Diagnosis and Management of Gestational Diabetes In the past, 50 g glucose challenge test cut-off is

Ramon M. Gonzalez, M.D. 130 g/dL. If it exceeds, proceed to OGTT

Professor Since Filipinos are high risk, we screen them at first
UST Medicine and Surgery prenatal visit

Classification of Diabetes during Pregnancy Overt Diabetes

Pre-gestational Diabetes Fasting Blood Sugar >126 mg/dL
o Type 1 (Insulin Deficient) Random Blood Sugar > 200 mg/dL
o Type 2 (Insulin Resistant) 2 hour plasma glucose > 200 mg/dL during a 75 g
Gestational Diabetes OGTT
HbA1c > 6.5%
Diabetes in Pregnancy Type 1 Patients

Autoimmune disease

Destruction of pancreatic B cells

No insulin production

Ketoacidosis

Diabetes in Pregnancy Type 2

Most common form of diabetes
Chronic condition that affects the way your body
metabolizes sugar
Does not produce enough insulin
Obese and sedentary lifestyle

Gestational Diabetes Mellitus (GDM)

Glucose tolerance that begins or is first recognized
during pregnancy
Preclinical Type 2 DM, unmasked by the hormonal
stress of pregnancy
Undiagnosed Type 2 DM
o Some of them were already diabetics before
pregnancy. It might be that they were
asymptomatic or there were no laboratory tests
done until they were pregnant.
Arises from significant maternal insulin resistance
30-70% will develop GDM in future pregnancies
10-50% will develop Type II DM within 5 years

Screening and Detection

Risk factors for DM during Pregnancy Fetal Effects (Uncontrolled blood sugar serves as a risk factor for these)
Maternal age > 25 years old Abortion
Previous macrosomic infant Congenital Anomalies
Previous unexplained fetal demise o Most common: CV defect and neural tube defects
Previous pregnancy with GDM o Important to give folic acid!
Member of an ethnic/racial group with high prevalence IUGR
of diabetes mellitus o Vasculopathy
o Hispanic-American, Native American, Asian- Fetal obesity
American, African American, or Pacific Islander Birth injury
Family history of DM Preterm delivery
Obesity Unexplained fetal death
Glucosuria o Fetal acidosis as the cause. If the mom is having
Polycystic ovary syndrome acidosis, the neonate is also acidotic
Current use of corticosteroids
Essential HPN or pregnancy related hypertension Maternal Effects
Previous birth of a malformed child Diabetic Nephropathy
Diabetic Retinopathy
Screening (IADPSG) Diabetic Neuropathy
High Risk screen at first prenatal visit Preeclampsia
o FBS Ketoacidosis
o RBS Infections
o HbA1c
Gestational DM Neonatal Effects
o If FBS is between 92 mg/dL and 126 mg/dL Respiratory Distress Syndrome
Low risk screen at 24-28 weeks AOG Hypoglycemia
o 2 hr 75 g OGTT Hypocalcemia
An abnormal 1 hour plasma glucose GDM Hyperbilirubinemia
If OGTT is normal repeat OGTT at 32 weeks or earlier Cardiac Hypertrophy
if clinical signs and symptoms of hyperglycemia are Childhood Obesity
present. Childhood Impaired Glucose Tolerance
Fasting, 1 hour and 2 hours are the only values taken.
o You only need one abnormal value to diagnose. Management: POGS Clinical Practice Guidelines
o 75 g OGTT is now used. Treatment plan for GDM
Diet
Exercise
Fasting > 92
Self monitoring of blood glucose (SMBG)
1 Hour > 180
Insulin
2 hour > 153 Oral hypoglycemic agents (OHA)

