Glucose Tolerance TestBe prepared for your exam by learning about glucose tolerance testing. Gestational Diabetes Mellitus is defined as glucose intolerance diagnosed during pregnancy. It is recommended that pregnant women with any risk factors be screened at the first prenatal visit.
For women at high risk not found to have GDM at the first visit, repeat testing is indicated between 24 and 28 weeks. If 2 or more values are abnormal then the patient has a positive diagnosis of gestational diabetes. It has been found that women diagnosed with gestational diabetes already have insulin resistance at baseline with a higher level of plasma insulin levels. Women diagnosed with GDM need training about daily self monitoring of glucose 6-7 times a day with a minimum of 4 times.
All women diagnosed with GDM require nutritional counseling for the appropriate amount of weight gain during pregnancy as well as dietary control.
It is a critical point in time for changing the lifestyles of these women since they are at a high risk for development of type 2 diabetes.
The use of oral medications is considered when diet and exercise do not adequately control blood sugars.
Some studies have recently evaluated the safety and efficacy of Glyburide [sulphonylurea] after the first trimester for treatment of GDM.
There is inadequate data in regards to the safety and efficacy of other oral antidiabetic medications such as Metformin, thiazolidinediones and Acarbose. The diagnosis and treatment of gestational diabetes is critical because elevated blood sugars adversely affect both the mother and the baby.


Approximately 50% women will develop type 2 diabetes within 5 years of development of gestational diabetes.
This could either be newly diagnosed type 1 or type 2 Diabetes Mellitus or this could be a new onset of hyperglycemia secondary to metabolic changes related to pregnancy. One can either take a two step approach, starting with the 50 gm glucose challenge test, followed by an oral glucose tolerance test if the results of the former test are abnormal. During the early part of pregnancy there is increase in insulin secretion and beta cell hyperplasia. It is recommended that pregnant women exercise for about 20-30 minutes everyday or at least most days of the week.
The older sulphonylureas were not recommended for use in pregnancy because they crossed the placenta. The fetus is at increased risk of macrosomia, hypoglycemia, hypocalcemia, hypomagnesaemia, jaundice, polycythemia, respiratory complications, congenital malformations and fetal loss including abortion, still births and neonatal deaths. The greatest risk factor for early-onset type 2 diabetes after pregnancy was early gestational age at the time of diagnosis and elevated fasting glucose. This leads to an increase in insulin sensitivity with low fasting blood sugar levels, increased glucose uptake by peripheral tissue and glycogen storage as well as decreased hepatic gluconeogenesis. The pancreas however, is unable to cope with this additional stress of elevated level of insulin resistance. Testing for the presence of ketones in a fasting urine sample is a valuable tool to assess the adequacy of caloric intake in these patients. These patients should restrict fat intake and substitute simple or refined sugars in their diet to more complex carbohydrates. This process is crucial for the build-up of maternal adipose tissue, to be used in the later part of pregnancy.


Positive urine for ketones indicates a state of starvation and the patients should be advised to increase their daily caloric consumption. There isn’t enough data regarding the safety of the long acting insulin glargine in pregnancy. It has been shown that it is as effective as insulin, more cost effective than insulin and safe for use in pregnancy. Women with normal pregravid glucose tolerance who develop gestational diabetes in late gestation have no increased risk of fetal congenital anomalies beyond the population risk for women with normal glucose metabolism. During the late phase, there is an increase in hormones such as cortisol, prolactin, progesterone and human placental lactogen which leads to a state of relative insulin resistance, possibly via a post receptor defect in the cells. Both American Diabetic Association [ADA] and American college of Obstetricians and Gynecologists [ACOG] await more research related to the effect of glyburide on maternal and perinatal outcomes before approving its use. The children of women diagnosed with GDM are at increased risk of obesity and abnormal glucose metabolism during childhood, adolescence and adulthood.
Women diagnosed with gestational diabetes are at increased risk of gestational hypertension including preecclempsia, caesarian section and assisted deliveries. One of the mechanisms thought to be contributing to the long term complications in these babies is ‘early onset hyperinsulinimia’.



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Comments

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