University of the Philippines - Manila

College of Medicine & Philippine General Hospital

Department of Obstetrics and Gynecology

GESTATIONAL DIABETES MELLITUS

OB CASE PROTOCOL

Objectives
1. To define gestational diabetes mellitus and discuss its etiology and pathophysiology
2. To differentiate gestational diabetes mellitus from overt diabetes mellitus
3. To discuss the epidemiology and risk factors for the development of gestational diabetes mellitus
4. To discuss the approach to the diagnosis of gestational diabetes mellitus
5. To discuss the management strategies for gestational diabetes mellitus
6. To identify the different the possible complications of gestational diabetes mellitus including congenital
anomalies and risk for future pregnancies

General Data
This is the case of GC, a 34-year-old G2P1(1001), married, Roman Catholic, housewife from
Dasmarinas, Cavite.

Chief Complaint
Regular uterine contractions

Past Medical History

(+) Gestational diabetes mellitus (G1, 2015)
- Diagnosed with a 3rd trimester FBS of 105;
- Maintained on human biphasic isophane insulin 30/70 12U BID;
- No fetomaternal complications
- 6-week-postpartum 75g OGTT and FBS were allegedly normal

(+) Corpus luteum cyst (2017):

- Presented with intermenstrual spotting
- Consulted at PGH OPD. TVS showed 1.0 cm corpus luteum cyst and otherwise normal
gynecologic findings
- Symptoms resolved after one month of ethinyl estradiol-cyproterone acetate

(+) Allergies
- Penicillin: rashes and dyspnea after taking amoxicillin-clavulanic acid
- Seafood

She denies any history of hypertension, bronchial asthma, tuberculosis, cancer, endocrine disorders, or
blood dyscrasias. She had no maintenance medications outside pregnancy.
She has had no other past hospitalizations or surgeries other than for this admission and her first
pregnancy: primary LSCS for non-reassuring fetal status (2015, Iloilo City)
Family Medical History
(+) Hypertension: father
(+) Diabetes Mellitus II: father

She has no family history of coronary artery disease, stroke, tuberculosis, cancers, endocrine disorders,
or blood dyscrasias.

Personal, Social, and Sexual History

She is a college graduate and is currently a housewife.
She does not smoke, drink alcohol, or use illicit drugs.
Her first coitus was at 29 y/o. She has only had 1 non-promiscuous sexual partner,
She used combined oral contraceptives for 1 month, only for the indication stated above.
She has had no history of sexually transmitted infections.
Her current diet consists of 3 meals. She tries to lower her portions of carbohydrates.

Menstrual History
Menarche: 13 years old.
Interval: Irregular (1-2 month intervals)
Duration: 4-5 days
Amount: 3-4 pads per day
Symptoms: (+) dysmenorrhea
LNMP: December 1, 2017

Obstetric History ​G2P1 (1001)

G Year AOG Manner Place Sex Weight FMCs Status
1 2015 FT LSCS for NRFS St Paul’s Hosp M AGA None Alive
2 ​Current pregnancy

History of Present Pregnancy

Age of gestation on day of examination: 37 weeks by amenorrhea, 36 4/7 weeks by EUTZ (2/24/17=11
4/7 wks AOG)

Morning sickness: 8-12 weeks AOG

Quickening 16-18 weeks AOG
Danger signs: She denies fever, headache, facial edema, blurring of vision, severe vomiting, right upper
quadrant pain, dysuria, bloody or watery discharge, or decreased fetal movement count
Review of systems: (+) polydipsia, (+) polyuria

Patient had 10 antenatal visits: 5 with a private MD, 1 in PGH OPD general clinic, and 4 in the PGH high
risk clinic. She denies vices during pregnancy. First antenatal visit was in March 2018 and her most
recent one was on August 17 2017 (the day of admission).

She was diagnosed with gestational diabetes mellitus on her 11th week with an FBS of 111 mg/dL
(​Appendix 1​). She was advised lifestyle modification but not CBG monitoring. She reported no symptoms
in the interim.
In June 2018, she decided to have her regular checkups done at PGH due to financial constraints. Her
75g OGTT showed a borderline 1st-hour value: 179.92 mg/dL. She was advised strict CBG monitoring,
which showed consistently elevated preprandial values. She was started on a daily insulin regimen:
insulin NPH 14U before breakfast and preprandial insulin HR 8U if her pre-meal finger-prick CBG levels
are more than 100 mg/dL. See CBG diary at ​Appendix 2​.

