Gestational Diabetes


Article Author:
Bryan Quintanilla Rodriguez


Article Editor:
Heba Mahdy


Editors In Chief:
Kranthi Sitammagari
Mayank Singhal


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
7/28/2019 4:29:29 PM

Introduction

The definition of gestational diabetes mellitus (GDM) is any degree of glucose intolerance with onset or first recognition during pregnancy. GDM can classify as A1GDM and A2GDM. Gestational diabetes managed without medication and responsive to nutritional therapy is diet-controlled gestational diabetes (GDM) or A1GDM. On the other side, gestational diabetes managed with medication to achieve adequate glycemic control is A2GDM.

Historically, the screening for gestational diabetes consisted of assessing patients history, past medical obstetric outcomes, and family history of type 2 diabetes mellitus. Even though it was useful, it was not appropriate. This screening method failed to identify approximately one-half of pregnant women with GDM. In 1973 a significant study suggested the use of the 50 g 1-hour oral glucose tolerance test as a screening for gestational diabetes; this is a very reliable method for screening, and it is used for approximately 95% of obstetricians in the united states of America as a method for screening GDM during pregnancy. In 2014, the U.S preventive service task force recommended screening all pregnant women for GDM at 24 weeks of gestation.[1][2][3][4]

Etiology

Gestational diabetes etiology is apparently related to 1) the pancreatic beta-cell dysfunction or the delayed response of the beta cells to the glycemic levels, and 2) the marked insulin resistance secondary to placental hormonal release. The human placental lactogen is the main hormone related to increased insulin resistance in GDM. Other hormones related to the development of this disease are growth hormone, prolactin, corticotropin-releasing hormone, and progesterone, these hormones contribute to the stimulation of insulin resistance and hyperglycemia in the pregnancy.

It has been reported some clinical risk factors for developing gestational diabetes. Those clinical factors include[3]:

  • Increased body weight (a body mass index greater than 25)
  • Decreased physical activity
  • A first degree relative with diabetes mellitus
  • Prior history of gestational diabetes or a newborn with macrosomia, metabolic comorbidities like hypertension
  • Low HDL
  • Triglycerides greater than 250
  • Polycystic ovarian syndrome
  • Hemoglobin A1C greater than 5.7
  • Abnormal oral glucose tolerance test
  • Any significant marker of insulin resistance (acanthosis nigricans)
  • Past medical history of cardiovascular diseases

Epidemiology

Gestational diabetes affects around 2 to 10% of pregnancies in the United States of America.

Women with gestational diabetes (GDM) have an increased 35 to 60% risk of developing diabetes mellitus over 10 to 20 years after pregnancy.[3][4]

Pathophysiology

The human placental lactogen is a hormone released by the placenta during the pregnancy. It holds a comparable composition to growth hormone and induces important metabolic changes during pregnancy to support the maintenance of fetal nutritional status. This hormone is capable of provoking alterations and modifications in the insulin receptors. The following molecular variations appear to have links to diminishing glucose uptake at peripheral tissues:1) molecular alteration of the beta-subunit insulin receptor, 2) diminished phosphorylation of tyrosine kinase, 3) remodelings in the insulin receptor substrate-1 and phosphatidylinositol 3-kinase.

Maternal high glucose levels cross the placenta and produce fetal hyperglycemia. The fetal pancreas gets stimulated in response to the hyperglycemia. Insulin anabolic properties induce fetal tissues to growth at an increased rate.[3]

There are reports that a higher body mass index and obesity can lead to low-grade inflammation. Chronic inflammation induces the synthesis of xanthurenic acid, which is associated with the development of pre-diabetes and gestational diabetes mellitus.[5]

History and Physical

The past medical obstetric outcomes and family history of type 2 diabetes mellitus are important components of the history taking in GDM. The clinical features of gestational diabetes mellitus can be varied. The disproportionate weight gain, obesity, and elevated BMI can be suggestive features. The diagnosis is established by the laboratory screening method at the 24 to 28 weeks of pregnancy.

Reports exist that the gestational age when DSM develops influences pregnancy outcome.

