Gestational Diabetes

DR. P. MANJULA GUNARATNE

MBBS(COLOMBO), MRCOG(UK)

Definition
GDM defined as glucose intolerance which first

occurs or is first detected during pregnancy

Epidemiology
The incidence of GDM varies both with

The ethnic origin of the population studied

Diagnostic criteria used

Usually incidence is 3-14% depending on population

studied

15% for South Asians

3% for Caucasians

Gestational diabetes most commonly arises at the

start of the third trimester (24-28weeks)

Risk factors for GDM

Obesity BMI >30kg/m2
Previous history of GDM
Family history of diabetes first degree relative
Racial origin (Asian, Hispanic, African-Caribbean)
Increasing maternal age (>25years)
Previous macrosomic baby - >4.5kg
PCOS
Twin pregnancy

Pathogenesis
Pregnancy causes metabolic changes leading to

increased insulin resistance.

Insulin resistance is a normal feature in pregnancy

In metabolic terms its development ensures reliable fuel delivery
to the fetus
Insulin resistance is largely due to the effect of circulating
placental hormones

Women who develop GDM have both a higher level of

insulin resistance and impaired pancreatic beta cell

response to insulin resistance

Women with GDM are unable to secrete insulin in response to the

level of insulin resistance

Diagnostic Criteria
No international consensus to the diagnostic criteria

for Gestational Diabetes

WHO Criteria (75g OGTT)

FBS >7.0mmol/l (126mg/dl)

2 hour value >7.8mmol/l (140mg/dl)

USA 100g OGTT with 1,2 & 3 hour values taken

Complications
Perinatal

Macrosomia
Shoulder dystocia
Birth injury ; fracture, nerve palsy
Caesarean
pre-eclampsia
Neonatal hypoglycaemia
Neonatal hyperbilirubinaemia

Late complications

Mother

Type 2 diabetes
Recurrent GDM in future pregnancies

Child

Impaired glucose tolerance

Obesity
Intellectual impairment

Pedersen Hypothesis
Accepted pathological mechanism which GDM leads to

complications
High maternal blood glucose lead to increased glucose
transport across placenta.
The fetal pancreas responds to this increased glucose
load with increased insulin secretion
Fetal hyperinsulinaemia then lead to excess fetal growth
as insulin is a growth factor
After delivery fetal hyperinsulinaemia may persists for a
period giving an increased risk of neonatal
hypoglycaemia

Screening
Selective screening in UK recommended by NICE

based on risk factors

This still require 80% of women to undergo screening

10% of cases would be missed

Universal screening American College of O&G

since it is more practical and sensitive

Selective screening based on risk factors suggested by NICE

BMI >30
Previous macrosomic baby >4.5kg
Previous GDM
Family history of Diabetes in first degree relative
Family origin with high prevalence of Diabetes

South Asian
Black Caribbean
Middle Eastern

Diagnostic tests
Fasting glucose is not recommended as a screening

because of its low sensitivity

NICE Recommendation

WHO 2hour 75g OGTT performed at 24-28 weeks

Those who had GDM in previous pregnancy are recommended
to have initial test at 16-18 weeks and further test at 28 weeks
if the first test is normal

ACOG Recommendation

Initially 1 hour 50g glucose challenge test (>7.2mmol/l or

130mg/dl) and then
Definitive testing with 2 hour 75g or 3 hour 100g OGTT

Management
Should be under the care of multi-disciplinary

diabetic and obstetric team

Diet and Life style

Should be given ethnically appropriate nutritional

advice preferably from a trained dietitian.

Limit carbohydrate intake to 40% total calories.

Complex carbohydrates with a low glycaemic index as whole grain

bread and cereals should be eaten in preference to simple sugars
Vegetables and food high in fiber are encouraged
Lean proteins including oily fish and balanced polyunsaturated
fats and monounsaturated fats

Increasing activity level and exercise

Walking, swimming or yoga 30minutes/day

Those with BMI>27 should restrict calorie intake
(<25kcal/kg/day)

Blood Glucose Monitoring

Advise to monitor 4 times a day. One on waking and

others 1 hour after each meal (diabetic who are not

pregnant usually check blood glucose either pre-meal
or 2 hour after meal)
1 hour post prandial monitoring gives both tighter
control and better outcome than pre-meal
monitoring
One hour post prandial monitoring give tighter
glucose control and better outcome compared with 2
hour post prandial monitoring

Blood Glucose Targets

NICE Recommendation

FBS 3.5 to 5.9 mmol/l

1 hour post prandial 7.8mmol/l

ACOG Recommendation

Fasting - <5.3mmol/l
1 hour post prandial - <7.2mmol/l

Pharmacological Treatment
If diet and lifestyle modifications fail to control

blood glucose levels within 1-2 weeks then

pharmacological treatment should be commenced
If ultrasound investigation suggest incipient fetal
macrosomia (AC>70th percentile) hypoglycaemic
therapy should be considered
This include

Insulin first line

Oral hypoglycaemics

Insulin
Four injections per day

3 injections of fast acting insulin before meals

Single injection of long acting insulin at bed time

This may include

Regular insulin
Rapid acting insulin analogues- aspart, lispro

Oral Hypoglycaemic agents

Recent UK NICE guideline cautiously encourage the off

licence use of glybenclamide and metformin

Glybenclamide

Oral sulphonylurea
Mechanism of action is to enhance insulin secretion by beta cells
Minimal passage occurs through placenta
(older sulphonylureas as tolbutamide and chlorpropamide have
been shown to cross the plaventa and cause fetal
hyperinsulinaemia and contraindicated in GDM)

Metformin

Increases insulin sensitivity

Metformin in Gestational Diabetes Trial (MiG trial) shows no
difference in perinatal morbidity between insulin & metformin

Obstetric Management
Growth should be assessed by serial ultrasound during 3 rd

trimester
Induction of labour often considered after 38 weeks
During labour maternal blood glucose should be maintained
between 4-7mmol/l using a sliding scale if necessary
In GDM blood glucose level usually normalize in hours and days
following delivery
Usually all treatments are discontinued as soon as the woman is
able to eat post partum and dietary restrictions are relaxed
Follow up testing 6 weeks by FBS (NICE recommendation)
should be performed to check for complete resolution of GDM
and to exclude type 2 DM

Long term risk to women

Women who have GDM have significantly increased

risk of developing T2DM and recurrent GDM

Incidence of developing Type 2 Diabetes ranges fro 3-70%

depending on the population ( roughly >50%)

To reduce the risks they should be advised to

Have annual FBS

Maintain ideal body weight : control diet
Remain active : adequate exercise

Long term risk for baby

Double the risk of childhood obesity
Increased risk of child developing T2DM in adult life
They have worse attention span, perform less well in

tests of motor function, have increased risk of

language impairment

References
Gestational Diabetes : Ben Whitelaw, Carol Gayle :

Obstetrics, Gynaecology and Reproductive Medicine,

february 2011
Diabetes in Pregnancy : NICE Guideline :March
2008
Gestational Diabetes: Aetiology and management:
Robert Fraser, Simon R Heller: Obstetrics,
Gynaecology and Reproductive Medicine: December
2007

Thank You