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Achieving Euglycaemia in Women with Gestational Diabetes Mellitus

Current Options for Screening, Diagnosis and Treatment

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Abstract

Gestational diabetes mellitus is one of the major medical complications of pregnancy. Untreated, the mother and the unborn child may experience morbidity and fetal death may even occur. It is important to diagnose and treat all hyperglycaemia appearing during pregnancy. Ideally, a screening and diagnostic test that identified all women at risk for hyperglycaemia-associated complications would be employed in all pregnant women. Unfortunately, there is no such test available currently. The best alternative is to administer an oral glucose challenge test to all pregnant women and then apply the best strategies for interpretation. This article discusses the limitations of our present diagnostic tools and suggests an option for the clinician until the definitive test has been elucidated.

In addition, this article outlines one dietary and management strategy that has been associated with an outcome of pregnancy that is similar to the outcome of pregnancies in healthy women. This strategy includes starting with a ‘euglycaemic’ diet (comprising <40% carbohydrates and >-40% fat), which can then be individualised according to the patient’s glucose levels. Appropriate exercise, such as arm ergometer training, may enhance the benefits of diet control. For patients who require insulin, if the fasting glucose level is >90 mg/dL or 5 mmol/L (whole blood capillary) then NPH insulin (insulin suspension isophane) should be given before bed, beginning with dosages of 0.2 U/kg/day. If the postprandial glucose level is elevated, pre-meal rapid-acting insulin should be prescribed, beginning with a dose of 1U per 10g of carbohydrates in the meal. If both the fasting and postprandial glucose levels are elevated, or if a woman’s postprandial glucose levels can only be blunted if starvation ketosis occurs, a four-injectionsper-day regimen should be prescribed. The latter can be based on combinations of NPH insulin and regular human insulin, timed to provide basal and meal-related insulin boluses. The total daily insulin dose for the four-injection regimen should be adjusted according to pregnant bodyweight and gestational week (0.7–1 U/kg/ day); doses may need to be increased for the morbidly obese or when there is twin gestation.

There is now some evidence that insulin lispro, other insulin analogues and oral antihyperglycaemic drugs may be beneficial in gestational diabetes, and more data on these agents are awaited with interest.

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References

  1. WHO Study Group: prevention of diabetes mellitus. Geneva: World Health Organization, 1994. WHO Technical Report Series no.: 844

  2. Metzger BE, Coustan DR. Summary and recommendations of the Fourth International Workshop-Conference on Gestational Diabetes Mellitus. Diabetes Care 1988; 21: B161–7

    Google Scholar 

  3. National Diabetes Data Group. Classification and diagnosis of diabetes mellitus and other categories of glucose intolerance. Diabetes 1979; 28: 1039–57

    Google Scholar 

  4. Martin FIR. The diagnosis of gestational diabetes: Ad Hoc Working Party. Med J Aust 1991; 155: 112

    PubMed  CAS  Google Scholar 

  5. Canadian Task Force on the Periodic Health Examination. Periodic health examination, 1992 update. 1: screening for gestational diabetes mellitus. CMAJ 1992; 147: 435–43

    Google Scholar 

  6. American College of Obstetricians and Gynecologists. Diabetes and pregnancy. Washington, DC: American College of Obstetricians and Gynecologists, 1994. ACOG Technical Bulletin no.: 200

    Google Scholar 

  7. WHO expert committee on diabetes mellitus: second report. Geneva: World Health Organization, 1980. WHO Technical Report Series no.: 646

  8. Diabetes mellitus: report of a WHO study group. Geneva: World Health Organization, 1985. WHO Technical Report Series no.: 727

  9. Freinkel N, Josimovich J. Conference planning committee: American Diabetes Association Workshop-Conference on Gestational Diabetes: summary and recommendations. Diabetes Care 1980; 3: 499–501

    Article  Google Scholar 

  10. O’Sullivan JB, Mahan CM. Criteria for the oral glucose tolerance test in pregnancy. Diabetes 1964; 13: 278–85

    PubMed  Google Scholar 

  11. Carpenter MW, Coustan DR. Criteria for screening tests for gestational diabetes. Am J Obstet Gynecol 1982; 144: 768–73

