Oral medication options for gestational diabetes -
There are three main sulfonylurea drugs used today, glimepiride Amaryl , glipizide Glucotrol and Glucotrol XL , and glyburide Micronase, Glynase, and Diabeta. These drugs are generally taken one to two times a day before meals. All sulfonylurea drugs have similar effects on blood glucose levels, but they differ in side effects, how often they are taken, and interactions with other drugs.
The most common side effects with sulfonylureas are low blood glucose and weight gain. Rosiglitazone Avandia and pioglitazone Actos are in a group of drugs called thiazolidinediones. These drugs help insulin work better in the muscle and fat and reduce glucose production in the liver.
A benefit of TZDs is that they lower blood glucose without having a high risk for causing low blood glucose. Both drugs in this class can increase the risk for heart failure in some individuals and can also cause fluid retention edema in the legs and feet. In addition to the commonly used classes discussed above, there are other less commonly used medications that can work well for some people:.
Acarbose Precose and miglitol Glyset are alpha-glucosidase inhibitors. These drugs help the body lower blood glucose levels by blocking the breakdown of starches, such as bread, potatoes, and pasta in the intestine.
By slowing the breakdown of these foods, this slows the rise in blood glucose levels after a meal. These medications should be taken with the first bite of each meal, so they need to be taken multiple times daily. Based on how these medications work, they commonly cause gastrointestinal side effects including gas and diarrhea.
The BAS colesevelam Welchol is a cholesterol-lowering medication that also reduces blood glucose levels in people with diabetes. BASs help remove cholesterol from the body, particularly LDL cholesterol, which is often elevated in people with diabetes.
The medications reduce LDL cholesterol by binding with bile acids in the digestive system. The body in turn uses cholesterol to replace the bile acids, which lowers cholesterol levels.
The mechanism by which colesevelam lowers glucose levels is not well understood. Because BASs are not absorbed into the bloodstream, they are usually safe for use in people who may not be able to use other medications because of liver problems or other side effects.
Because of the way they work, side effects of BASs can include flatulence and constipation, and they can interact with the absorption of other medications taken at the same time.
Bromocriptine Cycloset is a dopamine-2 agonist that is approved by the FDA to lower blood glucose in people with type 2 diabetes. Bromocriptine is taken once daily in the morning. A common side effect is nausea. Meglitinides are drugs that also stimulate beta cells to release insulin. Nateglinide Starlix and repaglinide Prandin are both meglitinides.
They are taken before each meal to help lower glucose after you eat. Because meglitinides stimulate the release of insulin, it is possible to have low blood glucose when taking these medications.
Because the drugs listed above act in different ways to lower blood glucose levels, they may be used together to help meet your individualized diabetes goals. For example, metformin and a DPP-4 inhibitor may be used together shortly after being diagnosed with type 2 diabetes to help keep blood glucose levels at goal.
That said, many combinations can be used. Work with your health care provider to find the combination of medicines that work best for you and your lifestyle and help you meet your health goals. Insulin may also be used to treat type 2 diabetes.
Learn more. Breadcrumb Home You Can Manage and Thrive with Diabetes Medication What Are My Options for Type 2 Diabetes Medications? DPP-4 Inhibitors DPP-4 inhibitors help improve A1C a measure of average blood glucose levels over two to three months without causing hypoglycemia low blood glucose.
There are four DPP-4 inhibitors currently on the market in the U. In a randomized trial of patients with GDM on nutritional therapy who demonstrated glucose levels in the target range after one week of four times daily glucose testing, those assigned to every other day testing had similar birth weights and frequency of macrosomia as those who continued to test four times daily [ 40 ].
Continuous glucose monitoring — Continuous glucose monitoring CGM allows determination of peak postprandial glucose levels, mean glucose level, episodes of nocturnal hyperglycemia, and percent time in range for a hour period. We do not routinely use CGM in patients with GDM because of cost and it has not been proven to improve maternal or fetal outcome, but few trials have been performed.
When CGM was compared with frequent self-monitoring of blood glucose in a meta-analysis of two small randomized trials, outcomes were similar for both approaches: cesarean birth risk ratio [RR] 0. There were no perinatal deaths. Larger trials may clarify whether the favorable trends that were observed are real.
