Diagnosis and Treatment of Hyperglycemia in Pregnancy

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D i a g n o s i s a n d Tre a t m e n t
of Hyperglycemia
i n P re g n a n c y
Maribeth Inturrisi, RN, MS, CNS, CDEa,b,c,*,
Nancy C. Lintner, RN, MS, ACNS, RNC-OBd, Kimberlee A. Sorem, MD
a,e
KEYWORDS
Gestational diabetes mellitus Type 2 diabetes
Large for gestational age Blood glucose
Oral glucose tolerance test Self-monitoring of blood glucose
American Association of the College of Endocrinologists
Certified diabetes educators
Gestational diabetes mellitus (GDM) has been defined as any degree of glucose intol-
erance with onset or first recognition during pregnancy.1 This definition is a misnomer
in that it includes unrecognized overt diabetes that may have existed before preg-
nancy and hyperglycemia that is diagnosed concurrently with pregnancy. Those
with suspected type 2 diabetes mellitus (T2DM) have been referred to as “hypergly-
cemia in pregnancy,” despite evidence of severe hyperglycemia consistent with pre-
existing T2DM. Because the term “gestational diabetes mellitus” is confusing, the
authors recommend use of the term “hyperglycemia in pregnancy,” as defined by
the Endocrine Society.2
SIGNIFICANCE
The prevalence of hyperglycemia in pregnancy varies in direct proportion to the prev-

alence of type 2 diabetes in a given population or ethnic group. Whereas in 1964 the
prevalence of hyperglycemia in pregnancy was 1% to 4%,3 the current estimate is 7%
The authors have nothing to disclose.

a
Region 1 & 3, California Diabetes and Pregnancy Program, San Francisco, CA, USA
b
Family Health Care Nursing, University of California, San Francisco, CA, USA
c
Department of Maternal-Fetal Medicine, Sutter Pacific Medical Foundation at California
Pacific Medical Center, San Francisco, CA, USA
d
Diabetes and Pregnancy Program, Division of Maternal-Fetal Medicine, Department of
Obstetrics and Gynecology, University of Cincinnati College of Medicine, 231 Albert Sabin
Way, 5553, PO Box 670526, Cincinnati, OH 45267–0526, USA
e
Sweet Success Program, Sutter Pacific Medical Foundation at California Pacific Medical
Center, 3700 California Street, G321, San Francisco, CA, USA
* Corresponding author. 2 Koret Way, PO Box 0606, San Francisco, CA 94143–0606.
E-mail address: maribeth.inturrisi@nursing.ucsf.edu
Endocrinol Metab Clin N Am 40 (2011) 703–726

doi:10.1016/j.ecl.2011.09.002 endo.theclinics.com
0889-8529/11/$ – see front matter Ó 2011 Elsevier Inc. All rights reserved.
704 Inturrisi et al
to 14%.3 In 1964, the number of adults estimated to have type 2 diabetes in the United
States was 2.3 million and in 2011 estimates were as high as 25.6 million, indicating
that type 2 diabetes in America is increasing in an epidemic pattern. Likewise, hyper-
glycemia in pregnancy is a silent epidemic. If current trends continue, by 2050 one in
three Americans will have diabetes.3
Hyperglycemia in pregnancy shares the pathophysiology of type 2 diabetes
(increased insulin resistance and hyperinsulinemia) and confers an increased lifetime
risk for future type 2 diabetes for both the mother and her newborn. Hyperglycemia in
pregnancy is not just a pregnancy problem. Soon after giving birth, 90% to 95% of
women with hyperglycemia in pregnancy are diabetes-free by a standard 2-hour
75-g oral glucose tolerance test (OGTT). By 6 to 12 weeks, 4% to 9% are diagnosed
with T2DM. More than 20% have impaired glucose tolerance or impaired fasting
glucose or both (prediabetes). By 36 months, 30% have metabolic syndrome (dysgly-
cemia, abnormal lipid profile, hypertension, and central adiposity). By 5 years, 50%
have T2DM. The cumulative risk over 10 years is 2.6% to 70%.4 Fetal, neonatal,
and adult consequences of uncontrolled maternal hyperglycemia include a variety
of serious short- and long-term consequences (Table 1).
Detection and diagnosis of hyperglycemia in pregnancy provides an opportunity to
assist women to establish healthy lifestyle habits and give them tools to reduce
maternal and fetal risks (see Table 1) by facilitating normoglycemia. Providers who
manage diabetes care during pregnancy are in the unique position to educate women
about a healthy lifestyle and prevention of T2DM. The primary goals of hyperglycemia in
pregnancy diagnosis are to reduce the short- and long-term risks associated with mild
to moderate hyperglycemia during pregnancy through healthy lifestyle education.5,6
SCREENING
For decades, the American Diabetes Association (ADA) published a two-step glucose
screening and diagnosis of hyperglycemia in pregnancy that was solely based on the
woman’s risk for developing T2DM in the future.7 The recommendations included the
avoidance of screening in women considered low risk: less than 25 years of age,
normal body weight, no family history of diabetes, and not a member of an ethnic or
racial group at high risk for diabetes. The Fifth International Workshop on Gestational
Diabetes in November 2005 recommended that hyperglycemia in pregnancy risk
assessment should be ascertained at the first prenatal visit. The American College
of Obstetricians and Gynecologists (ACOG) recommends that all pregnant patients
Table 1
Fetal, neonatal, and adult consequences of uncontrolled maternal hyperglycemia during
pregnancy
Short Term (Fetal and Neonatal) Long Term (Adult)

LGA Obesity
Organomegaly Visceral adiposity
Neonatal hypoglycemia Hyperinsulinemia
Transient tachypnea, respiratory distress Insulin resistance
Birth trauma (Erb palsy, asphysia, fractured bones) T2DM
Feeding abnormalities Cardiovascular disease
Metabolic syndrome
Treatment of Hyperglycemia in Pregnancy 705
be screened for hyperglycemia in pregnancy, whether by patient history, clinical risk