History of Present Illness

1 day PTA Patient experienced uterine contractions occurring every 10 minutes.
She noted no watery or vaginal discharge or other symptoms.
2 hours PTA The patient was seen in the high risk clinic for her scheduled checkup.
She noted that her contractions became more frequent, occurring every 5 minutes.
On physical exam, the patient’s cervix was noted to be 2-3 cm dilated and was therefore
directed to the OB Admitting Section. There was no watery or bloody vaginal discharge.

Physical Examination at the Labor Room

ANTHROPOMETRICS
Weight: 49.5 kg, Height: 145 cm, BMI: 23.5

HEENT
Anicteric sclerae, pink palpebral conjunctivae, (-) cervical lymphadenopathy, (-) neck vein engorgement,
(-) anterior neck mass, trachea is midline

Chest and Lungs

CVS: Adynamic precordium, (-) chest wall deformities, (-) heaves/thrills, PMI palpable at 5th ICS LMCL;
normal rate and regular rhythm, distinct heart sounds, no murmurs
Pulmonary: Equal chest expansion, equal tactile fremitus, clear breath sounds

Extremities
Full and equal peripheral pulses, capillary refill time <2s, pink nail beds, (-) ecchymoses, (-) edema

Abdomen
Gravid abdomen, normoactive bowel sounds, nontender
Fundic height: 29 cm
Estimated fetal weight: 2.2 - 2.4 kg
Presentation: cephalic
Fetal heart tones: 140s RLQ

Pelvic Exam / Internal Exam

External genitalia: Normal external genitalia, (-) palpable masses, (-) lesions, (-) lacerations or scars, (-)
discharge
Speculum exam: Pink vaginal walls, no lesions, no discharge; cervix pink, with (-) whitish discharge

Internal and bimanual exam: Smooth, parous vagina, cervix soft, dilated at 5 cm, fully effaced, medium
consistency, mid position, station 0 (Bishop Score of 10), corpus enlarged to 29 weeks AOG, no adnexal
mass/tenderness, intact bag of waters

Pelvimetry (adequate):
Pubic arch > 90 degrees, coccyx moveable, BT >8.5cm, BS >9.5 cm, DC >11.5 cm, ischial spines blunt,
sidewalls parallel, sacral incl. Posterior, sacral notches wide, sacral width wide, sacral curvature hollow

Rectovaginal exam: Good sphincter tone, intact rectal vault, (-) intraluminal masses, bilateral parametria
smooth and pliable, (-) fullness in the cul de sac, (-) blood/stool per examining finger

Initial Working Impression

Pregnancy uterine 37 weeks AOG by amenorrhea, cephalic, in labor

s/p primary low segment cesarean section for non-reassuring fetal status (G1, 2015, IloIlo City)
Gestational diabetes mellitus - insulin requiring, controlled.
Gravida 2 para 1 (1-0-0-1)

Course at the OB Admitting Section

The patient was received with stable vital signs (BP 120/80, HR 100, RR 20, temp 36.2), awake, alert,
and not in cardiorespiratory distress. CBG by finger prick testing was 167 mg/dL. The patient was placed
on NPO status and maintained on 1L of pNSS every 12 hours. Her usual insulin regimen at home was
maintained. Her monitored CBG and vital signs were within normal limits.

Course at the Labor Room

Patient was received with vital signs: BP: 120/80, HR: 74, RR: 18, Temp: 36.3, awake, conversant, not in
cardiorespiratory distress. Continuous fetal monitoring showed Category I trace. Though she was advised
that she could be a candidate for VBAC, she did not consent to trial of labor. Repeat low segment
cesarean delivery with spinal anesthesia was performed an hour upon arrival at the labor room. Vital
signs were stable throughout the operation. The baby and placenta were delivered 12 and 17 minutes
after cutting, respectively. Blood loss was 400 cc.

A live baby girl was born term or 36 weeks of gestation by pediatric aging, 2105 grams, appropriate for
gestational age, with an APGAR score of 9,9. Essential intrapartum and newborn care was performed
adequately.

