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gestational diabetes

Etiology: - no strong evidence supports a causal effect of vitamin D status on gestational hypertension or pre-eclampsia [22] - antidepressant use during pregnancy - RR= 1.2; SNRI RR=1.3; tricyclic antidepressants RR=1.5; venlafaxine RR=1.3; amitriptyline RR=1.5 [25] Epidemiology: 1) 2-4% of pregnancies with prevalence increasing [7] 2) 7% of pregnancies [1] 3) higher incidence in Native Americans, blacks & hispanics Pathology: -> insulin-resistance a) normally develops in 3rd trimester b) inadequately compensatated by islet cell hyperfunction Clinical manifestations: -> develops around 7th month of pregnancy Laboratory: Step 1 glucose tolerance test* - 50 grams of oral glucose - 1 hour serum glucose > 140 mg/dL, proceed to step 2 Step 2 glucose tolerance test - 100 grams of glucose load a) fasting serum glucose > 95 mg/dL b) 1 hour serum glucose > 180 mg/dL c) 2 hour serum glucose > 155 mg/dL d) 3 hour serum glucose > 140 mg/dL - positive test is 2 or more criteria met * All pregnant women should be screened after 24 weeks [12] Complications: 1) maternal risks - 50% will develop type-2 diabetes within 5-10 years [1] 2) fetal risks (treatment reduces serious risk [4]) a) intrauterine death b) acute respiratory distress syndrome c) hypoglycemia* d) hypocalcemia e) polycythemia* f) hyperviscosity g) hyperbilirubinemia (develops after birth) h) cardiomyopathy i) macrosomia (most common) j) shoulder dystocia k) bone fracture l) nerve palsy 3) treatment reduces preeclampsia, shoulder dystocia, & macrosomia [10] 4) increased risk of autism in offspring (RR=1.42) [16] 5) progression to type 2 diabetes - breast feeding may lower risk [18] 6) gestational diabetes increases maternal risk of cardiovascular disease - healthy lifestyle habits in midlife may mitigate this risk [20] 7) increased risk of early-onset cardiovascular disease in offspring (RR=1.2) [26] * risk at birth [27] Management: 1) goals: a) fasting blood glucose < 90 mg/dL b) 1 hour post-prandial glucose < 120 mg/dL [1] 2) successfully treated with diet in most patients - avoid ketosis associated with carbohydrate deprivation - Mediterranean diet may lower risk for gestational diabetes [24] 3) insulin is probably safest choice if diet ineffective 4) oral hypoglycemics may see more use [8] a) metformin is probably safe [5] - associated with higher incidence of preterm birth than insulin [14] - long-term outcomes associated with metformin are still uncertain [23] - metformin appears to be a reasonably safe alternative to insulin for patients who refuse insulin [28] b) glyburide - should not be used in pregnant women [14,15] - somewhat more effective than metformin in controlling hyperglycemia in mom [8,14] - may be an acceptable agent for women unable to tolerate insulin [2] - excess risk for adverse neonatal outcomes with glyburide [23] - associated with higher rates of macrosomia & neonatal hypoglycemia than insulin or metformin [14] - increased risk for neonatal ICU admission (10.2 vs 7.2%), respiratory distress (2.9 vs 1.7%), hypoglycemia (1.9% vs 1.3%), birth injury (2.2 vs 1.6%), & macrosomia (4.7 vs 3.2%) relative to treatment with insulin [15] - composite outcome of macrosomia, neonatal hypoglycemia, & hyperbilirubinemia 27.6% with glyburide vs 23.4% with insulin [21] c) GLP-1 receptor agonists, dipeptidyl peptidase-4 inhibitors, or flozins not associated with increased risk of birth defects [29] 5) hypoglycemia is common, but NOT clearly associated with risk to fetus 6) screening: - all pregnant women should be screened after 24 weeks of gestation [12] - women with risk factors should be screened at the onset of gestation [1] 7) eye examination once per trimester [1] 8) prevention: - healthy lifestyle factors (regular exercise, normal weight, healthy diet, no smoking) may reduce risk by at least 40% [13] - in obese women, myo-inositol 4 grams daily may reduce risk of gestational diabetes [17] 9) followup - screening for diabetes at 6-12 weeks postpartum & every 3 years thereafter [1]; annual screening [1]

Interactions

disease interactions

Related

diabetics who become pregnant glucose challenge (tolerance) test

General

pregnancy disorder; obstetric disorder; pregnancy complication diabetes mellitus

References

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