factors, or a laboratory test to determine blood glucose (BG) levels early in preg-
nancy.8 In 1996, the US Preventive Services Task Force concluded that evidence
was insufficient to recommend for or against routine screening for hyperglycemia in
pregnancy, and this recommendation remained unchanged in 2003.9 Two subse-
quently published studies show benefit (particularly a reduction in macrosomia)
when women are treated for hyperglycemia in pregnancy versus no treatment.5,6
Most American providers have used a two-step method involving a nonfasting 1-
hour 50-g oral glucose screen (glucose loading test) with a subsequent diagnostic
3-hour 100-g OGTT for those who failed the initial screen. Screening reduces the
number of women who would have to be subjected to a fasting plus 3-hour 100-g
OGTT. Using a plasma glucose threshold greater than or equal to 140 mg/dL for
screening has a sensitivity of 80% and specificity of 90% for a positive OGTT.
Lowering the threshold to greater than or equal to 130 mg/dL increases the sensitivity
to 90% but also increases the number of women requiring diagnostic testing by 60%.
ACOG and ADA endorse either cut point.5,6
DIAGNOSIS
Women who fail the 1-hour glucose loading test screen take a 3-hour 100-g glucola
OGTT and are considered to have hyperglycemia in pregnancy if two of the four values
equal or exceed the cut points of fasting BG 95 mg/dL, 1-hour after 100-g glucola of
180 mg/dL, 2-hour of 155 mg/dL, and 3-hour of 140 mg/dL.10 If hyperglycemia in preg-
nancy is not diagnosed, the OGTT should be repeated at 24 to 28 weeks gestation or
any time a patient presents with signs or symptoms suggestive of hyperglycemia.11
Women with an abnormal 3-hour OGTT who are less than 24 weeks gestation may
have undiagnosed T1DM, T2DM, or prediabetes but the diagnosis of preexisting dia-
betes or prediabetes can only be made definitively after delivery regardless of the
severity of hyperglycemia.11
This method remained the gold standard in the United States with changes in the
glucose cutoffs as glucose assays changed and the use of plasma replaced whole
blood. Internationally, more than 10 different ways of diagnosing hyperglycemia in
pregnancy included one- or two-step procedures primarily using a 2-hour 75-g
OGTT but with a variety of different cut points and numbers of abnormal values
required to diagnose hyperglycemia in pregnancy. Until now, no worldwide standard
existed for the diagnosis of hyperglycemia in pregnancy.
THE HYPERGLYCEMIA AND ADVERSE PREGNANCY OUTCOME STUDY
For the last 50 years, the diagnosis of hyperglycemia in pregnancy has been based on
the 100-g, 3-hour OGTT that predicts the risk of the mother developing diabetes in the
future.12 Physicians have not had useful guidelines to link the diagnosis of hypergly-
cemia in pregnancy to neonatal outcomes. The Hyperglycemia and Adverse Pregnancy
Outcome (HAPO) Study is a basic epidemiologic investigation designed to clarify unan-
swered questions about the association between various levels of glucose during the
third trimester of pregnancy that indicate that the mother, fetus, and newborn are at
increased risk for adverse outcomes. This 7-year international study was conducted
in 15 centers in nine countries with 23,325 women participating in the study.
The women were given a 2-hour 75-g OGTT at 24 to 28 weeks of gestation.
Providers and patients were blinded to the results unless they exceeded predefined
cutoff values requiring treatment. The cutoffs were as follows: fasting BG greater
than 105 mg/dL or 2-hour greater than 200 mg/dL or random BG at 34 weeks greater
706 Inturrisi et al
than 160 mg/dL. The women who exceeded the cutoffs were removed from the study
and treated for diabetes. The remainder received routine prenatal care, a random BG
at 34 weeks, and fetal kick counts. Primary outcomes included those listed in Boxes 1
and 2.10
Results indicated that there is a continuous, positive, independent relationship
between maternal BG and percent newborn body fat, and between cord C-peptide
concentrations and percent newborn body fat.11 This suggests that the relationship
between maternal glycemia and fetal fat deposition is mediated by fetal insulin produc-
tion. The association between hyperglycemia and poor outcomes was continuous,
making it difficult to identify threshold criteria below which no risk is present. The task
of translating these associations into diagnostic criteria was assigned to a committee
of experts formed by the International Association of Diabetes in Pregnancy Study
Groups (IADPSG). In March 2010, the group published recommendations for a global
method of diagnosing hyperglycemia in pregnancy using glucose cutoffs based on an
odds ratio of 1.75 for having one of the primary adverse outcomes listed in Box 1.11
Table 2 provides a comparison of the old and new methods for diagnosing hypergly-
cemia in pregnancy. The 2011 ADA Standards of Medical Care published the IADPSG
recommended method as the standard method of diagnosing hyperglycemia in preg-
nancy discontinuing all other methods.12 This was in concert with many countries.
PREGNANCY: A DIABETOGENIC STATE
Normal pregnancy can be viewed as a progressive condition of insulin resistance, hyper-

insulinemia, and mild postprandial hyperglycemia mediated by increasing placental
secretion of antiinsulin hormones including, progesterone, human placental lactogen,
cortisol, growth hormone, and tumor necrosis factor (TNF)-a. This prepares the mother
for the increased demands of the fetus for amino acids and glucose in the latter half of
pregnancy. Mild postprandial hyperglycemia serves to increase the amount of time that
maternal glucose levels are elevated above the basal after a meal, thereby increasing the
flux of ingested nutrients from mother to the fetus and enhancing fetal growth.13
The fetal demand for glucose in the third trimester is met during maternal fasting by
hepatic glucose production, which increases 15% to 30% by late third trimester. The
liver begins to supply glucose within 5 to 6 hours of the last meal when absorption of
nutrients from the intestinal tract ceases. Depletion of glycogen stores results from this
accelerated hepatic glucose production. Lower fasting values (55–65 mg/dL) offset
the postprandial elevations resulting in 24-hour mean glucose values similar to non-
gravid women.14
Fetal growth accelerates in the last trimester of pregnancy. During the last trimester,
the fetus is constantly feeding while the mother alternates between fasting and
Box 1
HAPO study primary neonatal outcomes
Birth weight above the 90th percentile for gestational age

Primary cesarean delivery
Clinically diagnosed neonatal hypoglycemia
Cord-blood serum C-peptide level above the 90th percentile
Data from The HAPO Study Cooperative Research Group. Hyperglycemia and adverse preg-
nancy outcomes. N Engl J Med 2008;358:1991–2002.
Box 2
Objectives of medical nutrition therapy in diabetes and pregnancy
Determine energy needs

Set appropriate weight goals
Develop an individualized, nutritionally balanced meal plan
Provide education concerning nutrition-related lifestyle issue
Counsel on the importance of normoglycemia before, during, and after pregnancy
Evaluate adherence to the meal plan
Adapted with permission from the California Department of Public Health, California Diabetes
and Pregnancy Program Sweet Success Guidelines for Care 2006. Funding for the development
of the original materials was provided by the Federal Title V block grant from the California
Maternal, Child and Adolescent Health Division.
feeding. Glucose is transported across the placenta from the mother to the fetus by
facilitated diffusion. The concentration of glucose within the fetus is approximately
15% to 20% lower than maternal glucose.13 Insulin does not cross the placenta.
The fetus synthesizes its own insulin starting at 9 to 12 weeks gestation. From gesta-
tional weeks 9 to 15, maternal insulin requirements decrease. Reasons for this
decrease are not well understood.
Fetal b cells respond to an increase in glucose and amino acids. Amino acids are
transported against a concentration gradient from the maternal to fetal circulation.
The fetal concentration of amino acids is three to four times that of the maternal
concentration.
Late pregnancy has also been characterized as a catabolic phase or a period of
accelerated starvation, which consists of an earlier switch from carbohydrate to fat
metabolism (lipolysis) with fasting.14 This metabolic response to fasting develops in
14 to 18 hours in pregnant women (accelerated starvation) and in 2 to 3 days in the
nonpregnant state.13 Ketones also cross the placenta in the direction of the concen-
tration gradient. Ketones may be used as an alternate fuel for the fetus when glucose is
not available. The hyperglycemia in pregnancy diet is designed to provide frequent
Table 2
Diagnosing hyperglycemia in pregnancy
Old Method10 New Method11