Laboratory Tests Done

Complete Blood Count

Aug 18, 2018

Result Normal Values

Hemoglobin 119 120-150 g/L
Hematocrit 0.37 0.38 – 0.47
WBC 12.60 4.5 – 11.0 x 109/L
Platelet 233 150 – 450 x 109/L
 Neutrophil 0.83 0.5 – 0.7
Lymphocyte 0.11 0.2 – 0.5
Monocyte 0.06 0.02 – 0.09

Blood Typing
AB positive

Serum Chemistry
Result Normal Values
Crea 43 umol/L 46 - 92 umol/L eGFR: 127 mL/min
Na 138 mmol/L 137 - 145 mmol/L
K 3.9 mmol/L 3.5 - 5.1 mmol/L

HbA1c 5.3%

Biometry/Biophysical Profile (Impression) to follow, still with the OOD.

Final Working Impression

Pregnancy uterine 36 weeks AOG by pediatric aging, delivered abdominally, term, cephalic, live birth,
appropriate for gestational age; Gravida 2 para 2 (2-0-0-2)
Gestational diabetes mellitus, insulin-requiring, controlled
s/p primary low segment cesarean section x2 ( G1, 2015, IloIlo City for non-reassuring fetal status; G2,
2018, PGH for repeat)

Plan

Therapeutic Goals:
1. Provide adequate nutritional support for the postpartum mother
2. Monitor the blood sugar of the mother and address possible hyperglycemia
3. Prevent surgical site infections
4. Promote proper breastfeeding
5. Establish continuity of care and advise about risks conferred by GDM
6. Reevaluate plans for future pregnancies and necessary contraceptive measures

Diet as tolerated.
Oral fluid intake: 2-3L per day.
Labs:
- 75g OGTT 6 weeks postpartum
Meds:
- Ferrous sulfate 325 mg tab OD
- Calcium carbonate 500 mg tab BID
- Multivitamins tab OD
 - Hold insulin.
Referrals: Endocrinology, outpatient
Clean wound dressing BID
Perineal hygiene, full body bath daily
Breastfeed as needed
Follow up at the Out Patient Department in 6 weeks.
Advise about the increased risk of Diabetes Mellitus 2 after the diagnosis of GDM.
Advise about contraception.

Guide Questions:
1. What are the pertinent data in the patient's history and physical examination?
2. What is gestational diabetes mellitus? Differentiate GDM from overt diabetes mellitus.
3. What are the risk factors for gestational diabetes mellitus? What are present in this case? How was
screening done?
4. How is GDM diagnosed? How is overt diabetes mellitus diagnosed?
5. How is GDM managed?
6. What is the best delivery management for GDM patients?
7. What are the most common congenital anomalies present in babies of GDM mothers?
8. What are the possible complications of GDM? What are the risks for future pregnancies? For this
case? What to advise pt re future pregnancies and risk of dm?
9. What would be the best treatment and postpartum management for this patient?

Appendix 1
Prenatal labs
CBC ​(2/23):
Hemoglobin 134
Hematocrit 0.40
WBC 7.9
Platelet Adequate
Neutrophil 0.74
Lymphocyte 0.21
Monocyte 0.05

Blood type (​ 2/23): AB positive

HBA1c​:
3/21: 6.2%
5/3: 5.8%
6/25: 6.6%

Urinalysis ​(2/23):
Color: Yellow Transparency: Hazy
Glucose: Normal Albumin: Negative pH: 6.0 SG: 1.015 RBC: 0-2/HPF
WBC: 0-2/HPF EC: few Urates: few Bacteria: few
Blood sugar
2/23 7/23
FBS 111.42 83.7
1-hr OGTT - 179.92
2-hr OGTT - 106.56

VDRL/RPR​ (2/23): nonreactive

HBsAg (​ 2/26): 0.306 - nonreactive
Pap smear (​ 7/14):
Negative for intraepithelial lesion or malignancy
With noted reactive cellular changes associated with marked inflammation
HIV Ag/Ab ​(7/27): 0.08 - nonreactive

