GDM SCREENING:

Epidemiology: ● most common medical problems in pregnancy with significant maternal, fetal and neonatal risks
Worldwide: Approximately 7% of all pregnancies ● Adverse outcome associated with diabetes mellitus during pregnancy increase continuously as
 Differs according to race, ethnicity, age, and body composition maternal FBS levels and OGTT value increases
- 1.9% of pregnant women admitted (in 147 accredited hospitals) in 2005 – 2009 have GDM ● Increasing prevalence of diabetes mellitus worldwide
- 5.1% of Filipino women surveyed had type 2 diabetes mellitus or GDM
DEFINITION WHOM TO SCREEN:
 Carbohydrate intolerance of variable severity with onset or first recognition during pregnancy (ACOG,  Universal - all pregnant women
2013)  Selective - only women with risk factors
 Diagnosed in the second or third trimester of pregnancy that was not clearly overt diabetes prior to gestation.  Universal screening for Filipino gravidas by virtue of race and ethnicity-during 1st prenatal
 Gestational implies that diabetes is induced in pregnancy because of exaggerated physiological changes in visit
glucose metabolism  We are of high risk
 gestational diabetes: used for enhanced surveillance and to stimulate women to seek further testing post partum WHEN TO SCREEN
 The most important perinatal correlate is excessive fetal growth, which may result in both maternal and fetal  Women with no risk factor
birth trauma - Routine testing is recommended at 24-28 weeks
 Importantly, more than half of women ultimately develop overt diabetes in ensuing 20 years  Women with risk factor
 Changes in carbohydrate and lipid metabolism occur during pregnancy accommodate fetal nutritional - Immediately at 1st prenatal visit or soonest possible time
requirements and ensure a continuous supply nutrients to the growing fetus, despite intermittent maternal  If initial tests results are normal, repeat tests at 24-28 weeks and again later at 32-34 weeks
food intake  All pregnant women should be evaluated at the first prenatal visit for risk factors for diabetes
Early Pregnancy All Filipino pregnant patients must be screened during the first prenatal by requesting FBS, HbAlc or RBS
 Anabolic Phase (increase in maternal fat stores; decrease free fatty acid concentration)  Perform a 75-g OGTT, with plasma glucose measurement when patient is fasting and at 1 and 2h, at 24-28
 Pregnancy hormones (HPL and cortisol) lower glucose levels and promote fat deposition weeks of gestation in women not previously diagnosed with overt diabetes. The OGTT should be
 Decrease post-prandial glucose level (This acts to protect the developing embryo from elevated blood performed in the morning after an overnight fast of at least 8 h. The diagnosis of GDM is made when any of
glucose levels. the following plasma glucose values are met or exceeded:
2nd trimester - Fasting: 92 mg/dL (5.1 mmol/L)
 Increased maternal fasting and postprandial glucose - 1h: 180 mg/dL (10.0 mmol/L)
 Increased hepatic glucose production by 16-30% - 2h: 153 mg/dL (8.5 mmol/L) OR 140 in POGS CPG
 Postprandial glucose concentrations are significantly elevated and prolonged glucose peak
PATHOPHYSIOLOGY TWO-STEP TESTING
During early gestation, insulin sensitivity increases, promoting the uptake of glucose into adipose stores in Step 1: OGCT: oral glucose challenge test:
preparation for the energy demands of later pregnancy. However, as pregnancy progresses, a surge of local - Identifies individuals at risk for DM
and placental hormones, including estrogen, progesterone, leptin, cortisol, placental lactogen, and placental growth - 50 g oral glucose challenge test (OGCT)
hormone together promote a state of insulin resistance. As a result, blood glucose is slightly elevated, and this - Determine plasma glucose concentration >130 mg/dL or >140 mg/dL 1 hour after
glucose is readily transported across the placenta to fuel the growth of the fetus. This mild state of insulin - Proceed with step 2 if value exceeds 130 or 140 mg/dL
resistance also promotes endogenous glucose production and the breakdown of fat stores, resulting in a Step 2 (Diagnostic)
further increase in blood glucose and free fatty acid (FFA) concentrations. in order to maintain glucose - Establishes the disease
homeostasis, evidence in studies reveal pregnant women compensate for these changes through hypertrophy and - 3-hour 100 g oral glucose tolerance test (OGTT)
hyperplasia of pancreatic β-cells, as well as increased glucose-stimulated insulin secretion (GSIS). The importance - Check blood glucose levels every hour for the next 3 hours
