Gestational diabetes resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Synonyms and keywords:

Overview

This section provides a short and straight to the point overview of the disease or symptom. The first sentence of the overview must contain the name of the disease.

Causes

Life Threatening Causes

There is no known life-threatening cause for gestational diabetes.

Common Causes

Common causes of gestational diabetes include:

• Increased age.
• High Body mass index.
• Low levels of physical activity.
• African American, Hispanic, Asian, and Native American race.

Diagnosis

Shown below is an algorithm summarizing the diagnosis of gestational diabetes according the American College of Obstetricians and Gynecologists guidelines.

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.

Patients with confirmed gestational diabetes

Lifestyle and dietary modification along with regular monitoring of blood glucose levels. Food with low or medium glycemic index along with high intake of fiber, fresh fruits, and vegetables. An active lifestyle with increased physical activity The patient is advised to monitor blood glucose levels 4 to 7 times each day.

Blood glucose level maintained in the normal range?

Yes

No

No need to initiate hypoglycemic medications.

Step- up approach with administration of hypoglycemic drugs. Insulin is the preferred choice with a starting dose of 0.7-1 unit/kg each day divided in a basal-bolus regimen. Metformin and glyburide can also be used but these drugs cross the placenta barrier and their long-term effects on neonates are unknown.

Do's

• 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. 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 . This cut-off criteria increased the prevalence of diabetes among pregnant women in various subpopulations .

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. Hence glyburide and metformin is only prescribed to pregnant females if they cannot tolerate insulin, obstetrician believes it’s a safer option or due to financial restrictions.

References

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