24–28 wk Screen high-risk or all women Universal testing of all pregnant
gestation women
Screen 1-h 50-g glucose load, nonfasting, None
glucose loading test; if 130 or 140,
proceed to diagnostic test
Diagnostic After 8- to 12-h fast, obtain fasting; After 8- to 12-h fast, obtain fasting,
test provide 100-g glucose load; then provide 75-g glucose load, then
obtain 1-, 2-, and 3-h venous BG obtain 1- and 2-h venous BG
Diagnosis If two of the following values meet If any 1 value meets or exceeds
of GDM or exceed: fasting 95 mg/dL, 1-h fasting 92 mg/dL, 1-h 180 mg/dL,
180 mg/dL, 2-h 155 mg/dL, 3-h 2-h 153 mg/dL
140 mg/dL
Data from American Diabetes Association. Standards of medical care in diabetes–2011. Diabetes
Care 2011;34(Suppl 1):S11–61.
708 Inturrisi et al
sources of small amounts of carbohydrate by encouraging small frequent meals and

a bedtime snack.
HEALTHY EATING
The cornerstone for diabetes management is healthy eating and appropriate physical
activity. The diagnosis of hyperglycemia in pregnancy gives women the opportunity to
focus on healthy eating and staying active to improve their lifestyle for better health.
The goal of the hyperglycemia in pregnancy meal plan is to attain and maintain eugly-
cemia and adequate nutrition for the growth and development of the fetus. The
achievement of these goals is based on the individualized medical nutrition therapy
(MNT) plan developed by the woman and the registered dietitian. Registered dieticians
should be central to the management team and should be included in the initial
assessment and on an ongoing basis.
Creating a Meal Plan
Calories for pregnancy should be comprised of 40% to 50% carbohydrates, including
high-fiber fruits and starches and milk as tolerated; 20% protein; and 35% fat, prefer-
ably unsaturated and monosatuarated types.15 Although caloric needs are deter-
mined, they no longer dominate the meal plan. The American Dietetic Association
has abandoned the 1800- to 2200-calorie ADA diet. Instead, a carbohydrate-
controlled meal plan that is culturally appropriate and individualized to take into
account the individual’s body habitus and physical activity is recommended to
achieve treatment goals. The Institute of Medicine (IOM) has set dietary reference
intakes as the minimum nutrient requirements for pregnancy.16 The hyperglycemia
in pregnancy meal plan should be built around these requirements. Women should
be taught to read labels and recognize total carbohydrates and serving sizes. Ideally,
they should keep food and BG records that allow providers to suggest strategies that
lead to optimal nutrition and glycemic control. Nutritional interventions should empha-
size overall healthy food choices, portion control, and cooking practices that can be
continued throughout life. The carbohydrates should be distributed in three meals
and several snacks to decrease postprandial hyperglycemia and the risk of
between-meal hypoglycemia. Aspartame has been determined to be safe as a nonnu-
tritive sweetener in pregnancy except in women with phenylketonuria. Saccharin does
cross into placental circulation but there is no evidence of harmful fetal effects.17
Because healthy eating is central to adopting a healthy lifestyle, emphasis on nutri-
tion education is fundamental. Assessment and reevaluation of the meal plan by
a registered dietician should occur at the first hyperglycemia in pregnancy visit and
then on an ongoing basis thereafter, and finally in the postpartum period. Dietary
adjustments are needed as a woman learns how certain foods influence her BG. “Prin-
ciples of Healthy Eating during Pregnancy” modified from the California Diabetes and
Pregnancy Program Sweet Success Guidelines for Care 2002, provides a general
guide in Box 3.
WEIGHT MANAGEMENT
In normal pregnancy, expected weight gain varies according to the prepregnancy

weight. The IOM recommendations for nonpregnant women are listed in Table 3.18
After the release of the 2009 IOM guidelines, some investigators and experts
expressed concern that higher weight gains among a population of normal and over-
weight women would not reduce adverse infant outcomes and would put women at
risk for delivering macrosomic infants and for postpartum weight retention.19 Since
Box 3
Principles of healthy eating during pregnancy
Distribute carbohydrates intake among three meals and three snacks spaced at 2.5- to 3-hour
intervals. Skipping meals or snacks can result in hypoglycemia, ketone production, or
overeating later in the day. Bedtime snack should provide 15–30 g of carbohydrates and
approximately 7–15 g of protein
Sample distribution of carbohydrates (individualize)
Dietary reference intakes 5 175 g carbohydrates per day in pregnancy
Breakfast Lunch Dinner

15------------30-------------- 45-------------15---------------45----------30 = 180 g carb
Macronutrient distribution:
Carbohydrates: w40%–50%; ideally, carbohydrates should be combined with protein.
Fat: <30%; use nuts, peanut butter, canola oil, or olive oil as primary sources of fat
Protein: w30%; look for lean meats, fish (check safety)
Avoid high glycemic foods at breakfast:
Processed, ready to eat cold cereals (instant cereals)
Milk
Fruit
Fruit juice
A breakfast that consists of whole grain starch plus protein is suggested
Limit fruit
Two to three fruit servings per day
Encourage nonstarchy vegetables
Greens, tomatoes, carrots, and so forth, at least five servings per day
Protein
71 g/day: meat, poultry, fish, eggs, cheese, tofu, and so forth
Fats
Minimum three servings per day: nuts, oils, and so forth; watch for excess calories with fats
and Pregnancy Program Sweet Success Guidelines for Care 2006 Updates by the California Dia-
betes and Pregnancy Program. Funding for the development of the original materials was
provided by the Federal Title V block grant from the California Maternal, Child and Adolescent
Health Division.
then, several studies have observed that the infants of women with pregnancy weight
gains within the IOM recommendations are relatively less likely to be at the extremes
of birth weight for a given gestational age.19 In one study, women who gained more
than recommended by the IOM were three times more likely to have an infant with
large for gestational age (LGA) and nearly 1.5 times more likely to have an infant
with hypoglycemia or hyperbilirubinemia, compared with women whose weight gain
710 Inturrisi et al
Table 3
IOM Guidelines for total gestational weight gaina
Body Mass Index Category Weight Gain Ranges

