Diabetes Mellitus 1

DIABETES MELLITUS IN PREGNANCY
INA S. IRABON, MD, FPOGS, FPSRM, FPSGE

OBSTETRICS AND GYNECOLOGY
REPRODUCTIVE ENDOCRINOLOGY AND INFERTILITY
TO DOWNLOAD MY LECTURE DECK…
REFERENCE
¡ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL,
Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014;
chapter 57 Diabetes Mellitus
Growth hormone
CRH
Gestational diabetes mellitus develops during pregnancy in women
whose pancreatic function
lactogen is insufficient to overcome the insulin
Diabetogenic
Placental
Insulin
resistance
hormones
associated with the pregnant state.
Resistance
Prolactin
Progesterone
TYPES OF DIABETES MELLITUS
Diabetes Mellitus
TABLE 57-3. Proposed Classification System for Diabetes in Pregnancy

¡ Diabetes is the most common
medical complication of pregnancy. Gestational diabetes: diabetes diagnosed during pregnancy that is not clearly overt (type 1 or type 2) diabetes
Type 1 Diabetes: Type 2 Diabetes:
¡ Pregestational/Overt Diabetes - Diabetes resulting from β-cell destruction, usually leading Diabetes from inadequate insulin secretion in the face of
patients who were known to have to absolute insulin deficiency increased insulin resistance
diabetes before pregnancy a. Without vascular complications a. Without vascular complications
b. With vascular complications (specify which) b. With vascular complications (specify which)
¡ Gestational diabetes - diagnosed Other types of diabetes: genetic in origin, associated with pancreatic disease, drug-induced, or chemically induced
during pregnancy
Data from American Diabetes Association, 2012.
Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 57 Diabetes Mellitus
PREGESTATIONAL DIABETES in pregnancy, The International Association of Diabetes and
Pregnancy Study Groups (IADPSG) Consensus Panel (2010)
American Diabetes Association. Standards of Medical Care in Diabetes 2011. Diabetes Care
2011; 34:S11. Copyright © 2011 American Diabetes Association.
Durnwald C. Diabetes Mellitus ins Pregnancy: Screening and Diagnosis. Feb 2019.
www.uptodate.com
PREGESTATIONAL/ OVERT DIABETES
with a random plasma glucose level > 200 mg/dL plus classic
signs and symptoms such as polydipsia, polyuria, and unex-
plained weight loss or those with a fasting glucose level exceed-
ing 125 mg/dL are considered by the ADA (2012) to have overt
PREGESTATIONAL/OVERT DIABETES diabetes. Women with only minimal metabolic derangement
may be more difficult to identify. To diagnose overt diabetes
¡ Defined as:
¡ random plasma glucose level > 200 mg/dL +
TABLE 57-4. Diagnosis of Overt Diabetes in Pregnancya
classic signs and symptoms such as polydipsia,
polyuria, and unexplained weight loss OR Measure of Glycemia Threshold
¡ fasting glucose level exceeding 125 mg/dL Fasting plasma glucose At least 7.0 mmol/L (126 mg/dL)
Hemoglobin A1c At least 6.5%
¡ For women with only minimal metabolic Random plasma At least 11.1 mmol/L (200 mg/dL)
derangement à the International Association of glucose plus confirmation
Diabetes and Pregnancy Study Groups (IADPSG)
Consensus Panel (2010) recommends the following a
Apply to women without known diabetes antedating
threshold values: pregnancy. The decision to perform blood testing for
evaluation of glycemia on all pregnant women or only
th
Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24 edition; 2014; chapter 57 Diabetes Mellitus
on women with characteristics indicating a high risk for
PREGESTATIONAL/OVERT DIABETES
¡ diagnosis of overt diabetes during pregnancy

