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Gestational Diabetes

Gestational diabetes is defined as any level of hyperglycemia occurring during pregnancy, inclusive of the possibility of onset during pregnancy or the presence of unrecognized glucose intolerance preceding the gestational period.


Presentation

Gestational diabetes mellitus (GDM) has a range of risk factors and is associated with a frightening spectrum of maternal and neonatal possible outcomes.

The recognized risk factors for GDM are higher body mass index (BMI) before pregnancy, higher BMI at 28 weeks of gestation, maternal age over 25 years, family history of diabetes mellitus, past history of GDM, multiparity, twin/multiple pregnancy, polycystic ovarian syndrome, and ethnicities such as Asian, Hispanic, or African-American [1] [2] [3] [4]. Of note, the pre-pregnancy BMI of Asian women have a higher bearing on insulin resistance than that of Caucasian women and they experience insulin resistance at much lower BMIs than do their European counterparts [5].

Women who suffer from GDM experience a range of adverse effects during pregnancy. This is generally because GDM places them at a higher risk of experiencing pregnancy-related complications such as the need for caesarian/ operative vaginal delivery, pregnancy-induced hypertension, preeclampsia, and eclampsia. These women also experience adverse effects following pregnancy, most notably the increased likelihood of developing type 2 diabetes mellitus.

The undesirable effects faced by the child due to maternal GDM are macrosomia, shoulder dystocia, neonatal hypoglycemia, hyperbilirubinemia, increased risk of stillbirth, and increased risk of developing diabetes mellitus and obesity in early life [6] [7].

Chills
  • Initial screening is accomplished by ingestion of 50 grams of glucose (usually chilled glucola) at any time of the day and without regard to prior meal ingestion.[web.archive.org]
Pharyngitis
  • DESIGN: Pregnant women and neonates suffering from GDM were enrolled and 581 maternal (oral, intestinal and vaginal) and 248 neonatal (oral, pharyngeal, meconium and amniotic fluid) samples were collected.[ncbi.nlm.nih.gov]
Diastolic Hypertension
  • To evaluate the prevalence of MS in the cohort on the basis of the conventional criteria established by NCEP, we examined the proportion of subjects 6 to 11 years of age in each of the 4 groups with 1 component (obesity, systolic or diastolic hypertension[doi.org]
Third Trimester Bleeding
  • Aerobic exercise during pregnancy is contraindicated in a number of medical conditions, including: cardiac disease; restrictive lung disease; incompetent cervix/cerclage; multiple gestation at risk of preterm birth; persistent second or third trimester[doi.org]
Purpura
  • A patient developed diabetes mellitus at 21 weeks' gestational age and had a previous history of thrombotic thrombocytopenia purpura, then in remission.[ncbi.nlm.nih.gov]
Blurred Vision
  • She suffered from severe headache, blurred vision, dizziness, and vomiting. Her baby was delivered by Cesarean section. The brain magnetic resonance images revealed pituitary necrosis.[ncbi.nlm.nih.gov]
  • Other symptoms may include: Blurred vision Fatigue Frequent infections, including those of the bladder, vagina, and skin Increased thirst Increased urination Gestational diabetes most often starts halfway through the pregnancy.[nlm.nih.gov]
  • Women may experience blurred vision, fatigue, vaginal infections, increased thirst, frequent urination, and nausea. Blood sugar levels will usually return to normal levels after delivery.[virtua.org]
  • Signs and symptoms can include: Sugar in urine (revealed in a test done in your doctor’s office) Unusual thirst Frequent urination Fatigue Nausea Frequent vaginal, bladder, and skin infections Blurred vision Who gets gestational diabetes, and why do I[americanpregnancy.org]
  • Blurred vision. Pregnancy causes most women to urinate more often and to feel more hungry. So having these symptoms doesn't always mean that a woman has diabetes.[myhealth.alberta.ca]
Incontinence
  • Benefits observed include cardio‐respiratory fitness, prevention of stress urinary incontinence, prevention of lumbar pain, decreased depression and control of weight gain during pregnancy ( Nascimento 2012 ).[doi.org]
Urinary Incontinence
  • Benefits observed include cardio‐respiratory fitness, prevention of stress urinary incontinence, prevention of lumbar pain, decreased depression and control of weight gain during pregnancy ( Nascimento 2012 ).[doi.org]
Learning Difficulties
  • difficulties, and possibly autism spectrum disorder (ASD)) ( Gardener 2009 ; Krakowiak 2012 ; Nomura 2012 ; Ornoy 2015 ).[doi.org]