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Diet o Fasting plasma glucose 60-90mg/dl
Classifications: o Preprandial 80-95mg/dl
2
o Normal Body Weight (BMI: 20-25kg/m ) o Postprandial - < 120mg/dl
30-35 kcal/kg/d There is no significant difference in blood glucose
2
o Obese (BMI >24-34kg/m ) monitoring premeals, post meals an HbA1c
24 kcal/kg/d No difference in neonatal outcomes, maternal
2
o Morbidly obese (BMI >34 kg/m ) outcomes, metabolic outcomes and perinatal
-20 kcal/kg/d outcomes
Caloric composition Glyburide and Insulin has the same outcome
o Complex carbohyrdrates 40-50 % Hypoglycemia is more prominent in those given
o Proteins 20% insulin than glyburide
o Unsaturated fats 30-40%
Given as 3 meals and 3 snacks daily Glyburide
o This should be distributed throughout the day Second generation sulfonylurea
Caloric distribution The primary action of sulfonylurea drugs is to increase
o Breakfast 10-20% insulin secretion, thereby deceasing hepatic glucose
o Lunch 20-30% production
o Dinner 30-40% Its onset of action is between 15-60 minutes, peak at
o Snacks 30% 4 hours and duration is 10 hours
Does not readily cross the placenta
Exercise Staring dose: 2.5 mg per orem in the morning
Lowers blood glucose level o Maximum dose: 20 mg/day
Burns calories and helps control weight Has not been associated with neonatal hypoglycemia
Improves the bodys response to insulin and may or fetal anomalies
make insulin and oral hypoglycemic agents more Undetectable in cord blood of neonate
effective Not present in the milk of lactating mother in vivo and
Promotes circulation and lowers cholesterol and in vitro
triglyceride levels Appears to be a safe and effective alternative to
insulin for the treatment of GDM
Blood Glucose Monitoring
Self monitoring of blood glucose (SMBG) Metformin vs Insulin:
o Premeals - 95 mg/dl (5.3mmol/L) Rowan et al, NEJM 2008
o 1 hour PP - 140 mg/dl (7.8 mmol/L) 733 Singleton pregnancies with GDM
o 2 hour PP - 120 mg/dl (6.7 mmol/L) o Metformin 363; Insulin - 370
HbA1c - 6% 20-33 weeks AOG
Fasting plasma glucose >97.2mg/dl or 2 hr
Insulin Preparation postprandial >120.6mg/dl
Peak Duration (Hour) Goals of Treatment
Regular Insulin 2-3 hours 8-10 o Fasting plasma glucose <99mg/dl
Insulin Lispro 1 hour 2-4 o 2 hour postprandial <126mg/dl
Insulin Aspart 31-70 min 2-4 Metformin has higher incidence of preterm birth
unexplained
Insulin Therapy
Maintain CBG levels as close to normal Metformin
1st trimester - 0.7 - 0.8 u/kg/d Oral biguanide antihyperglycemic drug used for Type
2nd trimester - 0.8 -1.0 u/kg/d II diabetics.
3rd trimester - 0.9 - 1.2 u/kg/d Category B
NPH insulin Reduces peripheral insulin resistance, inhibits hepatic
o 2/3 of daily dose is given before breakfast glucose production and enhances peripheral glucose
o 1/3 before dinner uptake.
Human regular insulin and rapid acting insulin Crosses the human placenta
o Best dosed with each meal Peak levels w/in 4 hours
Dosage 500-850mg increments
Glucose Monitoring o Maximum dose- 2000mg/day
GDM on Diet Effective and safe treatment option for women with
o SMBG 4 x/day GDM.
o FBS 1 x/day and postprandial 3 x a day It is not associated with increased perinatal
Women on pharmacologic therapy complications.
o SMBG 4-6 x a day include preprandial values Metformin is more acceptable to women with GDM
Urine ketone testing than insulin.
o Severe hyperglycemia, weight loss during
treatment or during starvation A Randomized Trial of Metformin Compared to Glyburide in the
Treatment of GDM
Oral Hypoglycemic Agents Moore et al, AMJOG 2006
ACOG does NOT recommend these agents during 46 Singleton pregnancies with GDM
pregnancy o Metformin 22; Glyburide - 24
o Not contraindicated but is not recommended as 11-35 weeks AOG
first line. Goals of Treatment
There is increasing support for use of glyburide as an o Fasting 60-90mg/dl
alternative to insulin in the management of DM o 2 hour postprandial - <120mg/dl
13% of ACOG fellows: No significant difference
o Glyburide as the first line therapy for diet failure
with GDM Oral Hypoglycemic Agents vs. Insulin in Management of GDM:
A Systematic Review and Metaanalysis
A Comparison of Glyburide and Insulin in Women with GDM Dhulkotia et al
Langer et. al., NEJM 2000 AmJOG 2010
404 Singleton pregnancies with GDM Metaanalysis of 6 RCTs, 1388 subjects
o Glyburide-200; Insulin-203 Glyburide/Metformin vs Insulin
11-33 weeks AOG Glycemic Control
18-40 y/o o No significant difference in the average blood
FPG >/= 95mg/dl or Postprandial plasma glucose sugar levels between OHA and insulin (WMD,
>/=120mg/dl 1.31; 95% CI-0.81 to 3.34)
Goals of Treatment
o Mean blood glucose 90-105mg/dl