should be confirmed 6 weeks postpartum.
¡ Risk factors: strong familial history of diabetes,
prior delivery of a large newborn, persistent
glucosuria, or unexplained fetal losses.
THE ADA AND ACOG DEFINE WOMEN AT INCREASED RISK OF OVERT
DIABETES BASED ON:
●Body mass index ≥25 kg/m2 (≥23 kg/m2 in Asian Americans) plus one or more of the following
1. Gestational diabetes mellitus in a previous pregnancy
2. HbA1C ≥5.7 percent (39 mmol/mol), impaired glucose tolerance, or impaired fasting glucose on
previous testing
3. First-degree relative with diabetes
4. High-risk race/ethnicity (eg, African American, Latino, Native American, Asian American, Pacific Islander)
5. History of cardiovascular disease
6. Hypertension or on therapy for hypertension
7. High-density lipoprotein cholesterol level <35 mg/dL (0.90 mmol/L) and/or a triglyceride level
>250 mg/dL (2.82 mmol/L)
8. Polycystic ovary syndrome
9. Physical inactivity
10. Other clinical condition associated with insulin resistance (eg, severe obesity, acanthosis nigricans)
11. Previous birth of an infant weighing ≥4000 g
Durnwald C. Diabetes Mellitus ins Pregnancy: Screening and Diagnosis. Feb 2019. www.uptodate.com
ent no problem in diagnosis. Similarly, women outcomes with overt diabetes is related somewhat to the degree
m plasma glucose level > 200 mg/dL plus classic of glycemic control, but more importantly, to the degree of
mptoms such as polydipsia, polyuria, and unex- underlying cardiovascular or renal disease. Thus, advanc-
ht loss or those with a fasting glucose level exceeding stages of the White classification, seen in Table 57-2,
L are considered by the ADA (2012) to have overt are inversely related to favorable pregnancy outcomes. As an
men with only minimal metabolic derangement example shown in Table 57-5, data from Yang and associates
PREGESTATIONAL/OVERT DIABETES: COMPLICATIONS
difficult to identify. To diagnose overt diabetes (2006) chronicles the deleterious pregnancy outcomes of overt
. Diagnosis of Overt Diabetes in Pregnancya TABLE 57-5. Pregnancy Outcomes of Births in Nova
Glycemia Threshold Scotia from 1988 to 2002 in Women with
and without Pregestational Diabetes
ma glucose At least 7.0 mmol/L (126 mg/dL)
A1c At least 6.5% Diabetic Nondiabetic
sma At least 11.1 mmol/L (200 mg/dL) (n = 516) (n = 150,598) p
plus confirmation Factor % % value
Gestational 28 9 < .001
omen without known diabetes antedating hypertension
The decision to perform blood testing for Preterm birth 28 5 < .001
of glycemia on all pregnant women or only Macrosomia 45 13 < .001
with characteristics indicating a high risk for Fetal-growth 5 10 < .001
based on the background frequency of abnor- restriction
metabolism in the population and on local Stillbirth 1.0 0.4 .06
es. Perinatal death 1.7 0.6 .004
m International Association of Diabetes and
Study Groups Consensus Panel, 2010. Adapted from Yang, 2006.
¡ 3-fold increase in the spontaneous abortion rate
¡ Preterm delivery: 5-fold increase risk
¡ Congenital malformations: 2 fold increase risk
¡ Altered fetal growth: incidence of macrosomia rises significantly when mean maternal
blood glucose concentrations chronically exceed 130 mg/dL
¡ Unexplained fetal demise: 3-4x higher in DM type 1
¡ Hydramnios: fetal hyperglycemia causes polyuria
¡ Preterm delivery: Most are due to advanced diabetes with superimposed
preeclampsia
¡ Hypoglycemia (< 45 mg/dL ): Newborns experience a rapid

drop in plasma glucose concentration after delivery due to
hyperplasia of the fetal β-islet cells induced by chronic
maternal hyperglycemia.
¡ Hypocalcemia (total serum calcium concentration < 8
mg/dL): Theories include aberrations in magnesium–calcium
economy, asphyxia, and preterm birth.
¡ Hyperbilirubinemia and Polycythemia: Polycythemia is thought
to be a fetal response to relative hypoxiaà polycythemia can lead
to hyperbilirubinemia
¡ sources of this fetal hypoxia are hyperglycemia-mediated increases in maternal
affinity for oxygen and fetal oxygen consumption. à hypoxia leads to
increased fetal erythropoietin levels and red cell production.
¡ Cardiomyopathy: Infants of diabetic pregnancies may have
hypertrophic cardiomyopathy that primarily affects the
interventricular septum à this cardiomyopathy may lead to
obstructive cardiac failure.
¡ Long-Term Cognitive development: some studies found an

