Learn about symptoms, treatments, diet, prevention, and more. Obesity is a condition in which you have too much body fat for your height.

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Many people with gestational diabetes are able to deliver their babies at full term of 39—40 weeks. But that delivery may be earlier if there are….

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A Quiz for Teens Are You a Workaholic? How Well Do You Sleep? Health Conditions Discover Plan Connect. Gestational Diabetes Test: What to Expect. Medically reviewed by Holly Ernst, PA-C — By Corey Whelan on June 25, Symptoms Causes Risk factors Preparation and procedure Diagnosis Treatments Complications Outlook Prevention What is gestational diabetes?

What are the symptoms of gestational diabetes? Many women who have gestational diabetes have no symptoms. What causes gestational diabetes? The exact cause of gestational diabetes is unknown, but it may be due to hormones your placenta produces.

These hormones help your baby grow, but they can also stop insulin from doing its job. The sugar is then unable to convert into energy in the cells.

This is called insulin resistance. This causes the blood sugar levels to increase. What are the risk factors for gestational diabetes? Any pregnant woman can get gestational diabetes. Gestational diabetes affects about 2 to 10 percent of pregnancies.

Certain factors might increase your risk and require you to get tested during the first prenatal visit. Your doctor may also test you several times afterward.

The risk factors include: having obesity being more than 25 years old having a family history of diabetes having a history of gestational diabetes during a previous pregnancy gaining a significant amount of weight in early adulthood and between pregnancies gaining an excessive amount of weight while pregnant being pregnant with multiples, such as twins or triplets having a previous delivery of a baby who weighted more than 9 pounds having high blood pressure having polycystic ovary syndrome PCOS taking glucocorticoids.

What happens during the test? Doctors use different types of screening tests. Many doctors use a two-step approach, starting with the glucose challenge test. This test determines your likelihood of having the disorder. Afterward, you drink an 8-ounce glass of glucose solution. Your doctor measures your glucose levels once per hour for the next three hours.

How long will it take to receive a diagnosis? If two of the measurements show high blood sugar, your doctor will diagnose gestational diabetes. Some doctors skip the glucose challenge test and only perform the glucose tolerance test. Talk to your doctor about which protocol makes sense for you.

What are the treatment options for gestational diabetes? If you have gestational diabetes, your doctor will monitor your condition frequently. During pregnancy, you may also self-monitor at home. You can use a tiny needle called a lancet to prick your finger for a droplet of blood.

You then analyze the blood using a blood glucose monitor. People usually perform this test when they wake up and after meals. Learn more about diabetes home tests. According to the Mayo Clinic, between 10 and 20 percent of pregnant women with gestational diabetes need this type of help to bring their blood sugar down.

Your doctor may also prescribe oral medication to control your blood sugar. What are the complications of untreated gestational diabetes? What is the outlook for people with gestational diabetes? Gestational diabetes usually goes away after delivery.

Eating right and exercising continue to remain important for your health after delivery. Choose foods high in fiber and low in fat for the both of you. You should also avoid sugary sweets and simple starches whenever possible. Although care was taken not to include the period within 5 days of antenatal steroid administration when calculating the percent fall in insulin dosing in this study, the substantially higher antenatal steroid use in the pregnancies with falling insulin requirements However, caution is required in the interpretation of these retrospective studies since decreasing insulin requirements may impact decisions regarding timing of delivery which may, in turn, impact pregnancy outcomes.

In contrast, results from other studies found no association with decreasing insulin requirements and birthweight, and neonatal weight distribution i. SGA to LGA However, 1 study observed a trend for greater LGA neonates in women with decreasing insulin requirements Caution is required when interpreting the findings as researchers used differing calculation methods to indicate fall in insulin requirements or perhaps due to heterogeneity in the population of women with type 2 diabetes included in the studies.

The use of advanced sonographic and fetal doppler assessment in the surveillance of the fetus at risk, as in other high-risk pregnancies, may allow further stratification of risk in this population, but the optimal indicator of feto-placental compromise, particularly in women with diabetes, remains unclear.

In summary, the impact of decreasing insulin requirements is still not certain. While fetal monitoring in this situation can provide reassurance of current fetal well-being, it should not be viewed as a substitute for a well thought out plan for timing of delivery that takes into consideration other risks for perinatal mortality, such as gestational age, maternal glycemic control both periconception and in later pregnancy , prepregnancy retinopathy 77 , maternal age, obesity and smoking history.

The goal of fetal surveillance and planned delivery in women with pre-existing diabetes in pregnancy is the reduction of preventable stillbirth. However, not all stillbirths can be avoided due to the fact that many stillbirths in pre-existing diabetes occur prior to 36 weeks of gestation and that in a large number of cases no obvious cause is noted Despite this, it is reasonable to apply surveillance strategies to pre-existing diabetes pregnancies that are similar to those in other pregnancies at high risk of fetal complications, such as intrauterine growth restriction IUGR , chronic hypertension, and systemic lupus erythematosis Although there is no single strategy for antenatal surveillance for pre-existing diabetes pregnancies, the initiation of some form of fetal surveillance in all women with pregnancies complicated by pre-existing diabetes while applying more intensive protocols for fetal surveillance in pregnancies with additional risk factors is required.

These risk factors include: evidence of poor glycemic control, prepregnancy retinopathy 77 , LGA, polyhydramnios or the presence of other comorbidities or high-risk conditions hypertension, obesity, late maternal age, IUGR, previous stillbirth.

As a general rule, intensified fetal surveillance should begin at a period in gestation when intervention i. delivery is possible and acceptable to both the parents and the neonatal care providers.

For GDM, fetal surveillance and timing of delivery are more complex as there is less evidence for increased perinatal mortality in this group. This is likely due to the fact that the risk for perinatal mortality is probably limited to the subgroup of women with poor glycemic control, inclusion of women with pre-existing diabetes in GDM cohorts, obesity and other comorbidities and the rarity of these events.

However, a large retrospective cohort showed an increased risk of stillbirth in women with GDM between 36 to 39 weeks of gestation unadjusted OR 1.

Based on the large dataset, a relative risk was calculated of expectant management compared with induction of labour, while taking into consideration both the risk of stillbirth expectant management and infant death expectant management and induction of labour and showed a significant increased risk of stillbirth with expectant management at both 39 and 40 weeks of gestation when compared with induction of labour.

As the absolute risk difference was small, the number needed to deliver to prevent 1 excess perinatal death was estimated as 1, at 39 weeks' gestation and 1, at 40 weeks' gestation. However, this study is limited by unadjusted confounders, including adequacy and method of glycemic control as well as obesity, thus limiting the generalizability of the study.

There are additional potential benefits of induction of labour in diabetic pregnancies, including reduction of excess fetal growth, shoulder dystocia and caesarean section rate. One randomized controlled trial compared induction of labour with expectant management of labour at term In this trial of insulin requiring GDM and pre-existing diabetes in pregnancies, expectant management after 38 weeks of gestation was associated with increased birthweight and macrosomia, but no change in caesarean section rate.

A recent retrospective cohort study from Ontario supports these findings, showing a significant reduction in caesarean section rate at both 38 and 39 weeks of gestation in women with GDM who underwent induction of labour when compared with those that underwent expectant management Conversely, induction of labour at 38 but not 39 weeks was associated with an increase in NICU admission.

Importantly, these results remained significant after adjusting for important confounders, including parity, insulin treatment and BMI. Two recently published randomized controlled trials shed additional light on this clinical question.

The study found no difference in caesarean section rates between groups, but an increase in hyperbilirubinemia was noted in the IOL group.

However, the study was underpowered and discontinued due to recruitment difficulties; thus any extrapolations from the study cannot be made In summary, there is a paucity of quality evidence to guide clinical decisions regarding optimal fetal surveillance and timing of delivery in diabetic pregnancies.

Clinical identification of increased risk of stillbirth should be the target of prenatal care and lead to an individualized approach to defining the appropriate regimen of fetal surveillance and timing of delivery. In pre-existing diabetes, poorly controlled GDM or pre-existing diabetes in pregnancy associated with comorbidities, initiation of weekly assessment of fetal well-being at 34 to 36 weeks gestation is recommended.

Acceptable methods of assessment of fetal well-being near term can include the nonstress test, amniotic fluid index, biophysical profile or a combination of these. When making decisions regarding timing of delivery before 40 weeks' gestation, the benefits with regards to prevention of stillbirth and a possible decrease in the caesarean rate need to be weighed against the likely increase in neonatal complications.

Planning insulin management during labour and delivery is an important part of care and must be adaptable given the unpredictable combination of work of labour, dietary restrictions and need for an operative delivery.

