Gestational diabetes resident survival guide
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mydah Sajid, MD[2]; José Eduardo Riceto Loyola Junior, M.D.[3]
Synonyms and keywords:
Overview
Gestational diabetes is a common complication that occurs in pregnancy. It is defined as the glucose intolerance that develops during gestation in patients who were not diabetic before pregnancy. [1]The hormones produced during pregnancy increase resistance to glucose. In these patients, the glucose levels are elevated to diabetic range. There are several risk factors for gestational diabetes including obesity, previous history of gestational diabetes, sedentary lifestyle, and significant family history of diabetes. This section provides a short and to the point overview of the gestational diabetes.
Causes
Life-Threatening Causes
There is no known life-threatening cause for gestational diabetes.
Common Causes
Gestational diabetes is caused by the production of placental hormones such as estrogen, cortisol, progesterone, leptin, placental lactogen, and placental growth hormone that increase insulin resistance. This promotes endogenous glucose production and facilitation of transportation of glucose through the placenta to the fetus due to a mild hyperglycemic state. This is compensated by the increased pancreatic beta-cells insulin production through hyperplasia and hypertrophy. Some patients, however, may not have the pancreatic reserve to compensate those hormone's effects, possibly due to previous pancreatic injury.[2] Risk factors for such cases include:[3][4]
- Increased age;
- High Body mass index;
- Low levels of physical activity;
- African American, Hispanic, Asian, and Native American race;
- Excessive weight gain;
- Advanced maternal age;
- Intrauterine environment (low or high birthweight);
- Family or personal history of gestational diabetes;
- Insulin resistance, such as polycystic ovarian syndrome.[2]
Diagnosis
Shown below is an algorithm summarizing the diagnosis of gestational diabetes according to the American College of Obstetricians and Gynecologists guidelines[5][6].
All pregnant women should be screened for GDM at 24 weeks or more of gestation | |||||||||||||||||
Two-step screening approach is recommended | |||||||||||||||||
50g of oral glucose load is administered to the patient followed by measurement of venous blood glucose level after 1 hour | |||||||||||||||||
Blood glucose level equal or higher than 190mg/dl or 10.6mmol/l | |||||||||||||||||
Yes | No | ||||||||||||||||
100g of oral glucose load is administered to the patient followed by measured of venous blood glucose level after 3 hours | Second screening test not required | ||||||||||||||||
Blood glucose level equal or more than 145mg/dl or 8mmol/l | |||||||||||||||||
Gestational diabetes mellitus diagnosed when there is an abnormal blood glucose level 2 or more times | |||||||||||||||||
Treatment
Shown below is an algorithm summarizing the treatment of gestational diabetes according to the American Diabetes Association guidelines[5][6][7].
Patients with confirmed gestational diabetes | |||||||||||||||||||||||||||||||||
Lifestyle and dietary modification along with regular monitoring of blood glucose levels.
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Blood glucose level maintained in the normal range? | |||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||
No need to initiate hypoglycemic medications. | Step- up approach with administration of hypoglycemic drugs. | ||||||||||||||||||||||||||||||||
Dos
- The goals for glycemic control in gestational diabetes are fasting plasma glucose level less than 95mg/dl, one hour and two hour post-meal glucose level less than 140 and 120mg/dl, respectively[5][8]. The insulin regimen can be adjusted according to the blood glucose level. In women with elevated early morning fasting glucose level, a single dose of intermediate-acting insulin should be administered at night. In females with elevated postprandial glucose levels, rapid-acting insulin should be administered half an hour before meals.
- A single step 75 gram oral glucose tolerance test can be used to diagnose gestational diabetes. The gestational diabetes is diagnosed when blood glucose level is equal or greater than 153 mg/dl [9]. This cut-off criteria increased the prevalence of diabetes among pregnant women in various subpopulations [10].
- An antenatal fetal monitoring is recommended in gestational diabetes pregnant females starting from 32nd week of gestation[5].
- Screening tests should be done 4-12 weeks after delivery in gestational diabetes to identify if patients have impaired fasting glucose, diabetes, and impaired glucose tolerance. The screening can be done with a fasting plasma glucose level or a 75gram oral glucose tolerance test. Patients with impaired levels should be referred for medical treatment[5].
