Amanda Latham

May 30th, 2019

Created in collaboration with Amanda Latham, Clarissa Baxter, and Lori Hedlund

Evaluation and management of Diabetes in pregnancy

1. Definition or Key Clinical Information:

Gestational diabetes mellitus (GDM) is a glucose intolerance which is first detected in
pregnancy. GDM occurs in approximately 7% of all pregnancies (Jordan, R., Engstrom, J.,
Marfell, J., & Farley, C., 2014), although, it is considered to be on the rise in the United States
due to the increase prevalence of obesities as well as the increase in birth rates of ethnic groups
who are at a higher risk of GDM. Physiological changes in pregnancy contribute to insulin
resistance in pregnant people. The pregnant person with GDM is unable to meet the challenge of
secreting additional amounts of insulin necessary to achieve and maintain euglycemia, therefore,
their blood sugar levels will remain elevated. Type 1 diabetes is caused by autoimmune
destruction of pancreatic ß cells and accounts for 5-10% of all diabetes in the United States
(Jordan, R., Engstrom, J., Marfell, J., & Farley, C., 2014). Type 2 diabetes can also be
preexisting and is the most common type of diabetes accounting for 90-95% of all diabetic cases
(Jordan, R., Engstrom, J., Marfell, J., & Farley, C., 2014). People with pregestational diabetes will
benefit from preconception care with a medical provider, as there are several associated risks that can be
mitigated with early care.
2. Assessment
i. Risk Factors
A. Overweight or obese; BMI >25
B. Prior history of GDM, glycosuria or impaired carbohydrate metabolism
C. Strong family history of type 2 diabetes (two first-degree relatives)
D. Prior history of still birth, infant with congenital anomalies, or macrosomia
E. Age ≥ 25
F. Ethnicity; Black American, Alaskan Native, Hispanic American, Native American, South
or East Asian, Indian, Middle Eastern, Pacific Islander.
G. Hx of unexplained fetal demise
H. Hx of child born with congenital anomaly
I. Hx of macrosomia
J. Polycystic ovarian syndrome
K. Hypertension or preeclampsia in current pregnancy
L. Polyhydramnios in current pregnancy
ii. Subjective Symptoms
A. Can be asymptomatic
B. Increased thirst
C. Frequent voiding
D. Weakness
E. Vaginal itching
F. Blurred vision
G. Peripheral neuropathy
iii. Objective Signs
A. Glycosuria
B. Recurrent vaginal yeast infections, UTIs, and/or skin infections
 C. Abnormal weight gain
D. Polyhydramnios
E. LGA fetus
iv. Diagnostic
Preexisting Diabetes
It is outside of our scope of practice as CPMs to provide care to people with preexisting diabetes,
however, it may be necessary to screen for preexisting diabetes at the initial visit, especially when
risk factors are present.
A. Initial visit; evaluation of HbA1c or
B. Random glucose or fasting glucose or
C. 50 g or 75 g glucose screen
Screening for GDM; there are multiple strategies available to screen for GDM in pregnancy.
A. Option 1: American College of Obstetrics (ACOG) supports universal screening for
everyone with a two-step process.
a. Step one: 24-28 weeks’ gestation 50 gram one-hour glucose challenge. Ingestion
of 50g of glucose in the form of liquid (typically glucola) or jellybeans or meal form,
such as the standardized breakfast challenge 50g load recipe* After one hour, blood
is drawn to determine blood glucose level.
i. > 200 mg/dL: GDM is diagnosed
ii. > 130 mg/dL: 3-hour glucose tolerance test (GTT) is indicated
iii. < 130 mg/dL: no further testing indicated
iv. * Standardized breakfast challenge 50g smoothie recipe:
v. 8oz. whole milk plain yogurt
vi. 1 medium banana
vii. 1c. frozen strawberries
viii. 6oz. OJ (not from concentrate)
ix. 3TBSP honey
b. If the client screens negative, no further testing is indicated.