Underweight <18.5 28–40 lb
Normal 18.5–24.9 25–35 lb
Overweight 25–29.9 15–25 lb
Obese 30 11–20 lb
a
Certain Asian populations may need lower body mass index cut points for each body mass index
category and this might impact weight gain goals for pregnancy.76
Data from Institute of Medicine Report Brief. Weight gain during pregnancy reexamining the
guidelines 2009. Available from: http://www.iom.edu/w/media/Files/Report%20Files/2009/Weight-
Gain-During-Pregnancy-Reexamining-the-Guidelines/Report%20Brief%20-%20Weight
%20Gain%20During%20Pregnancy.pdf. Accessed September 3, 2011.
was in the recommended range.20 In another study, weight gain ranges based on
adverse obstetric and neonatal outcome data were lower than the IOM recommenda-
tions, and the differences were most pronounced for overweight or obese women.21
Excess gestational weight gain can be associated not only with fetal LGA but also
with unhealthy maternal postpartum weight retention.22
Weight gain or loss should be monitored closely and the meal plan should be
adjusted accordingly. Plotting weekly body weights on a weight gain grid specific to
body mass index classification is encouraged to facilitate recognition of inadequate
or excess weight gain. Sample weight gain grids for pregnancy are available online
based on the 2009 IOM recommendations at http://www.cdph.ca.gov/pubsforms/
forms/Pages/MaternalandChildHealth.aspx.
Obesity
No discussion of weight during pregnancy can be adequate without a discussion of
obesity. Obesity has reached epidemic proportions globally, with more than 1 billion
adults overweight, at least 300 million of them clinically obese. The epidemic of
T2DM has paralleled the epidemic of obesity. The likelihood of developing T2DM and
hypertension rises steeply with increasing body fat. Confined to older adults for most
of the twentieth century, this disease now affects obese children even before puberty.
Approximately 90% of people with diabetes have T2DM, and of these, 85% are obese
or overweight.23 The strong presence of obesity in a population makes it certain that
a significant number of women with pregestational diabetes (type 1 and type 2 diabetes)
and women who subsequently develop hyperglycemia in pregnancy will enter preg-
nancy obese. Obese women are at increased risk for morbidity and mortality during
pregnancy.24 Several studies have demonstrated that the risk of congenital malforma-
tions, especially neural tube defects, is double among obese women compared with
fetus of normal-weight women, after correcting for diabetes as a potential confounding
factor.25,26 An increased incidence of miscarriage and intrauterine fetal demise has also
been associated with obesity even in the absence of diabetes.27–29
Obesity confers a certain elevated level of insulin resistance and inflammation that
may mediate these adverse outcomes. When combined with hyperglycemia, morbid-
ities increase. Even lactation can be negatively impacted because overweight or
obese women were found to have a lower prolactin response to suckling, and thus
diminished milk production.30 Limited or no weight gain in obese pregnant women
has favorable pregnancy outcomes.31 Obese women with hyperglycemia in preg-
nancy treated with diet therapy who achieved targeted levels of glycemic control
nevertheless had a twofold to threefold higher risk for adverse pregnancy outcomes
compared with overweight and normal-weight patients with well-controlled hypergly-
cemia in pregnancy. In obese women with body mass index greater than 30 and
hyperglycemia in pregnancy, achievement of targeted levels of glycemic control
was associated with enhanced outcome only in women treated with insulin.32 Several
studies show a protective effect of reduced gestational weight gain and even weight
loss on LGA births and cesarean delivery for obese women.33 An upper limit on gesta-
tional weight gain should be considered to prevent comorbidities among obese
women but controversy remains as to whether the 2009 IOM recommendation of 20
lb should be that upper limit.31 Weight loss during pregnancy has not been recommen-
ded in the past, but women who are obese and adhere to the meal plan prescribed for
managing diabetes during pregnancy are likely to lose weight while maintaining
a healthy, nutrient-rich diet. The issue of starvation ketones emerges with weight
loss. No correlation exists between ketonuria and ketonemia. Ketonemia is unlikely
to exist when the meal plan includes at least 1800 calories and small frequent meals.
However, obese women who want to become pregnant should be counseled about
the increased risks, including gestational diabetes, associated with obesity and preg-
nancy. Immediate referral to a dietitian to address safe weight loss before pregnancy
should occur.
Some women may choose bariatric surgery as a method of weight loss. Several
studies have indicated that previous bariatric surgery in patients with GDM is not asso-
ciated with adverse perinatal outcomes.34 Many individuals who had T2DM no longer
require medication to maintain normoglycemia. When screening for gestational dia-
betes, an alternate method for testing is necessary. Administration of a standard
glucose solution would precipitate “dumping syndrome.” Women with previous bari-
atric surgery may need to test their blood sugars fasting and after meals for several
days to determine if they are experiencing hyperglycemia. Some providers have
used continuous glucose monitoring systems to help with diagnosis.35
Staying Active
Research over the past 22 years has focused on the safety of physical activity during
pregnancy. The overwhelming results of most studies show primarily beneficial effects
on the maternal–fetal unit and very few negative effects.36 The role of physical activity
for pregnant women with diabetes has also gained acceptance and has become an
essential part of the treatment plan.
Exercise facilitates the glucose uptake that regulates glucose transport and intracel-
lular metabolism and sustains insulin sensitivity and improves glucose clearance.37,38
Furthermore, exercise regulates hepatic glucose output, evidenced in fasting BG
levels and the counterregulatory hormones.39 Additionally, weight-bearing exercise
may moderate insulin resistance, improve caloric expenditure, favorably alter basal
metabolic rate, and enhance weight loss. The effect of exercise on decreasing glucose
and insulin concentrations is greatest with low-intensity, prolonged exercise that uses
a large muscle mass shortly (<2 hours) after mixed caloric intake.38 Regular exercise
during pregnancy decreases TNF-a originating from the placenta, a substance that
directly correlates with the level of insulin resistance throughout pregnancy.38
The ADA suggests that “women without medical or obstetric contraindications be
encouraged to start or continue a program of moderate exercise as part of the treat-
ment” of hyperglycemia in pregnancy.40 The American College of Sports Medicine
recommends that every adult accumulate at least 30 minutes of moderate-intensity
aerobic activity on most, preferably all, days of the week.36 Walking is the most
popular form of aerobic exercise for adults, and walking at a normal-to-brisk pace
712 Inturrisi et al
constitutes moderate-intensity exercise. Walking is also an activity that many women

can fit into their lifestyles, even when pregnant. To reduce postmeal glucose excur-
sions, three 10-minute walks can meet this requirement. Many women with gestational
diabetes find this regimen reduces or in some cases eliminates the need for insulin
therapy. A 10-minute activity session timed at 30 minutes after each meal may help
to control postmeal glucose excursions and reduce the need for insulin.
Monitoring BG
The consideration of glycemic goals in the pregnant diabetic woman must take into
account the normal glucose ranges in nondiabetic pregnant women. Recently reex-
amined with the use of continuous glucose monitoring systems, mean fasting BG
values have been shown to range from 61 to 75 mg/dL decreasing over the course
of gestation.41 In diabetic and nondiabetic pregnancies, maximal postprandial
glucose excursions occur between 60 and 90 minutes after meal ingestion and corre-
late more closely with 1- than 2-hour postprandial measurements.42 Understanding
these nondiabetic pregnancy values, normal glucose ranges (Table 4) provide addi-
tional support to the previous observation that the LGA risk increases with increasing
maximal postprandial hyperglycemia.43
During a healthy pregnancy, mean fasting blood sugar levels decline progressively
to a remarkably low value of 75 12 mg/dL. However, peak postprandial blood sugar
values rarely exceed 126 mg/dL. Meticulous replication of the normal glycemic profile
during pregnancy has been demonstrated to reduce the LGA rate. Table 5 shows the
commonly held BG targets for hyperglycemia in pregnancy.
Daily BG self-monitoring, compared with weekly office-based testing, is associated
with a reduction in the incidence of LGA infants in women with hyperglycemia in preg-
nancy.44 Women should be taught to check their BG using a home meter. The
frequency of testing is determined by whether or not they need medication and how
well their blood sugars are controlled. Suggested frequencies are listed in Box 4
but can be modified depending on the individual circumstances.
Because of the high frequency of self-monitoring blood glucose testing required in
pregnancy, the use of alternative-site self-monitoring blood glucose testing is
appealing, but the dynamically changing BG concentrations after eating may be iden-
tified at finger sites before being detected at the forearm or thigh sites. Because there
Table 4
Ambulatory glycemic profile and postprandial glucose levels in nondiabetic pregnancies
Mean blood glucose (mg/dL) 83.7 18

Fasting glucose (mg/dL) 75 12
Preprandial glucose (mg/dL) 78 11
Peak postprandial glucose value (mg/dL) 110 16
Peak postprandial time (min) 70 13
Mean blood glucose of 3-h postprandial 98 12
measurements (mg/dL)
1-h postprandial glucose value (mg/dL) 105 13
Mean blood glucose at nighttime (mg/dL) 68 10
Data from Yogev Y, Ben-Haroush A, Chen R, et al. Diurnal glycemic profile in obese and normal
weight nondiabetic pregnant women. Am J Obstet Gynecol 2004;191:949–53.
Table 5
Blood glucose targets for hyperglycemia in pregnancy
Fasting and premeal 60–89 mg/dLa 95 mg/dLb

