Gestational Diabetes Risk of GDM

Glucose intolerance during pregnancy Everyone is screened for GDM

Epidemiology High risk pts are screened for pre-DM
6-7% of pregnancies in the U.S. Highest Risks:
GDM makes up 90% of all cases of DM in pregnancy (MC in pt with no Obesity
pMHx of DM) Advanced maternal age
10% of cases pre-existing pre-gestational Type1/Type 2 Glycosuria
Pathophysiology FMHx DM in first degree relative
Dt exaggeration of pregnancy-induced physiologic changes in carb PMHx glucose intolerance, GDM, macrosomia, poor pregnancy
metabolism (or pregnancy unmasked underlying propensity for glucose outcomes
intolerance) At Risk:
Hormone-mediated by the placenta-- caused by changes in the 25 year old
placenta that production of lactogen, estrogen, and progesterone BMI >25%
production by the placenta later in pregnancy Hispanic, Native American, African descent, Southeast
Normal pregnancy is associated w/ insulin resistance to provide Asian/Pacific Islander
consistent stream of glucose to the fetus
Historically placental lactogen allowed moms to live in a Diagnostics
starvation diet and have a healthy child One step testing would prevalence of GDM higher health care cost,
These genes have continued into modern times but do not but with no evidence of changes in maternal or neonatal outcomes
work as well bc there are few US women that live in a Recommendation = Two step approach (aka OSullivan Test)
starvation diet its an overshoot of what nature intended Screening between 24-28 weeks of pregnancy
Some populations experience this more than others (checks if mother is clearing the sugar properly)
Native American Indians lived on starvation diet NON-FASTING TEST
but now in modern times have very high Step 1:
prevalence of DM, GDM ~50-70% 50g OGTT (without regard to last mea, at least 1-2h after eating)
Occurs later in the pregnancy when the placenta is large enough to Measure plasma glucose after one hour.
make these hormones (>24w) thats why we test at 24-28w If glucose >135 mg/dL Step 2
Metabolic changes result in fasting hypoglycemia and postprandial >200 = GDM Dx
hyperglycemia Step 2:
GDM increases lifelong risk of DMthe day after delivery, the patient is 100g OGTT
no longer DM and often do no need insulin as soon as placenta is out Measure glucose at Q1H for 3 hours
Dx 2 abnormal values positive result
Screen all mothers at 24-28 weeks gestation for GDM FBG 95
Screen pt w/ addl. RF (abnl random BG or HgA1C) for preexisting DM 1h 180
pt with 2hr 75g OGTT at 1st prenatal visit 2h 155
If (-) at prenatal visit retest at 24-28 weeks gestation 3h 140
Complications of GDM Repeat Step 2 at 32-34 weeks if only 1 abnormal value
Macrosomia
asymmetrical growth, shoulders and head much bigger Treatment
Shoulder dystocia risk of getting stuck during 2005 Australian Carbohydrate Intolerance Study in pregnant women trial
delivery (anterior shoulder cannot be delivered Treatment (better control of BG) is assoc. with significant reduction in:
past pelvis) Perinatal death
head comes out but not the shoulders, requires Shoulder dystocia
manuvers that can harm the baby or require Birth trauma
c/section Large for gestational age (LGA = 9lbs or 4000g) 9%
HTN disorders (i.e. preeclampsia) preeclampsia 6%
Pts with GDM have higher risk of developing HTN disorders Retrospective studies have found similar results
Risk of pre-e is correlated with the severity of GDM Bottom line: Treatment is beneficial!