of placental hormones in this process is exemplified by the fact that maternal insulin sensitivity returns to pre- FETAL EFFECTS MATERNAL EFFECT
pregnancy levels within a few days of delivery. the normal metabolic adaptations to pregnancy do not adequately Fetal Macrosomia Maternal Obesity
occur in all pregnancies, resulting in GDM.  Perinatal goal is to avoid difficult delivery and  Maternal BMI is independent and more
RISK FACTORS birth trauma associated with shoulder dystocia substantial risk factor for fetal macrosomia than
● > 25 y/o  Greater risk of shoulder dystocia in newborns is glucose intolerance
● < 25 y/o and obese weighing ≥4200 g compared in those <3500 g  Highest fraction of LGA neonates was
● Pre pregnant weight of > 110% of IBW  maternal hyperglycemia -> fetal attributable to maternal obesity
● Family history of DM in 1st degree relatives, Glycosuria at first prenatal checkup hyperinsulinemia -> macrosomia  Excessive gestational weight gain is common in
● Previous delivery of baby > 9 lbs (7-8 lbs for Filipinos)  fetal hyperglycemia -> polyuria -> hydramnios women with gestational diabetes and confer and
● Member of an ethnic group with a high prevalence DM
● PCOS, Corticosteroids, Hypertension  Congenital anomaly (esophageal atresia -> additive risk for fetal macrosomia
● Previous unexplained perinatal loss/malformed child decreased intake of amniotic fluid ->
hydramnios
 PRECONCEPTION EVALUATION AND PREVENTION
PHAMACOLOGIC TREATMENT: INSULIN TREATMENT Generalizations for Pregestational Diabetes Mellitus
Giving of insulin is still recommended  Women with type 1 and type 2 DM are at greater risk for maternal morbidity and perinatal morbidity
 Insulin is the only recommended pharmacologic treatment for patients with GDM and mortality.
 Oral hypoglycemic agents are not recommended  Prevented by excellent control of maternal glycemia and during the critical weeks of organogenesis
 Insulin has been considered standard therapy in GDM when target glucose levels cannot be (5-8 weeks)
consistently achieved through nutrition and exercise.  Goal should be not only to improve pregnancy outcome but also to promote healthy lifestyle
 Recommended if diet modification does not consistently maintain the fasting plasma glucose levels changes for the affecte women for the rest of their lives after delivery
< 95 mg/dL or the 2-hour postprandial plasma glucose < 120 mg/dL.  Carefully developed plan for screening. Women with GDM will respond to dietary therapy
 Human regular insulin or rapid-acting insulin analogues for postprandial hyperglycemia.  The greatest perinatal risk in such cases is fetal macrosomia
 Basal insulin needs - neutral protamin hagedorn (NPH) insulin.  Women with GDM are at considerable risk for the development of type 2 diabetes mellitus later in
 Starting dose 0.7 to 1.0 units/kg/d life and will require careful follow-up.
 Severely obese women, may need to be increased to 1.5 to 2.0 U/kg  HbA1c levels should be as close to normal as possible (<7%) before conception is attempted
 Insulin dosage is increased as the pregnancy comes to term  Preconception counseling should be incorporated in the routine clinic visit for all women of
 Doubles in twin gestation childbearing potential
Administration  Diabetic women contemplating pregnancy should be evaluated and if indicated, treated
 2/3 of daily dose given before breakfast  Medications taken by such women should be evaluated prior to conception since drugs
 1/3 before dinner if NPH is used commonly used to treat diabetes mellitus and its complications may be contraindicated or
 HRI (preferable to use) and RAI are best dosed with each meal not recommended in pregnancy, including statins, angiotension converting enzyme (ACE) inhibitors,
 Subcutaneous route angiotensin receptor blockers (ARB) and most non-insulin therapies
ORAL HYPOGLYCEMIC AGENTS NON – PHARMACOLOGIC TREATMENT
• Glyburide MEDICAL NUTRITION THERAPY
 Conflicting data. Used with precaution  Individualized MNT:
• Metformin  Adequate calories & nutrients for pregnancy
 2nd and 3rd trimester  Consistent with maternal blood glucose goals
 Patients using metformin consistently were more likely to need supplemental insulin  Non-caloric sweeteners may be used in moderation Advise patient to control diet, and do physical
exercise
SELF MONITORING  MNT is a primary therapy for 30-90% of women with GDM (decrease HbA1c by 1%)
Self Monitored Blood Glucose  Carbohydrate-controlled diet – to maintain normoglycemia and avoid ketosis