c. Step two: 3-hour GTT. This is performed if the client has a positive screen with step
one. Requires ingestion of 100g sugar load, typically glucola. It is performed in the
morning after 14 hours of fasting. Blood is drawn at the fasting point to determine
fasting blood glucose level, then every hour after the glucose is consumed for the
next three hours. GDM is diagnosed if one value over the following limits is present:
i. Fasting: > 95 mg/dL
ii. 1-hour: > 180 mg/dL
iii. 2-hour: > 155 mg/dL
iv. 3-hour: > 140 mg/dL
B. Option 2: American Diabetes Association (ADA) and the International Association of the
Diabetes and Pregnancy Study Groups (IADPSG) support universal screening at the first
prenatal visit using the tests listed below. Results are either considered normal, GDM, or
overt diabetes.
a. Fasting blood glucose value: overt diabetes is diagnosed if the values are > 126
mg/dL
b. HbA1c: overt diabetes is diagnosed if values are > 6.5%.
c. Random plasma glucose: overt diabetes is diagnosed if values are > 200 mg/dL.
 If results are normal: A one-step 75g glucose load 2-hour GTT diagnostic test is performed
between 24-28 weeks. This can be glucola, jelly beans, or food based, such as the 75g
standardized breakfast challenge recipe*.
a. Overt diabetes if fasting is > 126 mg/dL
b. GDM is diagnosed if one value is over the following:
a. Fasting: > 92 mg/dL
b. 1-hour: > 180 mg/dL
c. 2-hour: > 153 mg/dL
*Standardized breakfast challenge 75g
Smoothie:
8 oz. whole milk plain yogurt
2 medium bananas
1C frozen strawberries
8 oz. OJ (not from concentrate)
4 TBSP honey
Pancake breakfast:
2/6” (4/4”) plain pancakes
2 oz. real maple syrup
8 oz. OJ (not from concentrate)
3. Management plan
i. Therapeutic measures to consider
A. Preexisting; will require referral and prescription for insulin during pregnancy
B. GDM not managed by lifestyle changes; requires referral
a. Oral medications such as glyburide and metformin
b. Insulin therapy
ii. Complementary measures to consider
A. Lifestyle changes
a. Nutrition; elimination of high glycemic foods; sweeteners (honey, sugar, maple
syrup, corn syrup), desserts, and soda. Fruit and juices must be eaten separate
from potatoes and white flour. Carbohydrates should not exceed 30-40% of the
daily caloric intake (and be spread out throughout the day); quality fats and
proteins should make up the caloric difference. High fiber diet. Smaller more
frequent meals.
b. Physical exercise; at least 30-40 minutes every day, preferably divided into 2-3
sessions per day. Examples: brisk walking, weight training, swimming,
bicycling, physical work, etc.
c. Stress reduction strategies such as prayer, yoga, meditation
B. Home Monitoring; blood glucose levels should be checked four times a day
a. Fasting: upon waking every morning; should not exceed 95mg/dL
b. 1-2 hours after each meal; 1-hour should not exceed 140mg/dL; 2 hour should
not exceed 120mg/dL
c. If normal values are maintained by at least 80-90% of the time for several weeks,
daily monitoring can be reduced.
C. Herbal Supplements
a. Fenugreek
b. American Ginseng
c. Cinnamon ¼- ½ tsp/day
 iii. Considerations for pregnancy, delivery and breastfeeding
There are several adverse pregnancy outcomes associated with pregestational diabetes, including:
miscarriage, macrosomia, LGA, shoulder dystocia, polyhydramnios, preeclampsia, preterm birth,
unexplained stillbirth, respiratory distress, hyperbilirubinemia, neonatal death, and congenital
anomalies (only among people with preexisting diabetes), such as, congenital heart defects,
neural tube defects, and/or renal agenesis/caudal dysgenesis syndrome (Jordan, R., Engstrom, J.,
Marfell, J., & Farley, C., 2014). Pregnant people with preexisting diabetes should consider dietary