association between maternal DM and decreased IQ and
autism/ developmental delay in offspring
¡ Inheritance of Diabetes: risk of developing type 1 diabetes if
either parent is affected is 3 to 4 percent. Type 2 diabetes has
a much stronger genetic component. If both parents have
type 2 diabetes, the risk of developing it approaches 40
percent.
¡ Preeclampsia: develops 3-4x more often among diabetic women: risk
factors for preeclampsia include any vascular complication and preexisting
proteinuria, with or without chronic hypertension.
¡ Diabetic Nephropathy: Diabetes is one of the leading causes of end-stage
renal disease
¡ Clinically detectable nephropathy begins with microalbuminuria—30 to
300 mg/24 hours
¡ Macroalbuminuria—more than 300 mg/24 hours—develops in patients
destined to have end-stage renal disease.
¡ In general, pregnancy does not appear to worsen diabetic
nephropathy.
¡ Diabetic Retinopathy
¡ Benign or background or
nonproliferative retinopathy: the
first and most common visible lesions
are small microaneurysms followed by
blot hemorrhages that form when
erythrocytes escape from the
aneurysmsà leak serous fluid that
creates hard exudates
Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS
(eds).William’s Obstetrics 24th edition; 2014; chapter 57 Diabetes Mellitus
Photo credit: http://hkuelcn.med.hku.hk/diabetic-retinopathy/
¡ Diabetic Retinopathy
¡ Preproliferative retinopathy: abnormal
vessels of background eye disease become
occluded à retinal ischemia and infarctions
(“cotton wool exudates”).
¡ Ischemia à neovascularization on the retinal
surface and out into the vitreous cavity.
¡ Vision is obscured when there is hemorrhage.
¡ Laser photocoagulation before hemorrhage
reduces the rate of visual loss progression and
blindness by half.
C unningham F G , Leven o K J, B lo o m SL, Sp o ng C Y , D ashe JS, H o ffm an B L, C asey B M , Sheffield JS
Photo credit: https://slideplayer.com/slide/3450776/ published by Thomas Sabb
th
(ed s).W illiam ’s O b stetrics 2 4 ed itio n; 2 01 4; ch apter 5 7 D iabetes M ellitus
¡ Diabetic Neuropathy: diabetic

gastropathy causes nausea and
vomiting, nutritional problems, and
difficulty with glucose control.
¡ Women with gastroparesis should be
advised that this complication is associated
with a high risk of morbidity and poor
perinatal outcome
¡ Treatment with metoclopramide and H2 –
receptor antagonist
P ho to cred it: http://kath leengrieve.blo gsp o t.co m /2 011/1 2/d iabetic-m o nd aysfact-28 -d iabetic.htm l
¡ Diabetic Ketoacidosis (DKA) may develop with hyperemesis
gravidarum, β-mimetic drugs given for tocolysis, infection, and
corticosteroids given to induce fetal lung maturation.
¡ DKA results from an insulin deficiency combined with an excess
in counter-regulatory hormones such as glucagon à
gluconeogenesis and ketone body formation.
¡ ketone body β-hydroxybutyrate is synthesized at a much
greater rate than acetoacetate, which is preferentially detected
by commonly used ketosis detection methodologies à serum
or plasma assays for β-hydroxybutyrate more accurately reflect
true ketone body levels.
2011). It is most often encountered in women with type 1 mal saline or Ringer lactate.
diabetes. It is increasingly being reported in women with
type 2 or even those with gestational diabetes (Sibai, 2014). Infections. Almost all types of infections are increased in
Diabetic ketoacidosis (DKA) may develop with hyperemesis diabetic pregnancies. Stamler and coworkers (1990) reported
gravidarum, β-mimetic drugs given for tocolysis, infection, and that almost 80 percent of women with type 1 diabetes develop
corticosteroids given to induce fetal lung maturation. DKA at least one infection during pregnancy compared with only
results from an insulin deficiency combined with an excess in 25 percent in those without diabetes. Common infections
PREGESTATIONAL/OVERT DIABETES: COMPLICATIONS counter-regulatory hormones such as glucagon. This leads to include Candida a vulvovaginitis, urinary and respiratory tract
TABLE 57-7. Protocol Recommended by the American College of Obstetricians

