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Diagnosis and Management of Diabetes Mellitus in Pregnancy. INTRODUCTIONFew pregnancy problems have been more dramatically impacted by the advances in technology and in our understanding of physiology during the past century than has pregnancy in the mother with diabetes. Prior to the availability of insulin in the early 1. The advent of insulin in 1.
A large body of information has accumulated thanks to the efforts of researchers and clinicians in multiple disciplines, including obstetrics and maternal–fetal medicine, pediatrics, and neonatology, internal medicine with its many subspecialties, pathology and laboratory medicine, psychology and psychiatry, nursing, social work, nutrition, and anesthesiology. Scientific organizations have been formed to foster the interdisciplinary interchange of information; these include the International Association of Diabetes in Pregnancy Study Groups (IADPSG), the Diabetes in Pregnancy Council of the American Diabetes Association (ADA), and similar organizations throughout the world. It is likely that no single disorder of pregnancy has sparked the interest of a more diverse group of investigators, and no single entity is a better example of the interplay of advances in all of the above- mentioned fields. It has been estimated that 0.
United States occur in women with preexisting diabetes mellitus,1 and that 4–8% more are complicated by gestational diabetes. This problem is likely to be encountered by every clinician caring for pregnant women. The above- mentioned advances in our understanding and management of diabetic pregnancy may have inspired increased confidence that perinatal outcomes are likely to be positive, but we must never lose sight of the fact that perinatal mortality and morbidity are markedly increased in diabetic pregnancies that are not managed by modern approaches, and that continued vigilance is necessary in order to optimize results. Ideally all pregnancies in women with preexisting diabetes should be cared for in a modern perinatal center with a team approach; those with gestational diabetes should be managed in a systematic fashion with appropriate resources available to address the obstetric, metabolic, pediatric, dietary, nursing, and social needs of the mother and fetus/neonate. DIAGNOSIS AND CLASSIFICATIONGestational diabetes. Gestational diabetes is defined as . The criteria were based on tests administered to 7.
Long term follow- up by the same investigator has revealed an approximately 6. It is important to note that the O'Sullivan criteria were validated on the basis of their predictive value for subsequent maternal diabetes, and not for pregnancy outcome. GLUCOSE TOLERANCE TESTINGThe glucose tolerance test, which is currently standard for pregnant women in the United States and is recommended for use in pregnancy by the American College of Obstetricians and Gynecologists,1. OGTT). The 1. 00- g glucose challenge is administered after an overnight fast of 8–1. The dietary preparation is important, since individuals who are carbohydrate depleted will not mount as effective an insulin response to a glucose challenge, and may manifest higher glucose levels than they would have if properly prepared. Blood samples are drawn in the fasting state, and at 1, 2 and 3 hours after ingestion of the glucose challenge.
Glucose should be analyzed with a standard laboratory technology, and not with test strips and reflectance meters which are designed for self glucose monitoring. Although quite useful in management of the individual with already diagnosed diabetes, the latter method is too imprecise for use in diagnostic testing. When O'Sullivan and Mahan originally derived their criteria for the diagnosis of gestational diabetes,8 they opted for the presence of at least two out of four values exceeding the given thresholds in order to improve specificity, and to avoid reliance on a single laboratory value to make an important diagnosis. Venous whole blood samples were analyzed using the Somogyi- Nelson method of glucose analysis, and the thresholds originally established are depicted in Table 1. Currently most laboratories measure glucose in plasma or serum specimens, which yield results approximately 1.
Any references to external publications, websites or journals within the Diabetes.co.uk website are stated below. Medscape - Diabetes mellitus type 2 dosing for Diabeta, Glynase (glyburide), frequency-based adverse effects, comprehensive interactions, contraindications, pregnancy. How to lose weight quickly and sustainably with no hunger, no calorie counting, no magic products and no exercise, eating real food. Your treatment for prediabetes will focus on losing weight, eating healthy foods, and getting active. This is your chance to reverse prediabetes so it doesn't turn. The administration of oral hypoglycaemic drugs has been reported to be associated with increased cardiovascular mortality as compared to treatment with diet alone or.
The National Diabetes Data Group (NDDG)1. O'Sullivan and Mahan's OGTT thresholds, applying them to plasma and serum specimens.
Metformin (dimethylbiguanide) is an orally administered drug used to lower blood glucose concentrations in patients with non-insulin-dependent diabetes mellitus.
These conversions are shown in Table 2, and in the past have been recommended by the ADA and the American College of Obstetricians and Gynecologists (ACOG). Table 1. Pregnancy oral glucose tolerance test thresholds of O'Sullivan and Mahan*Sample Time. Unrounded threshold(mg/d. L)Rounded threshold(mg/d. L)Rounded threshold(mmol/L)Fasting.
