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
 DEFINITION
 Gestational diabetes is formally defined as "any
degree of glucose intolerance with onset or first
recognition during pregnancy".
 This definition acknowledges the possibility that
patients may have previously undiagnosed
diabetes mellitus, or may have developed
diabetes coincidentally with pregnancy. Whether
or not symptoms subside after pregnancy is also
irrelevant to the diagnosis
 GESTATIONAL DIABETES – diabetes
diagnosed during pregnancy
 Undiagnosed PDM – during first half of
pregnancy
 GDM – during the late part of gestation

 OVERT DIABETES – patients known to

have diabetes even before pregnancy
What causes this?
 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.
PATHOPHYSIOLOGY
 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.
 During pregnancy, increased levels of
certain hormones made in the placenta
(the organ that connects the baby by the
umbilical cord to the uterus) help shift
nutrients from the mother to the
developing fetus. Other hormones are
produced by the placenta to help prevent
the mother from developing low blood
sugar. They work by stopping the actions
of insulin.
 Over the course of the pregnancy, these
hormones lead to progressive impaired
glucose intolerance (higher blood glucose
levels). To try to decrease the glucose
levels, the body makes more insulin to
shuttle glucose into cells.
 Usually the mother's pancreas is able to
produce more insulin (about three times
the normal amount) to overcome the effect
of the pregnancy hormones on glucose
levels. If, however, the pancreas cannot
produce enough insulin to overcome the
effect of the increased hormones during
pregnancy, glucose levels will rise,
resulting in gestational diabetes.
PATHOPHYSIOLOGY
EPIDEMIOLOGY
 Gestational diabetes affects 3-10% of
pregnancies, depending on the population
studied
 It occurs in between 5 and 10% of all
pregnancies (between 1-14% in various
studies).
RISK FACTORS
A previous diagnosis of gestational
diabetes or prediabetes, impaired
glucose tolerance, or impaired fasting
glycaemia
 A family history revealing a first
degree relative with type 2 diabetes
 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 obese
increases the risk by a factor 2.1, 3.6 and 8.6,
respectively.
 Previous pregnancy which resulted in a child
with a high birth weight (>90th centile, or >4000
g)
 Previous poor obstetric history
SIGNS AND SYMPTOMS
 Frequently women with gestational
diabetes exhibit no symptoms
 However, possible symptoms include
 increased thirst,
 increased urination,
 fatigue,
 nausea and vomiting,
 bladder infection,
 yeast infections and
 blurred vision.
DIAGNOSIS
 PregestationalDM (DM prior to pregnancy)
Diagnosis:
 FBS > 126 mg/dl on 2 occasions or
 RBS > 200 mg/dl or

 75 gm 2 hour OGIT > 200 mg/dl

 . Gestational DM
 A. Screening test (at 24-28 weeks usually or
earlier): 50 gm 1 hour Oral Glucose Challenge
of > 140 mg/dl or 7.8mmol/L
 b. If (+) screening test do Gold Standard For
Gestational DM Diagnosis: 100 gm 3 hour
Oral Glucose Tolerance test (OGTT) after an
overnight fast of 8-14 hours
DIAGNOSIS

TIMING OF Plasma Glucose Plasma Glucose

MEASUREMENT mg/dL mg/dL
National Diabetes Carpenter and
Group (1979) Coustan (1982)
Fasting 105 95
1 hour 190 180
2 hour 165 155
3 hour 145 140

If two values are above normal then the patient is + Gestational

DM.
MATERNALCOMPLICATIONS
 Increased risk for Cesarean Delivery
 Higher risk of Preeclampsia
 Diabetic ketoacidosis
 Coronary Artery Disease
 Nephropathy
 Retinopathy
FETAL COMPLICATIONS
 Large for gestational age (macrosomic)
 Macrosomia in turn increases the risk of
instrumental deliveries (e.g. forceps, ventouse
and caesarean section)
 Problems during vaginal delivery (such as
shoulder dystocia).
 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
(hypomagnesemia).
Potential Congenital Fetal
Anomalies
 1.CNS: spina bifida, anencephaly, holoprosencephaly,
hydrocephalus

