NOEL E.

RAYMUNDO, MD, FPOGS

OLFU - MEDICINE

Plan of Presentation Preconception counseling

• Physiology of fuel metabolism in normal pregnancy • All women of childbearing age diagnosed with T1 or T2 diabetes mellitus
• Risk factors of GDM should:
• Pathophysiology of GDM ✓ Preconceptual diabetes counseling
• Distinguish the difference between the various screening procedures and − Risk of uncontrolled diabetes during pregnancy
diagnosis for GDM ✓ Preconception evaluation and treatment of diabetes related complications
• Maternal and fetal risk ✓ Counseling on medications contraindicated during pregnancy
• Monitoring plan to maximize maternal and fetal outcome in patients • Teratogenic drugs may cause fetal renal dysplasia, oligohydramnios,
with GDM intrauterine growth restriction
• Optimal treatment regimen including non- pharmacologic and • Statins, angiotensin-converting enzyme (ACE) inhibitors,
pharmacologic therapy for GDM management angiotensin II blockers (ARBs)
• Role of oral hypoglycemic agents in GDM treatment
• Obstetrical management What’s important if she was diagnosed with diabetes before pregnancy is to have
COUNSELLING. Counselling is very important because there are congenital
How is diabetes classified based on the pathogenic processes involved? anomalies that are related with diabetes especially during the embryonic period.
(American Diabetes Association Diabetes Care 2017) What are we afraid of is during the first 8 week of gestation, that will precipitate or
1. Type 1 Diabetes mellitus might cause teratogenic effects either due to your diabetes per se or the
• Absolute insulin deficiency medications taken in order to lower down your blood sugar. Sometimes, we cannot
• Beta cell destruction identify any congenital anomalies related to it but as pregnancy progresses, patient
2. Type 2 Diabetes mellitus develops oligohydramnios or sometimes instead of gaining weight, the fetus
• Defective insulin secretion or insulin resistance becomes small for gestational age because of its teratogenic effects.
3. Gestational Diabetes mellitus (GDM)
4. Other specific type of diabetes: Normal pregnancy
• Monogenic diabetes syndromes ➢ Pregnant women with normal glucose metabolism is characterized by:
• Disease of the exogenous pancreas ▪ Fasting levels of blood glucose that are lower than the nonpregnant
• Drug-induced state
▪ Postprandial hyperglycemia and carbohydrate intolerance as a result
What are the changes in the classification of diabetes? (Powers, 2001) of diabetogenic placental hormones
• The terms insulin-dependent diabetes mellitus (IDDM) and non-insulin ➢ Increase tissue insulin resistance in the second trimester and continues
dependent diabetes mellitus (NIDDM) are no longer used. until birth
• Age is also no longer used in classification ▪ Increase in placental steroid and peptide hormones (anti-insulin
• Beta cell destruction can occur at any age effect)
• Common set is before age 30 1. Estrogen
2. Progesterone
Diabetes in pregnancy: 2 categories 3. chorionic somatomammotrophin or placental lactogen
1. Pregestational or Overt Diabetes – Pregnancy in preexisting diabetes 4. Cortisol
(Type I DM or Type II DM) 5. PRL
2. Gestational Diabetes - Diabetes diagnosed in pregnancy ➢ Insulin secretion also increases, resulting in normal glucose concentrations
(normoglycemia)
We should identify during the first prenatal check-up if the patient has diabetes ➢ Third trimester
before pregnancy, if she has Type 1 or Type 2. Type 1 DM are those receiving ▪ Decrease (50%) peripheral insulin sensitivity
insulin. Type 2 are those who are taking oral hypoglycemic agents. If you are able ▪ Higher insulin secretion
to establish during the first prenatal check-up that your patient is a KNOWN ▪ Higher (30%) hepatic glucose output
diabetic before pregnancy then consider her as PREGESTATIONAL diabetic or ↓
OVERT diabetes. As to classification of DM, it depends on the management being ▪ Imbalance between insulin resistance and secretion may lead to
used to address hyperglycemia. hyperglycemia
But if during the first prenatal check-up, your patient has normal blood sugar and ▪ Gestational diabetes typically develops because of preexisting
no risk factors and only diagnosed when you performed tests while she’s pregnant, increased insulin resistance.
then that’s when you consider her as GESTATIONAL DIABETIC CASE.
During pregnancy, we expect the patient to have NORMAL glucose metabolism. As
Pregestational or Overt Diabetes - Type 1 or Type 2 diabetes you increase your blood sugar, your pancreas will secrete insulin enough to combat
- Diabetes developing during the 1st trimester is considered type 2 the hyperglycemia especially during the first few hours after eating.
diabetes, although it can be type 1 or GDM (ADA, 2016)
Several hormones secreted by placenta (estrogen, progesterone, hCG, and
Type 1 Type 2 placental lactogen) has DIABETOGENIC effects. Hence, all pregnant women have a
tendency to become diabetic.
Diagnosis <35 years AND Diagnosis <35 years AND NOT on
continual insulin treatment within 6 continual insulin treatment within 6
BUT during the 2nd trimester, the number of hormones produced by the placenta
mos of diagnosis mos of diagnosis
is progressively increasing causing the patient to be diabetic. This will eventually
lead to INSULIN RESISTANCE.
-OR- -OR-