Evaluation

Recommendations are for screening for gestational diabetes at 24 to 28 weeks of pregnancy with a 50-g, 1-hour oral glucose challenge test. If the values are abnormal, greater than or equal to 130 mg/dL (7.22 mmol/L), or greater than or equal to 140 mg/dL (7.77 mmol/L), a confirmatory test is necessary with a 100-g, 3-hour oral glucose tolerance test, with the following values: first hour over 180 mg/dL, second hour over 155 mg/dL, third hour more than 140 mg/dL. The presence of two or more abnormal results establishes the diagnosis of gestational diabetes.

The ADA recommends to consider screening strategy for detecting pregestational diabetes or early gestational diabetes mellitus in all women who are overweight or obese and have one or more of the following risk factors:

  • Physical inactivity,
  • First degree relative with diabetes
  • High-risk race or ethnicity
  • Have previously birthed an infant weighing 4000 grams or more
  • Previously gestational diabetes, hypertension
  • HDL level less than 35mg/dL
  • Triglyceride level greater than 250 mg/dL
  • Women with polycystic ovarian syndrome
  • Hemoglobin A1c greater than 5.7%
  • Impaired glucose tolerance test
  • Impaired fasting glucose
  • History of cardiovascular disease
  • Other clinical conditions associated with insulin resistance

The American Diabetes Association (ADA) has noted that measurement of hemoglobin A1C is usable, but it may not be suitable to use alone, due to decreased sensitivity compared to oral glucose tolerance test.

The ACOG recommended levels of blood glucose in pregnancy is fasting plasma glucose under 95 mg/dL, 1 hour postprandial under 130-140 mg/dL, 2 hours postprandial below 120mg/dL.

In the postpartum period, 24 to 72 hours after the delivery, it is recommended to monitor glucose levels. After removing the placenta insulin resistance tends to improve, this can help escalate down insulin or hypoglycemic agents. Glycemic therapy will point towards achieving a euglycemic glucose level. At 4 to 12 weeks post-partum, it is recommended to perform a 75g oral glucose tolerance test to rule out the possibility of development of type 2 diabetes.[1][6][4][6]

Treatment / Management

Gestational diabetes management begins with nonpharmacologic measurements like diet modifications, exercise, and glucose monitoring. The ADA recommends nutritional counseling by a registered dietitian and development of a personalized plan based on the patients BMI. In some settings, in which dietitians are not able, the physician can provide recommendations based on the three major nutritional concepts: caloric allotment, caloric distribution, and carbohydrate intake.

The amount of exercise recommended in GDM is 30 minutes of moderate-intensity aerobic exercise at least five days a week or a minimum of 150 minutes per week.

If the patient glycemic control is not adequate despite optimal adherence to diet and exercise, it is recommended to begin pharmacologic treatment. The ADA first line of treatment for GDM is insulin. The therapy with insulin has been considered the standard therapy for gestational diabetes management when adequate glucose levels are unachievable with diet and exercise.

Insulin can help achieve an appropriate metabolic control, and it is added to the management if fasting blood glucose is greater or equal to 95 mg/dL, if 1-hour glucose level is greater or equal to 140 mg/dL, or if 2-hour glucose level is greater than 120 mg/dL.

The oral hypoglycemic agents, metformin and glyburide, are increasingly being used among women with gestational diabetes, despite the lack of FDA approval. Glyburide can initiate at a dose of 2.5 mg, and the maximum dose is 20mg. Metformin therapy should start at a dose of 500 mg, and the maximum dose is 2500 mg.

Basal insulin dose can be calculated using the patient’s weight formula, 0.2 units/kg/day. If the blood glucose level becomes elevated following a meal, rapid-acting insulin, or regular insulin can be prescribed before the meal, starting the dose with 2 to 4 units.

In the first trimester, the total daily insulin requirement is 0.7 units/kg/day, in the second trimester it is 0.8 units/kg/day, and in the third trimester, it is 0.9 to 1.0 units/kg/day.

The patient should divide the total daily dose of insulin into two halves; one half given as basal insulin at bedtime, and the other half divided between three meals and given as rapid-acting, or regular insulin before meals.

Lispro and aspart have approval for usage in pregnancy. The short-acting insulin is associated with less hypoglycemia.

