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Snapshot
  • A 33-year-old G3P2 female is at 25 weeks gestation. Fundal height measures 31 cm. Obstetric ultrasound reveals four quadrant amniotic fluid index (AFI) of 30 cm. An ultrasound is performed. 
Introduction
  • Glucose intolerance or diabetes mellitus (DM) first recognized during pregnancy
  • Occurs in 2-5% of all pregnancies
    • #1 medical complication of pregnancy
  • Caused by placental-released human placental lactogen (HPL) which antagonizes insulin
    • worsens with pregnancy as placenta enlarges and more HPL is released
  • Risk factors include
    • previous history of gestational diabetes mellitus (GDM)
    • obesity
    • history of prior abortions or stillbirths
    • family history of DM
    • maternal age > 30
Presentation
  • Asymptomatic
Evaluation
  • At 24 - 28 weeks
    • check fasting plasma glucose
      • if greater than 125 mg/dL, suspect diabetes mellitus
      • < 95 mg/dL considered normal 
    • administer a 1 hour 50 g oral glucose tolerance test (Glucola)
      • if blood glucose > 140 mg/dL at 1 hour, suspect gestational diabetes
      • this is a very sensitive test (a negative test rules it out)
    • confirm with a 3 hour 100 g oral glucose tolerance test; abnormal measurements are:
      • > 180 mg/dL at 1 hour
      • > 155 mg/dL at 2 hours
      • > 140 mg/dL at 3 hours
      • this is a very specific test (a positive test rules it in)
Treatment
  • Strict adherence to ADA diet and glucose control
  • If diet is insufficient to control administer insulin
  • Oral hypoglycemic medications can be used
    • metformin is currently approved for usage during pregnancy
    • glyburide is also considered safe
    • in general insulin is a better answer for step exams
  • Delivery
    • determined by estimated fetal weight
    • if 4000-4500 g, consider a caesarian section
Prognosis, Prevention, and Complications
  • 95% return to normal postpartum
    • glucose screen 2 months postpartum to confirm
  • Maternal complications include
    • type II DM later on in life (50%)
    • 2X risk of pregnancy induced hypertension, preeclampsia, eclampia
    • polyhydraminos (> 2000 mL)
      • caused by polyuria of the fetus
    • hyperglycemia
    • increased risk of UTIs
    • pre-term labor
    • retinopathy
    • caesarian secondary to macrosomia
    • no increased risk of spontaneous abortion if well controlled
  • Fetal complications include
    • perinatal mortality (2-5%)
    • abruption and preterm labor
    • 3X congenital malformations
      • limb deformities
      • neural tube
      • cardiac deformities 
        • secondary to trophic effect of insulin
      • macrosomia (> 4500 g)
        • shoulder dystocia during vaginal delivery 
    • neonatal hypoglycemia
      • due to abrupt separation from high maternal glucose supply with a large amount of fetal insulin present
      • ß-cell hyperplasia in the newborn leading to hypoglycemia
    • hyperbilirubinemia
    • polycythemia
    • respiratory distress syndrome (RDS)
 

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