Diagnosis of ≥35 years AND Diagnosis ≥35 years AND NOT on

continual insulin treatment from continual insulin treatment from
diagnosis diagnosis

Consider Phases
Pregestational or Overt Diabetes
• Preconception counseling
• Management during pregnancy
• Management in labor
• Postpartum
Gestational Diabetes
• Prevention, screening and
In insulin resistance, you have more than amount of insulin but the receptors that
diagnosis
will open in order for glucose to enter the tissue is ineffective.
• Management during pregnancy
Remember, Insulin acts as the key or a doorman at the entrance to your cell.
• Management in labor
Glucose arrives at the door of the cell. When your insulin is working effectively, it
• Postpartum
opens the door, just like a doorman. Then blood glucose enters the cell where it
is used for energy.

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 NOEL E. RAYMUNDO, MD, FPOGS
OLFU - MEDICINE

When you have insulin resistance, your cells don’t respond to insulin—they resist Normal Pregnancy
insulin’s commands—and insulin can’t do its job. Blood glucose still arrives at the Maternal response to feeding
cell door, but insulin can’t work effectively and the door to the cell won’t open. The ▪ Hyperglycemia
glucose won’t be able to enter the tissue and be utilized for energy. If the door ▪ Hyperinsulinemia
won’t be opened then the glucose will accumulate in blood. ▪ Hyperlipidemia
▪ Resistance to insulin
BUT what is happening during pregnancy is your pancreas tries to keep blood ▪ Insulin resistance increases up to 50% in the 3rd trimester
glucose levels normal by making extra insulin. At first, the extra insulin helps. But ▪ Borderline pancreas function
after a while, even extra insulin can’t open the cell doors and your blood glucose
will rise. Beta cells subsequently increase their production of insulin, further ✓ Gestational diabetes occurs when the pancreas despite increased insulin
contributing to a high blood insulin level. So, you have HYPERGLYCEMIA AND production cannot counter the insulin resistance caused by the pregnancy
HYPERINSULINEMIA. hormones