Although use of CGM has no clear advantages for most patients, it may be considered in patients who cannot consistently check fingerstick glucose levels and are willing to wear a device. In addition, some patients choose to use CGM because they want the detailed information about their glucose levels that it provides.
Cost may be a barrier to use. Glucose target — Glucose targets vary among countries and the precise target for optimum maternal, fetal, and newborn outcome is not well-established [ 42 ]. In the United States, the American Diabetes Association ADA and the American College of Obstetricians and Gynecologists ACOG recommend the following upper limits for glucose levels, with insulin therapy initiated if they are exceeded, but acknowledge that these thresholds have been extrapolated from recommendations proposed for pregnant patients with preexisting diabetes [ 24,43 ]:.
These targets are well above the mean glucose values in pregnant people without diabetes described in a literature review of studies of the normal hour glycemic profile of pregnant people [ 44 ]. These levels were derived from measurements on whole blood, plasma, self-monitored capillary glucose measurements, or tissue fluid CGM.
Although glucose levels in whole blood, plasma, and interstitial fluid differ, there was some consistency in the results. Glycated hemoglobin — A1C may be a helpful ancillary test in assessing glycemic management during pregnancy [ 45,46 ].
It is not clear whether or how often it should be monitored in patients with GDM with glucose levels are in the target range. If measured and there is a discrepancy between the A1C and glucose values, then potential causes should be investigated.
High-quality normative data for A1C in each trimester are not available. A1C values tend to be lower in pregnant compared with nonpregnant people [ 47 ] because the average blood glucose concentration is approximately 20 percent lower in pregnant people, and in the first half of pregnancy, there is a rise in red cell mass and a slight increase in red blood cell turnover [ 48,49 ].
Other factors that have been reported to affect A1C values include race although it is not clear whether the higher A1C levels observed in Black persons compared with White persons are due to differences in glucose levels or racial differences in the glycation of hemoglobin [ 50 ] and iron status chronic iron deficiency anemia increases A1C, treatment of iron deficiency anemia with iron lowers A1C.
Sources of variation in A1C levels are discussed in detail separately. See "Measurements of chronic glycemia in diabetes mellitus", section on 'Glycated hemoglobin A1C '.
Episodes of physiological ketonemia and ketonuria are not uncommon in pregnancy and can occur with hypocaloric diets [ 53 ]. Studies have reported inconsistent findings regarding a potential association between ketonuria and impaired cognitive outcome in offspring [ ]. Goal — The goal of pharmacotherapy is to manage glucose levels so that the majority are no higher than the upper limit of the target range, without inducing any episodes of hypoglycemia.
Indications for pharmacotherapy. We initiate pharmacotherapy when over 30 percent of the blood glucose values in a week are above target glucose thresholds see 'Glucose target' above. Our general approach is described in the algorithm algorithm 1. Randomized trials regarding when to initiate pharmacotherapy have not been performed.
In a meta-analysis including only two trials, compared with conventional hyperglycemia-based management in patients with a broad GDM severity spectrum, initiation of pharmacotherapy based on ultrasound findings of a large AC increased the percent of patients requiring insulin treatment 34 versus 23 percent, relative risk [RR] 1.
Rates of pregnancy-associated hypertension and cesarean birth were similar in both groups; data on frequency of maternal hypoglycemia were not provided.
Based on these and other findings, it is reasonable for patients with sonographic signs of fetal overgrowth to receive insulin to decrease the risk of large for gestational age and macrosomia despite having less than 30 percent of glucose values above target threshold.
Does early metformin initiation improve glycemic control and reduce need for insulin? Whether initiating metformin at the time of GDM diagnosis regardless of glycemic control improves clinical outcomes compared with usual care was investigated in a randomized trial [ 64 ].
Patients assigned to the metformin group had favorable trends in some secondary outcomes, but the trial was not powered to evaluate these individually:. There was no significant difference in maternal morbidity eg, gestational hypertension or preeclampsia , need for neonatal intensive care unit NICU care, or neonatal hypoglycemia.
Given these mixed findings, we recommend not initiating metformin at the time of GDM diagnosis except in a research setting. Choice of pharmacotherapy — The pharmacotherapy options in pregnant patients who require pharmacotherapy are insulin and some insulin analogs or selected oral antihyperglycemic agents metformin or glyburide.
