Gestational%20diabetes%20mellitus Management

Hyperglycemia Detection

• Goal is to detect hyperglycemia and maintain good glycemic control throughout pregnancy to decrease maternal and fetal adverse outcomes  
• High maternal glucose increases the risk of: 
  • Higher frequency of primary cesarean section delivery
  • Preeclampsia  
  • Preterm delivery
  • Shoulder dystocia or birth injury  
  • Fetal macrosomia  
  • Neonatal hypoglycemia  
  • Hyperbilirubinemia  
  • Intensive neonatal care
• Recommend daily self-monitoring of blood glucose (SMBG) over intermittent office monitoring
  • Done at fasting, pre-meal and either 1 or 2 hours after each meal, at bedtime if indicated

• Continuous glucose monitoring can help reach A1c targets and can lessen macrosomia and neonatal hypoglycemia in pregnancy complicated by type 1 DM
• Fasting and postprandial glucose monitoring is recommended in pregnant women with diabetes
• Glycemic targets for patients with GDM and pre-existing diabetes in pregnancy:

• A1c should be used as a secondary measure and if can be obtained without developing hypoglycemia, target A1c level in pregnancy is <6% (42 mmol/mol) as pregnancy continues, but may consider <7% (53 mmol/mol) if needed to prevent hypoglycemia

Other Monitoring

• Measure blood pressure, body weight, urinary protein, and check for edema every prenatal visit to detect the development of preeclampsia
• Regular retinal and renal assessment during pregnancy
• Monitor urine and/or blood ketones to confirm if diet is adequate
• Starvation ketosis is common in pregnancy and may have detrimental effects to the fetus
• Exclude diabetic ketoacidosis in the patient if she is ill or is hyperglycemic

Fetal Surveillance

• Should be individualized based on severity of hyperglycemia in the mother and presence of risk factors
• It is not recommended to routinely monitor fetal well-being before 38 weeks unless risk for fetal growth restriction exists; however, a more frequent fetal health assessment is recommended if comorbid factors are present 

• Mother should be taught to monitor fetal movement in the last 8-12 weeks of pregnancy and to report any reduction in movement
• If GDM is diagnosed during 1st trimester, it is recommended to do ultrasound at 18-22 weeks to detect congenital anomalies
• Non-stress testing, contraction stress testing, and/or biophysical profile assessments should be recommended to patient with GDM with poor glycemic control and comorbid conditions
• Assess fetal response to GDM by ultrasound measurement of fetal abdominal circumference during the 2nd trimester, early 3rd trimester and repeated every 2-4 weeks to guide management decisions
  • Lower goals for glycemic control may be recommended for bigger fetal abdominal circumference
• Initiate weekly fetal well-being assessment at 34-36 weeks if with pre-existing diabetes in pregnancy with or without comorbidities and poorly controlled GDM
• Intensify fetal surveillance when pregnancy is beyond 40 weeks of gestation

Other Considerations

• Women with history of GDM who had prediabetes should be offered intensive lifestyle intervention or Metformin to prevent diabetes
• Psychosocial assessment is also recommended to detect onset of anxiety, depression, stress and eating disorders
• GDM is not an indication for cesarean delivery
• GDM is also not a consideration for delivery before 37 weeks of gestation unless there is maternal or fetal compromise
• Patients with type 1 or type 2 diabetes without complications are advised to have an elective birth through labor induction or cesarean section if indicated between 37 and 38 weeks

• Gestation past 38 weeks increases risk of macrosomia
• Women with GDM are advised to give birth not later than 40 weeks and are offered elective birth if they have not delivered by this time, though elective labor induction is not necessary in women with good glycemic control and no other obstetric indication

• All women, including those with GDM, are encouraged to exclusively breastfeed
• It may decrease offspring obesity and prevent development of type 2 DM
• Except for Metformin and Glibenclamide, other oral hypoglycemic agents should be avoided while breastfeeding 

• Early feeding of the baby to reduce the risk of neonatal hypoglycemia