During the third trimester, there is decreased sensitivity in peripheral insulin so RISK FACTORS:
there will be more and more insulin resistance. Remember, HYPERINSULINEMIA TYPE 2 DM, PREDIABETES, OVERT, GDM
has a growth factor effect. It is the one that will stimulate the growth and ▪ HbA1c ≥5.7% (39 mmol/L, IGT or IFG) on previous testing
development of fetus so you’ll end up with a MACROSOMIC baby. This is the time hemoglobin A1c test tells you your average level of blood
and the last trimester of pregnancy when all of a sudden, the baby is enlarged. sugar over the past 2 to 3 months.
Upon monitoring, the expected weight of the baby is higher. ▪ Family history of diabetes (first degree: parent/siblings)
relatives
Don’t ask for the hx of your grandparents and titos and
titas. It is useless. Only ask first degree.
▪ High risk race/ ethnicity (African American, Latino, Native
American, Asian, American, Pacific Islander, Hispanic)
Being Filipino is already a risk. This is because of too much
food intake. Pagkain everywhere!
▪ Age ≥35 years old
▪ History of GDM
▪ Previous delivery to ≥10 lbs (> 4.5 kilos) baby
▪ Excessive early gestational weight gain
o 1st trimester gain of 2kgs/4.4 lbs
o 2nd trimester gain per week of:
o 0.6kg (1.3 lbs) for underweight
o 0.45kg (1.0 lb) for normal weight
o 0.32kg (0.7 lb) for overweight
This graph shows that the production of placental hormones increases especially o 0.27kg (0.6 lb) for woman with obesity
in the third trimester. ▪ Weight gain of more than 5kg (11lbs) since 18 yrs of age.
▪ Multiparity
What is the effect of pregnancy on glucose metabolism? ▪ Hypertension (≥ 140/90 mmHg) or on therapy for hypertension
▪ Maternal metabolism adjusts to provide nutrition both the fetus and the ▪ Hyperlipidemia
mother. ▪ HDL cholesterol level <35mg/dL (0.90 mmol/L) and/or a triglyceride level
▪ Increased insulin secretion of > 250 mg/dL (2.82 mmol/L)
→ Increase in pancreatic beta cell hyperglycemia from the increased levels ▪ PCOS
of estrogen and progesterone ▪ Sedentary or inactive lifestyle
▪ Increase insulin degradation by placental insulinase ▪ Overweight (BMI ≥kg/m2)
▪ Insulin antagonism ▪ History of smoking
→ Increase in human chorionic somatomammotrophin (hCS) or human ▪ Clinical condition associated with insulin resistance: Acanthosis negricans
placental lactogen (hPL)
✓ Decrease maternal insulin sensitivity → increase maternal glucose
levels What is the recommended screening for gestational diabetes?
✓ Inhibit glucose transport → hyperglycemia → increase beta cells UNIVERSAL or SELECTIVE SCREENING?
secretion of insulin → hyperglycemia → increase hPL secretion ▪ UNIVERSAL SCREENING.
▪ Selective screening may miss up to 50% of cases of gestational diabetes
Again, the effects of glucose metabolism on pregnancy is increased insulin ▪ Universal screening for GDM @ 24 to 28 weeks AOG
secretion by your pancreatic beta cell leading to increased insulin resistant. ▪ Screen earlier: Risk factors are identified for GDM
But if you look at some of the hormones secreted by the placenta, we have human
chorionic somatomammotrophin (hCS) or human placental lactogen (hPL). This How do we diagnose GDM?
hormone has antagonistic effect on insulin adding insulin insensitivity which Are we going to do universal screening or selective screening?
creates more insulin resistance. When we talk about Universal screening, it is the screening of ALL pregnant women
In the second half of pregnancy, HPL level rises approximately 10 folds. HPL without any exemption. Selective screening is screening based on RISK FACTORS.
stimulates lipolysis leading to an increase in circulating free fatty acids in order to So, what we do is UNIVERSAL SCREENING. Being a Filipino is already a risk. So, we
provide a different fuel for the mother so that glucose and amino acids can be need to screen all Filipino pregnant women. Aside from that, in selective screening
conserved for the fetus. The increase in free fatty acid levels, in turn directly we may miss up to 50% of GDM cases.
interferes with insulin-directed entry of glucose into cells. Therefore, HPL is In universal screening, all pregnant women between 24-28 weeks will be screened.
considered as a potent antagonist to insulin action during pregnancy. Furthermore, But if there is a risk factor found during the first pre-natal check-up, screening must
HPL and placental growth hormone act in concert in the mother to stimulate be done. That means in spite of universal screening, it is important to look and
insulin-like growth factor (IGF) production and modulate intermediary metabolism, consider the risk factors.
resulting in an increase in the availability of glucose and amino acids to the fetus.
Oral glucose tolerance test (OGTT) - the person fasts overnight (at least 8 hours,
PATHOPHYSIOLOGY INSULIN RESISTANCE but not more than 14hours).
▪ Insulin is secreted in response to plasma glucose Oral glucose challenge test (OGCT) is a short version of the OGTT, used to check
▪ With the onset of insulin resistance normoglycemia is achieved by: pregnant women for signs of gestational diabetes. It can be done at any time of
increasing the secretion of insulin from pancreatic B-cells resulting in day, not on an empty stomach.
hyperinsulinemia FPG (Fasting Plasma Glucose) /FBS(Fasting Blood Sugar)

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 NOEL E. RAYMUNDO, MD, FPOGS
OLFU - MEDICINE

