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Gestational diabetes
Written by Jeffrey R. Waggoner, MD   
“Gestational Diabetes Mellitus (GDM) is defined as any degree of glucose intolerance with onset or first recognition during pregnancy.” [1]

Clinical characteristics

There is some form of abnormality of maternal glucose regulation in 3% to 10% of pregnancies. The incidence of glucose intolerance appears to be increasing in America for all the reasons that it is increasing in the general population—sedentary life styles and obesity. Of the cases of abnormal glucose intolerance, roughly 90% are attributable to Gestational diabetes. Type 2 Diabetes Mellitus is responsible for 8% of cases.

There is significant fetal morbidity associated with Gestational diabetes. These include miscarriages; birth defects—estimated to be as high as 18% of associated pregnancies; growth restriction; fetal obesity; metabolic syndrome; and increased perinatal morbidity that includes birth injuries because of LGA infants, polycythemia, hypoglycemia, hypocalcemia, hyperbilirubinemia, and respiratory distress.

There is also increased maternal morbidity that includes diabetic retinopathy, decrease in renal function, chronic hypertension, and preeclampsia. [2]

Pathophysiology

There is a complex series of hormonal adjustments in a gravid patient designed to assure the fetus an adequate energy supply to continue its growth. One of the characteristics influencing the development of glucose intolerance an increased insulin resistance created by increasing levels of placental steroid and peptide hormones. If the maternal pancreas is unable to respond to this increased demand for insulin, hyperglycemia results. In a normal pregnancy, mean insulin levels may increase 50% during a pregnancy.

These intermettant states of maternal and fetal hyperglycemia and hyperinsulinemia cause excessive fetal storage of nutrient that leads to macrosomia (excessive birth weight). This in turn leads to a depletion in fetal oxygen levels, surges in adrenal catecholamines, secondary hypertension, stimulation of erythropoietin, and polycythemia. [3]

Diagnosis

Early diagnosis of glucose intolerance is one of the standard prenatal workups. It is crucial to both mother and neonate.

One step approach

A fasting plasma glucose level greater than 126 mg/dl or a casual plasma glucose greater than 200 mg/dl is sufficient to make a diagnosis of Gestational diabetes. These findings preclude further workup.

Two step approach

Measure plasma or serum glucose 1 hour after a 50-g oral glucose load. Then perform a diagnostic oral glucose tolerance test on those women who exceed threshold levels on the initial test. [4]

Treatment

The first step in treatment is aggressive nutritional counseling. Obese women should attempt a caloric reduction of as much as a third.

Close monitoring of finger stick glucoses and fetal size should continue throughout the pregnancy. If criteria as defined by the American Diabetic Association are not met, treatment with human insulin should be initiated. Oral hypoglycemics are not recommended. [5]

 
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