Class Notes: Gestational Diabetes Mellitus (GDM)
1. Introduction to GDM
• Definition: Gestational Diabetes Mellitus (GDM) is a condition characterized by
glucose intolerance with onset or first recognition during pregnancy.
• Incidence: Affects approximately 2-10% of pregnancies globally.
• Risk Factors:
o Obesity
o Advanced maternal age
o Family history of diabetes
o Previous GDM
o Polycystic ovary syndrome (PCOS)
o Multiple gestation (twins, triplets)
o Certain ethnic groups (e.g., Hispanic, African-American, Native American,
South or East Asian, Pacific Islander)
2. Pathophysiology
• Hormonal Changes: Pregnancy hormones (e.g., human placental lactogen,
progesterone) increase insulin resistance.
• Increased Insulin Demand: The pancreas may not produce enough insulin to
overcome insulin resistance.
• Hyperglycemia: Elevated blood glucose levels due to insufficient insulin action.
3. Screening and Diagnosis
• Screening:
o Typically performed between 24-28 weeks of gestation.
o Earlier screening for women with high risk factors.
• Screening Methods:
o Oral Glucose Tolerance Test (OGTT):
▪ One-Step Approach: 75-g glucose load, measure fasting, 1-hour, and
2-hour blood glucose levels.
▪ Two-Step Approach: 50-g glucose challenge test (non-fasting), if
positive, followed by 100-g OGTT (fasting).
• Diagnostic Criteria (One-Step Approach):
o Fasting: ≥ 92 mg/dL (5.1 mmol/L)
o 1-hour: ≥ 180 mg/dL (10.0 mmol/L)
o 2-hour: ≥ 153 mg/dL (8.5 mmol/L)
4. Clinical Presentation
• Often Asymptomatic: Most women with GDM do not experience symptoms.
• Possible Symptoms:
o Excessive thirst
o Frequent urination
o Fatigue
o Blurred vision
5. Management of GDM
5.1 Lifestyle Modifications
• Dietary Changes:
o Balanced diet with appropriate caloric intake.
o Distribution of carbohydrates throughout the day.
o Focus on low glycemic index foods.
• Physical Activity:
o Regular moderate exercise (e.g., walking, swimming).
o At least 30 minutes most days of the week.
5.2 Medical Management
• Blood Glucose Monitoring:
o Regular self-monitoring of blood glucose levels (fasting, postprandial).
• Pharmacotherapy:
o Insulin Therapy: Mainstay treatment if blood glucose levels are not
controlled by lifestyle modifications.
o Oral Hypoglycemic Agents: Metformin or glyburide may be considered, but
insulin is preferred.
6. Monitoring and Follow-Up
• Maternal Monitoring:
o Frequent prenatal visits to monitor glucose levels, fetal growth, and well-
being.
o Monitoring for potential complications (e.g., preeclampsia).
• Fetal Monitoring:
o Ultrasound to assess fetal growth, amniotic fluid volume, and other
parameters.
o Non-stress tests (NST) or biophysical profiles (BPP) if indicated.
7. Complications of GDM
7.1 Maternal Complications
• Preeclampsia
• Increased risk of cesarean delivery
• Future risk of type 2 diabetes mellitus
7.2 Fetal Complications
• Macrosomia (large baby)
• Shoulder dystocia during delivery
• Neonatal hypoglycemia
• Respiratory distress syndrome
• Increased risk of obesity and type 2 diabetes later in life
8. Postpartum Care
• Glucose Monitoring:
o Postpartum glucose testing (6-12 weeks postpartum) to assess for
persistent diabetes.
o Annual screening for type 2 diabetes for women with a history of GDM.
• Lifestyle Counseling:
o Continued healthy eating and physical activity to reduce future diabetes
risk.
• Breastfeeding: Encouraged, as it has beneficial effects on glucose metabolism.
9. Preventive Measures
• Preconception Counseling: For women with risk factors, focusing on weight
management and healthy lifestyle.
• Early Screening: In subsequent pregnancies, early glucose testing may be
recommended.
References:
• American Diabetes Association (ADA) Standards of Medical Care in Diabetes—2021
• International Association of Diabetes and Pregnancy Study Groups (IADPSG)
Consensus Panel
• ACOG Practice Bulletin No. 190: Gestational Diabetes Mellitus