The long-acting insulin detemir has received approval for the usage in pregnancy. Long-acting insulin causes less nocturnal hypoglycemia.[6][7][8][9][10][4]

Differential Diagnosis

Many women do not receive the appropriate screening for diabetes mellitus before pregnancy, so in some cases, it is challenging to distinguish gestational diabetes from preexisting diabetes.[7][9]

Prognosis

At 4 to 12 weeks post-partum, the recommendation is to perform a 75g oral glucose tolerance test to rule out the possibility of the development of type 2 diabetes, impaired fasting glucose or impaired glucose tolerance test.[11]

ADA and ACOG recommend repeating testing every 1 to 3 years for women who developed GDM and had normal postpartum screening results.[12][13]

Complications

The complications of developing gestational diabetes categorize as maternal and fetal. The fetal complications include macrosomia, neonatal hypoglycemia, polycythemia, shoulder dystocia, hyperbilirubinemia, neonatal respiratory distress syndrome, increased perinatal mortality, and hypocalcemia. Maternal complications include hypertension, preeclampsia, increased risk of developing diabetes mellitus, and increased risk of cesarean delivery.[12][13]

Consultations

OB/GYN physicians best manage gestational diabetes. However, it can include consultations with the endocrinology department to suggest recommendations for cases of hyperglycemia refractory to treatment.[14][13][14]

Deterrence and Patient Education

Patient education is necessary. Education regarding appropriate diet changes, exercise, and lifestyle modifications can help to improve outcomes in patient with gestational diabetes.[14][13]

Enhancing Healthcare Team Outcomes

Management and treatment of women with gestational diabetes is an emerging challenge for the health care providers and teams. Thus, today, gestational diabetes requires an interprofessional team approach, including physicians, specialists, specialty-trained nurses, and pharmacists, all collaborating across disciplines to achieve optimal patient results and prevent further complications. Efforts and strategies are necessary to recognize them effectively. Development of prevention strategies would facilitate treatment of gestational diabetes and would help improve health outcomes. Women with gestational diabetes have an increased risk of developing type 2 diabetes over 10 to 20 years after pregnancy.[14][13][11][4]

Many pregnant women who develop diabetes are not diagnosed until very late, which significantly increases the morbidity of the disease.

Many healthcare institutions are now operating pharmacy or nurse practitioner diabetic clinics which offer diabetic education to pregnant females. These clinics regularly monitor blood glucose and refer patients to an endocrinologist. This practice reduces the burden of the obstetrician, lowers the healthcare costs, and helps the delivery of optimal care for those who need it.

All members of the interprofessional healthcare team need to collaborate and work together to manage gestational diabetes. PHysician responsibilities have already received coverage above. Nursing stands at the forefront of patient encounters to determine adherence to therapeutic choices, and monitor for therapy efficacy as well as being alert for potential adverse effects, which they will communicate to other team members. Pharmacists need to perform medication reconciliation, verify dosing of insulin or other antihyperglycemic drugs, and assist with patient counseling about medication and lifestyle adherence. In this cooperative paradigm, the interprofessional team can guide outcomes most successfully. [Level V]


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Gestational Diabetes - Questions

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A 35-year-old obese pregnant woman at 38 weeks of gestation presents to the physician's office for a routine follow-up examination. She has a significant past medical history of chronic hypertension. Her medications include daily prenatal vitamins, and methyldopa 1000 mg once a day. Ultrasound abdomen and pelvis revealed a baby weighing 4000 grams at 38 weeks. A 100g oral glucose tolerance test done at 28 weeks was 190 mg/dL at the 1st hour, 165 mg/dL at the 2nd hour, and 150 mgdL at the 3rd hour. NPH insulin and short-acting insulin was added to her pharmacologic treatment. Which of the following statements is correct regarding this patient diagnosis?



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A 40-year-old woman, gravida 2, para 1, at 28 weeks gestation with a past medical history of chronic hypertension and preeclampsia presents to the outpatient clinic for a routine prenatal visit. Her medications include daily prenatal vitamins, methyldopa 2000 mg once a day, aspirin 75 mg once a day. A 50 g oral glucose challenge was abnormal. A 100 g oral glucose tolerance test shows 190 mg/dL at the 1st hour, 160 mg/dL at the 2nd hour, and 150 mgdL at the 3rd hour. Which of the following is the best next step?