We favor insulin because it is effective, easily adjusted based on glucose levels, and safe for the fetus, whereas data are lacking regarding long-term outcomes of offspring exposed to oral antihyperglycemic drugs in utero.
We believe that oral antihyperglycemic agents are a reasonable alternative to insulin for patients in whom pharmacotherapy is indicated but who decline to take, or are unable to comply with, insulin therapy. Our approach is generally consistent with national and international guidance [ 1,24,43,65,66 ].
Some guidelines consider oral antihyperglycemic drugs an acceptable first-line approach in selected patients, such as those with normal fasting blood glucose levels and modest postprandial hyperglycemia [ ].
See 'Society guideline links' below. Meta-analyses comparing use of oral antihyperglycemic agents with insulin therapy have generally found that both approaches can improve some pregnancy outcomes in patients with GDM or type 2 diabetes [ 61, ].
There is a trend toward more frequent maternal hypoglycemia with use of insulin [ 71 ], and some patients on oral agents need supplemental insulin to achieve and maintain glucose levels in the target range [ 74 ]. However, it is difficult to draw firm conclusions about the optimal approach because of inconsistencies in criteria for GDM, glucose targets, patient adherence to treatment, clinical outcome measures across studies, and lack of long-term safety data [ 71 ].
In randomized trials, compared with insulin, metformin :. In randomized trials, compared with insulin, glyburide :. 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.
Dose titration to blood glucose levels is based upon frequent self-monitoring. At least four daily glucose measurements are required fasting and one or two hours postprandial with the addition of pre-lunch and pre-dinner measurements as needed to optimize therapy and ensure timely dose increases as insulin requirements increase with pregnancy progression.
The insulin requirement in twin gestations complicated by GDM may double with pregnancy progression. We do not use insulin pumps in patients with GDM because there are no data to suggest that they are necessary or more effective than conventional therapy, and the cost of an insulin pump is not justified over the relatively short duration of a pregnancy.
However, case reports have described successful use in some pregnant people. Pragmatic approach to management of hyperglycemia — Hospitalization is not necessary to initiate insulin therapy; however, if teaching some patients the procedures they need to know is not possible in the outpatient setting, then an inpatient stay to utilize the expertise of the hospital's nursing staff may justify the cost of hospitalization.
One principle we have found useful is to start with the simplest regimen and increase the complexity as needed to address the particular situation. Typically, regardless of body weight, insulin dosing is based on the glucose levels recorded in the patient's blood glucose log.
Because any insulin regimen requires serial dosing adjustments in response to specific fasting or postprandial glucose levels, the starting dose should be considered just that, a starting point.
Weekly glucose log review is recommended so that insulin doses can be adjusted as needed to meet target glucose levels as the pregnancy advances. Some patients may be diagnosed with diabetes and therapy initiated early in pregnancy prior to 24 to 28 weeks screening ; these patients are managed differently and generally require slightly lower insulin doses since insulin resistance is lower early in pregnancy.
We prefer NPH due to the peak at four to six hours after the dose, which may also aid in covering postprandial lunch excursions.
Levemir can also be used but is peakless and would not help as much with the lunch post-meal peak. The upper end of this range is not likely to lead to hypoglycemia in patients with both obesity and GDM unless a meal is omitted after insulin is given.
If both post-breakfast and post-lunch glucose levels are elevated, increasing the morning NPH may be sufficient. The initial dose is 0.
Dosing based on glucose levels and weight — An alternative approach to insulin therapy, somewhat more complex and likely most appropriate for individuals whose glucose levels are not well managed with simpler paradigms, is described below:. A long-acting insulin analog insulin glargine or detemir may be used instead [ 77 ].
See "General principles of insulin therapy in diabetes mellitus". The starting dose is calculated by trimester of pregnancy and body weight: 0. In patients with class II or III obesity, the initial doses of insulin may need to be increased to 1. Two-thirds of the total daily dose is administered in the morning, with two-thirds of the morning dose given as basal insulin and one-third given as rapid-acting insulin up to 15 minutes before breakfast.
One-third of the total daily dose is administered in the evening, with half of this dose given as rapid-acting insulin up to 15 minutes before dinner and the other half given as basal insulin as a nighttime dose usually at bedtime but before dinner is another option on an individualized basis.