GESTATIONAL DIABETES (GDM) SCREENING because on a ≥153 you might miss almost 25-30% of GDM cases. And true enough,
through the 140, we were able to miss just at least 5% of GDM cases.
Pregnant women not known to have pre-existing diabetes and/or risk factors, Some would ask, what if the patient is not GDM but since you lowered it down to
should be screened for GDM at 24-28 weeks AOG. 140, she is considered positive. What if she would have complications? Will there
be a problem? The answer is NO. Since the initial treatment if the value is 140 is
DIET and EXERCISE then monitor the glucose. If its value returns to normal then
oral hypoglycemic agents or insulin will not be needed anymore.
Pregnant
Women
Some would opt 100g glucose (as you can see in the 3rd column under this
paragraph). If you can see, you need 4 blood extractions. The fasting, 1st, 2nd, and
3rd hour but when you use 75g glucose the blood extractions, it is limited to 3
High Risk factors No risk factors (fasting, 1st and 2nd hr.) or even 2 (fasting and 2nd hr.). If you’ll be looking at the
1st Prenatal check-up 24th - 28th weeks AOG values it is the same for both. Still it is ≥180 for 1hr then ≥155 for 2hr.
WHAT is important is you instruct the patient to fast for at least 8 hours but not
more than 14 hours. And the test should be performed with the patient seated and
the patient should not smoke during the test.
FPG FPG
>92-126 mg/dl ≤92mg/dl OGCT OGTT
(>5.1-7.0mmol/L) (≤5.1mmol/L GDM DIAGNOSTIC CRITERIA FOR OGTT (Carpenter/Coustan)
75g 2hr 100g 3hr
Fasting plasma >92 mg/dL (5.1 mol/L) > 95 mg/dL (5.3 mmol/L)
GDM Test for GDM
glucose (FPF)*
24-28 wks AOG
A 2hr 75g OGTT 1-hr challenge post >180 mg/dL (10.0 mol/L) >180 mg/dL(10.0 mmol/L)
glucose
WITHOUT RISK FACTOR → Wait until the 24-28th week then do your screening test 2-hr challenge post >153 mg/dL (8.5 mmol/L) >155 mg/dL (8.6 mmol/L)
either by Oral glucose challenge test (OGCT) or Oral glucose tolerance test (OGTT). glucose*
3-hr challenge post >140 mg/dL (7.8 mmol/L)
WITH RISK FACTOR → Screen on first prenatal Check-up. Request for Fasting Blood glucose
Sugar. If FBS >92-126 then the diagnosis is GDM. If it is equal or less than 92 then
test GDM on 24th-28th week either by OGTT or OGCT 75g OGTT: A positive (+) diagnosis requires that test results satisfy any one (1)
100g OGTT: A positive (+) diagnosis requires that > 2 threshold are met or
Criteria for diagnosing GDM exceeded

Pregnant females with risk factors Screen at 1st prenatal visit with FPG *POGS CRITERIA:
Pregnant females without diabetes Screen for GDM with a FPG: >92 mg/dL 2hr
risk factors 24 to 28 weeks 2hr OGTT using a 75g glucose load PCG: > 140 mg/dL
gestation
75g OGTT
▪ Performed after an overnight fast of at least 8 hours (but not more than
GDM DIAGNOSTIC CRITERIA
14 hours)
FPG > 92 mg/dL (5.1 mmol/L)
▪ Without having reduced usual carbohydrate intake for the preceding
1hr OGTT value >180 mg/dL (10.0 mmol/L)
several days
▪ Test should be performed with the patient seated and the patient should
not smoke during the test.
APPRAOCHES IN DIAGNOSIS GDM
▪ Oral glucose tolerance test (OGTT)
▪ 24 to 28 wks gestation
o 75g glucose load
▪ NOT previously diagnosed with overt diabetes
o 3 serum glucose determination
o Results:
IASPSG, WHO, NICE, POGS, AACE and 1 step:
Fasting value: > 92 mg/dL (> 5.1 mmol/L)
ADA recommended 75g 2hr OGTT
1hr value: > 180 mg/dL (> 10.0 mmol/L)
2hr value: > 140 mg/dL (> 7.8 mmol/L)
or
GDM is diagnosed if there at least one abnormal value.
ACOG and National Institute of Health 2 step:
(NIH) recommended 50g 1hr glucose challenge test
(OGCT)
POGS2011
IADPSG 2010
ACOG 2013
*if (+) OGCT: WHO 2013 NICE 2015 2018
ADA 2017 NIH2013
7.2 mmol/L (≥ 130 mg/dL)