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A 40-year-old woman with a past medical history of chronic hypertension, preeclampsia, gestational diabetes, diabetes type 2 presents to the outpatient clinic for a routine visit. She describes that she is looking forward to becoming pregnant. Her medications include daily multivitamins, metformin 2000 mg once a day, glipizide 10 mg once a day, losartan 100 mg once a day. What is the most essential advice for a diabetic female who wishes to become pregnant?



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A 37-year-old pregnant woman at 36 weeks of gestation presented to the physician's office. She has a past medical history of chronic hypertension and preeclampsia. Her medications include daily prenatal vitamins, methyldopa 2000 mg once a day, aspirin 75 mg once a day. Obstetric ultrasonography reported a baby weighing 3965 grams at 36 weeks. A 100 gm oral glucose tolerance test done at 28 weeks was 198 mg/dL at the 1st hour, 168 mg/dL at the 2nd hour, and 155 mgdL at the 3rd hour. Diet and exercise were started, but the patient remained hyperglycemic. NPH insulin and short-acting insulin was added to her pharmacologic treatment. Which of the following is a complication commonly seen in the infant born of this woman?



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A 34-year-old obese pregnant woman at 26 weeks of gestation comes to her physician's office for a regular follow-up. She has a past medical history of chronic hypertension. Her medications include daily prenatal vitamins, folic acid 1mg, and methyldopa 1000mg once a day. She describes gaining more weight, increased thirst, and increased hunger in the last 4 weeks. Body mass index is 30 kg/m2. Which of the following is the best initial screening test for this woman at this time?



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A 40-year-old woman, gravida 3, para 2, at 28 weeks gestation with a past medical history of chronic hypertension presents to the outpatient clinic for a routine prenatal visit. Her medications include daily prenatal vitamins, folic acid 1mg once a day, and methyldopa 1500 mg once a day. She describes gaining more weight, increased thirst, and increased hunger in the last 4 weeks. She also explains that she developed a similar condition in the last trimester of her previous pregnancy. The condition was resolved after delivery. Body mass index is 34 kg/m2. Her 50g oral glucose challenge test was abnormal. And a 100 g oral glucose tolerance test was done reporting 192 mg/dL at the 1st hour, 166 mg/dL at the 2nd hour, and 153 mgdL at the 3rd hour. She remains hyperglycemic despite adequate exercise and diet. Short-acting insulin and long-acting insulin was added to her pharmacologic treatment. An infant born to a mother with this current diagnosis will most likely have what condition?



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A 40-year-old pregnant woman at 32 weeks of gestation presents with a past medical history of preeclampsia. Her medications include daily prenatal vitamins and aspirin 75 mg once a day. A 100 g oral glucose tolerance test done at 28 weeks was 200 mg/dL at the 1st hour, 170 mg/dL at the 2nd hour, and 160 mgdL at the 3rd hour. Diet and exercise were started but the patient remained hyperglycemic. Metformin was added to her pharmacologic treatment. What is the pathophysiologic mechanism of this patients current diagnosis?



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A 32-year-old, gravida 1 para 0, at 38 weeks gestation with a past medical history of chronic hypertension presents to the obstetric emergency department complaining of contractions, and a watery discharge from her vagina. Her medications include daily prenatal vitamins, methyldopa 1000 mg once a day, NPH insulin, and short-acting insulin. A 100 g oral glucose tolerance test done at 28 weeks was 190 mg/dL at the 1st hour, 165 mg/dL at the 2nd hour, and 150 mgdL at the 3rd hour. NPH insulin and short-acting insulin was added to her pharmacologic treatment at that moment. On physical examination, upto three contractions are noticed every 10 minutes, and membranes are noted to be ruptured, the cervix is dilated at 3cm. Obstetric ultrasound reports a well-formed baby, in cephalic position, with no malformations, weighting 4,600g. What is the best next step regarding this patient delivery?