counseling to help with adjusting their diet as needed as the pregnancy causes metabolic changes
(Varney, 2015). Cesarean delivery is an option that should be offered to pregnant people with
GDM and an estimated fetal weight of 4500g or more (Jordan, R., Engstrom, J., Marfell, J., &
Farley, C., 2014). However, fetal growth monitoring for macrosomia has a high prevalence of
false positive results, which could lead to unnecessary cesarean birth. This decision should be
made collaboratively based on the client’s history, pelvimetry, and values. Euglycemia and
resolution of disease occurs almost immediately after delivery for most people with GDM
(Jordan, R., Engstrom, J., Marfell, J., & Farley, C., 2014).
iv. Client and family education
Educate all clients prior to 20w gestation on nutrition and exercise to support overall health.
Assist clients who smoke with smoking cessation as soon as possible in pregnancy. Children born
to people with GDM are at an increased risk of childhood obesity and developing diabetes later in
life. People who are diagnosed with GDM should be advised that they have a greater risk of
developing type 2 diabetes later in life; most will develop it within five years (Jordan, R.,
Engstrom, J., Marfell, J., & Farley, C., 2014).
Handout: exercise in pregnancy, nutrition in pregnancy, smoking cessation.
v. Follow-up
A. Client compliance
a. Ask the client if they have followed recommended complementary measure
regimens
b. Review of client’s blood glucose home monitoring readings
B. Additional follow up labs, as necessary, based on home monitoring readings
C. Routine follow up with physician due to risk of developing type 2 diabetes for those with
GDM.
D. If GDM is controlled by lifestyle choices, no additional monitoring is recommended.
4. Indications for Consult, Collaboration or Referral
A. Referral for care when:
a. Screening for preexisting diabetes is positive in order for physician to make
diagnosis, prescribe necessary medication, and order follow up testing for both
the client and the fetus.
b. All complementary measures have been exhausted without improvement in blood
glucose levels.
B. Preexisting type 1 or 2 diabetes
C. Routine follow up with physician due to the risk of developing type 2 diabetes for those
with GDM.
5. References
ACOG. (2017). Gestational diabetes. The American College of Obstetricians and Gynecologists.
Retrieved from: https://www.acog.org/patients/faqs/gestational-diabetes
ADA. (2016). Diabetes management guidelines. National Diabetes Education Initiative.
Retrieved from: https://www.ndei.org/ADA-diabetes-management-guidelines-diagnosis-
 A1C-testing.aspx.html
Argo, M. & Filmore, H. (2014). Screening for hyperglycemia in pregnancy: standardizing the breakfast
challenge. Midwifery Matters, 4-10.
Jordan, R., Engstrom, J., Marfell, J., & Farley, C. (2014). Common complications of pregnancy:
gestational diabetes. Prenatal and Postnatal Care: A Woman-Centered Approach, 387-395.
Jordan, R., Engstrom, J., Marfell, J., & Farley, C. (2014). Management of common health problems
during the prenatal and postnatal periods: pregestational diabetes. Prenatal and Postnatal Care: A
Woman-Centered Approach, 566-567.
King, T., Brucker, M., Kriebs, J., Fahey, J., Gegor, C., & Varney, H. (2014). Common conditions in
primary care: diabetes mellitus. Varney’s Midwifery, (5), 243-244.
King, T., Brucker, M., Kriebs, J., Fahey, J., Gegor, C., & Varney, H. (2014). Obstetric complications in
pregnancy: gestational diabetes. Varney’s Midwifery, (5), 740-743.
King, T., Brucker, M., Kriebs, J., Fahey, J., Gegor, C., & Varney, H. (2014). Medical complications in
pregnancy: pregestational diabetes. Varney’s Midwifery, (5), 781-782.