 2.Cardiac (most common): transposition of the great vessels,

ventricular septal defect, atrial septal defect, hypoplastic left heart,
cardiac hypertrophy, anomalies of the aorta

 3.GI: tracheoesophageal fistula, anal/rectal atresia

 4.Genitourinary: renal agenesis, double ureter, cystic kidneys

 5.Skeletal: caudal regression syndrome (most specific)

 6.Situs inversus
 GDM also interferes with maturation,
causing dysmature babies prone to
respiratory distress syndrome due to
incomplete lung maturation
PROGNOSIS
 Gestational diabetes generally resolves
once the baby is born.
 Based on different studies, the chances of
developing GDM in a second pregnancy
are between 30 and 84%, depending on
ethnic background.
 A second pregnancy within 1 year of the
previous pregnancy has a high rate of
recurrence
WHITE CLASSIFICATION
 Named after Priscilla White who pioneered
in research on the effect of diabetes types
on perinatal outcome, is widely used to
assess maternal and fetal risk.
 It distinguishes between gestational
diabetes (type A) and diabetes that
existed prior to pregnancy (pregestational
diabetes).
 Emphasizes that end organ
derangements, especially involving the
eyes, kidneys, have significant effects on
pregnancy outcomes
CLASS ONSET FASTING 2 HOUR THERAPY
PLASMA POST
GLUCOSE PRANDIAL
GLUCOSE
A1 Gestational <105mg/dl <120mg/dl Diet

A2 Gestational >105mg/dl >120mg/dl Insulin

CLASS AGE OF DURATION VASCUAL THERAPY
ONSET (YEARS) R
DISEAS
E
B Over 20 <10 None Insulin

C 10 – 19 10 – 19 None Insulin

D Before 10 >20 Benign Insulin

Retinopathy

F Any Any Nephropathy Insulin

R Any Any Proliferative Insulin

nephropathy

H Any Any Heart insulin

MANAGEMENT
GENERAL
 The patient with GDM is at higher risk of
developing glucose intolerance later in life.
 Approximately 40% of women with GDM
develop DM within 15 years.
 GDM may be an early manifestation of DM
type 2 that is temporarily unmasked by the
diabetogenic hormones of pregnancy.
 Women with GDM are commonly treated
on an outpatient basis.
 The primary focus for women with GDM is
dietary control of glucose intake and
adequate monitoring of glucose values.
 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.
DIET
 Diabetic Diet
 To provide the
necessary nutrients
for the mother and the
fetus
 To control glucose
levels
 To prevent starvation
ketosis
RECOMMENDED DAILY CALORIC
INTAKE AND PREGNANCY WEIGHT
GAIN IN WOMEN WITH GESTATION DM
CURRENT DAILY CALORIC RECOMMENDED
WEIGHT IN INTAKE PREGNANCY
RELATION TO (Kcal/Kg) WEIGHT GAIN
IDEAL BODY (LBS)
WEIGHT
<80-90% 36-40 28-40

