Gestational Diabetes Screening, Management and Postpartum Care

G E S TAT I O N A L D I A B E T E S
I R I S T H I E L E I S I P TA N M D , M S C
Professor 3, UP College of Medicine
Director, UP Manila Interactive Learning Center
Chief, UP Medical Informatics Unit
S C R E E N I N G M A N A G E M E N T P O S T PA R T U M C A R E

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Pregnancy in women
with normal
glucose
metabolism
Lower fasting
blood glucose
Postprandial
hyperglycemia
& carbohydrate
intolerance
American Diabetes Association. http://care.diabetesjournals.org/content/42/Supplement_1/S13

Women with GDM secrete 40-70% less insulin for
any degree of insulin resistance vs normal women
Buchanan TA et al. What is gestational diabetes? Diabetes Care 2007;30(S2):S105-11

Buchanan TA et al. What is gestational diabetes? Diabetes Care 2007;30(S2):S105-11
Progressive loss of beta cell compensation for
insulin resistance (Fig A) leads to progressive
hyperglycemia and diabetes (Fig B).

http://www.asean-endocrinejournal.org/
index.php/JAFES/article/view/98/186

UNITE for Diabetes CPG. http://www.asean-endocrinejournal.org/index.php/JAFES/article/view/98/186
pregnant women should be
screened for gestational
diabetes.
ALL

Increased risk of perinatal morbidity
Macrosomia
Birth injuries
Shoulder dystocia
Hypoglycemia

Increased risk of maternal morbidity
Cesarean section
Preeclampsia
Pregnancy-induced hypertension
Type 2 diabetes

ALL pregnant women
should be evaluated at the
ﬁrst prenatal visit for risk
factors for diabetes.

Risk Factors for
Gestational Diabetes
Prior history of GDM (OR 23.6 [95%CI 11.6, 48.0])3
Glucosuria (OR 9.04 [95%CI 2.6, 63.7]2; PPV 50% 4)
Family history of diabetes
(OR 7.1 [95%CI 5.6, 8.9]1; OR 2.74 [95%CI 1.47, 5.11]3)
First-degree relative with type 2 diabetes (PPV 6.7%)4
First-degree relative with type 1 diabetes (PPV 15%)4
Prior macrosomic baby
(OR 5.59 [95%CI 2.68, 11.7])3
Age >25 years old
(OR 1.9 [95%CI 1.3, 2.7]1; OR 3.37 [95%CI 1.45, 7.85]3)
1 Davey RX, Hamblin PS. Selective versus universal screening for gestational diabetes mellitus: an evaluation
of predictive risk factors. Medical Journal of Australia 2001;174(3):118–21.
2 Schytte T, Jorgensen LG, Brandslund I, et al. The clinical impact of screening for gestational diabetes. Clinical
Chemistry and Laboratory Medicine 2004;42(9):1036–42.
3 Ostlund I, Hanson U. Occurrence of gestational diabetes mellitus and the value of different screening indicators for
the oral glucose tolerance test. Acta Obstetricia et Gynecologica Scandinavica 2003;82(2):103–8.
4 Grifﬁn ME, Coﬀey M, Johnson H, et al. Universal vs. risk factor-based screening for gestational diabetes
mellitus: detection rates, gestation at diagnosis and outcome. Diabetic Medicine 2000;17(1):26–32.

Risk Factors for
Gestational Diabetes
1 Davey RX, Hamblin PS. Selective versus universal screening for gestational diabetes mellitus: an evaluation
of predictive risk factors. Medical Journal of Australia 2001;174(3):118–21.
3 Ostlund I, Hanson U. Occurrence of gestational diabetes mellitus and the value of different screening indicators for
the oral glucose tolerance test. Acta Obstetricia et Gynecologica Scandinavica 2003;82(2):103–8.
4 Grifﬁn ME, Coﬀey M, Johnson H, et al. Universal vs. risk factor-based screening for gestational diabetes
mellitus: detection rates, gestation at diagnosis and outcome. Diabetic Medicine 2000;17(1):26–32.
Diagnosis of polycystic ovary syndrome
(OR 2.89 [95%CI 1.68, 4.98])5
Overweight or obese before pregnancy
(BMI >27 kg/m2 OR 2.3 [95%CI 1.6, 3.3]1; BMI>30 kg/
m2 OR 2.65 [95%CI 1.36, 5.14]3
Macrosomia in current pregnancy (PPV 40% 4)
Polyhydramnios in current pregancy (PPV 40% 4)
Intake of drugs affecting CHO metabolism
5 Toulis KA, Goulis DG, Kolibiankis EM, Venetis CA, et al. Risk of gestational diabetes mellitus in women with
polycystic ovary syndrome: a systematic review and a meta-analysis. Fertil Steril 2009;92(2):667–77.

Test high-risk women at the
soonest possible time.
Test routinely at 24 to 28 weeks
gestation for women with no risk factors.
Test even beyond 28 weeks
gestation for women at risk.