The goal is to avoid maternal hypoglycemia while preventing significant hyperglycemia which, in turn, may increase the risk of neonatal hypoglycemia Options for peripartum BG control include watchful waiting until BG rises above a specified threshold e.

In a retrospective study of consecutive women with type 1 diabetes, women who chose to continue on CSII during labour had better glycemic control than women using CSII during pregnancy but who chose to convert to intravenous insulin infusion during labour. There was no increase in maternal hypoglycemia, suggesting that the continuation of CSII during labour and delivery appears safe and efficacious Similarly, another retrospective study found that women using CSII had excellent glycemic control without hypoglycemia Observational studies comparing the use of CGM to SMBG during labour and delivery identified improved glycemic control with CGM , ; however, neonatal hypoglycemia was comparable between groups , Each centre should establish protocols which include BG targets, monitoring frequency, insulin regimen and intravenous glucose, based on nursing, medical and anaesthesia expertise available, and patient choice , Postpartum care in women with pre-existing diabetes should include counselling on the following issues: 1 rapid decrease in insulin needs and risk of hypoglycemia in the immediate postpartum period; 2 risk of postpartum thyroid dysfunction in the first months; 3 benefits of breastfeeding; 4 contraceptive measures and; 5 psychosocial assessment and support during this transition period.

Diabetes management and insulin sensitivity immediately postpartum. In women with type 1 and type 2 diabetes, insulin requirements decrease rapidly immediately after the delivery of the placenta — However, a nonsignificant trend toward lower requirements in exclusively breastfeeding mothers compared to partial or full formula feeding was also noted A gradual return to pre-pregnant insulin doses has been noted after 6 to 8 weeks postpartum in some studies , ; however, another study found persistently reduced insulin needs up to 4 months postpartum In some studies, reduced insulin needs have been especially noted in women with type 1 diabetes who were breastfeeding , , although this has not been universally observed Nevertheless, most clinicians advise women with type 1 diabetes who are breastfeeding of the potential increased risk of hypoglycemia, especially during night breastfeeding.

Thus, for women with pre-existing diabetes in pregnancy, a post-delivery plan for reduced prepregnant insulin dosages, pump settings or noninsulin antihyperglycemic agents should be discussed with the woman and recorded before delivery.

Evidence suggests that despite good glycemic control during pregnancy, continuous weight loss, as well as substantial diabetes education and follow up during pregnancy and in the first months postpartum, glycemic control is managed less effectively by mothers with diabetes in the first year postpartum, and A1C levels gradually increase and return to the pre-pregnancy level , Postpartum A1C levels are positively associated with pre-pregnancy BMI and postpartum weight retention in type 1 diabetes In addition, most women are unable to return to prepregnancy weight Improved postpartum care and specific interventions for women with pre-existing diabetes should be developed to help women achieve their target weight postpartum , , to improve glycemic control in the first year postpartum and to increase breastfeeding rates Risk of postpartum thyroid dysfunction.

Women with type 1 diabetes are at high risk for autoimmune thyroid disease and, consequently, postpartum thyroid dysfunction. Screening for thyroid hormonal abnormalities during pregnancy and at approximately 3 months postpartum in women with type 1 diabetes is recommended.

Lower rate and difficulties around delayed lactation in women with diabetes. A Canadian group demonstrated that women with pre-existing diabetes were less likely to initiate breastfeeding compared with noninsulin-treated mothers with diabetes, GDM women and mothers without diabetes Concordant with other studies , , women with all types of diabetes in pregnancy GDM, pre-existing, insulin-treated or noninsulin-treated in this study had also lower rates of exclusive breastfeeding in hospital and on discharge.

However, women with pre-existing diabetes were disproportionately affected and had lower rates of breastfeeding , Lower education and maternal age less than 25 years of age were risk factors associated for lower rates of breastfeeding and exclusive breastfeeding postpartum Women with pre-existing diabetes tend to have delayed milk production.

There is a greater delay in lactation onset in mothers with type 1 diabetes who had poor glycemic control Women with type 1 diabetes also discontinue breastfeeding at a higher rate during the first week postpartum — Overall, women with any form of diabetes during pregnancy have more nursing difficulties with lower milk supply than women without diabetes However, once established, lactation persists and duration is similar in mothers with and without diabetes , There are several pathophysiologic and behavioural explanations for lower breastfeeding rates in women with diabetes.

Poor glycemic control, insulin resistance, obesity and impaired bonding between mother and child caused by obstetrical complications such as NICU admission, prematurity, caesarean section are the major factors associated with delayed lactation It has been demonstrated that ideal glucose and insulin levels are necessary for lactation Good glycemic control enhances maternal serum and milk prolactin concentrations and decreases the delay in the establishment of lactation that has been observed in mothers with type 1 diabetes , Moreover, infants of mothers with diabetes showed poorer and immature sucking patterns contributing to the difficulties to breastfeed for those mothers in the first days postpartum Protective factors associated with both higher rates of intention to breastfeed and exclusive breastfeeding included attending antenatal classes and having antenatal care delivered by a health-care provider other than an obstetrician.

Indeed, women who received antenatal care from a family physician or other health-care providers were respectively 2 and 3 times more likely to exclusively breastfeed Patient education with prenatal information and postnatal counselling on breastfeeding have been shown to lead to similar breastfeeding rates in women with type 1 diabetes as the population without diabetes Use of noninsulin antihyperglycemic agents during breastfeeding.

Few studies have examined breastfeeding and the use of noninsulin antihyperglycemic agents. A study looking at weight, height and motor-social development up to 6 months of age in children of mothers taking metformin while breastfeeding showed normal development and no difference from formula-fed infants Although metformin and glyburide can be considered for use during breastfeeding, further long-term studies are needed to better clarify the safety of these drugs.

Finally, there are no human studies to date looking at thiazolidinedione TZD , glucagon-like polypeptide-1 GLP-1 receptor agonist, dipeptidyl peptidase-4 DPP-4 inhibitor or sodium-glucose cotransporter-2 SGLT2 inhibitor use while breastfeeding and, therefore, they should not be taken during breastfeeding.

Use of insulin and newer insulin analogues during breastfeeding. There is no contraindication for women with diabetes treated with insulin to breastfeed Exogenous insulins are excreted into breastmilk, including newer insulin analogues i. aspart, detemir, glargine, glulisine, lispro.

Insulin is a normal component of breastmilk , and similar levels were found in the milk of women with type 1 diabetes, type 2 diabetes and women without diabetes, suggesting an active transport of endogenous and exogenous insulin into breastmilk Insulin normally found in breastmilk of mothers with or without diabetes is thought to be required for intestinal maturation of the infant and could act as a positive modulator of the immune response to insulin as suggested by certain groups — Benefits of breastfeeding.

Breastfeeding immediately postpartum can be part of an early feeding strategy to reduce the risk of neonatal hypoglycemia in women with diabetes Breastfeeding for more than 4 months has also been shown to be protective against the development of diabetes OR 0.

It was previously thought that early introduction of cow's milk protein could be involved in the development of beta cell autoimmunity in infants at risk for type 1 diabetes.

However, a randomized trial comparing the use of a hydrolyzed formula with smaller foreign proteins, compared with a conventional formula containing cow's milk protein, did not reduce the incidence of diabetes-associated autoantibodies 7 years after exposure in offspring with genetic susceptibility to type 1 diabetes and a family member with type 1 diabetes.

These data do not support a short-term benefit from the use of hydrolyzed formula but a longer effect on disease prevalence is under study see Reducing the Risk of Developing Diabetes chapter, p.

Finally, along with other known benefits of breastfeeding for mother and child, although not specific to women with pre-existing diabetes, there is evidence that breastfeeding is a significant protective factor against obesity in children — In summary, women with pre-existing diabetes should be encouraged to breastfeed immediately after delivery and for at least 4 months postpartum, as it may contribute to the reduction of neonatal hypoglycemia, offspring obesity and prevent the development of diabetes.

Furthermore, exclusive breastfeeding up to 6 months and continuation of breastfeeding up to 2 years with appropriate complementary feeding has shown further benefits and is currently recommended for all women by the Canadian Paediatric Society , Health-care providers should pay particular attention to promoting breastfeeding in women with diabetes , , especially in the context of maternal obesity, since this high-risk population has the lowest rates of breastfeeding despite demonstrated benefits for mother and child.

Attention should be paid, however, to potential increased risk of hypoglycemia, especially during night feeding, in breastfeeding women with type 1 diabetes.