GDM with FBG <115, there is 9.8~10% chance of Non-pharm
developing preeclampsia A1GDM -- Controlled with diet only
FBG > 115, there is 18% chance of developing pre-ecl If this can be accomplished, there is essentially 0%
Perinatal mortality additional risk to the babies
Cesarean Exercise
diet controlled GDM risk of c/section 17% C-section and GDM risk
Med controlled risk of c/section is 25-26% No risk of preterm labor or other problems
Neonatal hypoglycemia Diet appropriate diet not established
Babys insulin was used to correcting moms high BG level Low glycemic index carbohydrate intake 33-40% of total
but once that BG supply is not available after delivery the daily calories
babys BG drops after deliver Protein (20%)
BG can be as low as the teens Fat (40%)
Needs to be corrected quickly so there is no neurological Avoid starvation ketosis psychomotor development
injury and intelligence in offspring
Neonatal respiratory distress syndrome (RDS) Glucose monitoring 4x/day
secondary to delayed pulmonary maturation FBS < 92 mg/dL
Lungs mature more slowly & require the NICU 2hr PPBD <120mg/dL
Issue of deliverying early to avoid stillbirth 1hr PPBG < 130 mg/dL (more common)
Child has risk of obesity DM At-home Urine dip testing QPM - make sure there is no
Correlation btwn blood glucose levels and risk of C-section and ketonurea
preeclampsia
Pharm Post partum
A2GDM -- Needs medication Lifetime risk of T2DM later in life is up to 70% if GDM during pregnancy
FBG 95-100 or 2hr PPBG 120 20% of the time As high as 50% in 5 years for Hispanic/Latin American
Medication 6 weeks post partum (usually ends up at 10-12w after delivery) :
Neither of these cross the placenta! check 75g 2h OGTT and FBG
Insulin GOLD STANDARD Failure = T2DM Dx
Better outcomes than Glyburide PO Risk recurrent GDM 33-50%
Better dosing for tighter BG control needed in pregnancy 50% will have DM in approx. 22 years
Use carb ration to dose short acting insulin : 1U insulin per
3g carbs
Basal NPH Pre-Gestational DM
Prandial Humalog or NovoLog Management goals and medications used are the same as for GDM
Very fast acting! Given at time of meal better
control Pre-conceptual evaluation
Metformin Incidence of birth defects during organogenesis (1st 8 -10wk) =
used in pregnancy especially if mom was on it before or 5-8%
PCOS dx Cardiac, skeletal and neural tube defects are MC
Can use as new medication for GDM Good BG control spontaneous abortion and fetal malformation
Glyburide FBG =120mg/dL 2x risk of cardiac malformations
Long acting Sulfonylurea Ideally want tight BG control levels that would be used
insulin secretion and sensitivity in peripheral tissue during pregnancy BEFORE they get pregnant
Recent studies respiratory distress syndrome, Worse pregnancy outcomes if retinopathy, renal disease, or HTN
hypoglycemia, macrosomia nad birth injury to the fetus Preexisting retinopathy and renal disorders worsen
Do not use in sulfa allergy during pregnancy
1.25mg-2.5 mg qhs, to TID dosing Monitoring
Retinal exam or 24hr urine (check for
Management proteinuria) check at baseline and every
12 week early US trimester
20 week US to look at anatomy Folic acid supplementation risk of spina bifida
Third trimester sonogram (29-33 wks) estimated fetal weight No complications - 400-800mcg
Estimates are not very accurate usually over-estimate size Pre gestational DM 1-2mg
Diet control LGA to 45% Hx spina bifida 4mg
Begin insulin/glyburide if abdominal circumference > 75th Refer for contraceptive and pre-conceptual counseling:
%ile, 2/3 of pregnancies in DM unplanned compare
Insulin LGA (large gestational age) to 13% in general population
BG monitoring
QID once fasting and once after each meal
Higher NICU rate for early deliveries dt risk respilratroy distressed

Antepartum Monitoring & Delivery

NOT performed if diet controlled GDM (A1GDM)
Still do US to estimate fetal weight near end of pregnancy
No indication for early delivery
Deliver between 39-41
Medically managed GDM (A2GDM)
Ante-natal testing (ANT) at 34 weeks (32-34) if on medications
Neonatal Non-stress and amniotic fluid measurement test
weekly until delivery
Check size and fluid around the baby
Low fluid - risk stillbirth
high fluid (polyhydramnios) DM not
well controlled!!