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A 36-year-old woman, gravida 1, para 0, at 28 weeks gestation with a past medical history of chronic hypertension presents to the outpatient clinic for a routine prenatal visit. Her medications include daily prenatal vitamins, methyldopa 1000 mg once a day. A 100 g oral glucose tolerance test done at 28 weeks was 190 mg/dL at the 1st hour, 165 mg/dL at the 2nd hour, and 150 mgdL at the 3rd hour. NPH insulin and short-acting insulin was added to her pharmacologic treatment. Which of the following is a maternal complication of the patient's current diagnosis?



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A 25-year-old pregnant woman at 24 weeks of gestation presents to the physician's office for a follow-up appointment. Her medications include daily prenatal vitamins, folic acid 1mg once a day. Her 50 gm oral glucose challenge test was abnormal. And a 100 gm oral glucose tolerance test was done reporting 185 mg/dL at the 1st hour, 158 mg/dL at the 2nd hour, and 145 mg/dL at the 3rd hour. What is the next best step in the management of this patient?



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A 28-year-old obese pregnant woman with an unremarkable past medical history. Obstetric ultrasonography reported a baby weighing 3950 grams at 37 weeks. A 100 g oral glucose tolerance test done at 28 weeks was 190 mg/dL at the 1st hour, 165 at the 2nd hour, and 150 at the 3rd hour. Which of the following is the most common complication of the infant born of these women?



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A 30-year-old woman, gravida 1, para 0, at 37 weeks gestation with an unremarkable past medical history presents to the outpatient clinic for a routine prenatal visit. Her current medications include prenatal vitamins, insulin NPH, short-acting insulin. Obstetric USG reported a baby weighing 3970 grams at 37 weeks. A 100 g oral glucose tolerance test done at 28 weeks was 194 mg/dL at the 1st hour, 167 mg/dL at the 2nd hour, and 152 mg/dL at the 3rd hour. Exercise and diet were recommended at that moment. She remained hyperglycemic despite these measurements. At this point, the pharmacologic treatment was added. Which of the following is a complication that can be seen in the infant born of this woman?



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A 39-year-old pregnant woman at 28 weeks of gestation and with a past medical history of chronic hypertension, preeclampsia presents to the physician office. Her medications include daily prenatal vitamins, methyldopa 2500 mg once a day, aspirin 75 mg once a day. An oral glucose challenge test was 165 mg/dL. A 100 g oral glucose tolerance test done is 200 mg/dL at the 1st hour, 170 mg/dL at the 2nd hour, and 160 mgdL at the 3rd hour. Diet and exercise were started, but the patient remained hyperglycemic. Which of the following drugs is the best next step in the management of this patient?



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A 38-year-old obese pregnant woman at 28 weeks of gestation, presented to the physician's office for a regular physical examination. She has a past medical history of chronic hypertension, preeclampsia. Her medications include daily prenatal vitamins, methyldopa 2000 mg once a day, aspirin 75 mg once a day. A 50 gm oral glucose challenge was abnormal. A 100g oral glucose tolerance test done shows 190 mg/dL at the 1st hour, 160 mg/dL at the 2nd hour, and 150 mgdL at the 3rd hour. Diet and exercise are recommended. Which of the following statements is correct regarding the patient's current diagnosis?



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A 40-year-old woman, gravida 1, para 0, at 12 weeks gestation with an unremarkable past medical history presents to the outpatient clinic for a routine prenatal visit. Her medications include daily prenatal vitamins. Her body mass index is 35 kg/m2. Fasting plasma glucose is 101 mg/dL. She is worried because all her family has diabetes, and her sister underwent a cesarean section because the baby was too big for a vaginal delivery. Given the patient current risk factors, which of the following test is recommended in this patient?



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A 29-year-old pregnant woman with obesity and a significant past medical history of chronic hypertension presents to the physician's office at 28 weeks of gestation. Her medications include daily prenatal vitamins, folic acid 1mg, and methyldopa 1500mg once a day. She describes gaining more weight, increased thirst, and increased hunger in the last 4 weeks. She also explains that she developed a similar condition in the last trimester of her last pregnancy, that was treated with insulin. Body mass index is 30 kg/m2. A 100g oral glucose tolerance test done at 28 weeks was 197 mg/dL at the 1st hour, 169 mg/dL at the 2nd hour, and 158 mgdL at the 3rd hour. Which of the following is a risk factor for the development of her current condition?