Effective contraception is an important consideration until proper preparation occurs for a subsequent pregnancy in women with pre-existing diabetes. Regarding the choice of a contraceptive method, the same motivations and restrictions apply to women with type 1 and type 2 diabetes as with other women.

Evaluation includes discussing women's preferences for a contraceptive method that will ensure compliance. Absolute and relative contraindications to estrogen breastfeeding, high BP, and microvascular and CV diabetes-related complications or to an intrauterine device IUD also apply. The progesterone-only contraceptive and IUD are safe with breastfeeding The incidence of GDM is increasing worldwide.

The global prevalence of hyperglycemia during pregnancy has been estimated at There is a need for an effective and acceptable intervention that will prevent the development of GDM. Such an approach has the potential to improve maternal and child health, with significant savings to the health-care system.

Understanding the pathophysiology of GDM and its risk factors is important for the development of preventive strategies. The GDM population includes a heterogeneous group of women with different metabolic profiles when exposed to pregnancy hormones. Various presentations include:.

As insulin sensitivity decreases substantially with pregnancy , not all cases of GDM can be prevented. Studies need to focus on identifying the potential groups of women who can benefit from preventive interventions and adapt such strategies to their condition e.

preconception vs. during pregnancy, women with obesity or leanness. Considering the heterogeneity of GDM, it seems obvious that tailored recommendations will emerge for each identified group of at-risk women. More than 30 randomized controlled trials on GDM prevention have been reported. The interventions tested to date include different diets sometimes combined with diverse physical activity plans, vitamin D supplements, myo-inositol, probiotics and metformin.

However, only 3 interventions have demonstrated a significant risk reduction for GDM to date. Effective measures included healthy eating, myo-inositol supplementation and probiotic treatment. Among evaluated interventions, diet-based interventions appear to show the most potential for preventing GDM, especially when directed toward women with overweight or obesity as demonstrated in 3 meta-analyses — Interventions evaluated and compared to standard care included diet, physical activity alone, lifestyle changes diet and physical activity and metformin.

Dietary interventions were associated with a statistically significant lower incidence of GDM OR 0. There was no statistically significant difference in the incidence of GDM or in the secondary outcomes with physical activity alone, lifestyle changes diet and physical activity or metformin use compared to standard care.

In the 3 randomized controlled trials focusing on diet, a total of women were included, with comparable mean maternal age and mean BMI Healthy eating intervention consisted of a consultation with a trained dietitian, weighing at each antenatal visit and review of food records, but the duration and number of sessions differed among studies.

In the second meta-analysis , there was a trend toward a reduced risk of GDM in diet-based intervention groups, but a significant reduction in GDM was noted again in subgroup analysis of pregnant women with obesity or overweight RR 0.

Finally, the composition of protein content of daily meals may be important as a large prospective cohort study demonstrated that an increased prepregnancy intake of animal protein, in particular red meat, was significantly and positively associated with GDM risk, while vegetable protein intake, specifically nuts, was significantly and inversely associated with GDM risk Mixed-approach interventions, including diet, physical activity and lifestyle modifications, do not appear to prevent GDM in some studies ,, but seem effective in a recent meta-analysis when introduced before 15 weeks of gestation ; methodological problems with this study involving the inclusion of studies of diet alone and physical activity alone make this conclusion less reliable and in need of confirmation by further analyses.

It can be argued that the complexity of healthy behaviour interventions, the variability of adherence and delay before introduction, as well as the heterogeneity of the maternal metabolic profile and diagnostic criteria in GDM are the main factors that may explain the discrepancies seen and inconclusive evidence for healthy behaviour interventions.

Finally, results of meta-analyses on interventions based solely on physical activity programs to prevent GDM are not impressive small protective effect [] vs. nonsignificant impact [] and studies seem often underpowered with suspected low protocol adherence.

Studies looking at metformin use for GDM reduction in women with obesity and with PCOS have not shown benefit. Moreover, studies are currently insufficient to support clear clinical recommendations regarding vitamin D supplementation in pregnancy to prevent GDM. Only 3 of 8 observational studies and 1 meta-analysis demonstrate a significant inverse relationship between risk of GDM and maternal vitamin D status.

Also, incidence of GDM and other obstetrical outcomes were not influenced by vitamin D supplementation Overall, there is currently limited evidence to support lifestyle, physical activity interventions, metformin or vitamin D supplements for GDM prevention.

Probiotics combined with diet and myo-inositol have shown benefit for GDM prevention , but these nutritional supplements were assessed in only 1 trial each.

Moreover, probiotics did not show an impact on glycemic control in GDM women, but attenuated the normal pregnancy-related rise in low-density lipoprotein cholesterol LDL-C levels in the third trimester However, those studies have been conducted by only 1 research group, with small sample sizes and these results have not been replicated.

Before any further recommendations are made for probiotics or myo-inositol supplements for GDM prevention, large randomized trials are needed. Finally, a recent meta-analysis demonstrated that excessive GWG, occurring in the first and second trimester, increased the risk of GDM by a factor of 1.

On the other hand, a decrease in inter-pregnancy BMI in women with overweight or obesity significantly decreases their risk of developing GDM in their second pregnancy, reinforcing the importance of a healthy diet and lifestyle during the preconception period for women with overweight or obesity Along these lines, bariatric surgery is becoming increasingly common for the treatment of obesity, and studies looking at pregnancy outcomes following bariatric surgery have found both benefits decreased GDM, hypertensive disorders, LGA infants but also some adverse outcomes SGA infants, preterm deliveries and NICU admissions As suggested by most experts and the British Obesity and Metabolic Surgery Society , , women should delay pregnancy at least 12 to 18 months after bariatric surgery to limit adverse pregnancy outcomes and allow weight stabilization and replenishing of all vitamins and microelement deficiencies before conception.

A study on children born before and after maternal surgical weight loss demonstrated reduced obesity rate and improved cardiometabolic profiles during childhood and adolescence in offspring born after maternal bariatric surgery, positioning bariatric surgery as 1 of the potential options to limit intergenerational transmission of obesity In summary, evidence is limited but current literature suggests that the only effective GDM preventive measure in early pregnancy that can be considered in high-risk women, especially prepregnant women with obesity, is a healthy diet and close follow up of weight gain to prevent excessive GWG.

Nutritional supplements, such as probiotics and myo-inositol, have shown some encouraging results, but these need to be replicated in larger randomized trials. Early screening. Screening for diabetes in the first trimester should be considered for diagnosing overt diabetes diabetes present before pregnancy in women who are at risk see Screening for Diabetes chapter, p.

S16 , including those with a history of previous GDM. The ability to predict abnormal results on glucose screening tests at 24 to 28 weeks and risk of continued dysglycemia postpartum are other, but less compelling, reasons cited to screen in the first trimester.

The test of choice for early screening should be based primarily on the ability to predict poor obstetrical outcomes, which may be modifiable by lifestyle or pharmacological intervention.

To apply nonpregnant FPG or A1C criteria in early pregnancy does not take into account that both decrease early in pregnancy and may lead to underdiagnosis in women with pre-existing diabetes.

On the other hand, there has been no rigorous validation that criteria accepted for the diagnosis of GDM in the second or third trimester are appropriate for use in the first trimester.

First trimester FPG levels are associated with macrosomia and increased caesarean section rates, as well as an increased risk of second-trimester diagnosis of GDM. This suggests that first trimester FPG is not reliable for predicting second-trimester GDM.

First-trimester A1C has been used to predict risk of poor obstetrical outcomes, later development of GDM and persistence of postpartum dysglycemia. In 1 study of 16, women screened at a median of 47 days gestation, there were higher rates of major congenital anomalies RR 2.

A retrospective cohort study of 2, women compared first trimester A1C to week OGTT and found that an A1C of 5. Another recent study in a multiethnic population of 1, women who underwent first trimester A1C and to week 2-stage glucose tolerance test, 48 out of 1, had an A1C of 5.

However, an elevated first trimester A1C shows a low sensitivity Combining a first trimester FPG of 5. Although consideration can be given to treatment of women with A1C 5. In 1 small cohort study, early intervention appeared to lower the risk of preeclampsia If an OGTT is performed before 24 weeks of gestation and is negative by the thresholds used to diagnose GDM after 24 weeks, this test needs to be repeated between 24 to 28 weeks.

Finally, all women with diabetes diagnosed during pregnancy, whether diagnosed in the first trimester or later in pregnancy, should be retested postpartum.

As previously outlined in the Canadian Diabetes Association Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada CPG , Diabetes Canada continues to support universal screening and diagnosis of GDM based on large randomized control trials and meta-analyses demonstrating that treatment of women with GDM reduces fetal overgrowth, shoulder dystocia and preeclampsia 85,— Justification for supporting universal screening for GDM is outlined in detail in the CPG Assuming universal screening, the method of screening can be either a sequential 2-step or a 1-step process.

