GESTATIONAL

DIABETES
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 WHAT IS GDM?

Glucose intolerance developing during pregnancy

Insulin resistance is related to the metabolic changes of late
pregnancy, and the increased insulin requirements may lead to
IGT or
diabetes.
Most important perinatal correlate is excessive fetal growth
, which may result in both maternal and fetal birth trauma
 EPIDEMIOLOGY

Occurs in ~7% (range 114%) of pregnancies in the United States

Most women revert to normal glucose tolerance postpartum but h
ave a
substantial risk (3560%) of developing DM in the next 1020 years
The International Association of the Diabetes and Pregnancy Stud
y Groups
and the American Diabetes Association (ADA) recommend that diabe
tes
diagnosed at the initial prenatal visit should be classified as overt di
abetes
rather than GDM.
With the rising rates of obesity, the number of women being diagn
 PATHOPHYSIOLOGY
The precise mechanisms underlying gestational diabetes re
mains
unknown.
Pregnancy hormones and other factors are though to interfer
e with
the action of insulin as it binds to the insulin receptor.
It probably occurs at the level of the cell signaling pathway b
eyond the insulin receptor.
As a result, glucose remains in the bloodstream where the gl
ucose
levels rise.
SCREENING AND DIAGNOSIS

The recommended two-step approach begins with either uni

versal
or risk-based selective screening using a 50-g, 1-hour oral gluc
ose
challenge test.
Measured 1 hour after a 50-g oral glucose load without r
egard to the time of day or time of last meal.
135 or 140 mg/dL as the 50-g screen threshold.
Screening should be performed between 24 and 28 weeks
gestation in those women not known to have glucose intoleranc
e
SCREENING AND DIAGNOSIS

50-g screening test is followed by a diagnostic 100-g, 3-hour

oral glucose tolerance test (OGTT)
if screening results meet or exceed a predetermined pla
sma glucose concentration
Women were diagnosed as having gestational diabetes
if their blood glucose was < 100 mg/dL after an overnigh
t fast and was between 140 and 198 mg/dL 2 hours afte
r ingesting a 75-g glucose solution
Macrosomia defined by birthweight 4000 g
Mild gestational diabetes was identified in women with fastin
g glucose levels < 95 mg/dL
MATERNAL AND FETAL OUTCOMES

Women with elevated fasting glucose levels have increased

rates of unexplained stillbirths similar to women with overt di
abetes
fasting hyperglycemia > 105 mg/dL may be associated with
an increased risk of fetal death during the final 4 to 8 weeks
.
adverse maternal effects associated with gestational diabete
s include an increased frequency of hypertension and cesa
rean delivery.
 MANAGEMENT

Pharmacological methods are usually recommended if diet modification doe

s not consistently maintain the fasting plasma glucose levels < 95 mg/dL or
the 2-hour postprandial plasma glucose < 120 mg/dL

Diabetic Diet
On average, this includes a daily caloric intake of 30 to 35 kcal/kg
Carbohydrate intake be limited to 40 percent of total calories. 20 percent as
protein
and 40 percent as fat.
 MANAGEMENT
Exercise
Exercise improved cardiorespiratory fitness without improving pregnancy outc
ome
physical activity during pregnancy reduced the risk of gestational diabetes
moderate exercise program as a part of the treatment plan for women with ge
stational
Diabetes.
Glucose Monitoring
Women using daily blood-glucose self-monitoring had significantly fewer macro
somic
infants and gained less weight after diagnosis than women evaluated during cli
nic visits only.
Postprandial surveillance was shown to be superior in that blood-glucose contr
 MANAGEMENT
Insulin Treatment
standard therapy in women with gestational diabetes
does not cross the placenta
insulin is typically added if fasting levels persistently exceed 95 mg/dL in w
omen with gestational diabetes.
Insulin considered in women with 1-hour postprandial levels that persistently
exceed 140 mg/dL or those with 2-hour levels above 120 mg/dL
starting dose is typically 0.71.0 units/kg/day given in divided doses
 MANAGEMENT
Recurrent Gestational Diabetes
Obese women were more likely to have impaired glucose tolerance in subse
quent
pregnancies
lifestyle behavioral changes, including weight control and exercise between
pregnancies prevents gestational diabetes recurrence
loss of at least two BMI units was associated with a lower risk of gestational
diabetes
THANK YOU