Appendix 2.
Capillary Blood Glucose Diary
Date Breakfast Lunch Dinner

Before/ After 1 hr Before/ After 1 hr Before/ After 1 hr

7/19/18 101/130 86/181 91/155

7/20/18 101/130 114/122 95/143

7/21/18 99/127 97/171 107/110

7/22/18 86/117 131/141 104/109

7/25/18 87/122 134/136 100/116

7/26/18 85/121 123/96 87/149

7/28/18 84/103 124/113 158/141

7/29/18 87/111 146/91 119/90

7/31/18 90/174 95/104 114/128

8/01/18 74/90 78/115 92/88

8/02/18 85/193 95/134 123/103

8/03/18 74/103 69/121 130/95

8/04/18 77/122 104/138 136/106

8/05/18 77/106 81/132 99/125

8/06/18 81/91 85/114 100/96

8/07/18 74/121 90/99 126/126

 8/08/18 75/120 81/114s 130/97

8/09/18 76/121 142/121 102/116

8/11/18 94/121 98/148 122/115

8/12/18 102/118 112/140 135/134

8/14/18 84/169 87/161 94/111

8/15/18 90/120 95/112 134/83

8/16/18 74/111 107/112 118/115

Discussion
Etiology
The different types of diabetes are based on their etiopathogenesis and pathophysiological
manifestations. Type 1 is characterized by absolute insulin deficiency through B-cell destruction. This is
usually immune-mediated. Type 2 is characterized by defective insulin secretion, insulin resistance or
increased glucose production. B-cell destruction can begin at any age however, it is most apparent before
30 while Type 2 diabetes develops with advancing age but is increasingly diagnosed in the younger more
obese adolescents.

The most common medical complication of pregnancy is diabetes. Women can be classified into those
known to have diabetes during pregnancy, pregestational or overt, and those diagnosed during the
pregnancy, gestational diabetes.

Pathogenesis
Gestational diabetes mellitus develops in women with insufficient pancreatic function to overcome the
insulin resistance caused by placental secretion of diabetogenic hormones (growth hormone,
corticotropin-releasing hormone, placental lactogen and progesterone) leading to hyperglycemia in
pregnancy.

In pregnancy, progressive insulin resistance normally begins near mid-pregnancy and progresses through
the third trimester to levels similar to those seen in individuals with type 2 diabetes. The insulin resistance
appears to develop from a combination of increased maternal adiposity and the insulin-desensitizing
effects of hormonal products of the placenta. The fact that insulin resistance rapidly decreases following
delivery suggests that the major contributors to this state of resistance are placental hormones.
Pancreatic B cells normally increase their insulin secretion to compensate for the insulin resistance of
pregnancy. However in GDM women, a consistent finding is the large defect in pancreatic B cell function
leading to inadequacy of insulin secretion.
Potential causes of inadequate B cell function are categorized into: autoimmune; monogenic and;
occuring on a background of insulin resistance. B cell dysfunction in GDM can occur in all 3 settings,
however the majority of GDM women seem to subscribe to the last.

Signs and symptoms

Guide Questions:
1. What are the pertinent data in the patient's history and physical examination?
- ​Filipino, pacific islander considered high risk
- 34yo, inc risk of dec GDM
- GDM at G1, assoc with inc risk of GDM in succeeding pregnancies
- FH of type 2 DM, strong association
- Penicillin allergies, GDM are high risk for Infection and PT labor, important to note in antibiotic
administration
- 37W by amenorrhea/ 36 4/7 by eUtz, GDM patients have inc risk of PT labor
- MORNING SICKNESS of nausea/vomiting at 12-18weeks, can be an early sign of diabetic gastropathy
(complication of DM, autonomic nerves in the GIT are compromised by hyperglycemia. FBS at 11 weeks
111mg/dL)
- Polydipsia and polyuria, classic findings in DM
- S/p 1 CS, LSCS,2015 sec to NRFS, 0.9% utrne rupture in VBAC/trial of labor
- Pertinent negatives (esp for complications) no retinopathy, neg albuminuria/frothy urine, no sweet odor
urine, no symmetric somatosensory neuropathy, no thyroid disease , no painful neuritis in insulin
administration, neg congenital anom scan, no previous history of hp , PEC and IUGR, no history of
macrosomic baby (2.7kg) and dystocia, no recurrent infection/UTI, controlled glucose/ regular glucose
monitoring, no early pregnancy losses/ fetal demise
2. What is gestational diabetes mellitus? Differentiate GDM from overt diabetes mellitus.
GDM- glucose intolerance during pregnancy. Most patients subsides post partum. Although glucose
intolerance in subsequent years occurs more frequently. If any one of the following plasma values
Fbs >= 92mg/dl (patient 111mg/dL)
1hr >= 180 mg/dL
2hr >= 153 mg/dL
Overt DM- or pregestational DM. If any one of the following values in their first visit
Fbs >= 126mg/dl
Rbs >= 200 mg/dL
Hba1c >= 6.5%
2hr 75OGTT >=200mg/dL (CPG in DM in pregnancy,2011)

3. What are the risk factors for gestational diabetes mellitus? What are present in this case? How
was screening done?

Present:
Previous GDM
> 25 yo- 34 yo patient
Family history of T2DM
Pacific Islander (others: hispanic american, native american, asian-american, african american)