Methods for sequential screening include the use of glycosuria, A1C, FPG, random plasma glucose RPG and a glucose load. Aside from the glucose load, all the other methods mentioned have not been adopted due to their poorer performance as screening tests in most populations — The performance of the GCT as a screening test depends on the cut-off values used, the criteria for diagnosis of GDM and the prevalence of GDM in the screened population.

Results from a Canadian prospective study show that sequential screening is associated with lower direct and indirect costs while maintaining equivalent diagnostic power when compared with 1-step testing. Recent observational data demonstrated the feasibility and good uptake of the 2-step approach An additional question is whether there is a GCT threshold above which GDM can be reliably diagnosed without continuing to the diagnostic OGTT.

Since there is no clear glucose threshold above which pregnancy outcomes responsive to glycemic management occur ,, , controversy persists as to the best diagnostic thresholds to define GDM.

The International Association of the Diabetes and Pregnancy Study Groups IADPSG Consensus Panel decided to create new diagnostic thresholds for GDM based on data from the Hyperglycemia and Adverse pregnancy Outcome HAPO study.

IADPSG thresholds are the maternal glucose values from HAPO associated with a 1. These arbitrary thresholds, when applied to the HAPO cohort, led to a GDM incidence of However, since this publication, national organizations have published guidelines that are divergent in their approach to screening and diagnosis of GDM — , thus perpetuating the international lack of consensus on the criteria for diagnosis of GDM.

However, it was recognized that the IADPSG 1-step strategy has the potential to identify a subset of women who would not otherwise be identified as having GDM and could potentially benefit with regards to certain perinatal outcomes.

As outlined in the CPG, those who believe that all cases of hyperglycemia in pregnancy need to be diagnosed and treated i.

increased sensitivity over specificity will support the use of the 1-step method of GDM diagnosis. LGA rate and birth weight progressively increased with more dysglycemia and were increased in both groups.

However, in this study, only women who were positive by HAPO 2. Figure 1 Preferred approach for the screening and diagnosis of gestational diabetes. Figure 2 Alternative approach for the screening and diagnosis of gestational diabetes.

Since the publication of the IADPSG consensus thresholds, there have been numerous retrospective studies that have examined the impact of adoption of these criteria. It is difficult to apply the results of these studies to clinical practice due to their retrospective nature and the wide variation in the comparison groups used.

In all of these studies, adoption of IADPSG criteria has led to an increase in the number of cases diagnosed while the impact on perinatal outcomes is inconsistent — Studies comparing pregnancy outcomes before and after changing from a variety of different GDM diagnostic criteria to the IADPSG criteria show differing results.

LGA was lower in 1 study and caesarean delivery was lower in several studies , after adoption of the IADPSG criteria.

However, others did not find reductions in LGA ,,, , and 1 study found an increase in primary caesarean section rate Given this lack of evidence, it is possible that the decision regarding the recommended screening method will be determined by the economic implications on health-care resources.

Decision analysis modelling studies done in other countries ,— have yielded a variety of results and many are of questionable applicability in the Canadian setting because of differing cost and screening and diagnostic strategies. A small observational study from Ireland suggested that maternal BMI may be an important consideration in choice of which diagnostic thresholds to use Furthermore, secondary analysis of the Landon et al trial, that used a 2-step screening approach, found that GDM therapy had a beneficial effect on fetal growth only in women with class 1 and 2 obesity and not in women with normal weight or with more severe obesity Further higher-quality evidence would be helpful in establishing if maternal BMI and other clinical risk factors should guide which diagnostic thresholds are used.

Most cost analysis evaluations support a sequential screening approach to GDM. Therefore, adequately powered prospective studies to compare these 2 approaches are needed. Since pregnancy may be the first time in their lives that women undergo glucose screening, monogenic diabetes may be picked up for the first time in pregnancy.

Monogenic diabetes first diagnosed in pregnancy should be suspected in the women with GDM who lack risk factors for GDM and type 1 diabetes and have no autoantibodies see Definition, Classification, and Diagnosis of Diabetes, Prediabetes and Metabolic Syndrome chapter, p.

A detailed family history can be very helpful in determining the likely type of monogenic diabetes. This is important because the type of monogenic diabetes influences fetal risks and management considerations.

The most common forms of monogenic diabetes in Canada are maturity onset diabetes of the young MODY 2 heterozygotes for glucokinase [GCK] mutations or MODY 3 hepatocyte nuclear factor [HNF] 1 alpha mutation During pregnancy, the usual phenotype for MODY 2 of isolated elevated FBG is not always seen, even though this phenotype may be present outside of pregnancy in the same woman Fetuses without the GCK mutation of mothers with GCK mutation are at increased risk of macrosomia.

The best way to manage women with GCK mutation during pregnancy has yet to be established, but regular fetal growth assessment can aid in the establishment of appropriate glucose targets during pregnancy for women with documented or strongly suspected GCK mutations.

MODY 1 HNF4 alpha mutation has a similar phenotype to MODY 3 but is much less common. These forms of monogenetic diabetes have greater increased risk of macrosomia and neonatal hypoglycemia that may be prolonged especially in neonates that have MODY 1 HNF4 alpha mutation.

Although women with these later forms of monogenic diabetes are usually exquisitely sensitive to sulfonylureas, they should be transitioned to insulin as they prepare for pregnancy or switched to insulin during pregnancy, if this has not occurred preconception, for the same reasons as avoiding glyburide use in women with GDM.

Weight gain. The IOM guidelines for weight gain during pregnancy were developed for a healthy population and little is known regarding optimal weight gain in women with GDM. Retrospective cohort studies of GDM pregnancies show that only Those gaining more than the IOM recommendations had an increased risk of preeclampsia , caesarean deliveries , , macrosomia , , LGA — and GDM requiring pharmacological agents Modification of IOM criteria, including more restrictive targets of weight gain, did not improve perinatal outcomes of interest A large population-based study including women with GDM, concluded that while pre-pregnancy BMI, GDM and excessive GWG are all associated with LGA, preventing excessive GWG has the greatest potential of reducing LGA risk These researchers suggest that, in contrast to obesity and GDM prevention, preventing excessive GWG may be a more viable option as women are closely followed in pregnancy.

A large number of women with overweight or obesity and with GDM gain excessive weight in pregnancy , and a large proportion exceed their IOM total target by the time of GDM diagnosis A systematic review found that pregnant women with overweight or obesity who gain below the IOM recommendation, but have an appropriately growing fetus, do not have an increased risk of having a SGA infant , leading some to recommend that encouraging increased weight gain to conform with IOM guidelines will not improve maternal or fetal outcomes A Cochrane review 49 trials of 11, women was performed to evaluate the effectiveness of diet or exercise or both in preventing excessive gestational weight gain and associated adverse pregnancy outcomes Study interventions involved mainly diet only, exercise only and combined diet and exercise interventions compared with standard care.

Low glycemic load GL diets, supervised or unsupervised exercise only or diet and exercise in combination all led to similar reductions in the number of women gaining excessive weight in pregnancy.

There was no clear difference between intervention and control groups with regards to preeclampsia, caesarean section, preterm birth and macrosomia. Further studies are needed to develop weight gain guidelines for GDM patients and to determine whether weight gain less than the IOM guidelines or weight loss in pregnancy is safe.

Until this data are available, women with GDM should be encouraged to gain weight as per the IOM guidelines for the BMI category to reduce adverse maternal and neonatal outcomes and postpartum weight retention.

Nutrition therapy. Nutrition therapy is a cornerstone for managing GDM. All women at risk for or diagnosed with GDM should be assessed, counselled and followed up by a registered dietitian when possible — Nutrition therapy should be designed to promote adequate nutritional intake without ketosis, achievement of glycemic goals, appropriate fetal growth and maternal weight gain — Recommendations for nutrition best practice and a review of the role of nutrition therapy in GDM management is available.

A great variety of diets are used for managing GDM. While carbohydrate moderation is usually recommended as first-line strategy to achieve euglycemia , evidence available to support the use of a low-glycemic-index GI diet is increasing.

A randomized controlled trial of 70 healthy pregnant women, randomized to low glycemic index GI vs. a conventional high-fibre diet from 12 to 16 weeks' gestation, showed a lower prevalence of LGA without an increase in SGA in the low-GI group This led to the hypothesis that a low-GI diet may be beneficial in women with GDM.