A lunchtime dose of rapid-acting insulin may be added if there is continued postprandial lunch hyperglycemia. Hypoglycemia remote from meal or snack time is rare in patients with GDM treated with pharmacotherapy, and it is treated by administering 10 to 20 g of a fast-acting carbohydrate snack immediately.
Since the sugars in milk release more slowly into the bloodstream than pure sugar options, the glucose pattern seen with pure sugars ie, rapid elevation of glucose followed by a rapid decline may be dampened. See "Hypoglycemia in adults with diabetes mellitus", section on 'Reversing hypoglycemia'.
Patients who are feeling better may recheck their blood glucose 15 to 30 minutes after treatment. On the other hand, they may need to give themselves extra insulin to compensate for overtreatment of the symptoms.
If low glucose values are encountered more than once at the same time of day, insulin doses are adjusted downward accordingly. Type of insulin — Use of insulin preparations of low antigenicity may minimize transplacental transfer of insulin antibodies.
Human insulin is the least immunogenic of the commercially available preparations. The three rapid-acting insulin analogs lispro, aspart, glulisine are comparable in immunogenicity to human regular insulin , but only lispro and aspart have been investigated in pregnancy and shown to have acceptable safety profiles, minimal transfer across the placenta, and no evidence of teratogenesis.
Neonatal outcomes are similar to those of patients treated with regular insulin [ 61 ]. These two insulin analogs both improve postprandial excursions compared with human regular insulin and are associated with lower risk of delayed postprandial hypoglycemia.
Long-acting insulin analogs insulin glargine , insulin detemir have not been studied as extensively in pregnancy, but data from patients with preexisting pregestational diabetes and studies of placental transfer suggest that both detemir and glargine are safe and effective for use in pregnancy [ ].
See "Pregestational preexisting diabetes mellitus: Antenatal glycemic control", section on 'Type of insulin'. Based on available data, we prefer using human NPH insulin as part of a multiple injection regimen in pregnant people with GDM, especially given the peak at four to six hours after the morning dose, which can help decrease lunch postprandial blood glucose levels without an additional dose of rapid-acting insulin [ 86 ].
The body of data support the safety and effectiveness of NPH in pregnancy, and doses can be adjusted frequently and quickly in response to changing requirements in pregnant patients. If a longer-acting insulin analog is used, we prefer detemir insulin because it can be dosed twice a day, similar to NPH, with the advantage over NPH of more consistent absorption and less variability in absorption among patients.
Insulin detemir is preferred over insulin glargine because it has been studied more extensively in pregnancy and can be dosed twice per day more predictably than glargine, as previously mentioned. See "General principles of insulin therapy in diabetes mellitus", section on 'Safety'.
Oral hypoglycemic agents — Metformin and glyburide are the only noninsulin antihyperglycemic drugs used in pregnancy. Both oral hypoglycemic agents offer the advantage of significantly decreased cost compared with insulin.
Metformin is not associated with hypoglycemia. Choosing metformin versus glyburide — Clinically important pregnancy outcomes are generally similar for metformin and glyburide , with only limited evidence of benefit of one oral agent over the other.
Fetal metformin levels are percent of the maternal level and glyburide levels are 70 percent of the maternal level, which has unknown long-term consequences [ ]. 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 ].
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The effects of carbohydrate restriction in patients with diet-controlled gestational diabetes. Peterson CM, Jovanovic-Peterson L. Percentage of carbohydrate and glycemic response to breakfast, lunch, and dinner in women with gestational diabetes. Diabetes ; 40 Suppl Viana LV, Gross JL, Azevedo MJ.
Dietary intervention in patients with gestational diabetes mellitus: a systematic review and meta-analysis of randomized clinical trials on maternal and newborn outcomes. Cheng YW, Chung JH, Kurbisch-Block I, et al. Gestational weight gain and gestational diabetes mellitus: perinatal outcomes.
Franz MJ, Bantle JP, Beebe CA, et al. Evidence-based nutrition principles and recommendations for the treatment and prevention of diabetes and related complications. Brown J, Ceysens G, Boulvain M.
Exercise for pregnant women with gestational diabetes for improving maternal and fetal outcomes. Laird J, McFarland KF. Fasting blood glucose levels and initiation of insulin therapy in gestational diabetes. Endocr Pract ; Weisz B, Shrim A, Homko CJ, et al.
