Gestational Diabetes Mellitus * Preeclampsia

HISTORY, P.E., & FOLLOW-UP

OF HIGH-RISK PREGNANCIES
UPCM 2013 Block 8: TAN to YAP
 SUBJECTIVE
SETTING: 1ST VISIT
Screen for GDM and Preeclampsia
 HIGH-RISK PREGNANCIES
1. Extremes of reproductive age
2. Medical complications
3. Poor obstetrical history
4. Placenta previa
5. Gynecologic tumors
6. With co-existing trophoblastic disease/had TD within
last year
7. Problems w/ fetal aging, structure, and size
8. Polyhydramnios or oligohydramnios
 GENERAL DATA, CHIEF
COMPLAINT
+ Name, age, sex, civil status, work, religion

+ Age
 GDM: 20-40 years old
 PREEC: <18 or >35 years old

American Journal of Obstetrics & Gynecology, Vol. 198, No. 5, D Getahun, C Nath, CV Ananth, et al., Gestational diabetes in the United States:
temporal trends 1989 through 2004, pp. 525.e1–525.e5, Copyright 2008, with permission from Elsevier

Al-Rowaily MA, Abolfotouh MA. Predictors of gestational diabetes mellitus in a high-parity community in Saudi Arabia. East
Mediterr Health J. 2010 Jun;16(6):636-41
 MEDICAL HISTORY
+ previous hospitalizations, illnesses Thyroid
problems, CA, asthma & allergies

+ GDM prior GDM/T2DM, glucosuria, HTN,

preeclampsia

+ PREEC blood dyscrasias & thrombophilias, renal

diseases, chronic HTN, DM (microvascular disease),
SLE, migraine, use of SSRI anti-depressants
 FAMILY HISTORY
+ Similar illness? CA, thyroid, twin pregnancies,
complicated pregnancies, bleeding disorders

+ GDM T2DM in 1st degree relative

+ PREEC PREE in 1st degree relative

 PERSONAL SOCIAL HISTORY
+ intake of alcohol, drugs, and smoking before
and during pregnancy
+ activity & lifestyle of patient before and
GDM
during pregnancy
+ elicit a crude estimate of weight or BMI of the
patient before pregnancy

Activity and lifestyle van der Ploeg HP, van Poppel MN, Chey T, Bauman AE, Brown WJ The role of pre-pregnancy physical activity and sedentary
behaviour in the development of gestational diabetes mellitus. J Sci Med Sport. 2010 Oct 26.

Gunderson EP, Quesenberry CP Jr, Jacobs DR Jr, Feng J, Lewis CE, Sidney S. Longitudinal study of prepregnancy cardiometabolic risk factors and
subsequent risk of gestational diabetes mellitus: The CARDIA study. Am J Epidemiol. 2010 Nov 15;172(10):1131-43. Epub 2010 Oct 7
 MENSTRUAL HISTORY
+ Menarche
+ Interval
+ Duration
+ Amount
+ Severity
+ LNMP
 OBSTETRIC HISTORY
+ Gravidity and parity: where, when and outcome,
gestation, birth weight, sex, mode of delivery and
complications
+ GDM history of poor obstetrical outcome – 1)
miscarriages
+ 2) birth defects
+ 3) growth abnormalities
+ 4) fetal obesity
+ 5) metabolic syndrome in previously delivered
children
Al-Rowaily MA, Abolfotouh MA. Predictors of gestational diabetes mellitus in a high-parity community in Saudi Arabia. East Mediterr Health
J. 2010 Jun;16(6):636-41.
 OBSTETRIC HISTORY
+ PREEC
1) 1st pregnancy
2) multiple gestations
3) 20 weeks Hypertension prior to 20
weeks' gestation is almost always due to
chronic hypertension; preeclampsia is rare
prior to the third trimester

Al-Rowaily MA, Abolfotouh MA. Predictors of gestational diabetes mellitus in a high-parity community in Saudi Arabia. East Mediterr Health
J. 2010 Jun;16(6):636-41.
 GYNECOLOGIC HISTORY
+ previous cervical smears
+ gynecologic problems
+ intermenstrual/postcoital bleedings
+ vaginal discharge
 SEXUAL HISTORY
+ First coitus? New partner?
+ Number of partners (also of partner’s)
+ Dyspareunia
+ STD history