80-120% (ideal) 30 25-35

120-150% 24 15-25

>150% 12-18 15-25

DIABETIC DIET
 Ideal Body Weight = [(Height in inches X
2.54) - 100] - 10% (if female)
 Ideal Body Weight X 35 cal/Kg = Total
calories/day
SAMPLE DIET
Total calories = 1800-2400 cal/day
 60% Carbohydrate: Total cal/day X 0.60 =
1200 cal /4 = 300gm carbo
 20% Protein: Total cal/day X 0.20 = 400
cal / 4 = 100 gm protein
 20% Fat: Total cal/day X 0.20 = 400 cal / 9
= 45 gm fat
PRECONCEPTUAL AND
PREGNANCY WORKUP
 The patient should have a preconceptual history and
physical examination, an ophthalmologic examination,
and measurement of an ECG..
 The patient should be advised to maintain tight glucose
level control.
 Measurement of HbA1C may be helpful in evaluating
glucose control and assessing risk of fetal
malformations.
 HbA1C levels of 10% or higher are associated with
significant risk of fetal malformations. If the HbA1C level
is within the normal range, risk appears to be similar to
that of nondiabetic women.
 A 24-hour urine measurement of
creatinine clearance and protein excretion
should also be performed for evaluation of
kidney function.
 The patient should be started on folate
400 µg/day for spina bifida prophylaxis.
 The patient should be encouraged to
maintain an appropriate activity level or
exercise program.
FETAL MONITORING
FIRST TRIMESTER
 minimal fetal monitoring is required (i.e.,
assessment for heart tones by Doppler
ultrasonography at each visit during the
latter portion of the first trimester).
SECOND TRIMESTER
 Measurement of maternal serum alpha-
fetoprotein levels, along with levels of
unconjugated estriol and human chorionic
gonadotropin, represents the triple screen, which
is typically performed at 16–18 weeks' gestation.
 Ultrasonography (usually at 18–20 weeks) helps
to date the pregnancy and evaluate the fetus for
genetic abnormalities and other congenital
anomalies that may be present.
 Fetal cardiac anomalies are the most common
congenital anomalies with PDM, and so a fetal
echocardiogram is recommended at 19–22
weeks' gestation.
 THIRD TRIMESTER
 Regular fetal surveillance should be initiated for
all pregnancies in insulin-requiring diabetic
women.

 Fetal surveillance should be performed frequently

in the presence of maternal vascular disease,
hypertension, ketoacidosis, pyelonephritis,
preeclampsia, and poor patient compliance.

 In well-controlled DM without associated

complications of hypertension and vascular
disease, minimal ongoing evaluation of the fetus
may be required.
 In poorly controlled or complicated DM, the incidence of
fetal compromise and death is much higher, and
therefore frequent fetal evaluation is required.

 Repeat obstetrical ultrasonographic examinations for

fetal growth may be considered at 28–30 weeks and
then at 36–38 weeks.

 If the patient has evidence of microvascular disease,

monthly ultrasonographic examinationS starting at 24–26
weeks may be necessary to closely follow fetal growth to
assess for intrauterine growth restriction (IUGR).

 Tests commonly used for fetal assessment are the

nonstress test, biophysical profile, and contraction stress
test.
MEDICAL
TREATMENT
INSULIN TREATMENT
 Do not give oral hypoglycemic agents.
These are contraindicated during
pregnancy
 Sample Insulin Regimen:
 i.Humulin N (intermediate) or Humulin U
(Ultralente - long acting ) OD in a.m.
 ii.Humulin N & R combination (intermediate &
short acting) at 6 a.m. and 6 p.m.
 (2/3 of daily dosage to be given at 6 AM
and 1/3 of daily dosage at 6 p.m.)
 Note: Aim for normal blood glucose

(FBS =105 and Two-hour postprandial

blood glucose of < 140 mg/dl.
 Insulin requirements increase throughout
gestation, from approximately

0.7 U/kg (body weight)/day during

weeks 6–18, to
0.8 U/kg/day during weeks 18–26, to
0.9 U/kg/day during weeks 26–36, and
to 1.0 U/kg/day during weeks 36–40.
GOALS FOR GLUCOSE CONTROL

 Fasting: 60–90 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
 2–6 am: 60–90 mg/dL
TREATMENT
 Control diabetes at
first 6 weeks AOG to
prevent birth defects
 Deliver baby ideally at
36-37 weeks AOG
POSTPARTUM EVALUATION
 In the postpartum period, a woman with GDM
(A1 and A2) should have a follow-up GTT at 6–
12 weeks postpartum to assess for possible
PDM.
 The recommended test to further evaluate for
overt DM is as follows:
a fasting blood glucose value is taken, then
 a 75-g oral glucose load is administered, then
 a 2-hour glucose level is measured.
 If the threshold values are met or exceeded in follow-
up testing, the patient should then be followed and
treated for overt DM.
TIME SINCE 75g NO DM IMPAIRED OVERT DM
GLUCOSE GLUCOSE
LOAD TOLERANCE

FASTING < 110 mg/dl 110 – 125 > OR

mg/dl EQUAL TO
125 mg/dl
2 HOUR < 140 mg/dl 140 – 199 > OR
mg/dl EQUAL TO
200 mg/dl
 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 to
1200–1500 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 800–1200 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.
THANK YOU!!!