    PubMed  CAS  Google Scholar 

  12. Sacks DA, Abu-Fadil S, Greenspoon JS, et al. Do the current standards for glucose tolerance testing in pregnancy represent a valid conversion of O’Sullivan’s original criteria? Am J Obstet Gynecol 1989; 161: 638–41

    PubMed  CAS  Google Scholar 

  13. Moses RG, Moses J, Davis WS. Gestational diabetes: do lean young Caucasian women need to be tested? Diabetes Care 1998; 21: 1803–6

    Article  PubMed  CAS  Google Scholar 

  14. Moses RG, Moses M, Russell KG, et al. The 75-g glucose tolerance test in pregnancy: a reference range determined on a low risk population and related to selected pregnancy outcomes. Diabetes Care 1998; 21: 1807–11

    Article  PubMed  CAS  Google Scholar 

  15. American Diabetes Association. Position statement: gestational diabetes mellitus. Diabetes Care 2004; 27 Suppl. 1: S88–90

    Article  Google Scholar 

  16. Amadin RA, Famuyiwa OO, Adelusi BO. Glycemic response to 75gms and 100gms glucose load during pregnancy in Nigerian women. Diabetol Croat 1989; 18: 159–61

    Google Scholar 

  17. Pettitt DJ, Bennett PH, Hanson RL, et al. Comparison of World Health Organization and National Diabetes Data Group procedures to detect abnormalities of glucose tolerance during pregnancy. Diabetes Care 1994; 17: 1264–8

    Article  PubMed  CAS  Google Scholar 

  18. Deerochanawong C, Putiyanun C, Wongsuryrat M, et al. Comparison of National Diabetes Data Group and World Health Organization criteria for detecting gestational diabetes mellitus. Diabetologia 1996; 39: 1070–3

    Article  PubMed  CAS  Google Scholar 

  19. Naylor CD, Sermer M, Chen E, et al. Selective screening for gestational diabetes mellitus: Toronto Trihospital Gestational Diabetes Project Investigators. N Engl J Med 1997 Nov 27; 337(22): 1591–6

    Article  PubMed  CAS  Google Scholar 

  20. Sermer M, Naylor CD, Farine D, et al. The Toronto Tri-Hospital Gestational Diabetes Project: a preliminary review. Diabetes Care 1998 Aug; 21 Suppl. 2: B33–42

    PubMed  Google Scholar 

  21. Jensen DM, Molsted-Pedersen L, Beck-Nielsen H, et al. Screening for gestational diabetes mellitus by a model based on risk indicators: a prospective study. Am J Obstet Gynecol 2003 Nov; 189(5): 1383–8

    Article  PubMed  Google Scholar 

  22. Di Cianni G, Volpe L, Lencioni C, et al. Prevalence and risk factors for gestational diabetes assessed by universal screening. Diabetes Res Clin Pract 2003 Nov; 62(2): 131–7

    Article  PubMed  Google Scholar 

  23. American Diabetes Association. Position statement: gestational diabetes mellitus. Diabetes Care 2002; 25 Suppl. 1: S94–6

    Article  Google Scholar 

  24. ACOG practice bulletin: gestational diabetes. Obstet Gynecol 2001; 98(3): 525–38

    Google Scholar 

  25. HAPO Study Cooperative Research Group. The Hyperglycemia and Adverse Pregnancy Outcome (HAPO) Study. Int J Gynaecol Obstet 2002 Jul; 78(1): 69–77

    Article  Google Scholar 

  26. DeVeciana M, Major CA, Morgan MA, et al. Postprandial versus preprandial blood glucose monitoring in women with gestational diabetes mellitus requiring insulin Therapy. N Engl J Med 1995; 333: 1237–41