+ PREEC New partner/paternity

 HIGH-RISK PREGNANCIES
1. Extremes of reproductive age
2. Medical complications
3. Poor obstetrical history
4. Placenta previa
5. Gynecologic tumors
6. With co-existing trophoblastic disease/had TD within last year
7. Problems w/ fetal aging, structure, and size
8. Polyhydramnios or oligohydramnios
 GDM: RISK FACTORS
+ Low Risk: All of the ff: —Ethnicity with low prevalence of GDM —No
known diabetes in 1st-degree relatives —Age < 25 years —Weight N
before pregnancy —Weight N at birth —No history of abnormal
glucose metabolism —No history of poor obstetrical outcome

+ High Risk: Perform BG testing ASAP, if 1 or more of are

present:
—Severe obesity
—Strong family history of T2DM
—Previous history of GDM, impaired glucose metabolism,
or glucosuria
 UNIVERSAL SCREENING VS. RF
SCREENING
+ A 2010 article by Namak, et al: no RCTs
demonstrate that either universal screening or risk
factor screening for gestational diabetes mellitus
prevents maternal and fetal adverse outcomes.
That said, the common practice of universal
screening is more sensitive than screening based
on risk factors.

“Historic risk factors are poor predictors of GDM in

current pregnancy.”
Namak S, Lord RW Jr, Zolotor AJ, Kramer R. Clinical inquiries: which women should we screen for gestational diabetes mellitus? J Fam Pract.
2010 Aug;59(8):467-8.
 PREECLAMPSIA: RISK FACTORS
1) Gestational age
- HTN <20 wks gestation

2) Maternal personal risk factors

- 1st pregnancy, new partner/paternity
- Age < 18 years or >35 years
- Hx of/FHx of PREE in a 1st-degree relative
- Black race, Obese (BMI ≥ 30)
- Interpregnancy interval <2 years or >10 years
 PREECLAMPSIA: RISK FACTORS

3) Maternal medical risk factors: Chronic HTN,

Preexisting DM, Renal disease, SLE, obesity,
thrombophilia, history of migraine
4) Placental/fetal risk factors
- Multiple gestations
- Hydrops fetalis
- Gestational trophoblastic disease
- Triploidy
ASSESSING THE PATIENT
Hypertension & Diabetes Mellitus
in the Pregnant Patient
 INITIAL ASSESSMENT
+ Blood Pressure
+ Height
+ Weight
+ Pulse Rate
+ Respiratory Rate
+ Temperature
 CLINICAL METHODS
+ Chest: auscultate heart for possible
murmurs, thrills, etc.
+ Abdomen: Ask the patient if there is
persistent epigastric pain.
– Measure the fundic height and correlate with
known estimates
– Do Leopold’s 1 – 4.
 For Leopold’s 2, check for Fetal Heart Tones. If
there is already movement of the fetus, try to
evaluate such and ask the mother for info.
 CLINICAL METHODS
+ Fetal heart tones: may be appreciated as early
as 17 wk AOG. Normal is 120-160 bpm. Using
Doppler ultrasound, heart tones can be
appreciated at 10 wk AOG.
+ Fundic height
+ Fetal movements: can be appreciated 16-20
wks. Normal is 10 mvt/2 hr, monitored daily
QID.
 BLOOD GLUCOSE TESTING
+ Options:
– The 50 g oral challenge test is taken for
screening those who are average risk or high
risk for developing GDM.
 For patients reaching the threshold levels of the
GCT (140 mg/dL), a 100 g Oral Glucose Tolerance
Test is then required to clinch the diagnosis of GDM.
– Another option is to just have all patients take
the 100 g glucose tolerance test which will be
diagnostic.
 100-G OGTT
(CUTOFFS BASED ON CARPENTER & COUSTAN)