Peak postprandial 100–129 mg/dLa 140 mg/dLb
a
Handelsman Y, Mechanick JI, Blonde L, et al. American Association of Clinical Endocrinologists
Medical Guidelines for Clinical Practice for developing a diabetes mellitus comprehensive care
plan. Endocr Pract 2011;17(Suppl 2):1–53.
b
American College of Obstetricians and Gynecologists Committee on Practice Bulletins–Obstetrics.
ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists. Number
30, September 2001 (replaces Technical Bulletin Number 200, December 1994). Gestational dia-
betes. Obstet Gynecol 2001;98(3):525–38.
are no studies that have evaluated the use of BG values from alternative sites in preg-
nancy, alternative-site self-monitoring blood glucose testing must be discouraged.
TREATMENT OF HYPERGLYCEMIA IN PREGNANCY
Although some women can attain normoglycemia through MNT and exercise alone,
insulin or oral agents may be required for women to control BG levels during preg-
nancy. The percentage of women with hyperglycemia in pregnancy requiring insulin
varies based on the population served. In 2009, the California Diabetes and Pregnancy
Program Data System reported that of approximately 11,400 women with hypergly-
cemia in pregnancy, treated in the Sweet Success Program, about 40% (w4500)
required medication in addition to meal plan and exercise to achieve normalization
of BG during pregnancy complicated by hyperglycemia in pregnancy.45
When considering medication therapy for hyperglycemia in pregnancy, a number of
considerations are important as described in Box 5.
Insulin has been the gold standard for achieving tight control during pregnancy. Initi-
ating insulin with mild-to-moderate hyperglycemia can be accomplished with a simple
approach as described in Table 6. For more severe hyperglycemia, dose calculations
are similar to overt T2DM based on weight and gestational age.
A certified diabetes educator should teach the woman the safe and effective way to
administer insulin and should follow-up in a few days. Compliance and success with
insulin therapy has been positively correlated with provider contact.
Hyperglycemia in Pregnancy and Oral Glucose-Lowering Agents

Although insulin has been the gold standard for treatment of hyperglycemia during
pregnancy, there are disadvantages that make some women refuse or comply poorly
with the treatment plan when the treatment includes insulin. Some women restrict
carbohydrate intake severely to avoid requiring insulin. The effects of severe
Box 4
Self-monitoring blood glucose suggested frequencies
Fasting
1 hour postprandial
Bedtime
Preprandial, when indicated
3 AM, when indicated
714 Inturrisi et al
Box 5
When to initiate medication therapy for hyperglycemia in pregnancy
When BGs are greater than 20% beyond target despite meal plan and exercise adherence:
Three or more elevated fasting BGs and/or
Six or more postmeal elevations in 1 week
Before starting the woman with hyperglycemia in pregnancy on insulin evaluate for:
Persistent fasting plasma BG 90 mg/dL (three or more in 1 week)
BG records that indicate a pattern (six or more in 1 week) of elevations despite adherence to
the meal plan and exercise
The degree of elevation above the target values: mild to moderate
Fasting plasma BG 90–120 mg/dL, postmeals 130–180 mg/dL
Estimated LGA fetus >90th percentile or abdominal circumference >70th percentile on
ultrasound (Buchanan et al, 2007)
restriction are not known, but women with an average BG of less than 87 mg/dL have
an increased risk of a small-for-gestational-age infant.46 There is some evidence that
when carbohydrates have been severely restricted the pancreas is underdeveloped
leading to T2DM in the offspring later in life.47 Some women fear injections will be pain-
ful, hurt the fetus, or cause a reliance on injections for a lifetime. Although none of this
is true, some women remain fearful and resist therapy. Insulin therapy is associated
with risks of hypoglycemia and increase in appetite and weight.
As an alternative to insulin some providers are choosing to use oral medications,
such as glyburide and metformin (glucophage), based on studies supporting relative
safety and efficacy.48,49 Langer and colleagues48 have found that glyburide, a sulfonyl-
urea drug, did not seem to pass through the placenta in the laboratory. The
researchers speculated glyburide would be safe to use during pregnancy and
designed a study to test the efficacy. Their randomized study of 404 women with
gestational diabetes who received either insulin injections or glyburide pills confirmed
this hypothesis. The outcomes in each group were similar. The percentage of
newborns that were large for their gestational age was similar in both groups of
women. In addition, there were no statistically significant differences in the infants’
rates of birth defects, lung complications, or low blood sugar.
Table 6
Starting doses of insulin with mild hyperglycemia
Elevated fasting blood sugars 0.2 units/kg NPH at bedtime

Elevated postbreakfast Insulin to carbohydrate ratio is w2:15 at breakfast
(2–4 units) rapid-acting analog
Elevated postlunch or postdinner Insulin to carbohydrate ratio is w1:15 at lunch
(3–5 units) rapid-acting analog prelunch and
predinner
Adapted with permission from the California Department of Public Health, California Diabetes and
Pregnancy Program Sweet Success “Diabetes and Pregnancy Pocket Guide for Professionals” 2008
by the California Diabetes and Pregnancy Program. Funding for the development of the original
materials was provided by the Federal Title V block grant from the California Maternal, Child
and Adolescent Health Division.
The researchers also did not detect glyburide in the umbilical-cord blood of the 12
newborns that were tested. Only eight of the women taking glyburide needed to switch
to insulin to control their gestational diabetes. The number studied was insufficient to
show statistical difference in this subgroup. The incidence of fetal LGA in both groups
was greater than 12%. Glycemic control was not optimal in either group. Although the
protocol in the study allowed for up to 10-mg glyburide twice a day, other authors have
cautioned against such a high dose because hypoglycemia can accompany glyburide
use.50,51 Box 6 describes one approach to dosing glyburide during pregnancy.
Although glyburide works by stimulating insulin secretion, it is also associated with
risks of maternal hypoglycemia and weight gain. Metformin, an oral biguanide, may be
a possible alternative to insulin for women with hyperglycemia in pregnancy who are
unable to cope with the increasing insulin resistance of pregnancy. In another study,
Rowan and associates49 showed similar perinatal mortality and morbidity for women
treated with metformin compared with insulin. There are data from over 30 years ago
reporting use of metformin in women with hyperglycemia in pregnancy or T2DM in
pregnancy in South Africa with no reports of adverse outcomes.52 However, metfor-
min does cross the placenta and little is known concerning long-term effects resulting
from fetal exposure. There are ongoing studies. It should be noted that a total of 30%
of metformin-treated women with hyperglycemia in pregnancy ultimately required
insulin for adequate glucose control. Box 7 provides a sample protocol for metformin
use in pregnancy.
As with insulin, optimum care involves provider follow-up at frequent short intervals
(every 3 days) until an adequate dose is achieved. As pregnancy progresses insulin
resistance increases and doses need to be adjusted.
Box 6
Glyburide protocol for hyperglycemia in pregnancy
Begin with 1.25 mg/day either in the AM or PM depending on individual needs