and Gynecologists (2012) for Management of Diabetic Ketoacidosis
During Pregnancy
Laboratory assessment
Obtain arterial blood gases to document degree of acidosis present; measure glucose,
ketones, and electrolyte levels at 1- to 2-hour intervals
Insulin
Low-dose, intravenous
Loading dose: 0.2–0.4 U/kg
Maintenance: 2–10 U/hr
Fluids
Isotonic sodium chloride
Total replacement in first 12 hours of 4–6 L
1 L in first hour
500–1000 mL/hr for 2–4 hours
250 mL/hr until 80 percent replaced
Glucose
Begin 5-percent dextrose in normal saline when glucose plasma level reaches
250 mg/dL (14 mmol/L)
Potassium
If initially normal or reduced, an infusion rate up to 15–20 mEq/hr may be required;
if elevated, wait until levels decrease into the normal range, then add to
intravenous solution in a concentration of 20–30 mEq/L
Bicarbonate
Add one ampule (44 mEq) to 1 L of 0.45 normal saline if pH is < 7.1
From Landon, 2007, with permission.

¡ Infections: Common infections

include Candida vulvovaginitis, urinary
and respiratory tract infections, and
puerperal pelvic sepsis.
Photo credit: https://www.pinterest.ph/pin/562738915925411732/
MANAGEMENT OF DIABETES IN PREGNANCY:
PRECONCEPTIONAL CARE
¡ Optimal preconceptional glucose control using insulin (ADA):

¡ preprandial glucose levels 70 to 100 mg/dL
¡ peak postprandial values of 100 to 129 mg/dL
¡ daily glucose concentrations < 110 mg/ dL
¡ Glycosylated hemoglobin (HbA1C) reflects an average of circulating glucose for the past 4 to
8 weeks, is useful to assess early metabolic control à optimal value is < 7 percent (ADA)
¡ 4fold increased risk for malformations at levels HbA1C > 10 percent.
¡ If indicated, evaluation and treatment for diabetic complications such as retinopathy or
nephropathy should also be instituted before pregnancy.
¡ folate, 400 μg/day orally is given periconceptionally and during early pregnancy to decrease
the risk of neural-tube defects.
MANAGEMENT OF DIABETES IN PREGNANCY: FIRST TRIMESTER
¡ Insulin Treatment
¡ overtly diabetic pregnant woman is best treated with
insulin.
¡ Maternal glycemic control can usually be achieved
with multiple daily insulin injections and adjustment
of dietary intake.
¡ Subcutaneous insulin infusion by a calibrated pump
may be used during pregnancy. However, women who
use an insulin pump must be highly motivated and
compliant to minimize the risk of nocturnal
hypoglycemia
¡ Monitoring. TABLE 57-9. Self-Monitored Capillary Blood Glucose Goals

¡ Self-monitoring of capillary glucose levels Specimen Level (mg/dL)
using a glucometer is recommended Fasting ≤ 95
because this involves the woman in her Premeal ≤ 100
own care. 1-hr postprandial ≤ 140
¡ Glucose goals recommended during 2-hr postprandial ≤ 120
pregnancy are shown in the table. 0200–0600 ≥ 60
Mean (average) 100
Hemoglobin A1c ≤ 6%
¡ Diet.
¡ Nutritional planning includes appropriate weight gain
through carbohydrate and caloric modifications based
on height, weight, and degree of glucose intolerance
¡ the mix of carbohydrate, protein, and fat is adjusted
to meet the metabolic goals and individual patient
preferences, but a 175-g minimum of carbohydrate
per day should be provided.
¡ Carbohydrate should be distributed throughout the
day in three small- to moderate-sized meals and two
to four snacks.
¡ Diet.
¡ Weight loss is not recommended, but modest
caloric restriction may be appropriate for
overweight or obese women.
¡ An ideal dietary composition is 55 percent
carbohydrate, 20 percent protein, and 25
percent fat, of which < 10 percent is saturated
fat.
MANAGEMENT OF DIABETES IN PREGNANCY: 2ND TRIMESTER
¡ Maternal serum alpha-fetoprotein determination at 16 to 20 weeks’ gestation is used