An earlier systematic review of 9 randomized controlled trials, in which 11 different diet types were assessed within 6 different diet comparisons, did not support the recommendation of 1 diet type over another as no significant differences were noted in macrosomia, LGA or caesarean section rates However, a more recent systematic review and meta-analysis does support the use of low GI diets Only the low-GI diet was associated with less frequent insulin use and lower newborn weight without an increase in numbers of SGA and macrosomia Results of a meta-analysis of 5 randomized controlled trials and a systematic review in GDM patients showed that low-GI diets reduce the risk of macrosomia and LGA, respectively.

Low-GI diets are associated with lower postprandial blood glucoses in recent randomized controlled trials , In summary, current evidence although limited, suggests that women with GDM may benefit from following a low-GI meal pattern Physical activity. In combination with nutritional intervention, physical activity appears to be more effective for GDM management than GDM prevention.

No studies had an effect on infant birth weight or macrosomia rate and only 1 was successful in reducing GWG. It can be argued that these studies were not powered enough to demonstrate any impact on birthweight or on adverse pregnancy outcomes.

Indeed, relevant limitations for these studies include the following: samples were small mean of 43 participants per study , participants had different metabolic profiles and risks factors, and different diagnostic criteria for GDM were used. The best type of intervention that should be recommended is unclear since all the successful programs used different exercise modalities in terms of intensity, type, duration and frequency.

More recently, an initiative in India, the Wings Project, demonstrated that an intervention based on increasing total footsteps with pedometers was able to improve glycemic control in women with GDM and reduce adverse neonatal outcomes in the more active tertiles when compared to their GDM counterparts in the upper tertiles of sedentary behaviour Since no exercise-related injuries were experienced during pregnancy in all those studies, physical activity intervention seems safe to recommend.

All together, current knowledge suggests that physical activity interventions in women with GDM should be encouraged unless obstetrical contraindications exist as physical activity may be an important component of GDM management. However, identification of a specific program of physical activity that should be prescribed to GDM women is currently not possible.

Further studies are needed involving larger populations to enable the prescription of an evidence-based physical activity intervention. Glycemic control. In a systematic review of reports of BG levels in non-GDM pregnancies, normal BG levels during later pregnancy mean and 1 SD above mean were: fasting 3.

The peak postprandial BG occurred at 69±24 minutes However, it should be noted that the mean FBG derived from the total of subjects in this report was 0.

The HAPO study was the largest prospective study of glycemia in pregnancy and reported a mean FBG of 4. BG levels in pregnant women with obesity without diabetes were slightly higher than their lean counterparts in a study in which CGM was performed in early and late pregnancy after placing pregnant women with obesity or normal weight on a controlled diet Importantly, it has been demonstrated that the diagnostic OGTT values were not the best predictors of outcomes whereas CBG levels during treatment were strongly correlated to adverse pregnancy outcomes Even if BG can normally and physiologically decrease during pregnancy below the traditional level of 4.

On the other hand, recent studies have questioned the upper limit of the FBG target. Risks of maternal hypoglycemia or fetal low birth weight were not evaluated in this review and adjustment for maternal BMI and different diagnostic criteria for GDM was not performed.

Even if the frequency of SGA infants was lower across the tertile of mean maternal fasting glycemia in this study, SGA rate in women with the lowest mean FBG was not increased and was, in fact, comparable with the rate of the background population.

SGA rate was inversely correlated with maternal weight gain before assessment, suggesting that SGA could be partly prevented by adequate follow up of GWG in those women. However, large, well-conducted and randomized controlled trials comparing different BG targets are needed to directly address optimal fasting and postprandial BG targets.

Further studies should also assess the risk of maternal hypoglycemia, SGA, insulin use and cost-effectiveness of such modification. Despite reduced perinatal morbidity with interventions to achieve euglycemia in women with GDM, increased prevalence of macrosomia persists in this population.

To improve outcomes, 4 randomized controlled trials — have examined the use of fetal abdominal circumference AC as measured sonographically and regularly in the third trimester to guide medical management of GDM.

Indeed, it may be difficult to apply this flexible approach given the extreme glycemic targets that were used, the fact that routine determination of AC is not done or sufficiently reliable, and frequent ultrasounds may not be accessible to most centres.

Further analyses are needed to establish safe stricter and relaxed glycemic targets that should be recommended for women with GDM to limit LGA and SGA rates.

Frequent SMBG is essential to guide therapy of GDM , Both fasting and postprandial testing are recommended to guide therapy in order to improve fetal outcomes 89, CGMS have been useful in determining previously undetected hyperglycemia, but it is not clear if it is cost effective — Recent randomized controlled trials suggest that CGM may be of benefit in the treatment of GDM.

In a randomized trial, women were randomized to undergo blinded 3-day CGM every 2 to 4 weeks from GDM diagnosis at 24 weeks GA or routine care with SMBG Women using CGM had less glucose variability, less BG values out of the target range, as well as less preeclampsia, primary caesarean section and lower infant birthweight.

In a similar study of women with GDM, given CGM from 24 to 28 weeks or 28 weeks to delivery, excess maternal weight gain was reduced in the CGM group compared to women doing only SMBG, especially in women who were treated with CGM earlier, at 24 weeks GA A1C was lower in the CGM group but not statistically significantly different.

More studies are needed to assess the benefits of CGM in this population. In an effort to control their BG by diet, women with GDM may develop starvation ketosis.

Older studies raised the possibility that elevated ketoacids may be detrimental to the fetus 94, While the clinical significance of these findings are questionable, it appears prudent to avoid ketosis.

Use of new technologies and web-based platforms for BG monitoring in pregnant women with diabetes in Canada and worldwide is rapidly increasing. These initiatives allow for 2-way communication with women monitoring and transmitting their BG results in real time to health-care providers for feedback.

Studies have demonstrated Enhanced patient empowerment and greater satisfaction with the care received are also reported in groups using new monitoring technology —,,, However, generalizability of those studies is questionable as these studies were small, conducted in very specific settings and used different types of technologies and e-platforms.

Furthermore, acceptance of these interventions by marginalized population subgroups and in remote regions would also be important to determine. Finally, studies assessing cost effectiveness of these measures, both direct health system resources utilization and indirect work absenteeism, parking, daycare fees are needed.

Systematic reviews of the literature on the use of technology to support healthy behaviour interventions for healthy pregnant women and women with GDM , showed that good quality trials in this area are few and research on this topic is in its infancy stage.

This is evidenced by the focus on intervention acceptance measures, use of small sample sizes, lack of demonstration of causality and lack of examination of long-term effects or follow up. In summary, new technologies and telehomecare programs have so far shown encouraging results to reduce medical visits and favour patient empowerment without increasing complication rates in pregnant women with diabetes.

In an era of increased prevalence of GDM, well designed and sufficiently powered randomized controlled trials are needed to evaluate the effectiveness of technology as a tool for glucose management, healthy behaviour interventions and a way of relieving health-care system burden.

If women with GDM do not achieve BG targets within 2 weeks of initiation of nutritional therapy and exercise, pharmacological therapy should be initiated , The use of insulin to achieve glycemic targets has been shown to reduce fetal and maternal morbidity , A variety of protocols have been used, with multiple daily injections MDI being the most effective Insulin usually needs to be continuously adjusted to achieve glycemic targets.

Although the rapid-acting bolus analogues aspart and lispro can help achieve postprandial targets without causing severe hypoglycemia — , improvements in fetal outcomes have not been demonstrated with the use of aspart or lispro compared to regular insulin , see Pre-Existing Diabetes Type 1 and Type 2 in Pregnancy: Pharmacological therapy.

Glargine and detemir have primarily been assessed in women with pre-existing diabetes in pregnancy see Pre-Existing Diabetes Type 1 and Type 2 in Pregnancy: Pharmacological therapy. Randomized trial evidence suggests levemir is safe and may afford less maternal hypoglycemia compared to neutral protamine hagedorn NPH , while observational studies suggest that glargine, although theoretically less desirable, is also safe.

In several meta-analyses of randomized trials studying the use of metformin compared with insulin in women with gestational diabetes, women treated with metformin had less weight gain and less pregnancy-induced hypertension compared to women treated with insulin — Infants of mothers using metformin had lower gestational age and less neonatal hypoglycemia.

On the other hand, there was conflicting evidence regarding preterm birth, with some studies finding a significant increase with the use of metformin, while others did not.

This finding was mainly demonstrated by the Metformin in Gestational diabetes MiG trial , where there was an increase in spontaneous preterm births rather than iatrogenic preterm births. The reason for this was unclear.

