Snapshot A 33-year-old G3P2 female is at 25 weeks gestation. Fundal height measures 31 cm. Obstetric ultrasound reveals four quadrant amniotic fluid index (AFI) of 30 cm. An ultrasound is performed. Introduction Glucose intolerance or diabetes mellitus (DM) first recognized during pregnancy Occurs in 2-5% of all pregnancies #1 medical complication of pregnancy Caused by placental-released human placental lactogen (HPL) which antagonizes insulin worsens with pregnancy as placenta enlarges and more HPL is released Risk factors include previous history of gestational diabetes mellitus (GDM) obesity history of prior abortions or stillbirths family history of DM maternal age > 30 Presentation Asymptomatic Evaluation At 24 - 28 weeks check fasting plasma glucose if greater than 125 mg/dL, suspect diabetes mellitus < 95 mg/dL considered normal administer a 1 hour 50 g oral glucose tolerance test (Glucola) if blood glucose > 140 mg/dL at 1 hour, suspect gestational diabetes this is a very sensitive test (a negative test rules it out) confirm with a 3 hour 100 g oral glucose tolerance test; abnormal measurements are: > 180 mg/dL at 1 hour > 155 mg/dL at 2 hours > 140 mg/dL at 3 hours this is a very specific test (a positive test rules it in) Treatment Strict adherence to ADA diet and glucose control If diet is insufficient to control administer insulin Oral hypoglycemic medications can be used metformin is currently approved for usage during pregnancy glyburide is also considered safe in general insulin is a better answer for step exams Delivery determined by estimated fetal weight if 4000-4500 g, consider a caesarian section Prognosis, Prevention, and Complications 95% return to normal postpartum glucose screen 2 months postpartum to confirm Maternal complications include type II DM later on in life (50%) 2X risk of pregnancy induced hypertension, preeclampsia, eclampia polyhydraminos (> 2000 mL) caused by polyuria of the fetus hyperglycemia increased risk of UTIs pre-term labor retinopathy caesarian secondary to macrosomia no increased risk of spontaneous abortion if well controlled Fetal complications include perinatal mortality (2-5%) abruption and preterm labor 3X congenital malformations limb deformities neural tube cardiac deformities secondary to trophic effect of insulin macrosomia (> 4500 g) shoulder dystocia during vaginal delivery neonatal hypoglycemia due to abrupt separation from high maternal glucose supply with a large amount of fetal insulin present ß-cell hyperplasia in the newborn leading to hypoglycemia hyperbilirubinemia polycythemia respiratory distress syndrome (RDS)