One hour versus two hours postprandial glucose measurement in gestational diabetes: a prospective study. J Perinatol ; Moses RG, Lucas EM, Knights S. Gestational diabetes mellitus. At what time should the postprandial glucose level be monitored?
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Open access peer-reviewed chapter. Oral medication options for gestational diabetes 06 August Reviewed: 02 September Overcoming body negativity 08 October com medicatoon cbspd. The incidence of gestational diabetes mellitus GDM is still rising, and this pathological condition is strongly associated with some serious adverse pregnancy outcomes. Therefore, GDM must be timely recognized and adequately managed. Oded Langer; Mevication Antidiabetic Drugs in Pregnancy: Getational Other Alternative. Diabetes Spectr Breakfast for better nutrient absorption April Oral medication options for gestational diabetes 20 2 : — The diabetez of oral medcation drugs in pregnancy Oral medication options for gestational diabetes an accepted tor modality for women with gestational diabetes gewtational GDM. This diabetew option provides physicians more choices that, in turn, translate into more complex decision making for the management of GDM. However, regardless of the mode of therapy, whole patient care glucose monitoring, education, diet adherence, and so forth will determine overall success in managing this disease and the potential to maximize the quality of perinatal outcome. In the United States, depending on the diagnosis criteria used,—, women annually develop gestational diabetes mellitus GDMadding to the number of pregnant women who already have either type 1 or type 2 diabetes.Oral medication options for gestational diabetes -
Hypoglycemia is the main side effect of glyburide treatment in non-pregnant women. However, the majority of women with type 2 diabetes who used this drug in the non-pregnant state are older than the average gravida. Thus, the severity of the hypoglycemia can be less pronounced in the younger age-group of women with GDM.
In our original study, 20 we found that hypoglycemic episodes were more common in insulin-treated patients than in those taking glyburide.
Thus, although some laboratory hypoglycemic episodes using SMBG or laboratory plasma values may be identified during pharmacological therapy,the rate of these episodes will be significantly lower in glyburide- versus insulin-treated women. It is customary to evaluate the success rate of a new pharmacological modality that will potentially provide an alternative to the established treatment insulin.
In general, the success rate is defined as achieving targeted levels of glycemic control as a primary outcome. Secondarily, after achieving established glycemic levels, the success rate will also be determined by the ability of the therapy to achieve comparable perinatal outcome i.
When comparing different studies on the success rate of achieving glycemic control, it should be noted that different criteria for targeted levels of glycemic control will influence study results. Furthermore, different populations ethnic and geographical groups and sample size, as well as quality and method of glucose testing self-monitoring; postprandial, preprandial, or mean blood glucose will also influence the definition of success in a given study.
Finally, the physician factor in patient-provider communication and drug administration doses and algorithms was shown to significantly affect the failure rate to achieve targeted levels of control. Hellmuth et al. In a randomized study, 43 we found comparable pregnancy outcomes with either glyburide or insulin therapy.
Moreover, when insulin and glyburide were compared, similar success rates were reported and were comparable to insulin in glycemic control and pregnancy outcome. We further analyzed the association between glyburide dose, GDM severity,and selected maternal and neonatal factors.
The success rate i. However, there was no difference between glyburide- and insulin-treated patients at each level of severity. Thus, achieving glycemic control—not the mode of pharmacological therapy—is the key to improving pregnancy outcome in GDM.
When costs of insulin therapy and glyburide treatment are compared, the latter is considerably less expensive. In the future, more pharmacological alternatives will become available. These may include metformin and other oral antidiabetic drugs, insulin glargine, oral insulin, and a technologically improved insulin pump that can interact directly with blood glucose levels.
Different oral hypoglycemic agents have different mechanisms of action. A detailed discussion of the seven classes of oral agents is beyond the scope of this review but can be found elsewhere.
Insulin therapy involves daily injections, which may lead to suboptimal adherence by many women. In many developing countries, women cannot afford insulin therapy. Our studies and others 8 — 11 have demonstrated that both diet- and insulin-treated women have comparable psychological profiles in different ethnic groups.
However, it is self-evident that given the choice of insulin injection versus tablets, patients will invariably prefer taking two tablets daily instead of at least three daily injections. Sulfonylureas are the only oral agent group studied in women with GDM in randomized controlled trials.