While metformin appears to be a safe alternative to insulin therapy, it does cross the placenta. Results of The Offspring Follow Up of the Metformin in Gestational diabetes MiG TOFU trial, at 2 years, showed that the infants exposed to metformin have similar total fat mass but increased subcutaneous fat, suggesting a possible decrease in visceral fat compared to unexposed infants In another follow-up study of infants exposed to metformin during pregnancies with gestational diabetes, children exposed to metformin weighed more at the age of 12 months, and were heavier and taller at 18 months, however, body composition was similar as was motor, social and linguistic development.

Studies looking at neurodevelopment showed similar outcomes between exposed and nonexposed infants at 2 years of age , In summary, long-term follow up from 18 months to 2 years indicate that metformin exposure in-utero does not seem to be harmful with regards to early motor, linguistic, social, , metabolic , and neurodevelopmental , outcomes.

Longer-term follow up is not yet available. Glyburide has been shown to cross the placenta. In 2 meta-analyses of randomized trials studying the use of glyburide vs.

insulin in women with GDM, glyburide was associated with increased birthweight, macrosomia and neonatal hypoglycemia compared with insulin , In the same meta-analyses, compared to metformin, glyburide use was associated with increased maternal weight gain, birthweight, macrosomia and neonatal hypoglycemia ,

Pregnancy itself does not increase the risk of developing type 2 diabetes. However, having gestational diabetes does increase your risk of developing type 2 diabetes later in life.

After you deliver, you should have testing for type 2 diabetes. Typically, this is done between 4 and 12 weeks postpartum, ideally prior to your postpartum check-up. But it may be done in the hospital before you are discharged. Testing usually includes a two-hour glucose tolerance test GTT so that you are tested for both pre-diabetes and diabetes.

Risk of recurrent gestational diabetes — One-third to two-thirds of individuals who have gestational diabetes in one pregnancy will have it again in a later pregnancy.

If you are overweight or obese, weight reduction through diet and exercise can reduce this risk. Risk of developing type 2 diabetes — Individuals with gestational diabetes have an increased risk of developing type 2 diabetes later in life, especially if they have other risk factors eg, family history of type 2 diabetes.

The risk of developing type 2 diabetes is greatly affected by body weight. Individuals with obesity have a 50 to 75 percent risk of developing type 2 diabetes, while this risk is less-than percent in those who are a normal weight.

If you are overweight or obese, you can reduce your risk of type 2 diabetes by losing weight and exercising regularly. The American Diabetes Association ADA recommends that all persons with a history of gestational diabetes have testing for type 2 diabetes every one to three years after their initial post-pregnancy test for diabetes.

If you have elevations in your blood sugars in the pre-diabetes range at the time of your postpartum screening, the ADA recommends testing yearly testing. It is also recommended that you work with your primary care provider to eat a healthy diet, lose any excess weight, and exercise regularly to help decrease your risk of developing type 2 diabetes.

Cardiovascular disease — Individuals who have had gestational diabetes in the past are at increased risk of developing cardiovascular disease, including heart attack and stroke. While this is mostly tied to the risk of type 2 diabetes see above , even those who do not develop type 2 diabetes appear to have a small increase in their risk of heart disease later in life.

Continuing to make healthy lifestyle choices such as eating a balanced diet, exercising regularly, and avoiding smoking can help minimize this risk.

See "Patient education: Diet and health The Basics ". Birth control — Individuals with a history of gestational diabetes can use any type of birth control after pregnancy. A review of all of the birth control options is available separately. See "Patient education: Birth control; which method is right for me?

Beyond the Basics ". Your health care provider is the best source of information for questions and concerns related to your medical problem. This article will be updated as needed on our web site www. Related topics for patients, as well as selected articles written for health care professionals, are also available.

Some of the most relevant are listed below. Patient level information — UpToDate offers two types of patient education materials. The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Gestational diabetes The Basics. Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed.

These articles are best for patients who want in-depth information and are comfortable with some medical jargon. Patient education: Preeclampsia Beyond the Basics Patient education: Glucose monitoring in diabetes Beyond the Basics Patient education: Type 2 diabetes: Insulin treatment Beyond the Basics Patient education: Postterm pregnancy Beyond the Basics Patient education: C-section cesarean delivery Beyond the Basics Patient education: Deciding to breastfeed Beyond the Basics Patient education: Birth control; which method is right for me?

Beyond the Basics. Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based.

Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Clinical presentation, diagnosis, and initial evaluation of diabetes mellitus in adults Effects of advanced maternal age on pregnancy Infants of mothers with diabetes IMD Pregestational preexisting diabetes mellitus: Obstetric issues and management Gestational diabetes mellitus: Screening, diagnosis, and prevention Gestational diabetes mellitus: Glucose management and maternal prognosis Gestational diabetes mellitus: Obstetric issues and management Pregestational preexisting and gestational diabetes: Intrapartum and postpartum glucose management.

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Official reprint from UpToDate ® www. com © UpToDate, Inc. All Rights Reserved. Author: Celeste Durnwald, MD Section Editors: David M Nathan, MD Erika F Werner, MD, MS Deputy Editor: Vanessa A Barss, MD, FACOG.

All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Jan This topic last updated: Nov 16, If your blood sugar level is normal, no other tests are done.

AFTER-DELIVERY CARE After giving birth, most individuals with gestational diabetes have normal blood sugar levels and do not require further treatment with insulin.

Patient education: Gestational diabetes The Basics Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. Beyond the Basics Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings.

Clinical presentation, diagnosis, and initial evaluation of diabetes mellitus in adults Effects of advanced maternal age on pregnancy Infants of mothers with diabetes IMD Pregestational preexisting diabetes mellitus: Obstetric issues and management Gestational diabetes mellitus: Screening, diagnosis, and prevention Gestational diabetes mellitus: Glucose management and maternal prognosis Gestational diabetes mellitus: Obstetric issues and management Pregestational preexisting and gestational diabetes: Intrapartum and postpartum glucose management The following organizations also provide reliable health information.

Effect of treatment of gestational diabetes mellitus on pregnancy outcomes. N Engl J Med ; Dodd JM, Crowther CA, Antoniou G, et al.

Although metformin and glyburide have not been associated with an increased risk of congenital anatomic anomalies, when either drug is prescribed, patients should be made aware that information regarding the long-term effects of transplacental passage, including possible fetal programming effects, are largely unknown, so caution is warranted until more data are available [ ].

Metformin — A typical dosing regimen is to start metformin extended release XR mg orally once daily with dinner and, if tolerated, increase by mg eg, mg with dinner or mg with dinner plus mg with breakfast based on the degree of glucose elevations.

The dose can then be increased by to mg orally per week until reaching the usual effective dose of to mg orally per day divided into two doses maximum daily dose is mg [ 98 ]. An immediate release preparation is also available, but we prefer the XR as it may cause fewer gastrointestinal side effects and fewer daily doses may be needed.

The most common side effects of metformin are gastrointestinal, including a metallic taste in the mouth, mild anorexia, nausea, abdominal discomfort, and soft bowel movements or diarrhea. These symptoms are usually mild, transient, and reversible after dose reduction or discontinuation of the drug.

Symptoms can be mitigated by starting at a low dose with slow-dose escalation as needed. In a clinical trial, only 2 percent of study subjects discontinued metformin because of gastrointestinal side effects [ 98 ].

The ADA recommends avoiding metformin in patients with hypertension, preeclampsia, or at risk for intrauterine growth restriction due to the potential for growth restriction or acidosis in the setting of placental insufficiency [ 24,92 ]; however, any clinical impact of this effect has not been observed in human pregnancies.

The American College of Obstetricians and Gynecologists ACOG and the Society for Maternal-Fetal Medicine do not include this caveat in their recommendations. Glyburide — Starting doses of 2. Twice-daily dosing is often necessary to maintain glucose levels in the target range.

One group that investigated glyburide pharmacokinetics in pregnancy suggested pregnant patients take the drug 30 to 60 minutes before a meal, rather than with the meal, to improve efficacy [ 99 ].

In this study, plasma glyburide concentrations in pregnant patients with GDM did not increase until one hour after drug ingestion, peaked at two to three hours, and returned to baseline by 8 to 10 hours.

Thus, the drug took longer to reach peak concentration and was metabolized more rapidly than in nonpregnant females.

Maternal hypoglycemia is the most common side effect, and the risk was higher than that in patients with GDM using insulin in a large trial Patients who fail to achieve glycemic control with oral pharmacotherapy — If oral pharmacotherapy alone does not adequately manage glucose levels, supplemental insulin can be prescribed and may be easier for the patient than switching to a multidose insulin only regimen.