After 2–3 days without achieving target blood sugars, increase by 1.25 mg so total dose at one
time is 2.5 mg/day AM or PM
Next (after 2–3 days without achieving targets) add 2.5 mg to the opposite time of day so the
patient is taking 2.5 mg twice daily
Increase every 3 days by 1.25–2.5 mg total until targets are reached or maximum daily dose is
20 mg per day
Maintain meal plan and exercise therapy
Comply with recommended self-monitoring blood glucose schedule
Conduct fetal surveillance as recommended for patients using insulin therapy
Be aware that hypoglycemia can occur
Adhere to MNT meal and snack regimen to avoid hypoglycemia
Ensure that the woman can recognize and treat hypoglycemia
Monitor weight and assess for appropriate weight gain because weight gain has been
associated with this agent
and Pregnancy Program Sweet Success “Diabetes and Pregnancy Pocket Guide for Profes-
sionals” 2008 by the California Diabetes and Pregnancy Program. Funding for the development
716 Inturrisi et al
Box 7
Metformin protocol for hyperglycemia in pregnancy
Start at a dose of 500 mg once or twice daily with food or at bedtime depending on the target
pattern of hyperglycemia
Increase by 500 mg every 3–5 days over a period of 1–2 weeks, to meet glycemic targets up to
a maximum daily dose of 2500 mg
Obtain serum creatinine at start of therapy if renal dysfunction is suspected; metformin is
cleared in the kidneys
Common side effects are nausea, vomiting, diarrhea, loss of appetite, stomach fullness,
constipation, and heartburn
Drug should be discontinued before major surgery, or radiologic studies involving contrast
materials
Metformin is associated with mild weight loss
Hypoglycemia
Hypoglycemia is the result of insulin excess and compromised physiologic defenses
against falling plasma glucose concentrations. Hypoglycemia has been classified
as” asymptomatic” or “biochemical,” which is particularly common, and “symptom-
atic” or “severe,” which requires the assistance of another individual. The biochemical
definition is a BG less than or equal to 70 mg/dL because in nondiabetic individuals,
a BG of 65 to 70 mg/dL stimulates counterregulatory hormones epinephrine and
glucagon but after repeated episodes of low BG, this response is blunted.53 Episodes
of hypoglycemia are infrequent but do occur when insulin or glyburide are used. When
taking either of these agents, women must not further restrict their carbohydrates or
skip meals and snacks to prevent hypoglycemia. The treatment of hypoglycemia as
described in Box 8 is limited to those women taking insulin or glyburide, and the
recommendation is to eat a meal or snack containing a carbohydrate and a protein.
Box 8
Hypoglycedmia and the Rule of 15’s
Feeling low? Got symptoms? Check BG

If BG >50 mg/dL <70 mg/dL, treat with 15-g fast-acting carbohydrates (4 glucose tablets with
water or 8 oz nonfat milk or 4 oz juice)
Check BG in 15 minutes
BG should increase at least 15 points
If not 15 points higher, repeat treatment
Once BG is >70 mg/dL, have a 15 g carbohydrate snack with 7 g protein
Hyperglycemia
The Pedersen hypothesis, based on a glucocentric view of the pathophysiology of dia-
betes during pregnancy, theorizes that hyperglycemia mediates hyperinsulinemia in
the fetus. Because insulin does not cross the placenta, spikes in maternal BG cause
spikes in fetal BG, which stimulate fetal insulin production.52 This process works well
to encourage normal fetal growth when BG levels are in a normal range; however, high
glucose levels produce high fetal insulin levels, promoting visceral fat deposition,
abnormal growth, delay in lung maturation, and an overresponsive fetal pancreas.
Hyperglycemia is also known to cause oxidative stress and proinflammatory
responses. The effects of these processes on the fetus are not well known. In adults
with diabetes, hyperglycemia impairs the immune response and causes vascular
damage that eventually results in end-organ disease.
As pregnancy progresses particularly in the third trimester, hyperglycemia increases
as insulin resistance becomes greater. Increasing levels of progesterone, human
placental growth hormones, and cytokines, such as TNF-a, are among the placental
substances responsible for insulin resistance. Normoglycemia is more difficult to
achieve without meticulous attention to meal plan, exercise, and for some, medica-
tion. Healthcare providers need to recognize situations that increase the risk for hyper-
glycemia, anticipate them, and assist women to adjust the variables that control BG
levels to maintain normoglycemia (Box 9).
For example, individuals often have certain foods that trigger spikes in BG, such as
sourdough bread, white rice, or cereal and milk at breakfast. Recognizing these
patterns and intervening to avoid hyperglycemia is an integral part of problem solving.
Obtaining BG measurements at the appropriate time and frequency allows evaluation
of the appropriate intervention.
Reducing Risks
The three main goals of antepartum fetal surveillance are avoidance of fetal deaths,
early detection of fetal compromise, and prevention of unnecessary premature birth
and cesarean section. Fetal death in the final weeks of pregnancy has been associated
with poor glycemic control, hydramnios, and fetal macrosomia.54 All women with
hyperglycemia in pregnancy are encouraged to do kick counts beginning around 26
to 28 weeks gestation.
NONPLACENTAL INCREASED INSULIN NEEDS IN THE ANTEPARTUM PERIOD
Although specific detrimental outcomes of temporary hyperglycemia are not fully

known, it is known that the fetal pancreas is stimulated to overproduce insulin in
Box 9
High-risk situations for hyperglycemia
Stress
Sympathomimetics (terbutaline, ephedrine)
Steroids (eg, betamethasone)
Sepsis (infection)
Stout (obesity)
Advanced gestation (>24 weeks)
718 Inturrisi et al
accordance with glucose levels in the maternal bloodstream.52 The higher the
maternal BG, the more insulin the fetus produces. Overproduction of fetal insulin is
associated with adverse outcomes, described previously. Evidence-based literature
suggests that normal nonpregnant individuals exposed to transient glucose elevations
show rapid reduction in lymphocytes, including all lymphocyte subsets.55 Hypergly-
cemia is similarly associated with reduced T-cell populations for CD4 and CD8
subsets. These abnormalities are reversed when glucose is lowered.55 It is wise to
avoid hyperglycemia associated with such conditions as fever, infection, betamimet-
ics, or betamethasone administration. During these periods of “stress” all insulin
doses generally need to be doubled.
The most common stress during pregnancy is preterm labor often requiring tocoly-
sis. Use of betamimetics, such as terbutaline, should be avoided and either magne-
sium sulfate or nifedipine should be used if necessary. If delivery seems imminent
before 35 weeks, betamethasone may be indicated to accelerate fetal lung matura-
tion. Within about 4 hours after the first injection of 12 mg of betamethasone, hyper-
glycemia ensues. One method of avoiding hyperglycemia associated with
betamethasone treatment is illustrated in Table 7.
For women with hyperglycemia in pregnancy, BG should be checked more
frequently during betamethasone treatment. Women should check premeal and post-
meal BG, at bedtime, and at 3 AM for the first 3 to 5 days after beginning betametha-
sone two-dose therapy. For hyperglycemia in pregnancy, a premeal correction
algorithm should be instituted in addition to doubling doses of insulin to avoid post-
meal excursions out of target ranges (Table 8).
A premeal correction algorithm must be individualized. If the premeal glucose is
elevated, “correction insulin” according to the algorithm table is needed to prevent
postmeal hyperglycemia; this is not a sliding scale. An algorithm is directed at prevent-
ing hyperglycemia, not chasing it, which often results in “stacking” of insulin and
a deleterious cycle of hyperglycemia and hypoglycemia.
For hyperglycemia in pregnancy, basal insulin may be needed temporarily. Neutral
protamine Hagedorn insulin at 0.2 units per kg may be necessary every 8 to 12 hours
for 3 to 5 days.
FETAL SURVEILLANCE AND TIMING OF DELIVERY
Well-controlled uncomplicated women with hyperglycemia during pregnancy may not

require antenatal testing until 40 weeks and may await spontaneous labor.56 Most are
electively delivered by 41 weeks gestation. Women requiring medication with
adequate control generally start weekly nonstress test and amniotic fluid index testing
at 32 weeks gestation and twice weekly at 36 weeks gestation. A nonreactive non-
stress test requires further testing, usually a biophysical profile and rarely a contraction
Table 7
Recommendation for increased insulin needs with betamethasone
Day 1 Day 2 Day 3 Day 4