Early Induced Vaginal Delivery
Well controlled BG- Deliver between 39-39w 6d
Poor controlled BG - 37-38w 6d
<37 weels give mom betamethasone to help
risk of respiratory distress
Consider elective C-section if estimated fetal weight (EFW)
> 10 lbs(4500g) + VERY POOR BG CONTROL
macrosomia and its consequences and
neonatal hypoglycemia
Affects future pregnancy outcomes negatively
vaginal delivery preferred if at all possible
Gestational HTN Eclampsia
Sustained BP 140/90 after 20 weeks of pregnancy w/o preeclampsia Preeclampsia + seizures dt CNS end-organ damage
(no proteinurea/significant end-organ disease, i.e. LFTs, platelets, Management
HA) n a previously normotensive pt Delivery is the only cure BP and fluid normalize when placenta is
Prognosis delivered
Not associated w/adverse maternal or fetal outcomes Blood Pressure Control:
Diagnosis labetalol or hydralazine
Pre-eclampsia must be r/o and screened for Regular fetal testing
Isolated GHTN is rare most develop preeclampsia Modified best rest (evaluate for reliable home situations)
eventually Inpatient if severe or unreliable home situation
Treatment Severe preeclampsia (BP 160 or 110 diastolic)
No antihypertensive medications are indicated inpatient management
ANT weekly after 34 weeks Expectant if <34 weeks + BP can be controlled
2x/week office visits at 37 weeks keep ruling out preeclampsia Fetal monitoring
Urine dip with every visit (for protein urea) Maternal monitoring: urine output, CBC w/PLTS,
Consider delivery at 37 weeks (38-39w6d if no other conditions) CMP
Approx. 15% will ultimately shown to have preeclampsia Magnesium sulfate for seizure treatment and
(number is probably higher) prophylaxis
Ca gluconate antidote nearby (can be
Preeclampsia dangerous)
Newly BP 140/90mmHg + proteinuria (dt end organ damage) of Given before/during labor until 24hr
0.3g from 20 weeks gestation to 6 weeks post partum after labor
Complicates 7% of pregnancies in U.S. If delivering <37 weeks administer:
Pathophysiology - UNKNOWN betamethasone X 2 doses over 24 hours or
Abnormal development and implantation of the placenta and spiral dexamethasone X 4 doses with absent EDF,
arteries very early in gestation oligo, elevated Cr, PPROM, HELLP
Arteries do not develop into larger channels placental Timing and route of delivery depends on the severity of the
hypo perfusion disease, maternal condition, and gestational age of the fetus
Systemic endothelial dysfunction Vaginal delivery is preferred but most will have C-section
Renal contribution Strong indicators for delivery:
Low BV dt leaky capillaries epigastric pain, severe range BP, HELLP, visual
disturbances
Risk Factors Do not delay delivery if eclampsia, DIC, IUFD, abruption, NR-FHR (not
Primiparas (older and younger mothers) reassuring fetal heart rate)
Multiple gestations ( Vaginal delivery preferred, but if unfavorable if likelihood of vaginal
Chronic HTN delivery is only 15-20%
DM
Kidney disease Postpartum Management
Collagen-vascular and autoimmune disorders (late 2nd or early 3rd Continue magnesium sulfate 24 h postpartum
trimester) Hydralazine for acute BP control (IV or PO)
Gestational trophoblastic disease (aka molar pregnancies have VERY Labetolol
high rate): Hydratiform mole, Invasive Choriocarcinoma Analapril (ACE-I)
Dx
Mild: BP 140/90 after 20 wks gestation > 4 hr apart
Proteinuria 300mg/24 hrs
Severe: BP 160 or 110 diastolic
Progressive renal insufficiency (Cr >1.1)
Thrombocytopenia(<150,000 platelets)
HELLP (hemolysis, LFTs, enzymes, low PLTs)
Pulmonary edema
Nerologic damage - Vision changes (stocommata) or HA
Pre Eclamptic - signs of progression to more
severe form
Tx
Low dose ASA risk of developing preeclampsia in pt who have PMHx
of preeclampsia or known RF
Complications
Effects the CNS, kidneys, liver, hematologic system, vascular
system and fetal-placental unit
HELLP
Renal failure (capsule can rupture)
DIC
Pulmonary edema
Low bv dt leaky capillaries edema
Stroke
Placental abruption
Intrauterine growth restriction (IUGR)
Stillbirth
 Chronic Hypertension Delivery
HTN present prior to pregnancy, <20wks of pregnancy or persists >12 No SSx and good BP control - 38 weeks
weeks post partum + superimposed preeclampsia - 37 weeks
Mild >140/90 Twice weekly ANT
severe >160/110 Growth scans and dopplers if poor growth
Looser control than DM - main goal of management is to prevent stroke
Epidemiology Postpartum
Normal physiologic BP between 13-18 weeks gestation can mask Avoid NSAIDs if impaired renal fxn?