Status mg/dL

Fasting 95

1 hour 180

2 hours 155

3 hours 140
 BLOOD GLUCOSE TESTING
+ For patients with low risk, blood glucose
testing is not routinely recommended if:
– Member of ethnic group with low prevalence of
GDM
– No known DM in first degree relatives
– Age < 25 years
– Weight normal before pregnancy
– Weight normal at birth
– No history of abnormal glucose metabolism
– No history of poor obstetrical outcome
 BLOOD GLUCOSE TESTING
+ For patients with average risk assessment,
they are asked to have blood glucose
evaluated at around 24 – 28 weeks of
pregnancy (if no record of glucose
intolerance beforehand).
+ If the patient is high risk, this should be done
as soon as possible and repeated at 24-28
weeks of pregnancy or any time the patient
shows symptoms of hyperglycemia.
 FASTING OR POST PRANDIAL
PLASMA GLUCOSE MONITORING
+ Diet-treated GDM monitored with
glucometers daily are linked in studies of
Hawkins in 2009 to less incidence of
macrosomia in infants as compared to those
having weekly glucose measurements
evaluated at the clinic only.
+ Post Prandial Plasma Glucose monitoring
has been shown to be superior to fasting
plasma glucose monitoring in the study of
Deveciana and colleagues (1995).
 GLUCOSE MONITORING
+ Advise pregnant women with diabetes to
monitor fasting blood glucose (in the morning)
and 1 hr after every meal.
+ Women being treated with insulin should
check their blood glucose before sleeping at
night.
+ Additional: DM type 1 patients should be
offered ketone test strips and use them if they
become hyperglycemic or unwell.
 ROUTINE LABS
+ CBC (with platelet count)
+ Blood typing
+ UA
+ HBsAg
+ Khan VDRL
+ Pap smear
+ Additional: 24h urinary protein collection, BUN/Crea,
Uric Acid, ALT/AST, LDH, electrolytes, peripheral
blood smear, coagulation profile
 RETINAL ASSESSMENT
+ Pregnant women with DM should have retinal
assessment at the first prenatal clinical consult
and 28 wk after if normal. If retinopathy is
found, reassess at 16-20 wk after.
 RENAL ASSESSMENT
+ If a pregnant diabetic patient has not had
renal assessment for the past 12 mo, do renal
assessment of serum creatinine or 24 hr.
urine protein at first contact.
+ Refer to a nephrologist if CPK >120 uM/L or
urinary protein >2 g/d.
 ULTRASOUND
+ To check for fetal wellbeing
+ Assessing any growth restriction
+ To evaluate amniotic fluid volume
 ULTRASOUND
+ Fetal Biometry: crown-lump length, biparietal
diameter, head circumference, abdominal
circumference, femur length; every 10—14 d.
+ Congenital anomaly scan: usually done at 20
wk AOG
+ Biophysical profile: measure fetal tone,
movement, breathing, amniotic fluid volume,
non-stress test; 1-2x/wk.
 ULTRASOUND
+ Doppler flow studies: to assess blood flow and
vascular resistance in the uteroplacental &
fetal circulations; at least 1x/wk, 2x/wk if with
complications
ELECTRONIC FETAL HEART RATE
MONITOR
+ NST (as part of the BPP)
+ CST (if with indications for delivery in patients
who are not in labor)
 WHEN TO START?
+ Initial testing at 32-34 wk AOG
+ 26-28 wk AOG if particularly worrisome high-
risk conditions
+ Upon diagnosis of medical or fetal
complications
+ PGH: 28 wk AOG
FOLLOW-UP AND ADVICE
Pre-eclampsia
 FOLLOW-UP: PREECLAMPSIA
+ Pre-natal exams every 4 weeks during the 1st
and 2nd trimesters
+ 3rd trimester: check-ups minimally at 7-day
intervals (Ideal: Every 3-4 days)
+ If overt HPN (> 140/90 mmHg), proteinuria,
headache, visual disturbance, or epigastric
discomfort develop, admit for 2-3 days to
determine if due to preeclampsia and to
assess severity.
 HOSPITALIZATION:
PREECLAMPSIA
The following should be assessed:
+ Admittance weight, and weight everyday thereafter
+ Admittance analysis for proteinuria, and analysis at
least every 2 days thereafter.
+ Sitting BP readings every 4 hours except between
midnight and morning.
+ Plasma or serum creatinine, hematocrit, platelets,
and liver enzymes.
+ Frequent monitoring of fetal size and amniotic fluid