Workup

GDM has a number of guidelines for screening and diagnosing, with striking heterogeneity between the different recommendations. The recommendations from the International Association of the Diabetes and Pregnancy Study Groups (IADPSG) have been endorsed by a number of professional bodies [8].

The recommendations put forth by IADPSG suggest universal screening for GDM. Pregnant women need to be screened at the first antenatal visit with the standard criteria used in the non-pregnant state i.e. a diagnosis of GDM is made by fasting plasma glucose (FPG) level ≥ 7.0 mmol/l (126 mg/dl), random plasma glucose ≥ 11.1 mmol/l (200 mg/dl), or HbA1c (glycosylated hemoglobin) ≥ 6.5%. The aim of screening at this time is to diagnose women with pre-existing diabetes.

If the results at this stage are negative, screening needs to be repeated at 24-28 weeks of gestation with the use of oral glucose tolerance test (OGTT). The following cut off values in the OGTT point towards the diagnosis of GDM: FPG (5.1 mmol/l [92 mg/dl]), one hour plasma glucose (10 mmol/l [180 mg/dl]), and two hour plasma glucose (8.5 mmol/l [153 mg/dl]). These cut off values have been endorsed by the World Health Organization (WHO).

Following the diagnosis of GDM, there are other associated tests that need to be performed in each trimester to identify risks to the mother or child. Regular blood glucose testing needs to be done, either with HbA1c testing or capillary blood glucose.

Important tests in the first and second trimester are spot urine protein to creatinine ratio and ultrasonography (US). US in the first trimester is important for dating and establishing viability while a second trimester US is essential for assessing anatomical abnormalities. Furthermore, US remains important in the third trimester to assess fetal growth.

HLA-DR3
  • Typical of autoimmune diabetes, the autoantibody-positive women had a normal BMI and an increased prevalence of HLA DR3 or DR4-DQ8 haplotypes, and the majority required insulin to treat their diabetes during pregnancy.[doi.org]

Treatment

  • Any specific treatment versus routine antenatal care (subgroups by type of specific treatment) Comparison 2.[doi.org]
  • However, there has been no sound evidence base to support intensive treatment. The key issue for clinicians and consumers is whether treatment of GDM improves perinatal outcome.[ncbi.nlm.nih.gov]

Prognosis

  • In spite of poor prognosis, the child was born at the 39th gestation week in a good condition.[ncbi.nlm.nih.gov]
  • Prognosis Women with gestational diabetes tend to have larger babies and increased problems during delivery. Many times a C-Section is needed to avoid further complications during the birthing process.[virtua.org]
  • Prognosis The perinatal risks to mother and baby are similar to those with known diabetes, mainly relating to the problems of a large baby. Treatment of GDM is effective in reducing macrosomia, pre-eclampsia and shoulder dystocia [ 19 ] .[patient.info]
  • Follow-up and prognosis Gestational diabetes resolves postpartum in more than 90% of women. In general, all insulin and oral hypoglycaemic drugs are ceased immediately postpartum with ongoing blood glucose monitoring until discharge from hospital.[nps.org.au]