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A 35-year-old obese pregnant woman at 25 weeks of gestation presented to her physician's office for a regular physical examination. She has a significant past medical history of chronic hypertension. Her medications include daily prenatal vitamins, folic acid 1mg, and methyldopa 1000 mg once a day. During her current visit, she complains of gaining more weight, increased thirst, and increased hunger in the last 4 weeks. Body mass index is 30 kg/m2. Her one hour 50-gram glucose challenge test is 165 mg/dL. What is the best next step in this patient?



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A 32-year-old obese pregnant woman at 37 weeks of gestation presented with a past medical history of chronic hypertension. Her medications include daily prenatal vitamins, and methyldopa 1000 mg once a day. Obstetric ultrasonography showed a baby weighing 3950 grams at 37 weeks. A 100 g oral glucose tolerance test done at 28 weeks was 190 mg/dL at the 1st hour, 165 mg/dL at the 2nd hour, and 150 mgdL at the 3rd hour. Which of the following statements is correct regarding the diagnosis of this woman?



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A 38-year-old woman, gravida 2, para 1, at 27 weeks gestation with a past medical history of chronic hypertension presents to the outpatient clinic for a routine prenatal visit. Her medications include daily prenatal vitamins, folic acid 1mg once a day, and methyldopa 1500 mg once a day. She describes gaining more weight, increased thirst, and increased hunger in the last 4 weeks. She explains that she developed a similar condition in the last trimester of her last pregnancy, that was treated with insulin. The condition was resolved after delivery. Body mass index is 32 kg/m2. What is the best next step in this patient?



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A 38-year-old woman, gravida 2, para 1, at 27 weeks gestation with a past medical history of chronic hypertension presents to the outpatient clinic for a routine prenatal visit. Her medications include daily prenatal vitamins, folic acid 1mg once a day, and methyldopa 1500 mg once a day. She describes gaining more weight, increased thirst, and increased hunger in the last 4 weeks. She also describes that she developed a similar condition in the last trimester of her last pregnancy. The condition was resolved after delivery. Body mass index is 32 kg/m2. Her 50 g oral glucose challenge test was abnormal. And a 100 g oral glucose tolerance test was done reporting 185 mg/dL at the 1st hour, 158 mg/dL at the 2nd hour, and 145 mgdL at the 3rd hour. She remains hyperglycemic despite adequate exercise and diet. Which of the following is the best treatment for this patient current diagnosis?



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A 37-year-old obese pregnant woman at 36 weeks of gestation presents to the physician's office. She has a significant past medical history of chronic hypertension and preeclampsia. Her medications include daily prenatal vitamins, methyldopa 2000 mg once a day, aspirin 75 mg once a day. Obstetric ultrasonography reported a baby weighing 4100 grams at 38 weeks. A 100 gm oral glucose tolerance test done at 28 weeks was 205 mg/dL at the 1st hour, 172 mg/dL at the 2nd hour, and 164 mg/dL at the 3rd hour. Diet and exercise were started, but the patient remained hyperglycemic. Glyburide, NPH insulin, and short-acting insulin were added to her pharmacologic treatment. Which of the following hormone is related to the development of this patient condition?



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A 33-year-old obese pregnant woman at 37 weeks of gestation presents to her physician's office for a routine physical examination. She has a significant past medical history of chronic hypertension. Her medications include daily prenatal vitamins, and methyldopa 1000mg once a day. Obstetric ultrasonography reported a baby weighing 3950 grams at 37 weeks. A 100g oral glucose tolerance test done at 28 weeks was 190 mg/dL at the 1st hour, 165 mg/dL at the 2nd hour, and 150 mgdL at the 3rd hour. Which ethnic group has the highest risk factor for the development of this patient's current diagnosis?



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A 35-year-old obese pregnant woman at 38 weeks of gestation has a past medical history of chronic hypertension and preeclampsia. Her medications include daily prenatal vitamins, methyldopa 2000 mg once a day, and aspirin 75 mg once a day. Obstetric ultrasound reported a baby weighing 4000 grams at 38 weeks. A 100g oral glucose tolerance test done at 28 weeks was 200 mg/dL at the 1st hour, 170 mg/dL at the 2nd hour, and 160 mgdL at the 3rd hour. Diet and exercise were started, but the patient remained hyperglycemic. NPH insulin and short-acting insulin was added to her pharmacologic treatment. What is the desired blood sugar level in this patient pregnancy, given her current medical problems?



