Professional Documents
Culture Documents
Pregestational Diabetes
Many women found to have gestational diabetes are likely to
have type 2 diabetes that has previously gone undiagnosed
5-10% of women with gestational diabetes are found to have
diabetes immediately after pregnancy
Diagnosis
High plasma glucose levels, glucosuria, and ketoacidosis
Random plasma glucose leve > 200 mg/dL
Classic signs and symptoms: polydipsia, polyuria, and
unexplained weight loss
Fasting glucose level exceeding 125 mg/dL
Diagnosis of Overt Diabetes in Pregnancy
Measure of glycemia
Threshold
Fasting plasma glucose
At least 7.0 mmol/L
(126 mg/dL)
Hemogblobin A1c
At least 6.5%
Cardiomyopathy
Hypertrophic cardiomyopathy that primarily affects the
interventricular septum in severe case
These infants are typically LGA and die before labor, usually
after 35 weeks gestation or later
Hydramnios
Diabetic pregnancies are often complicated by excess amnionic
fluid:
amnionic fluid index (AFI) > 24 cm in the 3rd trimester
Neonatal effects
Increased frequency of preterm delivery in women diabetes due
to advanced diabetes with superimposed pre-eclampsia
Inheritance of Diabetes
Risk of developing type 1 diabetes if either parents is affected is
3-4%
Type 2 diabetes has much stronger genetic component. If both
parents have type 2 diabetes, the risk of developing it
approaches 40%
Hypoglycemia
Newborns of a diabetic mother experience a rapid drop in
plasma glucose concentration after delivery
Pre-eclampsia
Hypertension that is induced or exacerbated by pregnancy is the
complication that most often forces preterm delivery in diabetic
women.
Hypocalcemia
Total serum calcium concentration <8 mg/dL in term newborns
Diabetic neuropathy
Peripheral symmetrical sensorimotor diabetic neuropathy is
uncommon in pregnant women
Isotonic NaCl
Total replacement in 1st 12 hours of 4-6 L
1 L in 1st hour
500-1000 mL/h for 2-4 hours
250 mL/h until 80% replaced
Glucose:
Begin D5NS when glucose plasma level reaches
250mg/dL (14 mmol/L)
Potassium
If initially normal or reduced, an infusion rate up to 1520 mEq/h may be required; if elevated, wait until levels
decrease into the normal range, then add to IV solution
a concentration of 20-30 mEq/L
Bicarbonate
Add one ampule (44 mEq) to 1 L of 0.45 NS if pH <7.
Infections
Almost 80% of women with type 1 diabetes develop at
least 1 infection during pregnancy compared with only
25% in those without diabetes
Common infections include Candidia vulvovaginitis,
urinary and respiratory tract infections, and puerperal
pelvic sepsis
Level, mg/dL
95
100
140
120
60
100
6%
Second trimester
Maternal serum -fetoprotein determination at 16-20 weeks
gestation is used in association with targeted sonographic
examination at 18-20 weeks to detect neural-tube defects and
other anomalies.
Maternal -fetoprotein levels may be lower in diabetic
pregnancies, and interpretation is altered accordingly.
Because the incidence of congenital cardiac anomalies is 5X
greater in mothers with diabetes, fetal echocardiography is
important.
Puerperium
Often, women may require no insulin for the first 24 hours
postpartum
Subsequently, insulin requirements fluctuate next few days
Infection must be promptly detected and treated
Carbohydrate intolerance of variable severity with first
recognition during pregnancy
High Risk
Perform blood glucose testing as soon as feasible, using the
procedures described above, if one or more of these present:
Severe obesity
Strong family history of type 2 diabetes
Previous history of GDM, impaired glucose metabolism,
or glucosuria
If GDM is not diagnosed, blood glucose testing should be
repeated at 24-28 weeks gestation or at any time symptoms or
signs suggest hyperglycemia
Consensus development conference in 2013 concluded that
evidence is insufficient to adopt a 1-step approach
The recommended 2-step approach begins with either universal
or risk-based selective screening using a 50-g, 1-h oral glucose
challenge test
Screening should be performed between 24 and 28 weeks
gestation in those women not known to have glucose
intolerance earlier in pregnancy
Maternal obesity
Maternal BMI is an independent and more substantial risk factor
for fetal macrosomia than is glucose intolerance
Higher BMI levels were associated with increasing birthweight,
regardless of glucose levels.
Maternal obesity is an important confounding factor in the
diagnosis of gestational diabetes
Management
Women with gestational diabetes can be divided into two
functional classes using fasting glucose levels
Pharmacological methods are usually recommended if diet
modification does not consistently maintain the fasting plasma
glucose
Postpartum evaluation
50% likelihood of women with gestational diabetes developing
overt diabetes within 20 years
*75-g oral dose tolerance test at 6-12 weeks postpartum and
other intervals thereafter
Either a fasting glucose or the 75-g, 2-h OGTT for the diagnosis
of overt diabetes (ACOG 2013)
*ADA (2011) recommends testing at least every 3 years in
women with a history of gestational diabetes but normal
postpartum glucose screening
Contraception
Low-dose hormonal contraception
Rate of subsequent diabetes in oral contraceptive users is not
significantly different from that in those who did not use
hormonal contraception
*importantly, comorbid obesity, hypertensive, or dyslipidemia
should direct the choice for contraception toward a method
without potential cardiovascular consequences. In these
instances, the IUD is a good alternative.