In contrast to nonpregnant patients, dual use of oral agents eg, metformin plus glyburide is not recommended in pregnancy because of minimal safety and efficacy data [ 88 ] and concerns about adverse fetal effects since both drugs cross the placenta. See "Pregestational preexisting and gestational diabetes: Intrapartum and postpartum glucose management".

See "Gestational diabetes mellitus: Obstetric issues and management". MATERNAL PROGNOSIS — Most patients with GDM are normoglycemic after giving birth. However, they are at high risk for recurrent GDM and developing prediabetes impaired glucose tolerance or impaired fasting glucose or overt diabetes over the subsequent five years.

Optimum interpregnancy care to minimize these risks has not been well-studied in randomized trials [ ]. Feasibility trials of a web-based lifestyle intervention and a telephone-based intervention reported less postpartum weight retention in patients with GDM assigned to the intervention, suggesting this type of behavioral intervention may have a favorable impact [ , ].

Recurrence — GDM in one pregnancy is a strong predictor of recurrence in a subsequent pregnancy [ ]. In a study including over 65, pregnancies, the frequency of GDM in the second pregnancy among patients with and without previous GDM was 41 and 4 percent, respectively [ ].

Risk factors for recurrence include high birth weight in the index pregnancy, older maternal age, high parity, high prepregnancy weight, and high weight between pregnancies [ , ]. Long-term risk — A history of GDM is predictive of an increased risk of developing type 2 diabetes, metabolic syndrome, cardiovascular disease CVD , and even type 1 diabetes.

These risks appear to be particularly high in patients with both GDM and a hypertensive disorder of pregnancy [ ]. GDM has been called a "marker," "stress test," or "window" for future diabetes and CVD; it is not considered causal. The RR was 17 within the first five years after delivery and approximately 10 after that.

The lifetime maternal risk for diabetes has been estimated to be as high as 50 to 60 percent [ , ]. Waist circumference and body mass index BMI are the strongest anthropometric measures associated with development of type 2 diabetes in patients with GDM [ 61, ], as they are in those without GDM.

Other major risk factors are gestational requirement for insulin and early gestational age at the time of diagnosis ie, less than 24 weeks of gestation [ ].

Additional risk factors for impaired glucose tolerance and overt diabetes later in life include autoantibodies eg, glutamic acid decarboxylase, insulinoma antigen-2 , high-fasting blood glucose concentrations during pregnancy and early postpartum, higher-fasting plasma glucose at diagnosis of GDM and high glucose levels in the GTT, the number of abnormal values on the glucose tolerance test, neonatal hypoglycemia, and GDM in more than one pregnancy [ 61,,,, ].

In one study, an additional pregnancy increased the rate ratio of type 2 diabetes threefold compared with individuals without an additional pregnancy RR 3. The authors hypothesized that repeated episodes of insulin resistance contribute to the decline in beta-cell function that leads to type 2 diabetes in many high-risk individuals.

Parity, large birth weight, and diabetes in a first-degree relative are less correlated with later diabetes. Specific human leukocyte antigen HLA alleles DR3 or DR4 may predispose to the development of type 1 diabetes postpartum, as does the presence of islet-cell autoantibodies [ ] or antibodies against glutamic acid decarboxylase or insulinoma antigen 2.

GDM in lean pregnant people, need for insulin treatment of GDM, diabetic ketoacidosis during pregnancy, and postpartum hyperglycemia also suggest preexisting unrecognized type 1 diabetes or high risk of developing type 1 diabetes [ ]. Although testing for antibodies is not routinely recommended, it is important for clinicians to be aware of this association.

Distinguishing type 1 from type 2 diabetes, and monogenic forms of diabetes eg, maturity-onset diabetes of the young [MODY] from type 1 and type 2 diabetes, is reviewed in detail elsewhere.

See "Clinical presentation, diagnosis, and initial evaluation of diabetes mellitus in adults", section on 'Differentiating the cause' and "Classification of diabetes mellitus and genetic diabetic syndromes". In one study of patients with mild GDM ie, normal fasting glucose level on glucose tolerance test [GTT] , approximately one-third developed metabolic syndrome within 5 to 10 years after giving birth [ ].

Even mild glucose impairment defined as an abnormal 50 g one-hour GTT followed by a normal g three-hour GTT appears to identify individuals at increased risk of future development of CVD, usually myocardial infarction or stroke [ ].

In these studies, the increased risk was related to development of type 2 diabetes later in life. More recent data demonstrate that the increased risk of CVD in patients with a prior history of GDM may be independent of the development of type 2 diabetes. Meta-regression analysis showed that the rates of incident type 2 diabetes across the studies did not affect this risk and when individuals with type 2 diabetes were excluded, GDM was still associated with an increased risk of future CVD RR 1.

The increased mortality risk was primarily due to CVD 0. Testing — Long-term follow-up for development of type 2 diabetes is routinely recommended for individuals with GDM, given their high risk for developing the disorder [ 24,43 ].

GTT — A common approach is to order a GTT to be performed 4 to 12 weeks after giving birth, using the 75 g GTT, as recommended by the American Diabetes Association ADA [ 24 ]. Criteria for diagnosis of diabetes and prediabetes are shown in the tables table 2A-B. Suboptimal adherence has been attributed to not ordering the test, lack of patient follow-up for postpartum care, patient burden associated with a fasting and a two-hour laboratory procedure, and patient difficulty with childcare [ ].

There is increasing evidence that performing the test while the patient is still hospitalized after birth increases adherence to nearly percent and provides reliable results [ , ]. At one year postpartum, the A1C was consistent with impaired glucose metabolism in 35 percent and diabetes in 4 percent of individuals tested.

Fasting glucose — A fasting plasma glucose level is a reasonable alternative to the GTT but does not allow for diagnosis of impaired glucose tolerance.

A glycated hemoglobin A1C can be performed in patients in whom obtaining a fasting specimen is especially inconvenient but performs less well for diagnosis of diabetes or prediabetes in postpartum patients because of increased peripartum red cell turnover [ ].

See "Clinical presentation, diagnosis, and initial evaluation of diabetes mellitus in adults", section on 'Diagnostic tests'. They should have yearly assessment of glycemic status. Approaches to prevention of type 2 diabetes are reviewed in detail separately.

See "Clinical presentation, diagnosis, and initial evaluation of diabetes mellitus in adults", section on 'Prediabetes' and "Prevention of type 2 diabetes mellitus". Higher intensity and longer duration of breastfeeding during the first two years postpartum is associated with a reduced risk of developing type 2 diabetes in observational studies.

See "Gestational diabetes mellitus: Obstetric issues and management", section on 'Breastfeeding'. They should also be given advice regarding contraception and the planning of future pregnancies, especially the importance of good glycemic management prior to conception.

See "Overview of general medical care in nonpregnant adults with diabetes mellitus" and "Pregestational preexisting diabetes: Preconception counseling, evaluation, and management".

See 'Recurrence' above and 'Long-term risk' above. Lifestyle interventions are beneficial for reducing the incidence of type 2 diabetes in persons with prediabetes [ ] and these interventions diet and exercise, achieving a normal body mass index, avoiding smoking and excessive alcohol intake also appear to be beneficial in patients with a history of GDM, whether or not they meet criteria for prediabetes [ ].

The annual incidence of diabetes may be reduced by 30 to 50 percent or more compared with no intervention [ , ]. Pharmacotherapy eg, metformin , pioglitazone may also have a role in preventing future type 2 diabetes. In a multicenter randomized trial, both intensive lifestyle and metformin therapy reduced the incidence of future diabetes by approximately 50 percent compared with placebo in patients with a history of GDM; metformin was much more effective than lifestyle intervention in parous patients with previous GDM [ ].

This topic is discussed in detail separately. See "Prevention of type 2 diabetes mellitus". Reassessment of glycemic status should be undertaken at a minimum of every three years eg, every one to three years [ 24 ].

More frequent assessment may be important in patients who may become pregnant again, since early detection of diabetes is important to preconception and early prenatal care. More frequent screening every one or two years may also be indicated in patients with other risk factors for diabetes, such as family history of diabetes, obesity, and need for pharmacotherapy during pregnancy.

The best means of follow-up testing has not been defined. The two-hour 75 g oral GTT is the more sensitive test for diagnosis of diabetes and impaired glucose tolerance in most populations, but the fasting plasma glucose is more convenient, specific, and reproducible, and less expensive.