    Article  CAS  Google Scholar 

  27. Pedersen J. The pregnant diabetic and her newborn. Copenhagen: Munksgaard, 1967

    Google Scholar 

  28. Jovanovic L, Peterson CM, Reed GF, et al. Maternal postprandial glucose levels and infant birth weight: the diabetes in early pregnancy study. Am J Obstet Gynecol 1991; 164: 103–11

    Google Scholar 

  29. Combs CA, Gunderson E, Kitzmiller JL, et al. Relationship of fetal macrosomia to maternal postprandial glucose control during pregnancy. Diabetes Care 1992; 15: 1251–7

    Article  PubMed  CAS  Google Scholar 

  30. Jovanovic L, editor-in-chief. Medical management of pregnancy complicated by diabetes. 2nd ed. Alexandria (VA): American Diabetes Association, 1995

    Google Scholar 

  31. Buchanan TA, Metzger BE, Freinkel N. Accelerated starvation in late pregnancy: a comparison between obese women with and without gestational diabetes mellitus. Am J Obstet Gynecol 1990; 162: 1015–20

    PubMed  CAS  Google Scholar 

  32. American Diabetes Association. Position statement: nutrition recommendations and principles for people with diabetes mellitus. Diabetes Care 1999; 22 Suppl. 1: 1–11

    Article  Google Scholar 

  33. Jovanovic L, Peterson CM. Dietary manipulation as a primary treatment strategy for pregnancies complicated by diabetes. J Am Coll Nutr 1990; 9: 320–5

    Google Scholar 

  34. Jovanovic L, Peterson CM. Nutritional management of the obese gestational diabetic woman. J Am Coll Nutr 1992; 11: 246–50

    Google Scholar 

  35. Jovanovic L, Druzin M, Peterson CM. Effect of euglycemia on the outcome of pregnancy in insulin-dependent diabetic women as compared with normal control subjects. Am J Med 1981; 71: 921–7

    Article  PubMed  CAS  Google Scholar 

  36. Dexter L, Weiss S. Preeclamptic and eclamptic toxemia of pregnancy. Boston (MA): Little, Brown, 1941

    Google Scholar 

  37. King J, Allen L. Nutrition during pregnancy. Washington, DC: National Academy Press, 1990

    Google Scholar 

  38. Magee MS, Knopp RH, Benedetti TJ. Metabolic effects of 1200-kcal diet in obese pregnant women with gestational diabetes. Diabetes 1990; 39: 234–40

    Article  PubMed  CAS  Google Scholar 

  39. Knopp RH, Magee MS, Raisys V. Hypocaloric diets and ketogenesis in the management of obese gestational diabetic women. J Am Coll Nutr 1991; 10: 649–67

    PubMed  CAS  Google Scholar 

  40. Jovanovic L, Peterson CM. Sweet success, but an acid after taste? N Engl J Med 1991; 325: 959–60

    Article  Google Scholar 

  41. Churchill JA, Berrendes HW, Nemore J. Neuropsychological deficits in children of diabetic mothers: a report from the collaborative study of cerebral palsy. Am J Obstet Gynecol 1969; 105: 257–68

    PubMed  CAS  Google Scholar 

  42. Rizzo T, Metzger BE, Burns WJ, et al. Correlations between antepartum maternal metabolism and intelligence of offspring. N Engl J Med 1991; 325: 911–6

    Article  PubMed  CAS  Google Scholar 

  43. Mills JL, Knopp RH, Simpson JL, et al. Lack of relation between malformation rates in infants of diabetic mothers to glycemic control during organogenesis. N Engl J Med 1988; 318: 671–6

    Article  PubMed  CAS  Google Scholar 

  44. Jovanovic L, Metzger B, Knopp RH, et al. β-Hydroxybutyrate levels in type 1 diabetic pregnancy compared with normal pregnancy. Diabetes Care 1998; 21: 1–5

    Article  Google Scholar 

  45. Mills JL, Simpson JL, Driscoll SG, et al. Incidence of spontaneous abortion among normal women and insulin dependent diabetic women whose pregnancies were identified within 21 days of conception. N Engl J Med 1988; 319: 1617–23