OGTT 75 g 100g 75 g 75 g 75 g
Proceed to
Diagnostic ≥ 1 value ≥ 2 values ≥ 1 value ≥ 1 value ≥ 1 value
75g/100g 2hr OGTT
criteria
Fasting ≥92 mg/dL ≥95 mg/dL ≥101 mg/dL ≥92 mg/dL ≥92 mg/dL
Plasma (≥5.1mmol/L) (≥5.2mmol/L) (≥5.6mmol/L) (≥5.1mmol/L) (≥5.1mmol/L)
When we reach the 24th week, we can either do the 1-step oral glucose tolerance Glucose
test (OGTT) or 2-step procedure. 1 hr plasma ≥180 mg/dL ≥180 mg/dL ≥180 mg/dL ≥180 mg/dL
In the 1-step, during the scheduled time ask the patient to take 75 grams of glucose glucose (≥10mmol/L) (≥10mmol/L) (10mmol/L) (≥10mmol/L)
to see if her pancreas can tolerate the glucose. There will always be a first blood 2 hr plasma ≥153mg/dL 155mg/dL 140mg/dL ≥153mg/dL ≥140mg/dL
extraction for fasting plasma glucose level (FPG) before giving the 75-g glucose. glucose (≥8.5mmol/L) (8.6mmol/L) (7.8mmol/L) (≥8.5mmol/L) (≥7.8mmol/L)
After the intake of glucose, there are those who would extract blood 1 hour after 3 hr plasma Not required ≥140mg/dL Not required Not required Not required
the intake. There are also those who would consider the 2-hr plasma glucose glucose (7.8mmol/L)
response to 75g. Therefore, if you want to consider that - between the results
what’s important is the 2-hr post-75hr glucose intake. This is just a comparison of the values of several institutions and society but what
If the result is 140 or more, then it is considered positive. That means your patient we will always be following is the POGS - 75 g.
is a case of GDM. In the book it says that for 2-hr glucose test it is ≥153 but in
POGS (Philippine Obstetrics and Gynecologist Society), we lowered it down to ≥140
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 NOEL E. RAYMUNDO, MD, FPOGS
OLFU - MEDICINE

GLUCOSE MONITORING • Perineal injuries

▪ GDM patients must measure their blood glucose concentration 3 to 4 • Increase risk of CS
times daily (fasting and one or two hours after the first bite of each meal) • Subsequent development to T1 or T2 DM
• Preterm labor due to:
Fasting blood glucose concentration ≤ 95 mg/dL (≤5.3 mmol/L) ▪ Infection (pyelonephritis)
One-hour postprandial blood glucose ≤140 mg/dL (7.8mmol/L) ▪ Polyhydramnios
concentration • Maternal distresses due to:
Two-hour postprandial blood glucose ≤120 mg/dL ▪ Oversized fetus
concentration ▪ Polyhydramnios
• Microangiopathy
HbA1c ▪ Nephropathy
− is considered an additional optional but not primary diagnostic criterion ▪ Retinopathy
for diagnosis of diabetes ▪ Neuropathy
• Large vessel disease
▪ Coronary artery disease
▪ Thromboembolic disease infection
Pregnant
Women Fetal complications
• Abortion
• Unexplained stillbirth or fetal demise
+ High Risk factors No risk factors • Abnormal fetal intrauterine growth
1st Prenatal check-up 24th - 28th weeks AOG • Macrosomia
o Growth restriction
• Central nervous system
OGCT OGTT o Anencephaly
FPG HbA1c OGTT OGCT
50g 75g o Spina bifida
75g 50g
• Cardiac System
o Ventricular Septal Defects
o Situs inversus
Recommendations for HbA1c Testing • Embryopathy
Hba1c is NOT recommended for diagnosing gestational diabetes o Sacral agenesis
Misleading in some clinical settings: o Caudal regression
• Hemoglobinopathies
• Iron deficiency Neonatal complications
• Hemolytic anemia • Premature birth
• Thalassemia • Respiratory distress syndrome (RDS)
• Spherocytosis • Macrosomia
• Severe hepatic or renal disease • Shoulder dystocia
o Brachial plexus injury
GDM Postpartum • Hypoglycemia
▪ Screen women with GDM for persistent diabetes at 4 to 12 weeks • Hypocalcemia
postpartum using the OGTT. • Hyperbilirubinemia
▪ Women with GDM history should have lifelong screening for • Polycythemia
development of diabetes or prediabetes at least every 3 years • Childhood obesity
▪ Women with GDM history found to have prediabetes should receive
lifestyle interventions or metformin What are the effects or risk of diabetes on pregnancy?
• Long term complications of infant born to a mother with GDM
Complications • Increased risk of
▪ Fetal anomalies are not increased among GDM o Impaired glucose tolerance
▪ Lowest rates of adverse fetal outcomes in association with HbA1c <6-6.5% o Type 2 diabetes
(42-48 mmol/mol) early in gestation o HPN
o Increase risk of maternal hypoglycemia with HbA1c of < 6% (42 o Obesity
mmol/mol to <7% (53 mmol/mol) o Dyslipidemia
▪ Due to physiological increases in red blood cell turnover, HbA1c levels fall
during normal pregnancy.
▪ Second and third trimesters MANAGEMENT OF GDM
o HbA1c <6% (42 mmol/mol) has lowest risk of large for
gestational age (LGA) infants, whereas other adverse outcomes
Universal screening
increases with HbA1c > 6.5%
1st Prenatal Check-up
HbA1c of 66.5% (42 to 48 mmol/mol) is recommended but
<6% (42 mmol/mol) may be optimal as pregnancy progresses.