Don'ts
- Different clinical trials and meta-analysis have demonstrated considerable efficacy of metformin and glyburide for the treatment of gestational diabetes. Metformin has shown more efficacy for glycemic controlling compared to insulin in pregnant females. It does not have immediate adverse effects on fetus and neonates but, its long-term effects on neonates are still unclear[11][12]. Hence glyburide and metformin is only prescribed to pregnant females if they cannot tolerate insulin, it may be a safer option or more adequate due to financial restrictions.
References
- ↑ American Diabetes Association (2009). "Diagnosis and classification of diabetes mellitus". Diabetes Care. 32 Suppl 1: S62–7. doi:10.2337/dc09-S062. PMC 2613584. PMID 19118289.
- ↑ 2.0 2.1 Plows JF, Stanley JL, Baker PN, Reynolds CM, Vickers MH (2018). "The Pathophysiology of Gestational Diabetes Mellitus". Int J Mol Sci. 19 (11). doi:10.3390/ijms19113342. PMC 6274679. PMID 30373146.
- ↑ Snowden JM, Mission JF, Marshall NE, Quigley B, Main E, Gilbert WM; et al. (2016). "The Impact of maternal obesity and race/ethnicity on perinatal outcomes: Independent and joint effects". Obesity (Silver Spring). 24 (7): 1590–8. doi:10.1002/oby.21532. PMC 4925263. PMID 27222008.
- ↑ Bouthoorn SH, Silva LM, Murray SE, Steegers EA, Jaddoe VW, Moll H; et al. (2015). "Low-educated women have an increased risk of gestational diabetes mellitus: the Generation R Study". Acta Diabetol. 52 (3): 445–52. doi:10.1007/s00592-014-0668-x. PMID 25344768.
- ↑ 5.0 5.1 5.2 5.3 5.4 "ACOG Practice Bulletin No. 190: Gestational Diabetes Mellitus". Obstet Gynecol. 131 (2): e49–e64. 2018. doi:10.1097/AOG.0000000000002501. PMID 29370047.
- ↑ 6.0 6.1 American Diabetes Association (2017). "13. Management of Diabetes in Pregnancy". Diabetes Care. 40 (Suppl 1): S114–S119. doi:10.2337/dc17-S016. PMID 27979900.
- ↑ "Erratum: Borderud SP, Li Y, Burkhalter JE, Sheffer CE and Ostroff JS. Electronic cigarette use among patients with cancer: Characteristics of electronic cigarette users and their smoking cessation outcomes. Cancer. doi: 10.1002/ cncr.28811". Cancer. 121 (5): 800. 2015. doi:10.1002/cncr.29118. PMID 25855820.
- ↑ American Diabetes Association (2019). "9. Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes-2019". Diabetes Care. 42 (Suppl 1): S90–S102. doi:10.2337/dc19-S009. PMID 30559235.
- ↑ International Association of Diabetes and Pregnancy Study Groups Consensus Panel. Metzger BE, Gabbe SG, Persson B, Buchanan TA, Catalano PA; et al. (2010). "International association of diabetes and pregnancy study groups recommendations on the diagnosis and classification of hyperglycemia in pregnancy". Diabetes Care. 33 (3): 676–82. doi:10.2337/dc09-1848. PMC 2827530. PMID 20190296.
- ↑ American Diabetes Association (2011). "Standards of medical care in diabetes--2011". Diabetes Care. 34 Suppl 1: S11–61. doi:10.2337/dc11-S011. PMC 3006050. PMID 21193625.
- ↑ Martis R, Crowther CA, Shepherd E, Alsweiler J, Downie MR, Brown J (2018). "Treatments for women with gestational diabetes mellitus: an overview of Cochrane systematic reviews". Cochrane Database Syst Rev. 8: CD012327. doi:10.1002/14651858.CD012327.pub2. PMC 6513179 Check
|pmc=
value (help). PMID 30103263. - ↑ Butalia S, Gutierrez L, Lodha A, Aitken E, Zakariasen A, Donovan L (2017). "Short- and long-term outcomes of metformin compared with insulin alone in pregnancy: a systematic review and meta-analysis". Diabet Med. 34 (1): 27–36. doi:10.1111/dme.13150. PMID 27150509.