Etiology

  • The etiology is thought to depend on excessive vasopressinase activity, a placental enzyme that degrades arginine-vasopressin (AVP), but not 1-deamino-8-D: -arginine vasopressin (dDAVP), which is a synthetic form.[ncbi.nlm.nih.gov]
  • Incidence & Etiology Inability to maintain glucose levels required by the body for proper functioning is a growing health problem in the United States; thus it is not surprising that more women are found during pregnancy to be unable to attain the low[web.archive.org]
  • The clinical role of maternal hyperglycemia below the threshold for the diagnosis of gestational diabetes (GDM) in the etiology of macrosomia remains an area of controversy.[doi.org]

Epidemiology

  • Author information 1 Department of Epidemiology and Biostatistics, School of Public Health, Tianjin Medical University, Tianjin, China. 2 Department of Epidemiology and Biostatistics, School of Public Health, Tianjin Medical University, Tianjin, China[ncbi.nlm.nih.gov]
  • Mitchell, Descriptive Epidemiology of Non‐syndromic Complete Atrioventricular Canal Defects, Paediatric and Perinatal Epidemiology, 26, 6, (515-524), (2012). ZHIXIAN SUI, ROSALIE M. GRIVELL and JODIE M.[doi.org]
Sex distribution
Age distribution

Pathophysiology

  • Data presented tie in insights with underlying pathophysiologic processes leading to GDM. Screening and diagnostic thresholds are discussed along with management upon diagnosis.[ncbi.nlm.nih.gov]
  • Having fetal hyperinsulinism is a risk factor for development of both obesity and abnormal glucose metabolism, and might be implicated in pathophysiology.[doi.org]

Prevention

  • Women who don't have diabetes should be advised about their risk and participate in family planning to prevent subsequent pregnancies with undiagnosed hyperglycemia.[ncbi.nlm.nih.gov]
  • Prevention You can lower your chance of getting gestational diabetes by losing extra weight before you get pregnant if you are overweight. Being physically active before and during pregnancy also may help prevent gestational diabetes.[niddk.nih.gov]
  • True effectiveness of specific structured exercise programs remains untapped in GDM prevention and treatment and many well-controlled exercise studies are warranted.[doi.org]

References

Article

  1. Metzger BE, Lowe LP, Dyer AR, et al. Hyperglycemia and adverse pregnancy outcomes. N Engl J Med. 2008;358:1991–2002.
  2. Berkowitz GS, Lapinski RH, Wein R, Lee D. Race/ethnicity and other risk factors for gestational diabetes. Am J Epidemiol. 1992;135:965–973.
  3. Cypryk K, Szymczak W, Czupryniak L, Sobczak M, Lewiński A. Gestational diabetes mellitus - an analysis of risk factors. Endokrynol Pol. 2008;59:393–397.
  4. Callesen NF, Ringholm L, Stage E, Damm P, Mathiesen ER. Insulin requirements in type 1 diabetic pregnancy: do twin pregnant women require twice as much insulin as singleton pregnant women? Diabetes Care. 2012;35:1246–1248.
  5. Retnakaran R, Hanley AJ, Connelly PW, Sermer M, Zinman B. Ethnicity modifies the effect of obesity on insulin resistance in pregnancy: a comparison of Asian, South Asian, and Caucasian women. J Clin Endocrinol Metab. 2006;91:93–97.
  6. World Health Organization. Diagnostic criteria and classification of hyperglycaemia first detected in pregnancy: a World Health Organization Guideline. Diabetes Res Clin Pract. 2014;103:341–363.
  7. O’Sullivan JB, Charles D, Mahan CM, Dandrow RV. Gestational diabetes and perinatal mortality rate. Am J Obstet Gynecol. 1973;116:901–904.
  8. International Association of Diabetes and Pregnancy Study Groups Consensus Panel. Metzger BE, Gabbe SG, Persson B, Buchanan TA, Catalano PA, et al. International association of diabetes and pregnancy study groups recommendations on the diagnosis and classification of hyperglycemia in pregnancy. Diabetes Care. 2010;33:676–682.

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Last updated: 2019-06-28 11:02