75-g OGTT to screen
for gestational diabetes
Any one value meeting the
threshold is considered
gestational diabetes
FBS 92 mg/dL
1h 180 mg/dL
2h 153 mg/dL

Consume at least 150 g carbohydrate
for 3 days preceding OGTT
No walking during OGTT
Water is allowed during fasting

Preexisting
pregestational diabetes
Diagnosed using standard
criteria for diabetes in the
ﬁrst semester
GDM diagnostic criteria
were not derived from data
in the first half of pregnancy

Lifestyle change is essential and may suffice
Add medications if needed to achieve glycemic targets  
70-85% can be managed with lifestyle
modification alone with old GDM criteria
Possibly more with lower thresholds of
new criteria

Provide adequate calorie intake for
Fetal/neonatal and maternal health
Glycemic goals
Appropriate gestational weight gain

Calorie needs not different
from pregnant women
without GDM
Dietary reference intake for
all pregnant women:
minimum of 175 g carbohydrate,
71 g protein and 28 g fiber

Non-caloric sweeteners
in moderation
Avoid concentrated
sweets (cookies, cakes, pies,
soft drinks, chocolate, juice drinks,
jams or jellies)
Jovanovic L (Ed). Medical Management of
Pregnancy Complicated by Diabetes (2009)

Eat small frequent meals
(every 3 hours)
Include a good source of protein at every meal and snack
(low-fat meat, chicken, fish, low-fat cheese, nuts, peanut butter, cottage cheese, eggs)
Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)

Eat a very small breakfast
No more than 1 starch exchange
(<15 g CHO so limit cereal, bread,
pancakes, toast, bagels, muffins and
Danishes and no fruit or juice)

Choose high-ﬁber food
Vegetables
Beans & legumes
Fresh fruit (except at breakfast)

http://www.diabetesforecast.org/2015/adm/diabetes-
plate-method/what-is-the-plate-method.html

Monitor urine ketones before
breakfast to detect starvation ketonuria.
Three meals and three snacks

Fasting <95 mg/dL
1h postprandial <140 mg/dL
2h postprandial <120 mg/dL
G LY C E M I C TA R G E T S

Hernandez TL. Patterns of Glycemia in Normal Pregnancy: Should the Current
Therapeutic Targets be Challenged? Diabetes Care 2011;34(7):1660-8
MEAN PATTERN OF GLYCEMIA IN NORMAL
PREGNANCY (12 studies)
vs 140 mg/dL
vs 120 mg/dL

Insulin is recommended as first-line agent.

I N S U L I N
T I M E T O
O N S E T
P E A K T I M E D U R AT I O N
P R E G N A N C Y
C AT E G O RY
Regular 30 min 3 h 8 h B
Aspart 10-15 min 40-50 min 3-5 h B
Lispro 10-15 min 30-90 min 3-5 h B
Glulisine 10-15 min 55 min 3-5 h C
NPH 1-2 h 4-8 h 10-20 h B
Detemir 1-2 h None 24 h B
Glargine U -100 1-2 h None 24 h
No human pregnancy data
(previously C)
Glargine U-300 >6 h None 24 h No human pregnancy data
Degludec 1 h None 42 h (steady state) C
Blum AK. Insulin use in pregnancy: an update. Diabetes Spectr 2016;29(2):92-97.

MEAN PATTERN OF GLYCEMIA IN
NORMAL PREGNANCY (12 studies)
Hernandez TL. Patterns of Glycemia in Normal Pregnancy: Should the Current
Therapeutic Targets be Challenged? Diabetes Care 2011;34(7):1660-8

Metformin and glibenclamide cross
the placenta and are not recommended.

Discontinue metformin once pregnancy
is confirmed for women with PCOS.
No beneﬁt in preventing
spontaneous abortion or GDM

CBG q 4h
D5-containing IVF
Short- or rapid-
acting insulin for
CBG >140 mg/dL

Breastfeeding may
reduce diabetes risk
after GDM pregnancy.

Entire cohort n=522
Gunderson EP et al. Diabetes Care 2012;35:50–56
Glucose tolerance categories among infant-feeding groups of
women with history of GDM at 6-9 weeks’ postpartum
Normal
PreDM
DM Entire cohort n=522

Obese women only n=241
Gunderson EP et al. Diabetes Care 2012;35:50–56
Normal
PreDM
DM
Obese women only n=241
Glucose tolerance categories among infant-feeding groups of
obese women with history of GDM at 6-9 weeks’ postpartum

75-g OGTT 4-12 weeks
postpartum
OGTT is recommended
over HbA1c

Lifetime maternal risk for
diabetes is 50-70% after
15-25 years
Test every 1-3 years if
postpartum OGTT is
normal; frequency
depends on risk factors

Both metformin &
intensive lifestyle
intervention prevent
or delay progression to
diabetes in women with
prediabetes & a history
of GDM.

G E S TAT I O N A L D I A B E T E S
I R I S T H I E L E I S I P TA N M D , M S C
Professor 3, UP College of Medicine
Director, UP Manila Interactive Learning Center
Chief, UP Medical Informatics Unit
S C R E E N I N G M A N A G E M E N T P O S T PA R T U M C A R E
@endocrine_witch

Gestational Diabetes Screening, Management and Postpartum Care

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