Double insulin dose Continue with Decrease the Revert to pre-
(if basic dose is increased dose; previous day’s betamethasone
10 units, then modify as needed increased dose insulin dose and
give 20 units) for BG (1) by 50% and add regime (ie, 20 units)
doubled dose to the basic dose
of 20 units (ie, 15 units)
Data from Kitzmiller J, Gavin L, Inturrisi M. Diabetes and pregnancy pocket guide. UCSF, 2002.
Table 8
Premeal correction algorithm
If Premeal BG is Correct the Basic Dose by And

<70 mg/dL 2 units less Eat right away, inject
insulin after the meal
70–99 mg/dL Give basic dose Inject, eat carbohydrates
right away
100–129 mg/dL 1 unit more Inject, eat right away
130–159 mg/dL 2 units more Inject, check BG in 15 min,
eat when <110
160–189 mg/dL 3 units more Inject, check BG in 15 min,
eat when <110
>190 mg/dL Add 4 units, call doctor, May need to wait up to 1 h
check ketones
Adapted with permission from the California Department of Public Health, California Diabetes and
Pregnancy Program Sweet Success Guidelines for Care 2006 and the “Diabetes and Pregnancy
Pocket Guide for Professionals” 2008 by the California Diabetes and Pregnancy Program. Funding
for the development of the original materials was provided by the Federal Title V block grant from
the California Maternal, Child and Adolescent Health Division.
stress test. Delivery before 39 weeks carries a risk of delivering an infant with immature
lungs; therefore, most physicians opt for amniocentesis and lung maturity studies
before elective induction of labor or cesarean delivery before 39 weeks. If the lung
indices are immature and the gestational age is less than 35 weeks, betamethasone
should be considered. Poor metabolic control or history of stillbirth is also an indica-
tion for amniocentesis and scheduled delivery before 39 weeks. Suspected LGA as an
indication for delivery is controversial and contributes to the high cesarean section
rate in women with diabetes.54
INTRAPARTUM RISKS
Intrapartum risks include prolonged labor, shoulder dystocia, operative delivery, poor
metabolic control resulting in fetal hypoxia and neonatal hyperinsulinemia and reactive
hypoglycemia, and birth injuries to the mother and newborn. A plan of care should be
coordinated by the outpatient diabetes team well in advance of delivery so that the
woman, her partner, and the delivery team is well informed and everyone understands
the same plan. The plan must be clearly communicated in written and oral form. One
approach is for the diabetes team to send a plan of care with the patient and to the
labor delivery unit on or before the 36th week gestation.
Dystocias
A greater risk for labor abnormalities (dystocias) is unknown for women with diabetes.
Arrest disorders were described in 9%, 19.4%, and 23.9% of women with diabetes in
three reports compared with 6% to 8% in nondiabetic women with newborns of similar
birth weights (3000–4500 g).57,58 Risk for shoulder dystocia increases with increasing
birth weight in both diabetic and nondiabetic women, varying from 8% to 23% across
the 4000- to 4500-g range.59 In one study fetal LGA predicted shoulder dystocia in
84% of the cases.60 Because of wider shoulder width and central adiposity in infants
of diabetic mothers in addition to increased obesity in diabetic mothers, the risk of
shoulder dystocia maybe greater than in nondiabetic women even at birth weights
of 3000–3900 g.57,59,60 Birth trauma was found in 20% to 40% of the cases of shoulder
720 Inturrisi et al
dystocia, including fracture of the clavicle or humerus, facial palsy, or brachial plexus
palsy.59,60 Women with labor complicated by shoulder dystocias also incurred injuries,
such as third- and fourth-degree perineal lacerations.61
Another approach to reduce the risks associated with dystocias is to induce labor
before LGA becomes too severe or to electively perform a cesarean at 39 weeks gesta-
tion.62 The ACOG clinical practice guideline does not endorse induction before 40
weeks (in nondiabetic pregnancies) because accurate determination of fetal size is diffi-
cult to determine.63 The ADA recommendation is to induce labor or perform a cesarean
delivery on an individualized basis when the estimated fetal weight is between 4000 and
4500 g. Primary cesarean is recommended in most cases when the estimated fetal
weight is greater than 4499 g.64 Labor induction protocols do not differ for women
with diabetes versus no diabetes. However, continuous electronic fetal heart rate moni-
toring is advised.64 There are no contraindications to epidural anesthesia, although
the use of betamimetics for hypotension may raise the maternal BG for several hours.
Cesarean delivery raises the risk for infection, both uterine (endometritis) and wound
infection, if BG is not meticulously controlled peripartum. The risk for deep vein thrombus
after cesarean delivery is five times higher than that after a vaginal birth. Obesity
increases these risks and women with diabetes are more likely to be obese. Prevention
generally includes use of pneumonic pressure stockings intraoperatively and postoper-
atively until the woman is fully ambulatory. Heparin prophylaxis has no advantage over
stockings in this setting and may cause heparin-induced thrombocytopenia.65
Intrapartum Insulin Management

