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19-19: Diabetes Mellitus in Pregnancy

Vanessa L. Rogers; Scott W. Roberts

Normal pregnancy can be characterized as a state of increased insulin resistance that helps ensure a steady stream of glucose delivery to the developing fetus. Thus, both mild fasting hypoglycemia and postprandial hyperglycemia are physiologic. These metabolic changes are felt to be hormonally mediated with likely contributions from human placental lactogen, estrogen, and progesterone.

A. Gestational Diabetes Mellitus

Gestational diabetes mellitus is abnormal glucose tolerance in pregnancy and is generally believed to exaggerate the pregnancy-induced physiologic changes in carbohydrate metabolism. Alternatively, pregnancy may unmask an underlying propensity for glucose intolerance, which will be evident in the nonpregnant state at some future time if not in the immediate postpartum period. Indeed, at least 50% of women with gestational diabetes will have an overt diabetes diagnosis at some point in their lifetime. During the pregnancy, the principal concern in women identified to have gestational diabetes is excessive fetal growth, which can cause increased maternal and perinatal morbidity. Shoulder dystocia occurs more frequently in infants of mothers with diabetes because of fetal overgrowth and increased fat deposition on the shoulders. Cesarean delivery and preeclampsia are also significantly increased in women with diabetes, both gestational and overt.

All asymptomatic pregnant women should undergo laboratory screening for gestational diabetes after 24 weeks’ gestation. The diagnostic thresholds for glucose tolerance tests in pregnancy are not universally agreed upon, and importantly, adverse pregnancy outcomes appear to occur along a continuum of glucose intolerance even if the diagnosis of gestational diabetes is not formally assigned. A two-stage testing strategy is recommended by the ACOG, starting with a 50-g screening test offered to all pregnant women at 24–28 weeks’ gestation. If this test is abnormal, the diagnostic test is a 100-g oral glucose tolerance test (Table 19–4).

Table 19–4.Screening and diagnostic criteria for gestational diabetes mellitus.
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Table 19–4. Screening and diagnostic criteria for gestational diabetes mellitus.

Screening for gestational diabetes mellitus

  1. 50-g oral glucose load, administered between 24 and 28 weeks, without regard to time of day or time of last meal.

  2. Venous plasma glucose measured 1 hour later.

  3. Value of 140 mg/dL (7.8 mmol/L) or above in venous plasma indicates the need for a diagnostic glucose tolerance test.

Diagnosis of gestational diabetes mellitus

  1. 100-g oral glucose load, administered in the morning after overnight fast lasting at least 8 hours but not more than 14 hours, and following at least 3 days of unrestricted diet (> 150 g carbohydrate) and physical activity.

  2. Venous plasma glucose is measured fasting and at 1, 2, and 3 hours. Patient should remain seated and should not smoke throughout the test.

  3. The diagnosis of gestational diabetes is made when two or more of the following venous plasma concentrations are met or exceeded: fasting, 95 mg/dL (5.3 mmol/L); 1 hour, 180 mg/dL (10 mmol/L); 2 hours, 155 mg/dL (8.6 mmol/L); 3 hours, 140 mg/dL (7.8 mmol/L).
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