chronic HTN Monitor and treat BP
5% of pregnant women Safe HTN Meds When Breastfeeding
MC in Methyldopa, most beta-blockers
African American women Nifedipine (CCB), some ACE inhibitors
advanced maternal age HTN Meds CI in Breastfeeding:
obese patient acebutolol and atenolol
Risk Factors Diuretics milk production
Preterm delivery (in 2/3 of patients) Insufficient data regarding ARBs
IUGR Pre conceptual counseling
Fetal demise/perinatal mortality 2-4 X compared to general Low risk, pregnancy outcomes similar to general population
population High risk: renal insufficiency, DM with vascular involvement,
Preeclampsia collagen vascular disease, cardiomyopathy, renal failure with
13-40% of chronic HTN dialysis
Monitor urine for baseline proteinurea Contraceptive counseling:
Double the risk of placental abruption 30 mcg estradiol BP
Cesarean section Lower dose estrogen
Not CI if <35 y/o, nonsmoker, HTN well controlled and
Management no vascular disease
HTN for several years: progestin only contraception No impact on BP or CVD risk
EKG, ECHO
eye exam
renal evaluation
serum Cr
BUN
24h urine for protein and Cr Cl
Young women with essential HTN:
baseline renal studies
Treat all severe HTN as increased risk for intracerebral
hemorrhage
Serial 24h urines and metabolic profile every trimester
uncontrolled BP Hospitalize
Worsening HTN in pregnancy + new proteinuria
superimposed preeclampsia
HTN crisis
Labetolol or hydralazine IV
Nifedipine PO

Tx
Treatment risk of maternal death
Beta blockers
Atenolol
associated w/ fetal growth restriction
Labetolol
preferred treatment
associated with neonatal hypoglycemia.
Avoid with asthma and CHF
Calcium channel blockers
avoid short acting SL dt acute hypotension
Diuretics do not use
Hydralazine
Selective arteriolar smooth mm relaxer
Urgent control of severe HTN
3rd line drug in multidrug regiment for refractory HTN
(neonatal thrombocytopenia and Lupus have been reported)
ACE-I and ARBs
1st trimester - cardio and CNS malformations
2nd and 3rd trimester CI dt renal failure, oligohydraminios,
anuria, pulmonary hypoplasia IUGR, fetal demise.
Placenta Abnormalities Common in 3rd Trimester Placenta Accreta
Extensive growth of placental tissue into the myometrium of the uterus
Placenta Previa Epidemiology
Placenta covers the opening of the cervix Incidence: 3 per 1000 deliveries
Classified as partial or complete Risk factors
Cant deliver the baby this way placenta will Abnormalities in the uterine lining from previous scarring
come first and mom +baby will bleed out (previous uterine surgeries, maternal age, previous
Not the same as a low lying placenta childbirth)
Uterus grows in opposite direction More C sections risk
Epidemiology PMHx Placenta previa risk
Occurs in 0.3-0.5% of pregnancies in U.S. Presentation
Risk of mortality 1% No symptoms, possibly 3rd trimester bleeding, often detected on
Risk factors ultrasound
Multiparity Complications
Advanced maternal age Risk for postpartum hemorrhage
Prior placenta previa MC indication for peripartum hysterectomy (at time of C-
Multiple gestations section)
Pathophysiology Management:
Defective decidual vascularization occurs over the os possibly C-section followed by hysterectomy
secondary to inflammation or atrophic changes HIGH risk! massive blood loss, may have spread to bladder
Presentation multidisciplinary team (OBGYN and urologist) at a facility with
Painless vaginal bleeding in the 3rd trimester adequate resources is needed
Important to know this before doing pelvic exam can rupture the
placenta Other Complications
20% may have contractions
Dx Intrauterine Growth Restriction
US Delayed growth in utero due to a pathologic process
Management Infant weight <10 %ile
C-section delivery BEFORE you go into labor Not the same as small for gestational age (SGA): infant
Steroids to lung maturity whose birth weight was below the 10th percentile for the
Delivery at 36-37 weeks appropriate gestational age.