Whole blood samples, Somogyi- Nelson method of analysis. Gestational diabetes is diagnosed if two or more threshold values are met or exceeded.(Adapted from O'Sullivan JB, Mahan CM: Criteria for the oral glucose tolerance test in pregnancy. Diabetes 1. 3: 2. Table 2. Gestational diabetes is diagnosed if two or more threshold values are met or exceeded.(Adapted from American Diabetes Association: Position statement of gestational diabetes mellitus. Diabetes Care 1. 8(suppl 1): 2. National Diabetes Data Group: Classification and diagnosis of diabetes mellitus and other categories of glucose intolerance.
Diabetes 2. 8: 1. The original method of glucose analysis, which also measured some nonglucose reducing substances, has been replaced by more specific enzymatic methods such as glucose oxidase and hexokinase.
Consequently, our center. O’Sullivan OGTT criteria which are somewhat lower than those derived by the NDDG, having been based on the unrounded original cutoffs, then corrected for the more specific enzymatic methodology by subtracting 5 mg/d. L from each value, then increased by 1. These thresholds are shown in Table 3. Table 3. Pregnancy oral glucose tolerance test thresholds established by Carpenter and Coustan,1. O'Sullivan and Mahan. Sample Time. Threshold(mg/d.
L)Threshold (SI Units)(mmol/L)Fasting. Plasma or serum samples, enzymatic (e. Gestational diabetes is diagnosed if two or more threshold values are met or exceeded.(Carpenter MW, Coustan DR: Criteria for screening tests for gestational diabetes. Am J Obstet Gynecol 1. When performing the OGTT in pregnancy, it is important that the laboratory understand that a 1. Furthermore, diagnostic criteria for pregnancy should be applied to the results.
If the laboratory is unaware of the fact that the patient is pregnant, or is unaware of the need for different criteria in pregnancy, it is possible that gestational diabetes could be over- or underdiagnosed. Another problem that may arise is the patient who is unable to undergo oral glucose tolerance testing because of vomiting.
It may help to try a different flavor of glucose challenge, and to administer the oral load on crushed ice. Another option is the use of a relatively tasteless glucose polymer as the challenge. If oral testing is still not possible, an intravenous glucose tolerance test. Although the thresholds shown in Table 2 were once widely used in the United States, it should be pointed out that both sets (Tables 2 and 3) are theoretical conversions from those shown in Table 1. When Sacks et al. O'Sullivan and Mahan's. NDDG thresholds were above 9.
Table 3 were within those confidence limits at all intervals. Such a finding may help to explain reports of increased perinatal morbidity in pregnancies where the glucose tolerance test criteria were nearly, but not quite, exceeded. Furthermore, a large observational study demonstrated that the criteria listed in Table 3 identify individuals with significantly increased perinatal morbidity compared to the general population, at rates similar to those in the population identified by the criteria in Table 2. In a sub- analysis of patients with GDM enrolled in a multi- institutional randomized clinical trial,2. GDM to a similar extent compared to untreated controls in subjects who met the NDDG criteria in Table 2, and those meeting only the Carpenter & Coustan criteria in Table 3.
A likely explanation of these findings is the determination that maternal hyperglycemia is associated with perinatal risk in a continuum, and that any set of thresholds for gestational diabetes must be rather arbitrary with borderline cases on either side. A blinded multi- institutional multinational observational study has demonstrated a continuous relationship between 7. C- peptide (a surrogate for insulin) among individuals without gestational diabetes. INTERNATIONAL ASSOCIATION OF THE DIABETES AND PREGNANCY STUDY GROUPS CRITERIAIn addition to the various derivations of cutoffs for the 1.
OGTT based on the O’Sullivan and Mahan criteria. GDM have been in use around the world. These include, but are not limited to, the 1. World Health Organization criteria.
OGTT. None were based on pregnancy outcomes. This was a large (> 2. OGTT and a number of adverse pregnancy outcomes including fetal macrosomia, primary cesarean section, preeclampsia, shoulder dystocia and neonatal hypoglycaemia. If the relationship between OGTT glucose values and adverse outcomes demonstrated an inflection point, above which problems were markedly increased and below which adverse outcomes were minimal, the choice of cutoffs for diagnosing gestational diabetes would have been relatedly straightforward. As noted above, the relationships were all continuous, with no obvious inflection points. This meant that the cutoffs for diagnosing GDM would be somewhat arbitrary.
In order to achieve the hoped for worldwide acceptance of outcomes- based GDM criteria, the International Association of Diabetes in Pregnancy Study Groups (IADPSG) convened a large panel of experts from around the world, and carried out an iterative process to achieve consensus. The final recommendation.
C- peptide above the 9. These criteria are shown in Table 4 below: Table 4. IADPSG criteria for gestational diabetes mellitus. Sample Time. Threshold (mg/d. L)Threshold (mmol/L)Fasting.