FBS
What are the effects or risks of gestational diabetes mellitus?
Maternal complications
• Preeclampsia and eclampsia
• Gestational HPN FBS <92mg/dL FBS 92-125mg/dL FBS ≥126mg/dL
• Postpartum hemorrhage (<5.1mmol/L) 5.1-.6.9mmol/L) HbA1c≥6.5%
• Prolonged labor
Non-GDM GDM Overt Diabetes
• Hypoglycemia
• Ketoacidosis
• Polyhydramnios
• Mortality
TREAT
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 NOEL E. RAYMUNDO, MD, FPOGS
OLFU - MEDICINE

GESTATIONAL DIABETES Fetal surveillance and timing of delivery in GDM

(American Diabetes Association 2017 Guidelines)
• Lifestyle modification may suffice for many women (70 to 85%) with GDM
• Insulin is treatment of choice
• Metformin and Glibenclamide must be 2nd choice
▪ These drugs do not have long term safety data
• ADA and ACOG guidelines recommend INSULIN as 1st line treatment for
GDM uncontrolled by nutritional therapy
• The National Institute for Health and Care Excellence (NICE) guideline
advises:
▪ Initial treatment with insulin either with or without metformin, for
any patient with a fasting glucose of 7 mmol/L (126 mg/dL) or
greater at diagnosis
• All women with GDM should receive dietary counseling at the time of
diagnosis
▪ Preferably provided by a registered dietitian or nutritionist
experienced at GDM management
• The ACOG 2013 guidelines recommend a caloric distribution
▪ 33 to 40%: Carbohydrates
▪ 20%: Protein
▪ 40%: Fat
• The goals of dietary modification in GDM
▪ To attain the desired level of glycemic control
▪ To provide adequate weight gain, which contributes to maternal
and fetal wellbeing
▪ To prevent the development of ketosis.
When to initiate drug therapy?
• ACOG guidelines recommend initiating drug therapy if
o fasting glucose concentrations are > 95 mg/dL or 2-hour postprandial
concentration routinely 140 mg/dL and 120 mg/dL or greater
• To begin drug therapy if
o Two or more values at the same meal (e.g post breakfast or post lunch)
in a 2-week period exceed desired glucose concentration by >10mg/dL
(Moore 2010)
o Two or more fasting or postprandial blood glucose values >100 mg/dL
or 126 mg/dL, respectively in a 2-week period (Crowther 2005)
• Women with GDM can be offered induction of labor between 38 to 40
weeks gestation
✓ To reduce the risk of stillbirth and the risk of CS
• Earlier or later induction of labor should be considered based on:
✓ Glycemic control
✓ Presence or absence of other comorbid conditions
Intrapartum glucose management
• Women with GDM should be monitored during labor and delivery
• Maternal blood glucose levels should be kept between 72 to 126 mg/dL
(4.0 - 7.0 mmol/L) to minimize the risk of neonatal hypoglycemia.
How will you monitor patients with GDM?
First trimester
• Ultrasound between 6 to 8 weeks gestation
o for accurate dating
• FPG or HbA1c: to assess glycemic control
o Risk for congenital abnormalities increases with higher
HbA1c values
• Assess overall health for effects of background vascular involvement
o Renal, ophthalmologic or cardiac
Second trimester: Screening for malformations
• Maternal serum alpha fetoprotein (AFP) screening at 15 to 20 weeks
o to assess the risk for fetal neural tube defects
• Ultrasound at 16 to 20 weeks
o for Evaluation of fetal anatomy
• Fetal echocardiography at 20 to 22 weeks
o screen for fetal cardiac abnormalities
Third trimester: Assessment of fetal well being
• Surveillance of fetal well-being at 28 weeks
o With maternal fetal activity assessment (kick counts)
because the risk of unexplained stillbirth is increased
• Non-stress testing (NSTs) or Biophysical profiles (BPP) at 32 weeks
o earlier if significant maternal vascular disease exists or there
is evidence of fetal growth restriction
• Ultrasound every 4 to 6 weeks to assess fetal growth

