Gestational diabetes resident survival guide

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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]

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.
  • Food with low or medium glycemic index along with high intake of fiber, fresh fruits, and vegetables.
  • Frequent small meals are recommended. The patient should have three meals with snacks in between twice a day.
  • 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.
 

Dos

Don'ts

References

  1. 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. 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.
  3. 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.
  4. 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. 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. 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.
  7. "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.
  8. 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.
  9. 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.
  10. 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.
  11. 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.
  12. 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.


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