However, other oral hypoglycemic agents may have an even greater therapeutic effect in controlling abnormal levels of glycemia. Although the evidence suggests that glyburide is as effective as insulin in maintaining desired glycemic levels and results in comparable outcomes, it should be noted that achievement of both glucose and outcome goals is conditional on the overall successful management of women with GDM.
The use of glyburide should be based on evidence-based criteria. To be considered Level I in the U. Preventive Service Task Force criteria for quality, evidence needs to be the result of a single properly designed, randomized, controlled trial.
Clinical experts have consistently applauded and welcomed the results of the glyburide study 21 — 29 as convincing data that glyburide is a safe and effective alternative therapy for use in women with GDM. The existing body of research should encourage us to rely on evidence-based knowledge and not emotion-based misinformation when considering this medication for use with diabetic pregnant women.
Oded Langer, MD, PhD, is a professor and chairman of the Department of Obstetrics and Gynecology at St. Luke's-Roosevelt Hospital Center, University Hospital of Columbia University in New York.
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Article Navigation. Oral Antidiabetic Drugs in Pregnancy: The Other Alternative Oded Langer, MD, PhD Oded Langer, MD, PhD. This Site. Google Scholar. Diabetes Spectr ;20 2 — 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 , Therefore, the use of glyburide during pregnancy is not recommended as first- or second-line treatment, but may be used as third-line treatment if insulin is declined by the mother and metformin is either declined or insufficient to maintain good glycemic control.
There is only 1 small randomized trial looking at the use of acarbose in women with GDM. Other antihyperglycemic agents. There is no human data on the use of DPP-4 inhibitors, GLP-1 receptor agonists or SGLT2 inhibitors.
The use of these noninsulin antihyperglycemic agents is not recommended during pregnancy. The primary goal of intrapartum glucose management in women with gestational diabetes is to prevent neonatal hypoglycemia, which is thought to occur from the fetal hyperinsulinism caused by maternal hyperglycemia Longer-term follow-up studies have found that infants with neonatal hypoglycemia had increased rates of neurological abnormalities at 18 months, especially if hypoglycemic seizures occurred or if hypoglycemia was prolonged , and at 8 years of age with deficits in attention, motor control and perception Maternal hyperglycemia during labour, even when produced for a few hours by intravenous fluids in mothers without diabetes, can cause neonatal hypoglycemia , Studies have generally been performed in mothers with pregestational diabetes or insulin- treated GDM.
These have been observational with no randomized trials deliberately targeting different levels of maternal glycemia during labour.
Most have found that there is a continuous relationship between mean maternal BG levels during labour and the risk of neonatal hypoglycemia with no obvious threshold. Insulin requirements tend to decrease intrapartum , There are very few studies although many published protocols that examine the best method of managing glycemia during labour , Given the lack of studies, there are no specific protocols that can be recommended to achieve the desired maternal BG levels during labour.
Women with GDM should be encouraged to breastfeed immediately after delivery and for at least 4 months postpartum, as this may contribute to the reduction of neonatal hypoglycemia and offspring obesity , and prevent the development of metabolic syndrome and type 2 diabetes in the mother ,— Longer duration and more intense breastfeeding is associated with less diabetes in the mother with hazard ratios as low as 0.
Furthermore, offspring that are breastfed for at least 4 months have lower incidence of obesity and diabetes longer term However, GDM is associated with either similar or poor initiation rates compared to those without diabetes, as well as poor continuation rates Factors associated with cessation of breastfeeding before 3 months include breastfeeding challenges at home, return to work, inadequate support, caesarean section and lower socioeconomic status In conclusion, women with GDM should be encouraged to breastfeed as long as possible as intensity and duration of nursing have both infant and maternal benefits current recommendation by Canadian Paediatric Society is up to 2 years , but more support is needed as this group is at risk for early cessation.
