CLINICAL DIABETES

VOL. 17 NO. 3 1999

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CASE STUDIES
Case Study: A 34-Year-Old Woman in Her
Second Pregnancy at 24 Weeks Gestation
Steven G. Gabbe, MD
Presentation
A34-year-old Hispanic-American woman who is in her second pregnancy and has had
one live birth and no abortions is seen for prenatal care at 24 weeks gestation. Her weight
is 220 lb, and her blood pressure is 130/80 mmHg. Uterine size is appropriate for
gestational age. The patient's past obstetric history includes the spontaneous vaginal
delivery of a 9 lb, 8 oz. male infant at 40 weeks gestation, 8 years ago in Mexico. The
patient reports that the child is doing well. Her family history reveals that her mother has
type 2 diabetes mellitus. A urine dipstick shows 3+ glycosuria and negative ketones.
Questions
1. What tests should be done to evaluate the patient's glucose tolerance?
2. How is the diagnosis of gestational diabetes mellitus (GDM) established?
3. What would be the best treatment and follow-up strategy?
Commentary
This patient presents with several risk factors for GDM, defined as carbohydrate
intolerance of varying degrees of severity with onset or first recognition during pregnancy,
regardless of whether insulin is used for treatment or the condition persists after pregnancy.
She is over 30 years of age, from an ethnic group at increased risk for type 2 diabetes
mellitus, is obese, and has a first-degree relative with type 2 diabetes.
The findings of significant glycosuria should prompt the performance of a glucose
determination before the patient leaves the clinic. The usual approach to screening would
be a 50-g oral glucose load administered to the patient between 24 and 28 weeks
gestation when the "diabetigenic stress" of pregnancy is present. A positive test is a venous
plasma glucose value 1 hour later of > 140 mg/dl. This would lead to a 100-gm oral
glucose tolerance test (OGTT) with the diagnosis of GDM made if two of the following
values are met or exceeded: fasting, 95 mg/dl; 1-hour, 180 mg/dl; 2-hour, 155 mg/dl; and
3-hour, 140 mg/dl. These cutoff values are those proposed by Carpenter and Coustan and
recommended most recently by the Fourth International Workshop-Conference on
Gestational Diabetes Mellitus and the American Diabetes Association.
The patient's capillary glucose reading, performed in the clinic, was 193 mg/dl. She was
instructed to return the next morning for a fasting venous plasma glucose, which was 143
mg/dl. Given this finding, the diagnosis of GDM was established. While it is likely that the
patient had diabetes before pregnancy, given the significant elevation of her fasting glucose
level, this is GDM because its first recognition was during pregnancy. There is no need to
performfurther testing in this patient. A single elevated fasting glucose of >126 mg/dl
obviates further testing. A glycohemglobin could be performed, and, if elevated, supports
the likelihood of pre-existing diabetes mellitus.
The patient was begun on both dietary and insulin therapy as an outpatient. Her diet
included 25 kcal/kg actual body weight divided into three meals and a bedtime snack. The
diet emphasized complex carbohydrates with the avoidance of simple carbohydrates. In
addition, she was instructed on self-monitoring of blood glucose, performing tests while
fasting and 2 hours after each meal. The targets for therapy were a fasting value of < 95
mg/dl and values no higher than 140 mg/dl at 1 hour or no higher than 120 mg/dl at 2
hours after eating. She was started empirically on 20 U of NPH and 10 U of regular insulin
administered in the morning, to be adjusted after reviewing her glucose log sheets. The
patient was seen each week. Given the significant elevation of her fasting glucose level, a
trial of diet only was not advisable.
The patient did well on this regimen, maintaining good control until 30 weeks gestation,
when her total insulin dose was increased by 20%. At 28 weeks, the patient was
instructed in daily fetal movement counting to assess fetal well-being, and at 32 weeks
gestation antepartumfetal heart rate testing with nonstress tests was begun twice weekly.
An ultrasound examination at 37 weeks revealed the fetus to be growing normally with an
estimated weight of 7 lb, 1 oz. At 39 weeks, the patient started spontaneous labor and
underwent the vaginal delivery of an 8 lb, 1 oz boy. The infant was evaluated for but did
not demonstrate hypoglycemia or other morbidities.
Postpartum, the patient breastfed her infant and, with her partner, decided on a barrier
method of contraception: foam and condoms. Six weeks after delivery, she returned to the
clinic for an evaluation of her glucose tolerance. Her fasting plasma glucose was 128
mg/dl. She returned the next day, and a repeat fasting plasma glucose was 132 mg/dl.
Given these findings, the diagnosis of diabetes mellitus was made, and a 75-g OGGT test
was not needed.
Clinical Pearls
1. When patients present with significant risk factors for GDM, early
screening for GDM, before 20 weeks gestation, might be undertaken.
2. The finding of glycosuria should prompt a random capillary glucose
performed immediately and a follow-up fasting venous plasma glucose.
3. Given an elevated fasting venous plasma glucose, such patients should be
started immediately on diet and insulin therapy and followed with self-
monitoring of blood glucose using the criteria recommended by the Fourth
International Workshop-Conference on Gestational Diabetes Mellitus.
4. Patients treated with not only diet but also insulin are at increased risk for
an intrauterine fetal death, and for that reason, antepartum fetal testing with
nonstress tests should be performed.
5. For such patients who do not enter spontaneous labor, induction of labor
at 39 weeks is appropriate.
6. Postpartum, this patient was found to have an elevated fasting plasma
glucose and the diagnosis of diabetes mellitus was made. That diabetes
persisted after delivery is not surprising given that the diagnosis of GDM was
made relatively early in pregnancy, that the fasting plasma glucose exceeded
140 mg/dl, and that the patient was obese.
SUGGESTED READINGS
Carpenter MW, Coustan DR: Criteria for screening tests for gestational diabetes. Am J
Obstet Gynecol 144:76873, 1982.
Expert Committee on the Diagnosis and Classification of Diabetes Mellitus: Report of the
expert committee on the diagnosis and classification of diabetes mellitus. Diabetes Care
20:118297, 1997.
Gabbe SG, Mestman JH, Freeman RK, Anderson GV, Lowensohn RI: Management and
outcome of Class A diabetes mellitus. Am J Obstet Gynecol 127:46569, 1977.
Gregory KD, Kjos SL, Peters RK: Cost on non-insulin-dependent diabetes in women
with a history of gestational diabetes: implication for prevention. Obstet Gynecol
81:18286, 1993.
Kjos SL, Buchanan TA, Greenspoon JS, Montoro M, Bernstein GS, Mestman JH:
Gestational diabetes mellitus: the prevalence of glucose intolerance and diabetes mellitus in
the first two months postpartum. Am J Obstet Gynecol 163:9398, 1990.
Metzger BE, Coustan DR, The Organizing Committee: Proceedings of the Fourth
International Workshop-Conference on Gestational Diabetes Mellitus. Diabetes Care
21(Suppl. 2):B16167, 1998.
American Diabetes Association: Position statement: Standards of medical care for patients
with diabetes mellitus. Diabetes Care 22(Suppl. 1): S3241, 1999.
Steven G. Gabbe, MD, is a professor and chair of the Department of Obstetrics and
Gynecology at the University of Washington School of Medicine in Seattle.
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