PREECLAMPSIA AND ASPIRIN

• In order to lower risk of preeclampsia, GDM should be prescribed low Timing of delivery
dose aspirin 60-150 mg/day (usual dose 81 mg/day) from the end of the • The time at which delivery occurs depends on both maternal glycemic
first trimester until the baby is born control and the health and maturity of the fetus.
• In patients with good glycemic control and reassuring fetal testing,
NEURAL DEFECT AND FOLIC ACID o Wait for the onset of labor until 40 weeks’ gestation
• To reduce the risk of neural tube defects: • If induction of labor is considered before 39 weeks
o Folic acid (5mg/day) supplement o Assessment of fetal lung maturity by amniocentesis
o Assess the lecithin-sphingomyelin (L/S) ratio and the
presence of phosphatidylglycerol in the amniotic Fluid
MANAGEMENT IN PREGNANCY • If testing does not reveal and L/S ratio of 2:1 or the presence of
• Women who receive antenatal corticosteroids to improve fetal lung phosphatidylglycerol
maturation should follow a protocol which increases insulin doses proactively o Delivery should be delayed until repeat testing confirms
to prevent hyperglycemia and diabetic ketoacidosis (DKA) fetal lung maturity or after 39 weeks as long as fetal testing
remains reassuring.
Following the first dose of betamethasone
Day 1 Increase the night insulin dose by 25%
Day 2 & 3 Increase all insulin doses by 40% Method of delivery
Day 4 Increase all insulin doses by 20% • If the suspected weight of the fetus does not exceed 4000g, vaginal
Day 5 Increase all insulin doses by 10 to 20% delivery (including induction of labor) can be attempted.
• If the suspected weight of the fetus exceeds 4000g (macrosomia),
Institute of Medicine Guidelines for Gestational Weight Gain elective caesarian can be offered.
• For all deliveries, euglycemia should be maintained and ketosis avoided.
Recommended Recommended
Prepregnancy
BMI Range of Range of Postnatal care for women who were diagnosed with GDM
Weight Category
Total Weight (kg) Total Weight (lb) • Stopping medication
Underweight <18.5 12.5 – 18.0 28–40 o Women who have been diagnosed with gestational
Normal Weight 18.5–24.9 11.5 – 16.0 25–35 diabetes should discontinue blood glucose lowering
Overweight 25–29.9 7.0 – 11.5 15–25 therapy after birth.
Obese (all classes) ≥30 5.0 – 9.0 11–20 • Offer lifestyle advice (including weight control, diet and exercise)
Recommended rate of weight gain and total weight gain for singleton • Offer a fasting plasma glucose test 6-12 weeks after the birth to exclude
pregnancies according to pre-pregnancy BMI diabetes
• If a fasting plasma glucose test has not been performed by 13 weeks
o Offer a HbA1c test after 13 weeks

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 NOEL E. RAYMUNDO, MD, FPOGS
OLFU - MEDICINE

• Do not routinely offer 75g 2hr OGTT

• Both metformin and intensive lifestyle intervention prevent or delay
progression to diabetes in women with prediabetes and a history of
GDM.
• Lifestyle intervention and metformin reduced progression to diabetes
by 35% and 40% respectively, over 10 years

Contraceptive
• Progesterone only pills are safe.
• Combined oral contraceptive pills may be avoided especially when
diabetes mellitus is of a long duration.
• Intrauterine devices may predispose to infection.
• A diabetic patient may undergo tubal sterilization with precaution.
• Counseling the husband for vasectomy is a good option.

Sources: Recording, PPT

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