in association with targeted sonographic examination at 18 to 20 weeks to detect
neural-tube defects and other anomalies
¡ Maternal alpha-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 an important part of second-trimester
sonographic evaluation
¡ euglycemia with self-monitoring continues to be the goal in management.
MANAGEMENT OF DIABETES IN PREGNANCY: 3RD TRIMESTER
¡ American College of Obstetricians and Gynecologists (2012) suggests initiating

fetal surveillance testing starting at 32 to 34 weeks’ gestation: fetal movement count-
ing, periodic fetal heart rate monitoring, intermittent biophysical profile
evaluation, and contraction stress testing.
¡ patients are routinely instructed to perform fetal kick counts beginning early in
the third trimester.
¡ At 34 weeks, admission is offered to all insulin-treated women. While in the hospital,
they continue daily fetal movement counts and undergo fetal heart rate
monitoring three times a week. Delivery is planned for 38 weeks.
MANAGEMENT OF DIABETES IN PREGNANCY: 3RD TRIMESTER
1136 Medical and Surgical Complications
TABLE 57-10. Insulin Management During Labor and Delivery

• Usual dose of intermediate-acting insulin is given at bedtime.
• Morning dose of insulin is withheld.
SECTION 12
• Intravenous infusion of normal saline is begun.

• Once active labor begins or glucose levels decrease to < 70 mg/dL, the infusion is changed from saline to 5-percent dextrose
and delivered at a rate of 100–150 mL/hr (2.5 mg/kg/min) to achieve a glucose level of approximately 100 mg/dL.
• Glucose levels are checked hourly using a bedside meter allowing for adjustment in the insulin or glucose infusion rate.
• Regular (short-acting) insulin is administered by intravenous infusion at a rate of 1.25 U/hr if glucose levels exceed
100 mg/dL.
Data from Coustan DR. Delivery: timing, mode, and management. In: Reece EA, Coustan DR, Gabbe SG, editors. Diabetes
in women:
Cunningham adolescence,
FG, Leveno KJ, Bloom SL,pregnancy, and
Spong CY, Dashe menopause.
JS, Hoffman BL, Casey 3rd ed. Philadelphia
BM, Sheffield (PA):
JS (eds).William’s Lippincott
Obstetrics th
Williams
24 edition; & Wilkins;
2014; chapter 2004;
57 Diabetes and
Mellitus
GESTATIONAL DIABETES
RISK FACTORS
¡ Personal history of impaired glucose tolerance, A1C ≥5.7 percent,
impaired fasting glucose, or gestational diabetes mellitus in a previous
pregnancy.
¡ Member of one of the following ethnic groups, which have a high
prevalence of type 2 diabetes: Hispanic American, African American, Native
American, South or East Asian, Pacific Islander.
¡ Family history of diabetes, especially in first-degree relatives
¡ Prepregnancy weight ≥110 percent of ideal body weight or BMI
>30 kg/m2 , significant weight gain in early adulthood and between
pregnancies or excessive gestational weight gain during the first 18 to 24
weeks
¡ Older maternal age (>25 or 30 years of age).
RISK FACTORS
¡ Previous unexplained perinatal loss or birth of a malformed infant.
¡ Glycosuria at the first prenatal visit.
¡ Previous birth of an infant ≥4000 or 4500 g (approximately 9 or 10 pounds).
¡ High density lipoprotein <35 mg/dL (0.90 mmol/L), triglyceride
>250 mg/dL (2.82 mmol/L).
¡ Medical condition/setting associated with development of diabetes, such as
metabolic syndrome, polycystic ovary syndrome, current use of
glucocorticoids, hypertension or cardiovascular disease, acanthosis nigricans.
¡ Multiple gestation.
GESTATIONAL DIABETES
¡ Two-step approach
¡ One-step approach
GESTATIONAL DIABETES: 2 STEP APPROACH
¡ Screening should be performed between 24 and 28 weeks AOG in those women not
known to have glucose intolerance earlier in pregnancy.
¡ 50-g screening test (50g OGCT) is followed by a diagnostic 100-g, 3-hour oral
glucose tolerance test (100g OGTT) if screening results for 50g OGCT is positive.
¡ For the 50-g OGCT, the plasma glucose level is measured one hour after a 50-g oral
glucose load without regard to the time of day or time of last meal (no fasting
required).
¡ the American College of Obstetricians and Gynecologists (2013) recommends using
either 135 or 140 mg/dL as the 50-g screen threshold.
Co
GESTATIONAL DIABETES TABLE 57-11. Threshold Values for Diagnosis of
evi
Gestational Diabetes
Glucose Concentration Above Threshold ver
Plasma Thresholda (%) glu
Glucose mmol/L mg/dL Cumulative W
of
5.1 92 8.3
scr
Screening and Diagnosis: 1-hr OGTT 10.0 180 14.0
vey
One step approach using 2-hr OGTT 8.5 153 16.1b
un
an
75g OGTT a
One or more of these values from a 75-g OGTT must
glu
be equaled or exceeded for the diagnosis of gestational
diabetes. is
b
In addition, 1.7% of participants in the initial cohort test
were unblinded because of fasting plasma glucose mi
levels > 5.8 mmol/L (105 mg/dL) or 2-hr OGTT values
> 11.1 mmol/L (200 mg/dL), bringing the total to 17.8%. 1
OGTT = oral glucose tolerance test. tim
sen
Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 57 Diabetes Mellitus 83
the IADPSG Consensus Panel (2010) (Table 57-11). This (va
screen and diagnose gestational diabetes. Similarly, the NIH we continue to use 140 mg/dL.
TABLE 57-12. Fifth International Workshop-Conference on Gestational Diabetes:

Recommended Screening Strategy Based on Risk Assessment for
Detecting Gestational Diabetes (GDM)
GESTATIONAL DIABETES GDM risk assessment: should be ascertained at the first prenatal visit
Low Risk: Blood glucose testing not routinely required if all the following are present:
Member of an ethnic group with a low prevalence of GDM
No known diabetes in first-degree relatives
Age < 25 years
Weight normal before pregnancy
Weight normal at birth
No history of abnormal glucose metabolism
No history of poor obstetrical outcome
Average Risk: Perform blood glucose testing at 24 to 28 weeks using either:
Two-step procedure: 50-g oral glucose challenge test (GCT), followed by a diagnostic
100-g OGTT for those meeting the threshold value in the GCT
One-step procedure: diagnostic 100-g OGTT performed on all subjects
High Risk: Perform blood glucose testing as soon as feasible, using the procedures
described above, if one or more of these are 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 to
28 weeks’ gestation or at any time symptoms or signs suggest hyperglycemia
OGTT = oral glucose tolerance test.

Modified from Metzger, 2007.
MATERNAL AND FETAL EFFECTS
¡ ADA (2003): fasting hyperglycemia > 105 mg/dL

may be associated with an increased risk of
fetal death during the final 4 to 8 weeks
¡ Increased frequency of hypertension and
ceasarean delivery
¡ Macrosomia
¡ Neonatal hypoglycemia
¡ Maternal obesity
MANAGEMENT
¡ Pharmacological methods are usually recommended if

diet modification does not consistently maintain the
fasting plasma glucose levels < 95 mg/dL or the 2-
hour postprandial plasma glucose < 120 mg/dL
¡ fasting capillary glucose levels should be kept
≤ 95 mg/dL
DIET
¡ individualized nutritional counseling based on height and

weight (carbohydrate- controlled diet sufficient to
maintain normoglycemia and avoid ketosis.)
¡ daily caloric intake of 30 to 35 kcal/kg.
¡ American College of Obstetricians and Gynecologists (2013)
suggests: carbohydrate 40 % of total calories, protein 20% and
fat 40%
¡ obese women with a BMI > 30 kg/m2: 30% caloric

restriction, which approximates 25 kcal/kg/d.
EXERCISE
¡ American College of Obstetricians and