Long-term maternal risk of dysglycemia. With the diagnosis of GDM, there is evidence of impairment of both insulin secretion and action , These defects persist postpartum and increase the risk of impaired fasting glucose, IGT and type 2 diabetes , The cumulative risk increases markedly in the first 5 years and more slowly after 10 years , While elevated FPG during pregnancy is a strong predictor of early development of diabetes — , other predictors include age at diagnosis, use of insulin, especially bedtime insulin or oral agents, and more than 2 pregnancies — A1C at diagnosis of GDM is also a predictor of postpartum diabetes , Any degree of dysglycemia is associated with increased risk of postpartum diabetes Some women with GDM, especially lean women under 30 years of age who require insulin during pregnancy, progress to type 1 diabetes , Women with positive autoantibodies anti-glutamic acid decarboxylase [anti-GAD], anti-insulinoma antigen 2 [anti- IA2] are more likely to have diabetes by 6 months postpartum Postpartum testing is essential to identify women who continue to have diabetes, those who develop diabetes after temporary normalization and those at risk, including those with IGT.
However, many women do not receive adequate postpartum follow up, and many believe they are not at high risk for diabetes — Despite this finding, more work in this area is needed to improve uptake. Women should be screened postpartum to determine their glucose status.
Postnatal FBG has been the most consistently found variable in determining women at high risk for early postpartum diabetes Some recent trials have shown that early postpartum testing day 2 postpartum may be as good at detecting diabetes as standard testing times; however, follow up in the standard testing group was poor.
If this can be confirmed in more rigorous trials, it may be useful to do early postpartum testing in women at high risk for type 2 diabetes or at high risk for noncompliance with follow up A1C does not have the sensitivity to detect dysglycemia postpartum and, even combined with FBS, did not help improve its sensitivity , Given the increased risk of CVD OR 1.
Education on healthy behaviour interventions to prevent diabetes and CVD should begin in pregnancy and continue postpartum , Awareness of physical activity for prevention of diabetes is low , and emphasis on targeted strategies that incorporate women's exercise beliefs may increase participation rates Although 1 study showed women with prior gestational diabetes and IGT reduced their risk of developing diabetes with both a lifestyle intervention or metformin, these women were, on average, 12 years postpartum.
More recent intervention studies of women with GDM alone who were closer to the time of delivery were often underpowered and compliance with the intervention was low. The 2 largest randomized controlled trials to date were conflicting.
The Mothers After Gestational Diabetes in Australia MAGDA study randomized women within the first year postpartum to a group-based lifestyle intervention vs.
standard care. In another randomized controlled trial, women were randomized to receive the Mediterranean diet and physical activity sessions for 10 weeks between 3 to 6 months postpartum, and then reinforcement sessions at 9 months, 1, 2 and 3 years.
At 3 years, women in the intervention group had a lower BMI and better nutrition but similar rates of physical activity. However, engaging women to adopt health behaviours may be challenging soon after delivery.
More studies are needed to explore interventions that may help this population reduce their risk. Long-term metabolic impact of fetal exposure to maternal GDM.
Observational studies have linked maternal GDM with poor metabolic outcomes in offspring However, 3 systematic reviews — have concluded that maternal GDM is inconsistently or minimally associated with offspring obesity and overweight and this relationship is substantially attenuated or eliminated when adjusted for confounders.
The HAPO offspring study extended their follow up to 5- to 7-year-olds and found that after adjustment for maternal BMI, higher maternal plasma glucose PG concentrations during pregnancy were not a risk for childhood obesity In contrast, a recent cohort found an association between maternal FPG and offspring BMI at 7 years of age that persisted after adjustment for birth weight, socioeconomic status and maternal pre-pregnancy BMI Current evidence fails to support the hypothesis that treatment of GDM reduces obesity and diabetes in offspring.
Three follow-up studies of offspring whose mothers were in randomized controlled trials of GDM management found that treatment of GDM did not affect obesity at 4 to 5 years, 5 to 10 years or a mean age of 9 years — This follow up may be too short to draw conclusions about longer-term impact.
However, it is interesting to note that the excess weight in offspring of women with diabetes in the observational work by Silverman et al was evident by 5 years of age.
Furthermore, a subanalysis of another trial follow-up study revealed that comparison by age at follow up 5 to 6 vs. Association between maternal diabetes and other long-term offspring outcomes, such as childhood academic achievement and autism spectrum disorders ASD , have been explored in observational studies.