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A 32-year-old woman, gravida 1, para 0, at 28 weeks gestation with a past medical history of chronic hypertension presents to the outpatient clinic for a routine prenatal visit. Her medications include daily prenatal vitamins, methyldopa 1000 mg once a day. Her body mass index is 30 kg/m2. A 100 g oral glucose tolerance test done at 28 weeks was 190 mg/dL at the 1st hour, 165 mg/dL at the 2nd hour, and 150 mgdL at the 3rd hour. NPH insulin and short-acting insulin was added to her pharmacologic treatment. For which of the following patine should the physician perform early screening tests for gestational diabetes?



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A 35-year-old pregnant woman at 38 weeks of gestation with a past medical history of chronic hypertension and preeclampsia presents to the clinic for evaluation. Her medications include daily prenatal vitamins, methyldopa 2000 mg once a day, and aspirin 75 mg once a day. Obstetric ultrasound reports a baby weighing 4000 grams at 38 weeks. A 100 g oral glucose tolerance test done at 28 weeks was 200 mg/dL at the 1st hour, 170 mg/dL at the 2nd hour, and 160 mgdL at the 3rd hour. Diet and exercise were started, but the patient remained hyperglycemic. NPH and short-acting insulins were added to her pharmacologic treatment. A cesarean section is planned due to the baby's weight. 24 hours after the section, fasting glucose reports glucose of 85 mg/dL. Which of the following is the best next step regarding her hyperglycemic management?



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Gestational Diabetes - References

References

Coustan DR, Gestational diabetes mellitus. Clinical chemistry. 2013 Sep;     [PubMed]
Jawad F,Ejaz K, Gestational diabetes mellitus in South Asia: Epidemiology. JPMA. The Journal of the Pakistan Medical Association. 2016 Sep;     [PubMed]
Spaight C,Gross J,Horsch A,Puder JJ, Gestational Diabetes Mellitus. Endocrine development. 2016;     [PubMed]
Law KP,Zhang H, The pathogenesis and pathophysiology of gestational diabetes mellitus: Deductions from a three-part longitudinal metabolomics study in China. Clinica chimica acta; international journal of clinical chemistry. 2017 May;     [PubMed]
Mack LR,Tomich PG, Gestational Diabetes: Diagnosis, Classification, and Clinical Care. Obstetrics and gynecology clinics of North America. 2017 Jun;     [PubMed]
Chiefari E,Arcidiacono B,Foti D,Brunetti A, Gestational diabetes mellitus: an updated overview. Journal of endocrinological investigation. 2017 Sep;     [PubMed]
Brzozowska M,Bieniek E,Szosland K,Lewinski A, Gestational diabetes - is diet and insulin the only solution? Neuro endocrinology letters. 2017 Oct;     [PubMed]
Zheng J,Wang H,Ren M, Influence of exercise intervention on gestational diabetes mellitus: a systematic review and meta-analysis. Journal of endocrinological investigation. 2017 Oct;     [PubMed]
Senat MV,Deruelle P, [Gestational diabetes mellitus]. Gynecologie, obstetrique     [PubMed]
Ashwal E,Hod M, Gestational diabetes mellitus: Where are we now? Clinica chimica acta; international journal of clinical chemistry. 2015 Dec 7;     [PubMed]
Lindsay RS,Mackin ST,Nelson SM, Gestational diabetes mellitus-right person, right treatment, right time? BMC medicine. 2017 Aug 28;     [PubMed]
Alfadhli EM, Gestational diabetes mellitus. Saudi medical journal. 2015 Apr;     [PubMed]
Zhu Y,Zhang C, Prevalence of Gestational Diabetes and Risk of Progression to Type 2 Diabetes: a Global Perspective. Current diabetes reports. 2016 Jan;     [PubMed]
ACOG Practice Bulletin No. 190: Gestational Diabetes Mellitus. Obstetrics and gynecology. 2018 Feb     [PubMed]

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