Gynecologists (2013) recommends a
moderate exercise program as part of
the treatment plan for women with
gestational diabetes.
Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter
57 Diabetes Mellitus
GLUCOSE MONITORING
¡ the American College of Obstetricians

and Gynecologists (2013) recommends
four-times daily glucose monitoring
performed fasting and either 1 or 2 hours
after each meal.
INSULIN
¡ Insulin is added if fasting levels persistently exceed 95 mg/dL in
women with gestational diabetes.
¡ American College of Obstetricians and Gynecologists (2013) also
recommends that insulin be considered in women with 1-hour
postprandial levels that persistently exceed 140 mg/dL or those with 2-
hour levels above 120 mg/dL.
¡ If insulin is initiated, the starting dose is typically 0.7– 1.0
units/kg/day given in divided doses
¡ A combination of intermediate-acting and short-acting insulin may
be used, and dose adjustments are based on glucose levels at
particular times of the day.
ORAL HYPOGLYCEMIC AGENTS
¡ Glyburide
¡ Metformin
Gynecologists (2013) acknowledges that both
glyburide and metformin are appropriate, for first-
line glycemic control in women with gestational
diabetes à the committee recommends
appropriate counseling when hypoglycemic agents
are used.
MODE OF DELIVERY

Gynecologists (2013): ceasarean delivery
should be considered in women with
gestational diabetes whose fetuses have a
sonographically estimated weight ≥ 4500 g.
POSTPARTUM EVALUATION Diabetes Mellitus 1143
TABLE 57-14. Fifth International Workshop-Conference: Metabolic Assessments Recommended after Pregnancy with
Gestational Diabetes
Time Test Purpose
CHAPTER 57
Postdelivery (1–3 d) Fasting or random plasma glucose Detect persistent, overt diabetes
Early postpartum (6–12 wk) 75-g, 2-hr OGTT Postpartum classification of glucose metabolism
1-yr postpartum 75-g, 2-hr OGTT Assess glucose metabolism
Annually Fasting plasma glucose Assess glucose metabolism
Triannually 75-g, 2-hr OGTT Assess glucose metabolism
Prepregnancy 75-g, 2-hr OGTT Classify glucose metabolism
Classification of the American Diabetes Association (2013)
Impaired Fasting Glucose or
Normal Values Impaired Glucose Tolerance Diabetes Mellitus
Fasting < 100 mg/dL 100–125 mg/dL ≥ 126 mg/dL
2 hr < 140 mg/dL 2 hr ≥ 140–199 mg/dL 2 hr ≥ 200 mg/dL
Hemoglobin A1c < 5.7% 5.7–6.4% ≥ 6.5%
OGTT = oral glucose tolerance test.

From American Diabetes Association, 2013; Metzger, 2007.
(2013). Hunt and colleagues (2010) reviewed performance out gestational diabetes in their first pregnancy were diagnosed
Thank you!
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DIABETES MELLITUS IN PREGNANCY

INA S. IRABON, MD, FPOGS, FPSRM, FPSGE

TABLE 57-3. Proposed Classification System for Diabetes in Pregnancy

¡ diagnosis of overt diabetes during pregnancy

¡ Hypoglycemia (< 45 mg/dL ): Newborns experience a rapid

¡ Long-Term Cognitive development: some studies found an

¡ Diabetic Neuropathy: diabetic

TABLE 57-7. Protocol Recommended by the American College of Obstetricians

From Landon, 2007, with permission.

¡ Infections: Common infections

Photo credit: https://www.pinterest.ph/pin/562738915925411732/

¡ Optimal preconceptional glucose control using insulin (ADA):

¡ Monitoring. TABLE 57-9. Self-Monitored Capillary Blood Glucose Goals

¡ Maternal serum alpha-fetoprotein determination at 16 to 20 weeks’ gestation is used

¡ American College of Obstetricians and Gynecologists (2012) suggests initiating

TABLE 57-10. Insulin Management During Labor and Delivery

• Intravenous infusion of normal saline is begun.

TABLE 57-12. Fifth International Workshop-Conference on Gestational Diabetes:

OGTT = oral glucose tolerance test.

¡ ADA (2003): fasting hyperglycemia > 105 mg/dL

¡ Pharmacological methods are usually recommended if

¡ individualized nutritional counseling based on height and

¡ obese women with a BMI > 30 kg/m2: 30% caloric

¡ American College of Obstetricians and

¡ the American College of Obstetricians

¡ American College of Obstetricians and

OGTT = oral glucose tolerance test.

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