Not present:
1. Pre pregnant weight >110% of IBW or >30mg/m2 or significant wt gain in early adulthood and between
pregnancies
2. <25 yo and obese( >20% over desired body weight or BMI >27kg/m2
3. Previous history of 4.1 kg baby, polyhydramnios, fetal abn, IUFD
4. Previous unexplained perinatal loss or birth of a malformed child
5. Maternal birth weight greater than 9pounds (4.1kg) or less than 6 pounds (2.7 kg)
6. Glycosuria at first prenatal visit
7. Corticosteroid use, beta mimetics
8. Hypertension

Screening should be limited to women with any of the risk factors above.
All Filipino gravidas are considered high risk by race or ethnic group and should be screened for type 2
DM in first prenatal visit
High Risk Groups:
1. Historical risk factors
2. Past pregnancy- macrosomia, cong malformation, recurrent abortion, unexplained IUFD
3. Present pregnancy- FH, Mat obesity >27 bmi, steroids/beta mimetics, 30yo, racial predilection
4. Obstetrics risk factors- polyhydramnios, macrosomic fetus, fetal abn, recurremt genital Tract infection
When: 24-28w AOG. For women with RF, immeditely screen at first prenatal. If normal, rpt at
24-28weeks then later at 32-34 weeks.
All Filipinos are High Risk by race or ethnic and should be screened for T2DM in frst prenatal (fbs, rbs or
HBA1C)

4. How is GDM diagnosed? How is overt diabetes mellitus diagnosed?

Overt (fbs 126, rbs 200, or HBA1C 6.5%)
Gdm (75g OGTT: FBS 92, 1hr 180, 2hr 140)

5. How is GDM managed?

Diet and lifestyle modification. Cho 55%, CHON 20%, fat 25%-<10%saturated
Insulin
Oral Hypoglycemics, glyburide and metformin ( tendency to pass placenta causing fetal hypoglycemia
and possible cong malformation. But studies comparing insulin and oral hypoglycemics showed no
significant difference. Pero FDA, no approval sa oral hypoglycemics)
6. What is the best delivery management for GDM patients?
7. What are the most common congenital anomalies present in babies of GDM mothers?
8. What are the possible complications of GDM? What are the risks for future pregnancies? For
this case? What to advise pt re future pregnancies and risk of dm?

GDM increases the risk of macrosomia, shoulder dystocia, and birth injuries. It is also associated with
gestational hypertension and preeclampsia, and likewise an increased rate in abdominal deliveries.
9. What would be the best treatment and postpartum management for this patient?

Management
Diet Control: Diet low in food with high glycemic index, processed red meat, refined grains, high fat dairy.
MOre consumption of vegetables, fruits, whole grain, fish.
Pharmacologic Intervention: Despite adherence to diet, FBS consistently higher than 100 mg/dl and > 120
mg/dl at 2 hour postprandial warrants pharmacologic treatment or more than 50% of patient’s blood sugar
measurements are above the cut-off values
 First line: insulin both short (aspart, lispro, regular insulin) and long acting (glargine, protamine
hagrdorn, detemir)
Oral hypoglycemic agents: met former in (significantly reduced rate of hypertensive diisorders in
pregnancy) and glyburide.
CBG monitoring to gauge response to therapy
Ideal Weight Gain: 30-35 kcal/kg IDEAL BW distributed as 500 calories for protein and the rest divided
between fat and carbohydrates.
Fetal Surveillance: Fetal growth and well-being monitoring upon diagnosis. Biometry every 4-6 weeks
correlating to CBG measurements. Starting 32 weeks, BPP every week and Nonstress test 2x a week.
Intrapartum Glucose Monitoring: Increased utilization of glucose intrapartum thus monitored every 4
hours. However, those on insulin or oral hypoglycemics need closer surveillance of evert 1-2 hours.
Delivery: Good control and diet controlled: no indication to deliver before 41 weeks, given that the mother
and fetus are in good condition
Insulin and/or oral hypoglycemics best to deliver between 39 1/7 to 39 6/7 days to prevent
increased complications (shoulder dystocia).
If estimated birthweight is 4500 grams or higher, abdominal delivery is advised.
Postpartum Glucose Test: 70% of women with GDM develop DM, thus follow-up 6-12 weeks postpartum
with a 75gOGTT is done to rule out diabetes mellitus type II.