosuria [H] How to know if pregnant woman have diabetes mellitus? Frequently women with gestational diabetes exhibit no symptoms, so women who are at very high risk should undergo testing as soon as possible. All pregnant women should be screened for gestational diabetes at 24-28 weeks gestation, including those with negative test result in the first trimester (low risk). Diagnosis criteria for Gestational diabetes Perform blood glucose testing at 24-28 weeks using one of the following One-step protocol: 75gr, 2hr Oral Glucose Tolerance Test on all women, normally : Fasting 1 hour 2 hour 3 hour <95 mg/dL (5,3 mmol/L) <180 mg/dL (10 mmol/L) <155 mg/dL (8,6 mmol/L) <140 mg/dL (7,8 mmol/L)

Two-step protocol: 50gr, 1hr plasma glucose on all women: if test done in fasting state, threshold is >130 mg/dL (>7,2mmol/L); if test done in fed state, threshold is >140 mg/dL (>7,8mmol/L). Then test with 100 gr 3hr, in fasting state: Fasting 1 hour 2 hour 3 hour <95 mg/dL (5,3 mmol/L) <180 mg/dL (10 mmol/L) <155 mg/dL (8,6 mmol/L) <140 mg/dL (7,8 mmol/L)

If one value is abnormal or exceed any of these threshold, repeat test in 4 weeks. One abnormal value on 3hr GGT can increased risk for fetal macrosomia.

Potential risk of unrelated gestational diabetes 1. Maternal complication Increased risk for caesarean delivery Higher risk of preeclampsia Diabetic ketoacidosis Coronary artery disease Diabetic Nephropathy Retinopathy 2. Fetal complication Large for gestational age (macrosomia) Macrosomia in turn increase the risk of instrumental deliveries (e.g. forceps, ventouse, and caesarean section) Problems during vaginal delivery (such as shoulder dystocia) Stillbirth Neonates are also at an increased risk of low blood glucose (hypoglycemia), jaundice, high red blood cell mass (polycythemia) and low blood calcium (hypocalcemia) and magnesium (lypomagnesemia) 3

 GDM also interfere with maturation, cause dysmature babies prone to respiratory distress syndrome due to incomplete lung maturation Become obese as children or adults Higher risk for developing diabetes 2 in adulthood and may get it at a younger age Gestational diabetes usually does not cause birth defects or deformities. Most developmental or physical defects happened during the first trimester of pregnancy, and GDM typically develops around the 24th week of pregnancy Prognosis Gestational diabetes generally resolves once the baby is born. Based in different studies, the chances of developing GDM in a second pregnancy are between 30-84%, depending on ethnic background A second pregnancy within 1 year of the previous pregnancy has a higher rate of recurrence Management GDM is divided into two categories: A1 (glucose control by diet alone) and A2 (glucose control with diet and insulin). If glucose levels cannot be controlled with diet alone, then insulin therapy should be started.

Insulin Treatment: Do not give oral hypoglycemic agents. These are contraindicated during pregnancy Initiation : 2/3 of daily dosage before breakfast and 1/3 of daily dosage before supper Note: Aim for normal blood glucose (FBS =105 and Two-hour postprandial blood glucose of < 140 mg/dl. More stringent regimens of administering short-acting subcutaneous insulin three times a day before meals and intermediate insulin at bedtime to control overnight and fasting glucoseor of continuous subcutaneous insulin infusion with portable pumpis necessary to achieve normoglycemia in many women. 4

Insulin requirements increase throughoutgestation, from approximately o 0.7 U/kg (body weight)/day during weeks 618 o 0.8 U/kg/day during weeks 1826, o 0.9 U/kg/day during weeks 2636, and o 1.0 U/kg/day during weeks 3640.

Goal for glucose control - Fasting: 6090 mg/dL - Premeal: less than 100 mg/dL - 1 hour postprandial: less than 140 mg/dL - 2 hours postprandial: less thAn 120 mg/dL - Bedtime: less than 120 mg/dL - 26 am: 6090 mg/dL Postpartum Evaluation (Follow up) Encourage for breastfeeding In this period, perform 75-gr 2hr OGGT at 6-12 weeks postpartum If the tresold values are met or exceeded in follow up testing, the patient should then be followed and treated for overt DM.

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Patient should be placed back on an ADA diet (with increased soluble fiber and reduced fat). She should do a lifestyle assessment and attempt to keep her weight near ideal for her height. Weight reduction is generally necessary, and thus, if the patient is not breastfeeding, calories are reduced to12001500 kcal with repeat dietary instruction, and the same calorie ADA diet is continued as the patient is breastfeeding. The caloric demand of breastfeeding increases with neonatal size but can reach 8001200 kcal per day. Exercise equivalent to expend the energy is to run hard for 1 hour (900 kcal). It takes 3500 kcal expended to reduce weight by 1 pound! She should enter a regular exercise program.