Gestational Diabetes Management

1. Indications: Gestational Diabetes
   1. Abnormal Glucose Tolerance Test 3 hour
   2. Preexisting Diabetes Mellitus
2. Monitoring: Blood Glucose
   1. Frequency of Blood Glucose Monitoring
      1. Insulin therapy: qid Blood Sugar Monitoring
      2. Diet control: 4 Blood Sugars on 2 days per week
         1. Increase monitoring if 2 values/week abnormal
   2. Target Levels
      1. Before Breakfast or early morning (2-6 am): 60 to 96 mg/dl
      2. Before Lunch,Dinner: 60 to 115 mg/dl
      3. One hour post prandial goal: under 140 mg/dl
      4. Two hour post prandial goal: under 120 mg/dl
      5. Check Urine Ketones in early morning
   3. Preferred monitoring: Postprandial Blood Glucose
      1. Post-prandial Blood Glucose Monitoring preferred
      2. Associated with improved outcomes
         1. Lower Hemoglobin A1C levels
         2. Lower birth weights
         3. Fewer cesarean sections
      3. References
         1. De Veciana (1995) N Engl J Med 333:1237-41
3. Evaluation: Initial
   1. Diabetic diet
   2. Diabetic nurse consultation
   3. Initiate home Blood Sugar Monitoring
      1. See Blood Glucose Monitoring above
4. Management: Diet controlled management
   1. Indications
      1. Blood Sugars within target range (see above)
   2. Monitoring
      1. See Blood Glucose Monitoring above
   3. Dietary recommendations
      1. Restrict carbohydrates to <40% of daily calories
      2. Caloric restriction if BMI > 30 kg/m2
         1. Limit to 25 KCal/kg of actual weight per day
         2. Avoid severe caloric restriction
            1. Ketonemia associated with psychomotor delay
            2. Rizzo (1995) Am J Obstet Gynecol 173:1753-8
   4. Exercise recommendations
      1. Regular aerobic Exercise improves glycemic control
      2. Circuit Resistance Training improves glycemic control
         1. Brankston (2004) Am J Obstet 190:188-93
5. Management: Insulin
   1. Indications
      1. Failed diet control (see above)
         1. Fasting Blood Glucose > 95 mg/dl or
         2. Two hour postprandial Blood Glucose >120 mg/dl
      2. Preexisting Insulin Dependent Diabetes Mellitus
   2. Protocol
      1. See Insulin Management in Pregnancy
      2. Endocrine consult as needed for Insulin Dosing
6. Protocols: Experimental (not to be used in practice)
   1. Glyburide is only hypoglycemic not contraindicated
      1. ACOG and ADA do not recommend use until further RCT
      2. Unclear whether Glyburide crosses the placenta
      3. Jacobson (2005) Am J Obstet Gynecol 193(1): 118-24
   2. Glucophage is also being studied in pregnancy
      1. Rowan (2008) N Engl J Med 358(19):2003-15
      2. Glueck (2002) Hum Reprod 17:2858-64
      3. Pregnancy in Metabolic Syndrome on Metformin: 42%
         1. If occurs on Metformin, continue for first 20 weeks
         2. Prevents Rebound Hyperglycemia
   3. Second Generation Sulfonylureas experimentally used
      1. Blood Sugar controlled as well as Insulin
      2. Markedly reduced Hypoglycemia with Oral Hypoglycemic
      3. No increased fetal anomaly or perinatal death
   4. References
      1. Greene (2000) N Engl J Med 343:1178-9
      2. Langer (2000) N Engl J Med 343:1134-8
7. Monitoring: Antepartum aggressive monitoring for complications
   1. Monitoring starting at 32 weeks gestation
      1. Weekly Non-Stress Test (biweekly if on Insulin or poor control)
      2. Amniotic fluid weekly if on Insulin or poor control
      3. Some protocols include Biophysical Profile
   2. Daily Fetal Kick Counts starting at 34 weeks gestation
   3. Obstetric Ultrasound monthly
      1. Assess Fetal Growth
   4. Prenatal Visit frequency and monitoring based on Blood Sugar control
   5. Plan Labor Induction by 39-40 weeks
8. Management: Intrapartum
   1. See Insulin Management in Labor
   2. Timing of delivery
      1. Consider offering Cesarean section for EFW > 4500 g
      2. Delivery prior to 40 weeks not indicated unless
         1. Poor glycemic control
         2. Other fetal or maternal complications
9. Management: Postpartum Care
   1. Consider Glucose Tolerance Test 2 hour (75 g Glucola)
      1. Non-Lactating: Schedule at 6 weeks to 3 months
      2. Breast Feeding: Schedule at 6 months
   2. Maintain ideal body weight
   3. Moderate intensity Exercise for 150 minutes per week
   4. Fasting Blood Glucose yearly
      1. Risk of developing Type II Diabetes Mellitus within 10 years: 50%
10. References
    1. Serlin (2009) Am Fam Physician 80(1):57-62
    2. Turok (2003) Am Fam Physician 68(9):1767-72