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Gestational Diabetes Management
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Gestational Diabetes Management
Indications
Gestational Diabetes
Abnormal
Glucose Tolerance Test 3 hour
Preexisting
Diabetes Mellitus
Monitoring
Blood Glucose
Frequency of
Blood Glucose Monitoring
Insulin
therapy
Blood Sugar Monitoring
4 times daily
Diet control
Blood Sugar
s 4 times on 2 days per week
Increase monitoring if 2 values/week abnormal
Target Levels
Before Breakfast or early morning (2-6 am): 60 to 95 mg/dl
Before Lunch,Dinner: 60 to 115 mg/dl
One hour post prandial goal: under 140 mg/dl
Two hour post prandial goal: under 120 mg/dl
Check
Urine Ketone
s in early morning
Preferred monitoring: Postprandial
Blood Glucose
Post-prandial
Blood Glucose Monitoring
preferred
Associated with improved outcomes
Lower
Hemoglobin A1C
levels
Lower birth weights
Fewer
Cesarean Section
s
References
De Veciana (1995) N Engl J Med 333:1237-41 [PubMed]
Evaluation
Initial
Diabetic Diet
Diabetic nurse
Consultation
Initiate home
Blood Sugar Monitoring
See
Blood Glucose Monitoring
above
Management
Diet controlled management
Indications
Blood Sugar
s within target range (see above)
Monitoring
See
Blood Glucose Monitoring
above
Dietary recommendations
Restrict carbohydrates to <33 to 40% of daily calories
Some studies have recommended a low
Glycemic Index
diet
Caloric restriction if BMI > 30 kg/m2
Limit to 25 KCal/kg of actual weight per day
Weight Gain in Pregnancy
>40 pounds (18 kg) is associated with
Fetal Macrosomia
in 40% of cases
Black (2013) Diabetes Care 36(1): 56-62 [PubMed]
Avoid severe caloric restriction
Ketone
mia associated with psychomotor delay
Rizzo (1995) Am J Obstet Gynecol 173:1753-8 [PubMed]
Exercise
recommendations
Regular aerobic
Exercise
improves glycemic control
Circuit
Resistance Training
improves glycemic control
Brankston (2004) Am J Obstet 190:188-93 [PubMed]
Management
Oral Hypoglycemic
s
Indications: Failed diet control (see above)
More than 50% of
Glucose
values in a week are above goal (see above) OR
More than 2
Glucose
values >10 mg/dl above goal at the same meal in a 2 week period
Precautions
Oral agents are first-line
Gestational Diabetes
agents
Followed experimental use in 2005-2010 to confirm safety, efficacy
Metformin
is not FDA approved in pregnancy
However, it is pregnancy category B
Metformin
crosses the placenta
However, it is not associated with birth defects or short term adverse neonatal outcomes
Metformin
is the only
Oral Hypoglycemic
that appears safe in pregnancy
Sulfonylurea
s are not recommended in pregnancy
Of the
Sulfonylurea
s, only
Glyburide
is a pregnancy category B
Glyburide
was initally thought the only safe
Sulfonylurea
in pregnancy
Jacobson (2005) Am J Obstet Gynecol 193(1): 118-24 [PubMed]
As of 2015,
Glyburide
is no longer recommended in pregnancy as of 2015
Greater risk of
Neonatal Hypoglycemia
and macrosomia (compared with
Insulin
)
Balsells (2015) BMJ 350:h102 [PubMed]
Insulin
is FDA approved in pregnancy and has a longer track record
Up to 40% of women started on
Oral Hypoglycemic
s require transition to
Insulin
in pregnancy
Glucophage
(
Metformin
)
Start at 500 mg once daily with food and titrate to a maximum of 2500 mg daily
Glucophage
has also been used in
Metabolic Syndrome
and
PCOS
to facilitate conception (effective in 42% of cases)
If patient conceives on
Glucophage
, continue for first 20 weeks (prevents
Rebound Hyperglycemia
)
Rowan (2008) N Engl J Med 358(19):2003-15 [PubMed]
Glueck (2002) Hum Reprod 17:2858-64 [PubMed]
References
Greene (2000) N Engl J Med 343:1178-9 [PubMed]
Langer (2000) N Engl J Med 343:1134-8 [PubMed]
Management
Insulin
Indications
Failed diet control (see above)
Fastin
g
Blood Glucose
> 95 mg/dl or
Two hour postprandial
Blood Glucose
>120 mg/dl
Preexisting
Insulin Dependent Diabetes Mellitus
Protocol
See
Insulin Management in Pregnancy
See
Insulin Management in Labor
Endocrine consult as needed for
Insulin Dosing
Monitoring
Antepartum aggressive monitoring for complications
Aggressive monitoring is not needed for diet controlled
Gestational Diabetes
(no medications)
No increased risk of
Stillbirth
Loomis (2006) J Fam Pract 55(3): 238-40 [PubMed]
Mitanchez (2010) Diabetes Metab 36(6 pt 2): 617-27 [PubMed]
Monitoring as directed by local established protocols
Monitoring starting at 32 weeks gestation
Weekly
Non-Stress Test
(biweekly if on
Insulin
or poor control)
Amniotic fluid index weekly if on
Insulin
or poor control
Some protocols include
Biophysical Profile
Daily
Fetal Kick Count
s starting at 34 weeks gestation
Obstetric Ultrasound
monthly
Assess
Fetal Growth
for macrosomia
Not universally adopted as
Ultrasound
may unnecessarily increase the cesarean delivery rate
Little (2012) Am J Obstet Gynecol 207(4): 309.e1-309.36 +PMID:22902073 [PubMed]
Prenatal Visit
frequency and monitoring based on
Blood Sugar
control
Plan
Labor Induction
by 39-40 weeks
Management
Intrapartum
See
Insulin Management in Labor
Timing of delivery
Consider offering
Cesarean Section
for EFW > 4500 g (9 lb 14 oz)
Delivery prior to 40 weeks not indicated unless
Poor glycemic control
Other fetal or maternal complications
Management
Postpartum Care
Consider
Glucose Tolerance Test 2 hour
(75 g Glucola)
Non-Lactating: Schedule at 6-12 weeks
Breast Feeding
: Schedule at 6 months
Abnormal in up to 36% in post-partum women
Prevention
Maintain
Ideal Body Weight
Moderate intensity
Exercise
for 150 minutes per week
Fastin
g
Blood Glucose
every 1-3 years
Risk of developing
Type II Diabetes Mellitus
within 10 years (GDM high risk groups): 50%
References
(2014) Diabetes Care 37(suppl 1): S14-80 [PubMed]
(2013) Obstet Gynecol 122(2 pt 1): 406-16 [PubMed]
Garrison (2015) Am Fam Physician 91(7): 460-7 [PubMed]
Serlin (2009) Am Fam Physician 80(1):57-62 [PubMed]
Turok (2003) Am Fam Physician 68(9):1767-72 [PubMed]
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