    Article  PubMed  CAS  Google Scholar 

  46. Peterson CM, Jovanovic L. Percentage of carbohydrate and glycemic response to breakfast, lunch and dinner in women with gestational diabetes. Diabetes 1990; 40 Suppl. 2: 172–4

    Google Scholar 

  47. Taylor R, Badcock J, King H, et al. Dietary intake, exercise, obesity and noncommunicable disease in rural and urban populations of three Pacific Island countries. J Am Coll Nutr 1992; 11: 283–93

    PubMed  CAS  Google Scholar 

  48. Kanaya AM, Narayan KM. Prevention of type 2 diabetes: data from recent trials. Prim Care 2003 Sep; 30(3): 511–26

    Article  PubMed  CAS  Google Scholar 

  49. Emmanouilides GC, Hobel CJ, Yashiro K. Fetal responses to maternal exercise in the sheep. Am J Obstet Gynecol 1972; 112: 130–7

    PubMed  CAS  Google Scholar 

  50. Hohimer AR, Bissonnette JM, Metcalfe J. Effect of exercise on uterine blood glow in the pregnant pygmy goat. Am J Physiol 1984; 246: H207–12

    PubMed  CAS  Google Scholar 

  51. Terada M. Effect of physical activity before pregnancy on fetuses of mice exercised forcibly during pregnancy. Teratology 1974; 10: 141–4

    Article  PubMed  CAS  Google Scholar 

  52. Artal R, Romem Y, Wiswell R. Fetal bradycardia induced by maternal exercise. Lancet 1984; II: 258–60

    Article  Google Scholar 

  53. Hon EH, Wohlgemuth R. The electronic evaluation of fetal heart rate. IV: the effect of maternal exercise. Am J Obstet Gynecol 1961; 81: 361–71

    CAS  Google Scholar 

  54. Pomerance JJ, Gluck L, Lynch VA. Maternal exercise as a screening test for uteroplacental insufficiency. Obstet Gynecol 1974; 44; 383–7

    PubMed  CAS  Google Scholar 

  55. Dale E, Mullinax K, Bryan D. Exercise during pregnancy: effect on the fetus. Can J Appl Sports Sci 1982; 7: 98–103

    CAS  Google Scholar 

  56. Jovanovic L, Kessler A, Peterson CM. Human maternal and fetal response to graded exercise. J Appl Physiol 1985; 58: 1719–22

    Article  PubMed  CAS  Google Scholar 

  57. Collings C, Curet LB. Fetal heart rate response to maternal exercise. Am J Obstet Gynecol 1985; 151: 498–501

    PubMed  CAS  Google Scholar 

  58. Hauth JC, Gilstrap LC, Widmer CK. Fetal heart rate reactivity before and after maternal jogging during the third trimester. Am J Obstet Gynecol 1982; 142: 545–7

    PubMed  CAS  Google Scholar 

  59. Edwards M, Metcalfe J, Dunham M, et al. Accelerated respiratory response to moderate exercise in late pregnancy. Respir Physiol 1981; 45: 229–41

    Article  PubMed  CAS  Google Scholar 

  60. Dressendorfer E, Goodlin R. Fetal heart rate response to maternal exercise testing. Phys Sportsmed 1980; 8: 91–4

    Google Scholar 

  61. Paolone AM, Shangold M, Minnetti PJ, et al. Fetal heart rate measurement during maternal exercise-avoidance of artefact. Med Sci Sports Exerc 1987; 19: 605

    PubMed  CAS  Google Scholar 

  62. Morris N, Osborn SB, Wright HP. Effective uterine blood flow during exercise in normal and preeclamptic pregnancies. Lancet 1956; II: 481–4

    Article  Google Scholar 

  63. Erkkola R. The physical work capacity of the expectant mother and its effect on pregnancy, labor and the newborn. Int J Gynaecol Obstet 1976; 14: 153–9