Reassuringly, offspring of mothers with pre-existing type 1 diabetes had similar average grades when finishing primary school compared to matched controls Associations between autism and different types of maternal diabetes during pregnancy have been inconsistent and usually disappear or are substantially attenuated after adjustment for potential confounders , Unspecified antihyperglycemic medications were either not associated with ASD or not independently associated with ASD risk , , but merit further investigation to assess if there are differences in the association between different types of antihyperglycemic agents and ASD.
Contraception after GDM. Women with prior GDM have numerous choices for contraception. Risk and benefits of each method should be discussed with each patient and same contraindications apply as in non-GDM women. Special attention should be given as women with GDM have higher risk of metabolic syndrome and, if they have risk factors, such as hypertension and other vascular risks, then IUD or progestin-only contraceptives should be considered The effect of progestin-only agents on glucose metabolism and risk of type 2 diabetes in lactating women with prior GDM merits further study as in 1 population this risk was increased , Planning future pregnancies.
Women with previous GDM should plan future pregnancies in consultation with their health-care providers , Screening for diabetes should be performed prior to conception to assure normoglycemia at the time of conception see Screening for Diabetes in Adults chapter, p.
S16 , and any glucose abnormality should be treated. In an effort to reduce the risk of congenital anomalies and optimize pregnancy outcomes, all women should take a folic acid supplement of 1. Literature Review Flow Diagram for Chapter Diabetes and Pregnancy.
From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group P referred R eporting I tems for S ystematic Reviews and M eta- A nalyses: The PRISMA Statement. PLoS Med 6 6 : e pmed For more information, visit www.
Feig reports non-financial support from Apotex. Kader reports personal fees from Eli Lilly, Sanofi, Novo Nordisk, Merck, Janssen, Medtronic, and Hoffman Laroche, outside the submitted work.
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Key Messages Pre-Existing Diabetes Preconception and During Pregnancy All women with pre-existing type 1 or type 2 diabetes should receive preconception care to optimize glycemic control, assess for complications, review medications and begin folic acid supplementation.
Effective contraception should be provided until the woman is ready for pregnancy. Women should consider the use of the continuous glucose monitor during pregnancy to improve glycemic control and neonatal outcomes.
Postpartum All women should be given information regarding the benefits of breastfeeding, effective birth control and the importance of planning another pregnancy. It occurs only in pregnant women due to changes in the body during pregnancy.
What does a diet for gestational diabetes typically consist of? A diet for gestational diabetes focuses on foods high in fiber and important nutrients, while being low in fat and calories. It includes vegetables, fruit, and whole grains, and avoids refined carbohydrates and sugar.
What type of exercise is recommended for women with gestational diabetes? Women with gestational diabetes should engage in at least 30 minutes of moderate to intense exercise, such as brisk walking, swimming, or low-impact aerobics, at least five days a week. Certain activities should be avoided to prevent harm to the baby.
How should blood glucose levels be monitored for gestational diabetes? Blood glucose levels should be checked regularly with a glucose monitor. Medication may be necessary if target levels are not reached through diet and exercise alone. Gestational Diabetes Diet Treatment for gestational diabetes always includes specialized healthy meal plans — often recommended by a registered dietician — and regular exercise, according to the American Diabetes Association ADA.
Exercise as Treatment for Gestational Diabetes Regular physical activity is important to help keep your blood glucose under control. Monitoring Blood Glucose Levels As with any form of diabetes, it's important to regularly check your blood glucose level with a glucose monitor.
Gestational Diabetes Medications Insulin injections are the standard medication for gestational diabetes. Editorial Sources and Fact-Checking. Resources A. Gilmartin, S. Ural, and J.
Repke What I need to know about Gestational Diabetes; National Institute of Diabetes and Digestive and Kidney Diseases. Gestational diabetes; MedlinePlus. How to Treat Gestational Diabetes; American Diabetes Association.
Jump to diaebtes. Globally the number of women being diagnosed with Brown rice for digestion diabetes mellitus GDM Oral medication options for gestational diabetes fot. GDM is dabetes intolerance to glucose leading to high blood Oral medication options for gestational diabetes, first gestaitonal during pregnancy and usually resolving after birth. Standard care involves lifestyle advice on diet and exercise. Treatment for some women includes oral anti-diabetic medications, such as metformin and glibenclamide, which are an alternative to, or can be used alongside, insulin to control the blood sugar. This review aimed to investigate benefits of taking oral medication to treat GDM in pregnant women.
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