Gestational Diabetes

By Lisa Tang, MD August 10, 2005

Case Presentation:
Mrs. N.M. is 24 y.o. G1P0 overweight woman at 8 wks by LMP who recently found out she was pregnant, presented to the ED with two weeks hx of polydipsia and polyuria. Random blood sugar was 239. UA noted for 3+ glucose. Pt was discharged from the ED and arranged to have follow up for prenatal visit.

Case Presentation-cont:
PMH: None Meds: None SH: From Mexico, has been in the U.S. x 6 yrs Unplanned but desired pregnancy FOB in Mexico Good social support lives with her parents High school education Used to smoke, 1 pack/wk x 3 yrs, quitted in 7/04 Denies EtOH, and drugs

Allergies: NKDA
FH: No FH of DM

Gestational Diabetes (GDM) Epidemiology:

Diabetes Mellitus Complicates 3-5% of all pregnancies. Affects more than 200,000 women in the U.S. per year. Is a major cause of perinatal morbidity and mortality as well as maternal morbidity.

Gestational Diabetes (GDM) Epidemiology-cont:

GDM Represents approximately 90% of all cases of diabetes. Is especially common in populations with a higher rate of type 2 DM: -African Americans -Asian Americans -Hispanic Americans -Native Americans

Definition:
CHO intolerance of variable severity that begins or is first recognized during pregnancy. (1) Applies regardless of whether insulin is used for treatment or the condition persists after pregnancy. (1) Does not exclude the possibility that unrecognized glucose intolerance may have antedated the pregnancy. (1)

Modified Whites Classification of Diabetes in Pregnancy (6)

Class A: Abnormal GTT at any age or of any duration treated only by diet therapy A1 -Diet Controlled GDM A2 -Insulin-treated GDM

Pathophysiology:
Caused by placental production of human placental lactogen (HPL) and progesterone. Other hormones that may contribute include prolactin and cortisol.

Pathophysiology-cont:
Early in pregnancy, relatively higher levels of estrogen enhance insulin sensitivity. As placenta develops, estrogen decreases as HPL and progesterone rise, resulting in increased insulin resistance at the end organs. Insulin resistance is most marked in the third trimester at which time GDM most often occurs.

Pathophysiology-cont:
Insulin is the major fetal growth hormone . produces excessive fetal growth particularly in fat, the most insulinsensitive tissue.

Growth Abnormalities(1) Two Extremes Of Growth Abn:

Early Complications:
Congenital malformations in infants of mothers with chronic DM (1) Leading cause of perinatal mortality in pregnancies complicated by DM occurring in 6-12% of all infants Result of poor glucose control during the critical weeks of organogenesis, 5-8 wks of gestation

Infant of a Diabetic Mother with Sacral Agenesis

Cardiovascular anomalies: ASD, VSD Skeletal anomalies: sacral agenesis CNS anomalies Genitourinary anomalies: renal agenesis, polycystic kidneys

Late Complications:
The fetus is likely: to weigh > 4000 gram and be disproportionately large with increased risk of shoulder dystocia. to be at greater risk of intrauterine fetal death during the last 4-6 weeks of gestation. to be at higher risk of respiratory distress syndrome.

Screening:
Controversial whether all patients should be screened for GDM. The U.S. Preventive Services Task Force concludes that the evidence is insufficient to recommend for or against universal screening for GDM; screening for high risk women may be beneficial. (2) The American Diabetes Association has proposed that screening be limited to women with RF for GDM.

Screening-cont:
Women (at low risk) with ALL of the following characteristics need not be screened with a laboratory blood glucose test. Less than 25 years of age Normal body weight with BMI < 25 No first degree relative with DM Not a member of an ethnic group at increased risk for type 2 DM: women of Hispanic, African, Native American, South or East Asian or Pacific Islands ancestry No hx of abnormal glucose metabolism No hx of poor obstetric outcome

Screening-cont:
For women who do not meet the above criteria, screening should be conducted at 24 -28 wks of gestation with use of a 50 g one hour oral glucose load An abnormal one hour screening test with a venous plasma glucose of >140 mg/dL necessitates a full diagnostic 100 g three hours oral glucose tolerance test (GTT)

Screening-cont:
Women at high risk for GDM have the following characteristics: Personal past hx of GDM A strong FH of type 2 DM Marked obesity They should be tested as soon as possible and if initial screen is negative, be retested at 24-28 wks of gestation.

Dx of GDM with Use of a 100 gram Oral Glucose Load

Management:
The goal is to prevent adverse pregnancy outcomes. A multidisciplinary approach is used. Patient is seen every 1-2 wks until 36 wks gestation and then weekly. Patient is asked to keep an accurate diary of their blood glucose concentration.

Dietary Therapy:
Refer to a dietitian Recommend a complex, high fiber CHO diet Avoid concentrated sweets

When Dietary Therapy Fails:

Insulin Oral Hypoglycemic Agents: -Glyburide -Metformin

Insulin Regimen:
Pt should check their fasting glucose and a 1 hour or 2 hour postprandial glucose level after each meal, for a total of four determinations each day. If the fasting value is > 95 mg/dL, or 1 hr value > 130-140 mg/dL or 2 hr value > 120 mg/dL, insulin therapy needs to be initiated.