    PubMed  CAS  Google Scholar 

  64. Balfour M. The effect of occupation on pregnancy and neonatal mortality. Public Health 1988; 51: 106–10

    Article  Google Scholar 

  65. Naeye RL, Peters EC. Working during pregnancy: effects on the fetus. Pediatrics 1982; 69: 724–7

    PubMed  CAS  Google Scholar 

  66. Gorski J. Exercise during pregnancy: maternal and fetal responses: a brief review. Med Sci Sports Exerc 1985; 17: 407–16

    Article  PubMed  CAS  Google Scholar 

  67. Durak EP, Jovanovic L, Peterson CM. Comparative evaluation of uterine response to exercise on five aerobic machines. Am J Obstet Gynecol 1990; 162: 754–6

    PubMed  CAS  Google Scholar 

  68. Jovanovic L, Durak EP, Peterson CM. Randomized trial of diet versus diet plus cardiovascular conditioning on glucose levels in gestational diabetes. Am J Obstet Gynecol 1989; 161: 415–9

    Google Scholar 

  69. Hollingsworth DR, Moore TR. Postprandial walking exercise in pregnant insulin-dependent (type I) diabetic women: reduction of plasma lipid levels but absence of a significant effect on glycemic control. Am J Obstet Gynecol 1987; 157: 1359–63

    PubMed  CAS  Google Scholar 

  70. Bung P, Artal R, Khodiguian N, et al. Exercise in gestational diabetes: an optional therapeutic approach? Diabetes 1991; 40 Suppl. 2: 182–5

    PubMed  Google Scholar 

  71. Bung P, Bung C, Artal R, et al. Therapeutic exercise for insulinrequiring gestational diabetics: effects on the fetus. Results of a randomized prospective longitudinal study. J Perinat Med 1993; 21(2): 125–37

    CAS  Google Scholar 

  72. Mulford MI, Jovanovic L, Peterson CM. Alternative therapies for the management of gestational diabetes. Clin Perinatol 1993; 20: 619–34

    PubMed  CAS  Google Scholar 

  73. Jovanovic L, Bevier W, Peterson CM. The Santa Barbara County Health Care Services Program: birthweight change concomitant with screening for and treatment of glucoseintolerance of pregnancy. A potential cost-effective intervention. Am J Perinatol 1997; 14: 221–8

    Google Scholar 

  74. Jovanovic L, Peterson CM. Rationale for prevention and treatment of glucose-mediated macrosomia: a protocol for gestational diabetes. Endocr Pract 1996; 2: 118–29

    Google Scholar 

  75. Jehle PM, Fussgaenger RD, Kunze U, et al. The human insulin analog insulin lispro improves insulin binding on circulating monocytes of intensively treated insulin dependent diabetes mellitus patients. J Clin Endocrinol Metab 1996; 81: 2319–27

    Article  PubMed  CAS  Google Scholar 

  76. Jovanovic L, Ilic S, Pettitt D, et al. The metabolic and immunologie effects of insulin lispro. Diabetes Care 1999; 22: 1422–7

    Article  PubMed  CAS  Google Scholar 

  77. Pettitt DJ, Ospina P, Kolaczynski JW, et al. Comparison of an insulin analog, insulin aspart, and regular human insulin with no insulin in gestational diabetes mellitus. Diabetes Care 2003; 26: 183–6

    Article  PubMed  CAS  Google Scholar 

  78. Langer O, Conway DL, Berkus MD, et al. A comparison of glyburide and insulin in women with gestational. N Engl J Med 2000 Oct 19; 343(16): 1134–8

    Article  PubMed  CAS  Google Scholar 

  79. Langer O. Oral hypoglycemic agents in pregnancy: their time has come. J Matern Fetal Neonatal Med. 2002 Dec; 12(6): 376–83

    Article  PubMed  CAS  Google Scholar 

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  1. Sansum Medical Research Institute, 2219 Bath Street, Santa Barbara, California, 93105, USA

    Lois Jovanovic

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Jovanovic, L. Achieving Euglycaemia in Women with Gestational Diabetes Mellitus. Drugs 64, 1401–1417 (2004). https://doi.org/10.2165/00003495-200464130-00002

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