The goals of intrapartum insulin management are to maintain maternal normoglycemia
(BG 70–110 mg/dL) to optimize fetal tolerance of labor and prevent neonatal hypogly-
cemia. In the largest published experience with 233 insulin-treated pregnant women,
the lowest risk of neonatal hypoglycemia occurred when intrapartum maternal glucose
was maintained at less than 100 mg/dL. Intrapartum hyperglycemia had more effect
on neonatal hypoglycemia than did antepartum glucose levels.66
Women with hyperglycemia in pregnancy generally do not require insulin during
labor because the uterine muscle contractions of the labor process increase insulin
sensitivity and reduce insulin needs. Even women with hyperglycemia in pregnancy
may not require insulin during labor if carbohydrate intake (intravenous and oral) is
restricted. To determine the need for insulin the BG should be followed closely as
described in the section on monitoring.63
When intrapartum insulin is needed it is optimally delivered by intravenous drip
(Table 9). The usual dose of intermediate-acting subcutaneous insulin is given at
bedtime the night before induction of labor but the morning dose is withheld.63
POSTPARTUM RISKS
The most immediate risk postpartum is the risk for neonatal hypoglycemia. BG cutoffs
for neonatal hypoglycemia vary slightly but on average the value of 45 mg/dL or less is
consistent with the need for intervention. This risk, however, can also be attenuated by
early (within the first hour of life) and often (every 2 hours) breastfeeding. The healthy
newborn should be dried off and kept warm (preferably skin-to-skin with the mother)
and placed at breast as soon after birth as possible. Acquisition of colostrum by the
newborn may stimulate hepatic gluconeogenesis to help stabilize the newborn’s
BG. The newborn will have heel-stick glucose levels checked beginning around 30
minutes after birth. Various protocols exist to monitor the newborn’s glucose until
stable. Breastfeeding provides numerous health benefits to women with diabetes
Table 9
Intrapartum intravenous insulin algorithm for hyperglycemia in pregnancy
1 Unit Intravenous
Capillary BG Insulin 5 1 mL Fluids BG Checks
<70 mg/dL 0 D5 0.5 NS at 200 mL/h Every 15 min
until >70 x2
70–110 mg/dL 0 D5 0.5 NS at 100 mL/h Every 1–2 h
111–130 mg/dL 1 NS or LR at 100 mL/h Every 30 min
131–150 mg/dL 2 NS or LR at 100 mL/h until <110
151–170 mg/dL 3 NS or LR at 100 mL/h Then every 1 hour
171–190 mg/dL 4 NS at 150/h while on
>190 mg/dL Check urine ketones NS at 150/h intravenous
call doctor for insulin drip
insulin dose
Abbreviations: D5, 5% dextrose; LR, lactated Ringers solution; NS, normal saline.
Data from Palmer D, Inturrisi M. Insulin infusion therapy in the intrapartum period. J Perinat
Neonat Nurs 1992;6(1):B14–25.
and offspring. Among those benefits is improved glucose use and reduced lipid levels
in the mother.67 A relationship has also been shown between breastfeeding and
reduction of type 2 diabetes in Pima Indian children.68 Infants of women with mild
to severe glucose intolerance are at risk for infant and childhood obesity.69,70
Breastfed infants tend to be leaner than formula-fed infants.71 Lactation removes
glucose from the maternal blood to create lactase for the breast milk, thus lowering
maternal BG independent of the action of insulin.
Contraception for Women with a History of Hyperglycemia in Pregnancy
The use of progestin-only oral contraceptives almost tripled the conversion to type 2
diabetes in the 2 years after hyperglycemia in pregnancy in a study of Latina women
who were breastfeeding compared with equivalent use of low-dose combination pills.72
Because the underlying mechanism for conversion to type 2 diabetes in Hispanic
women is the same for most other women (impaired b cell function and insulin resis-
tance), the recommendation is that progesterone-only birth control be avoided when
possible in previous hyperglycemia in pregnancy. Low-dose combination pills can be
used safely in breastfeeding women with previous hyperglycemia in pregnancy.72
The interaction of medroxyprogesterone acetate (Depo-Provera) with breastfeeding
is similar to that of progestin-only contraception with breastfeeding, adversely effect-
ing diabetes risk.72 Thus, medroxyprogesterone acetate should be used with caution
in breastfeeding women and those with elevated triglyceride levels (150 mg/dL).
Close attention should be paid to weight gain, which also has been demonstrated
to increase the risk of subsequent diabetes.72
Progesterone does increase insulin resistance and lowers low-density lipoprotein and
raises high-density lipoprotein. The lowest dose and potency of progestin should be
used to minimize adverse effects on lipids and glucose control. The intrauterine device
is metabolically neutral and highly efficacious. This is a good choice for most women with
diabetes. The guidelines for use follow the same guidelines as healthy parous women,
such as low risk for sexually transmitted disease and pelvic inflammatory disease.
Reducing Future Risk for T2DM in Hyperglycemia in Pregnancy

Hyperglycemia in pregnancy is not just a pregnancy problem. Approximately 55% of
women with diagnosed hyperglycemia in pregnancy have overt T2DM, and another
722 Inturrisi et al
20% to 30% have prediabetes.73 Independent antepartum predictors of conversion

from hyperglycemia in pregnancy to T2DM include low insulin sensitivity (elevated
postmeal requiring insulin); high basal glucose production (elevated fasting BG
requiring insulin); and abnormal 1-hour value on the OGTT.74 Postpartum predictors
of conversion from hyperglycemia in pregnancy to T2DM include obesity, pregnancy
weight gain, high-fat diet, inactivity, and progesterone contraception.74
A woman who had hyperglycemia in pregnancy but has a negative test for preexist-
ing diabetes should be counseled on the increased risk for developing hyperglycemia
in pregnancy in future pregnancies. Women with a history of hyperglycemia in preg-
nancy have an increased risk for presenting with undiagnosed diabetes at the first
prenatal visit in subsequent pregnancies. Counseling should include discussing the
lifetime risk for developing T2DM and dyslipidemias. Because approximately one-
third of women with a history of hyperglycemia in pregnancy have abnormal lipid
profiles, lipid testing is recommended 1-year postpartum and annually thereafter.
The 2-hour adult OGTT more accurately identifies this population than the fasting
plasma glucose test.75 The current recommendation is to obtain a 2-hour 75-g
OGTT at 6 to 8 weeks postpartum and at 1 year. If within normal limits, then obtain
fasting or hemoglobin A1C yearly and OGTT every 3 years.
SUMMARY
Women who had hyperglycemia in pregnancy and have prediabetes on the OGTT
should be referred for management that includes nutrition and exercise counseling
and possibly treatment with metformin to prevent the conversion to T2DM. Women
with prediabetes need to be tested for overt diabetes every year thereafter.
Women who have a history of hyperglycemia in pregnancy and have a subsequent
positive test for T2DM should be referred for appropriate follow-up with a healthcare
provider familiar with diabetes care. Women should be counseled on the importance
of preconception care and also advised of the long-term complications associated
with poor glycemic control. Attention should be given to attainment and maintenance
of appropriate weight.
Hyperglycemia in pregnancy is an opportunity for women at risk for complications
during pregnancy and beyond to change their life course to improve outcomes for
themselves and their offspring. Providers of diabetes care during pregnancy compli-
cated by hyperglycemia in pregnancy have the unique opportunity to make a signifi-
cant difference.
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Diagnosis and Treatment of Hyperglycemia in Pregnancy

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This article appeared in a journal published by Elsevier.

The prevalence of hyperglycemia in pregnancy varies in direct proportion to the prev-

The authors have nothing to disclose.

Endocrinol Metab Clin N Am 40 (2011) 703–726

Short Term (Fetal and Neonatal) Long Term (Adult)

be screened for hyperglycemia in pregnancy, whether by patient history, clinical risk

THE HYPERGLYCEMIA AND ADVERSE PREGNANCY OUTCOME STUDY

PREGNANCY: A DIABETOGENIC STATE

Normal pregnancy can be viewed as a progressive condition of insulin resistance, hyper-

 Birth weight above the 90th percentile for gestational age

 Determine energy needs

Old Method10 New Method11

sources of small amounts of carbohydrate by encouraging small frequent meals and

In normal pregnancy, expected weight gain varies according to the prepregnancy

Breakfast Lunch Dinner

Body Mass Index Category Weight Gain Ranges

constitutes moderate-intensity exercise. Walking is also an activity that many women

Mean blood glucose (mg/dL) 83.7  18

Fasting and premeal 60–89 mg/dLa 95 mg/dLb

TREATMENT OF HYPERGLYCEMIA IN PREGNANCY

Hyperglycemia in Pregnancy and Oral Glucose-Lowering Agents

Elevated fasting blood sugars 0.2 units/kg NPH at bedtime

Begin with 1.25 mg/day either in the AM or PM depending on individual needs

Feeling low? Got symptoms? Check BG

NONPLACENTAL INCREASED INSULIN NEEDS IN THE ANTEPARTUM PERIOD

Although specific detrimental outcomes of temporary hyperglycemia are not fully

FETAL SURVEILLANCE AND TIMING OF DELIVERY

Well-controlled uncomplicated women with hyperglycemia during pregnancy may not

Day 1 Day 2 Day 3 Day 4

If Premeal BG is Correct the Basic Dose by And

Intrapartum Insulin Management

Reducing Future Risk for T2DM in Hyperglycemia in Pregnancy

20% to 30% have prediabetes.73 Independent antepartum predictors of conversion

1. Expert Committee on the Diagnosis and Classification of Diabetes Mellitus.

68. Pettitt DJ. Breastfeeding and incidence of non-insulin-dependent diabetes melli-

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Birth weight above the 90th percentile for gestational age

Determine energy needs

Mean blood glucose (mg/dL) 83.7 18