 Glucose assessment four times daily  Daily caloric intake of 30 to 35 kcal/kg
o Fasting, remainder are done 1 or 2 hours after each meal  Diet based on ideal pre-pregnancy weight
o Glucose Targets according to ADA and ACOG are:
 Do not use the present weight of the pregnant patient as basis for kcal/kg
o FBS < 95mg/dL
 30 kcal/kg for average weight
o 1hr PPBG <140mg/Dl (suggestive if at risk of developing a macrosomic baby)
o 2hr PPBG <120mg/dL (if increased, possible full blown T2DM)  35 kcal/kg for underweight
 25 kcal/kg for overweight
 Generally, 2000-2200 calories per day
 Caloric Distribution of Meals
 40-45% of total calories for Carbohydrates
 20-25% of total calories for Protein
 35-40% of total calories for Fat
Lifestyle Changes
 Offering advice regarding alcohol consumption and smoking cessation
 Regular physical activity in the absence of contraindications to improve glucose control , reduce
cardiovascular risk, weight management goals and overall wellbeing
A diagnosis of overt diabetes mellitus is given with any of the following results in their first visit
 ANTEPARTUM FETAL SURVEILLANCE INTRAPARTUM GLUCOSE MANAGEMENT/ INTRAPARTUM MANAGEMENT
 Frequency is dependent on:  Keep maternal blood glucose between 72-120mg/dL to reduce risk of neonatal hypoglycemia
 Patient’s degree of metabolic control  Women should receive adequate glucose during labor in order to meet the high energy requirements
 Type of therapy the patient is receiving  During labor: monitor every 1-4 hours. Plasma glucose should be 80-120 mg/dL or capillary glucose
 Presence of other risk factor 70-110 mg/dL
 The poorer the glycemic control, the more frequent the surveillance  Cesarian Section: take immediately prior to CS and 2 hours after CS. Plasma glucose should be kept
 Fetal surveillance in women with GDM and poor glycemic control below 120 mg/dL
 Expectant management for women with adequate glycemic control  Immediate Postpartum Period: monitor plasma glucose every 4-6 hours for 24 hours
 Perceived Fetal Movements  Fetal Surveillance
 Count to 10 method 
 Identifies fetal viability monitoring is recommended
 Non Stress Test  Timing of Delivery
 Needs to be done every 2 weeks in diabetic patient with poor glycemic control  Individualized: Should be atleast 38 weeks AOG
 Contraction Stress Test  Deliver only before 38 weeks AOG for compelling maternal or fetal indications
 Advantage of detecting hypoxia prior to onset of acidosis  Well-controlled DM and no complications may await spontaneous labor and allow to progress to EDD
 Ultrasound Examination  If patient is for elective CS for any indication, goal is to deliver at 39 weeks rather than 38 weeks to
 Fetal viability, well-being, Macrosomia reduce neonatal respiratory morbidity
 Induction of labor may be performed before 41 weeks
POST PARTUM MANAGEMENT Mode of Delivery
 EFW <4000g (Filipina: <3500g)
 15% of women with GDM have impaired glucose tolerance or diabetes after delivery o Vaginal delivery is usually appropriate
 Greater likelihood if: o trial of labor
 Obese o Offer elective birth through induction of labor or elective CS if indicated after 38 completed
 GDM diagnosed early in pregnancy weeks
 Treatment required (insulin therapy)  EFW 4000-4499 (Filipina: 3500 – 4000g)
 Postpartum evaluation with a 75-g OGTT o consider past delivery history, clinical pelvimetry, evidence of body to head disproportion and
 ACOG recommends either a fasting glucose or the 75 g, 2-hour OGTT at 4-12 weeks postpartum for the progression of labor
diagnosis of overt diabetes o Vaginal delivery, individualize
 Interval periodic screening for high risk patients done yearly & 2-3 years interval for low risk patients  EFW >4500g (Filipina >4000g)
 Infant blood glucose should be monitored very closely o cesarean section may be considered
 Risk for subsequent diabetes almost fourfold if gestational diabetes complicated at least one subsequent  Vaginal delivery at term
pregnancy o Possible for women with good glycemic control
 Risk for cardiovascular complications associated with dyslipidemia, hypertension and abdominal obesity  Cesarean section
(metabolic syndrome) o GDM itself is not an indication
RECURRENT GESTATIONAL DIABETES
 Recurrence rate of 48%
 Rates in primiparas were lower than in multiparas
 Maternal BMI, insulin use, fetal macrosomia and weight gain additional risk factors for recurrence
 Lifestyle behavioral changes (weight control and exercsise) to prevent recurrence
 Prepregnancy loss of at least two BMI units associatd with lower subsequent risk of GDM in women who were
overweight or obese in first pregnancy