volume.
+ Detailed PE and assessment for headache, visual
disturbances, epigastric pain, and rapid weight gain.
PREECLAMPSIA: COMPLICATIONS
+ Maternal Complications
– HELLP Syndrome (Hemolysis, Elevated Liver Enzymes, Low
Platelet)
– Placental Abruption
– Pulmonary Edema
– Acute Renal Failure
– Eclampsia
– Rarely, cerebral edema, confusion, obtundation, coma
+ Fetal Complications
– Small for gestational age
– Perinatal mortality
 ADVICE
+ No need for absolute bed rest and
tranquilizers
+ Sedentary activity for most of the day
+ Home BP, weight and urine protein
monitoring
+ Diet should include adequate protein and
calories
+ Do not limit sodium and fluid intake
+ Instruct mother to monitor and report her
symptoms properly
PREECLAMPSIA: COMPLICATIONS
+ Maternal Complications
– HELLP Syndrome (Hemolysis, Elevated Liver Enzymes, Low
Platelet)
– Placental Abruption
– Pulmonary Edema
– Acute Renal Failure
– Eclampsia
– Rarely, cerebral edema, confusion, obtundation, coma
+ Fetal Complications
– Small for gestational age
– Perinatal mortality
FOLLOW-UP AND ADVICE
Gestational Diabetes Mellitus
 FOLLOW-UP: GESTATIONAL
DIABETES MELLITUS
+ Prenatal Examinations:
– Every 2 weeks until 32 weeks
– Every week thereafter
+ Daily postprandial self blood glucose monitoring
– Fewer macrosomic infants
– Gained less weight
– Fewer cases of neonatal hypoglycemia
– Fewer cases of shoulder dystocia
 FOLLOW-UP: GESTATIONAL
DIABETES MELLITUS
+ Postpartum Evaluation:
– Fasting or random plasma glucose 1-3 days after
delivery
– 75-g 2-hr OGTT 6-12 weeks postpartum
– 75-g 2-hr OGTT 1 yr postpartum
– 75-g 2-hr OGTT trianually
– Fasting plasma glucose anually
– 75-g 2-hr OGTT prepregnancy
 ADVICE: GESTATIONAL DIABETES
MELLITUS
+ Diet:
– Avoid single large meals and foods rich in
simple carbohydrates.
– Preferred: 6 feedings per day – 3 meals and 3
snacks
+ Proper exercise
– Can improve cardiorespiratory fitness
– Can reduce the need for insulin
 REFERENCES
+ Cunningham et al. (2010). Williams Obstetrics, 23rd ed.
USA: McGraw-Hill Companies. Chapters 34 and 52.
+ DeVeciana M, Major CA, Morgan M, et al: Postprandial
versus preprandial blood glucose monitoring in women
with gestational diabetes mellitus requiring insulin
therapy. N Engl J Med 333:1237, 1995 
+ Hawkins JS, Casey BM, Lo JY, et al: Weekly compared
with daily blood glucose monitoring in women with
diet-treated gestational diabetes. Obstet Gynecol
113(6):1307, 2009 
THANK YOU.
 REFERENCES
+ Cunningham et al. Williams Obstetirics. 23rd edition. USA: The McGraw-Hill Compaines: 2010.
+ Namak S, Lord RW Jr, Zolotor AJ, Kramer R. Clinical inquiries: which women should we screen for
gestational diabetes mellitus? J Fam Pract. 2010 Aug;59(8):467-8.
http://www.ncbi.nlm.nih.gov/pubmed/20714459
+ Hunsberger M, Rosenberg KD, Donatelle RJ. Racial/ethnic disparities in gestational diabetes
mellitus: findings from a population-based survey.Womens Health Issues. 2010 Sep;20(5):323-8.
http://www.ncbi.nlm.nih.gov/pubmed/20800768 (accessed on Nov. 22, 2010)
+ Karcaaltincaba D, Buyukkaragoz B, Kandemir O, Yalvac S, Kıykac-Altınbaş S, Haberal A. Gestational
Diabetes and Gestational Impaired Glucose Tolerance in 1653 Teenage Pregnancies:
Prevalence, Risk Factors and Pregnancy Outcomes. J Pediatr Adolesc Gynecol. 2010 Aug 14. [Epub
ahead of print] ttp://www.ncbi.nlm.nih.gov/pubmed/20709580. (accessed on Nov. 22, 2010)
+ Al-Rowaily MA, Abolfotouh MA. Predictors of gestational diabetes mellitus in a high-parity
community in Saudi Arabia. East Mediterr Health J. 2010 Jun;16(6):636-41.
http://www.ncbi.nlm.nih.gov/pubmed/20799591 (accessed on Nov. 22, 2010)
+ Gunderson EP, Quesenberry CP Jr, Jacobs DR Jr, Feng J, Lewis CE, Sidney S. Longitudinal study of
prepregnancy cardiometabolic risk factors and subsequent risk of gestational diabetes mellitus:
The CARDIA study. Am J Epidemiol. 2010 Nov 15;172(10):1131-43. Epub 2010 Oct 7.
http://www.ncbi.nlm.nih.gov/pubmed/20929958 (accessed on Nov. 22, 2010)