Insulin Regimen:

Alternative to Insulin Therapy Glyburide:

2nd generation sulfonylurea Does not cross the placenta Some physicians are using glyburide in lieu of insulin given its ease of use. Both the ACOG and ADA do not endorse the use of glyburide in the tx of GDM until additional RCTs support its safety and effectiveness.

Alternative to Insulin Therapy Metformin:

Is used as a tx for infertility in PCOS. Is a category B drug Hasnt been well studied for use in pregnancy. Both the ACOG and ADA do not endorse the use of metformin in the tx of GDM until additional RCTs support its safety and effectiveness.

Antepartum Testing:
First trimester u/s and a fetal echo to assess congenital cardiac anomalies. Second trimester u/s to assess fetal growth. Twice weekly testing NSTs and amniotic fluid volume determination beginning at 32 wks gestation to assess fetal wellbeing.

Delivery:
Early delivery may be indicated for: women with poor glycemic control pregnancies complicated by fetal abnormalities Otherwise, pregnancies are allowed to go to term.

Intrapartum:
The goal is to maintain normoglycemia in order to prevent neonatal hypoglycemia. Check patients glucose q1-2 hours. Start insulin drip to maintain a glucose level of between 80 - 110 mg/dL. Observe infant closely for hypoglycemia, hypocalcemia, and hyperbilirubinemia after birth.

Postpartum Care:
After delivery: Measure blood glucose. -fasting blood glucose concentrations should be <105 mg/dL and one hour postprandial concentrations should be < 140 mg/dL. Administer one half of the pre-delivery dose before starting regular food intake.

Postpartum Care-cont:
Follow up: Per American Diabetes Association, a 75 g two hours oral GTT should be performed 6-8 wks after delivery.

Postpartum Care-cont:
Follow up: If the pts postpartum GTT is normal, she should be re-evaluated at a minimum of 3 years interval with a fasting glucose. All pts should be encouraged to exercise and lose wt. All pts should be evaluated for glucose intolerance or DM before a subsequent pregnancy.

Management of Mrs. N.M:

First Trimester: Ht: 60 inches Current Wt: 179 lbs Pre-pregnancy Wt: 155 lbs Routine prenatal labs: wnl HgbA1C: 8.8 19 wks u/s: normal, with EDD 5/13/2005 Fetal echo was done at 20 wks with BPD and FL c/w stated GA. No obvious structural or functional fetal heart dz.

Management of Mrs. N.M-cont:

Initial prenatal visits issues addressed: Diabetic teaching-including how to use a glucometer and how to inject insulin. Pt was educated about the signs of hypoglycemia and was told to eat small snacks if that happen. Self monitoring and diet modification Exercise pt began to walk daily x 30 mins

Management of Mrs. N.M-cont: Second Trimester:

Level II U/S was done. Result was normal with a single IUP, posterior placenta and no e/v of placenta previa. Size=Date Insulin regimen consisted of NPH and Lispro was initiated. HgbA1C: 5.0

Management of Mrs. N.M-cont:

Third Trimester: Biweekly antenatal testing began. Insulin regimen was adjusted according to increased needs. HgbA1c: 5.3 Two more u/s were done with normal fetal growth.

Delivery:
Pt had NSVD on 5/7/2005 at 39 wks of gestation. She delivered a healthy boy, B.M. with wt 2895 g (6 lb 6 oz) and Apgar 8, 9. Delivery was complicated by 1st deg lac. Blood sugar was monitored q2 and insulin drip per protocol was used.

Postpartum:
Insulin regimen was decreased to of her previous regimen. Given that Mrs. N.M.s RF and elevated HgbA1c at presentation, she most likely has pre-existing DM Type II.

Now:
On metformin 500 mg po daily the first week, then BID after Mrs. N.M. is breastfeeding. Her mother has been helping her out with child care. Baby boy, B.M. is growing appropriately and meeting all his developmental milestones.

Take Home Message:

As obesity increases in the U.S., the rate of gestational diabetes will rise. All pregnant women should be screened for GDM, whether by pts hx, clinical risk factors, or a lab screening test to determine blood glucose levels. (3) It is important that multidisciplinary approach be used to improve pregnancy outcome.

Questions?

Bibliography:
Gabbe, Steven MD and Graves, Cornelia R MD, Management of Diabetes Mellitus Complicating Pregnancy, Obstetrics & Gynecology 2003;102(4):857-868 Turk, David K MD, MPH, Ratcliffe, Stephen D, MD, and Baxley, Elizabeth G. MD, Management of Gestational Diabetes Mellitus, Am Fam Physician 2003;68:1767-72,1775-6 ACOG Practice Bulletin No 30 Gestational Diabetes. Volume 98 No 3 September 2001 Jovanovic, Lois MD, Screening and Diagnosis of Gestational Diabetes Mellitus, Up to Date version 13.2 Jovanovic, Lois MD, Treatment and Course of Gestational Diabetes Mellitus, Up to Date version 13.2 Barss, Vanessa MD and Blatman, Robert N. MD, Obstetrical Management of Pregnancy Complicated by Diabetes Mellitus, Up to Date version 13.2 USPSTF Guidelines: Screening for Gestational Diabetes: Recommendations and Rationale ADA Position Statement: Gestational Diabetes Mellitus