Risk factors
Placental Abruption Anything that vasoconstricts
Premature separation of the placenta from the uterus Drug abuse (cocaine, heroine, amphetamines)
Associated with fetal and maternal morbidity and mortality Smoking
Poor maternal nutrition
Epidemiology (has to be VERY bad to cause problems not usually the
Complicates 0.5%- 1.5% of all pregnancies cause )
Pathophysiology EtOH abuse
Placental separation initiated by hemorrhage into the decidua Cyanotic heart disease
basalis with formation of a hematoma Pulmonary insufficiency
DDx Anti-phosolipid Ab syndrome
Important on DDx for bleeding in 3rd trimester Complications
Risk Factors Growth restricted fetuses are prone to low birth weight, meconium
Maternal HTN (44% cases) aspirations, asphyxia, polycythemia, hypoglycemia, and mental
Maternal trauma retardation
Smoking during pregnancy Monitor growth Q2W on US
Constricts placental BV If improper diastolic flow or reversal of flow through uterine
Cocaine use artery on US Doppler deliver baby sooner than 37w
Constricts placental BV
Short umbilical cord Intrauterine Fetal Demise (IUFD)
Premature rupture of membrane Fetal death >20 wk gestation but BEFORE delivery
i.e. hyperhydraminous DM 0t Etiology
Sudden decompression of the uterus 50% of the cases cause is unknown
Previous placental abruption Risk factors
Presentation Gestational HTN
PAINFUL vaginal bleeding in 3rd trimester , DM
uterine contractions Umbilical cord accidents
fetal distress on non-stress cardiac testing Fetal congenital abnormalities
Management C-section Fetal or maternal infections
Fetomaternal hemorrhage
Antiphosolipid antibody syndrome
Heroine/opioid use
Toxoplasmosis and CMV infections
Premature Rupture of Membranes (PROM) Indications for C-Section
Spontaneous rupture of membranes prior to the onset of labor at any Fetal Distress - Emergent
stage of gestation Fetal distress
< 37 weeks= PPROM (premature preterm) 10 min for brain damage
Epidemiology 15-20 min for fetal demise
PROM occurs 3% of pregnancies Cord Prolapse emergency
Risk factors: Maternal hemorrhage- emergency
Vaginal and cervical infections Shoulder dystocia- emergent
Abnormal membrane physiology Labor arrest urgent
Incompetent cervix Non-reassuring fetal HR urgent
Nutritional deficiencies Cephalopelvic disproportion (CPD)-
Management Malpresentation
24-34 weeks
expectant management inpatient
Antibiotics 7 days (Azithromycin) delays delivery If you can rate of 1o C-section you can rate overall
MgSul Perform inductions for the right reasons will help C-section rate
BMZ lung development
Monitor baby daily
Move towards induction if SSx maternal/fetal distress or
infection
>36 weeks,
induce labor (reasonable to wait up to 24h (prob less in most
cases) prior to induction of labor)

Other Complications of Pregnancy

Obesity
risk for complications of GDM and Gestational HTN
Recommended weight gain in pregnancy changes
Underweight - 28-40 lb wt gain
Normal weight - 25-25 lbs
Overweight - 15-25 lbs
Obese - 11-20 lbs
Not part of objectives
Acute fatty liver of pregnancy
Cholecystitis
Intrahepatic cholestasis of pregnancy (ICP)
Thyroid disease
Others..