A1C is convenient and the preferred test for patients who have not fasted overnight. See "Screening for type 2 diabetes mellitus", section on 'Screening tests'. See "Overview of primary prevention of cardiovascular disease". Follow-up of patients not screened for GDM — For patients who did not undergo screening for GDM, but diabetes is suspected postpartum because of newborn outcome eg, hypoglycemia, macrosomia, congenital anomalies , a postpartum GTT may be considered.

A normal postpartum GTT excludes the presence of type 1 or type 2 diabetes or prediabetes; it does not exclude the possibility of GDM during pregnancy and the future risks associated with this diagnosis. Indications for screening and tests used for screening are discussed separately.

See "Screening for type 2 diabetes mellitus". SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately.

See "Society guideline links: Diabetes mellitus in pregnancy". These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed.

These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon. Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients.

You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword s of interest. We suggest glucose self-monitoring before breakfast and at one or at two hours after the beginning of each meal. See 'Glucose monitoring' above. See 'Can the frequency of self-monitoring be reduced?

Moderate exercise also improves glycemic control and should be part of the treatment plan for patients with no medical or obstetric contraindications to this level of physical activity. See 'Rationale for treatment' above and 'Exercise' above.

Calories are generally divided over three meals and two to four snacks per day and are composed of approximately 40 percent carbohydrate, 20 percent protein, and 40 percent fat.

Gestational weight gain recommendations are shown in the table table 1. See 'Medical nutritional therapy' above. Pharmacotherapy can reduce the occurrence of macrosomia and large for gestational age in newborns.

See 'Indications for pharmacotherapy' above. We start with the simplest insulin regimen likely to be effective based on the glucose levels recorded in the patient's blood glucose log and increase the complexity as needed.

An alternative approach based on both patient weight and glucose levels is somewhat more complex and likely most appropriate for individuals whose glucose levels are not well managed with simpler paradigms. See 'Insulin' above. The long-term effects of transplacental passage of noninsulin antihyperglycemic agents are not known.

See 'Oral hypoglycemic agents' above. Testing can be performed while the patient is still in the hospital after giving birth. Otherwise it is performed 4 to 12 weeks postpartum and, if results are normal, at least every three years thereafter.

See 'Maternal prognosis' above. Why UpToDate? Product Editorial Subscription Options Subscribe Sign in. Learn how UpToDate can help you. Select the option that best describes you. View Topic. Font Size Small Normal Large. Gestational diabetes mellitus: Glucose management and maternal prognosis. Formulary drug information for this topic.

No drug references linked in this topic. Find in topic Formulary Print Share. View in. Language Chinese English. Author: Celeste Durnwald, MD Section Editors: David M Nathan, MD Erika F Werner, MD, MS Deputy Editor: Vanessa A Barss, MD, FACOG Contributor Disclosures.

All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Jan This topic last updated: Nov 16, There were no significant maternal or neonatal harms from treatment of GDM.

Insulin Dose — The insulin dose required to achieve target glucose levels varies among individuals, but the majority of studies have reported a total dose ranging from 0. Follow-up Testing — Long-term follow-up for development of type 2 diabetes is routinely recommended for individuals with GDM, given their high risk for developing the disorder [ 24,43 ].

Electronic address: pubs smfm. SMFM Statement: Pharmacological treatment of gestational diabetes. Am J Obstet Gynecol ; B2. Catalano PM, McIntyre HD, Cruickshank JK, et al. The hyperglycemia and adverse pregnancy outcome study: associations of GDM and obesity with pregnancy outcomes.

Diabetes Care ; Crowther CA, Hiller JE, Moss JR, et al. Effect of treatment of gestational diabetes mellitus on pregnancy outcomes. N Engl J Med ; HAPO Study Cooperative Research Group, Metzger BE, Lowe LP, et al.

Hyperglycemia and adverse pregnancy outcomes. Han S, Crowther CA, Middleton P. Interventions for pregnant women with hyperglycaemia not meeting gestational diabetes and type 2 diabetes diagnostic criteria. Cochrane Database Syst Rev ; 1:CD Durnwald CP, Mele L, Spong CY, et al.

Glycemic characteristics and neonatal outcomes of women treated for mild gestational diabetes. Obstet Gynecol ; Uvena-Celebrezze J, Fung C, Thomas AJ, et al. Relationship of neonatal body composition to maternal glucose control in women with gestational diabetes mellitus.

J Matern Fetal Neonatal Med ; Catalano PM, Thomas A, Huston-Presley L, Amini SB. Increased fetal adiposity: a very sensitive marker of abnormal in utero development. Am J Obstet Gynecol ; Moss JR, Crowther CA, Hiller JE, et al. Costs and consequences of treatment for mild gestational diabetes mellitus - evaluation from the ACHOIS randomised trial.

BMC Pregnancy Childbirth ; US Preventive Services Task Force, Davidson KW, Barry MJ, et al. Screening for Gestational Diabetes: US Preventive Services Task Force Recommendation Statement.

JAMA ; Pillay J, Donovan L, Guitard S, et al. Screening for Gestational Diabetes: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force.

Poprzeczny AJ, Louise J, Deussen AR, Dodd JM. The mediating effects of gestational diabetes on fetal growth and adiposity in women who are overweight and obese: secondary analysis of the LIMIT randomised trial. BJOG ; Landon MB, Rice MM, Varner MW, et al.

Mild gestational diabetes mellitus and long-term child health. American Diabetes Association, Bantle JP, Wylie-Rosett J, et al. Nutrition recommendations and interventions for diabetes: a position statement of the American Diabetes Association.

Diabetes Care ; 31 Suppl 1:S Landon MB, Spong CY, Thom E, et al. A multicenter, randomized trial of treatment for mild gestational diabetes. Hernandez TL, Brand-Miller JC.

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J Perinatol ; Moses RG, Lucas EM, Knights S. Gestational diabetes mellitus. At what time should the postprandial glucose level be monitored? Aust N Z J Obstet Gynaecol ; Sivan E, Weisz B, Homko CJ, et al. When you go into hospital to give birth, take your blood sugar testing kit with you, plus any medicines you're taking.

Usually you should keep testing your blood sugar and taking your medicines until you're in established labour or you're told to stop eating before a caesarean section. During labour and delivery, your blood sugar will be monitored and kept under control.

You may need to have insulin given to you through a drip, to control your blood sugar levels. You can usually see, hold and feed your baby soon after you've given birth. It's important to feed your baby as soon as possible after birth within 30 minutes and then at frequent intervals every hours until your baby's blood sugar levels are stable.

Your baby's blood sugar level will be tested starting 2 to 4 hours after birth. If it's low, your baby may need to be temporarily fed through a tube or a drip. If your baby is unwell or needs close monitoring, they may be looked after in a specialist neonatal unit.

Any medicines you were taking to control your blood sugar will usually be stopped after you give birth. You'll usually be advised to keep checking your blood sugar for 1 or 2 days after you give birth.

If you're both well, you and your baby will normally be able to go home after 24 hours. You should have a blood test to check for diabetes 6 to 13 weeks after giving birth. This is because a small number of women with gestational diabetes continue to have raised blood sugar after pregnancy.

If the result is normal, you'll usually be advised to have an annual test for diabetes. This is because you're at an increased risk of developing type 2 diabetes — a lifelong type of diabetes — if you've had gestational diabetes.

This video gives advice about gestational diabetes and Kimberly talks about her pregnancy after being diagnosed. Page last reviewed: 08 December Next review due: 08 December Home Health A to Z Gestational diabetes Back to Gestational diabetes.

Treatment - Gestational diabetes Contents Overview Treatment. Checking your blood sugar level You'll be given a testing kit that you can use to check your blood sugar glucose level.

Diabetes UK has more information about checking your blood sugar levels A healthy diet Making changes to your diet can help control your blood sugar levels. You may be advised to: eat regularly — usually three meals a day — and avoid skipping meals eat starchy and low glycaemic index GI foods that release sugar slowly — such as wholewheat pasta, brown rice, granary bread, all-bran cereals, pulses, beans, lentils, muesli and plain porridge eat plenty of fruit and vegetables — aim for at least 5 portions a day avoid sugary foods — you do not need a completely sugar-free diet, but swap snacks such as cakes and biscuits for healthier alternatives such as fruit, nuts and seeds avoid sugary drinks — diet or sugar-free drinks are better than sugary versions.

Fruit juices and smoothies can also be high in sugar, and so can some "no added sugar" drinks, so check the nutrition label or ask your health care team eat lean sources of protein, such as fish It's also important to be aware of foods to avoid during pregnancy , such as certain types of fish and cheese.

Diabetes UK: Glycaemic index GI and diabetes Exercise Physical activity lowers your blood glucose level, so regular exercise can be an effective way to manage gestational diabetes.