M 2
 o No significant difference in postprandial Intrapartum Management
glycemic control between OHAs and insulin Goal maintain normoglycemia in order to prevent
(WMD, 0.80;95% CI,-3.26 to 4.87) neonatal hypoglycemia
Neonatal Outcome Diet controlled diabetes
o No significant difference in the incidence of o Does not require insulin
neonatal hypoglycemia in the glyburide and o Glucose monitoring on admisssion
metformin groups (OR 1.59; 95% CI, 0.70-3.62) Insulin requiring diabetes
o No significant difference in the birthweight o The last insulin dose is given subcutaneously the
between the OHA and insulin groups (WMD night before or that morning
56.11; 95% CI, 42.62 to 154.84) o Monitor blood glucose hourly
o No significant difference in the incidence of LGA o Target values capillary glucose 70-110mg/dl or
between the OHA and insulin groups (OR plasma glucose 80-120 mg/dl
1.01;95% CI, 0.61-1.68) o Give short-acting insulin via IV infusion at a dose
o NICU admission (OR, 04;95%CI, 0.61-1.17) of 0.5-1 unit per hour for plasma glucose above
o RDS (OR, 0.83; 95% CI, 0.45-1.53) 120 mg/dl
o Birth injuries (OR, 1.01;95% CI, 0.51-1.99)
o SGA (6.75% OHA vs 9.85% insulin; OR, 0.51; For CS patients
95% CI, 0.12-2.12) The last insulin dose is given subcutaneously the
o Preterm births (11.9% OHA vs 7.6% insulin; OR, night before
1.63; 95% CI, 1,01-2.63) Determine random plasma glucose immediately prior
o Congenital anomalies (OR, 0.81; 95% CI, 0.17- to cesarean section
5.83) Infuse short acting insulin (0.5-1 unit per hour) if
o IUFD (OR, 1.0; 95% CI, 0.17-5.83) plasma glucose is above 120mg/dl
Maternal Outcomes Discontinue IV insulin immediately prior to delivery
o Maternal hypoglycemia was 8.8% in OHA and Check plasma glucose 2 hours post CS up to 24
22.2% in insulin group (OR, 0.34, 95% CI, 0.02- hours
5.82)
o Hypertensive disorders was slightly higher in
insulin group (10.65% vs 8.16%; OR, 0.75; 95%
CI, 0.50-1.12)
o No significant difference in the incidence of CS
(OHA 33.7% vs insulin 36.02%)
o Patient preference was significantly higher in the
OHA (metformin) group (76.6% vs 27.2% P<
0.001)
Supplemental Insulin
o Conversion rate from OHA to insulin was very low
in the studies using glyburide, 4% in the study
by Langer et al.
o Conversion rate from OHA to insulin was higher
in the studies using metformin , 46.3% in the
study by Rowan et al.
Conclusion
o OHAs are suitable for use in the management of
GDM because good glycemic control and
maternal and perinatal outcomes are comparable
with insulin.
o OHAs should be considered as credible and safe
alternatives to insulin.
o OHAs are patient friendly and convenient and do
not require intensive educational instruction at the
time of initiation of therapy.

Fetal Surveillance
Accurate dating
Congenital Anomaly Screening
Monitoring of Fetal Growth
Antepartum Fetal Monitoring

Frequency of Fetal Monitoring

Patients degree of metabolic control
Type of therapy she is receiving
Presence of other risk factors
At least once a week

Fetal Surveillance
NST
CST
BPP
Doppler studies

Timing of Delivery
Expectant management
o Good glucose control
o Not recommended beyond the estimated due
date
Early delivery
o Vasulopathy, nephropathy, prior stillbirth, and
poor glucose control
o Maternal or fetal indications

M 3