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Table 18 3 Screening and diagnostic criteria for gestational diabetes mellitus
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Screening for gestational diabetes mellitus 1 50-g oral glucose load, administered between the 24th and 28th weeks, without regard to time of day or time of last meal Universal blood glucose screening is indicated for patients who are of Hispanic, African, Native American, South or East Asian, Pacific Island, or Indigenous Australian ancestry Other patients who have no known diabetes in first-degree relatives, are under 25 years of age, have normal weight before pregnancy, and have no history of abnormal glucose metabolism or poor obstetric outcome do not require routine screening 2 Venous plasma glucose measure 1 hour later 3 Value of 130 mg/dL (72 mmol/L) or above in venous plasma indicates the need for a full diagnostic glucose tolerance test Diagnosis of gestational diabetes mellitus 1 100-g oral glucose load, administered in the morning after overnight fast lasting at least 8 hours but not more than 14 hours, and following at least 3 days of unrestricted diet (> 150 g carbohydrate) and physical activity 2 Venous plasma glucose is measured fasting and at 1, 2, and 3 hours Subject should remain seated and should not smoke throughout the test 3 Two or more of the following venous plasma concentrations must be equaled or exceeded for a diagnosis of gestational diabetes: fasting, 95 mg/dL (53 mmol/L); 1 hour, 180 mg/dL (10 mmol/L); 2 hours, 155 mg/dL (86 mmol/L); 3 hours, 140 mg/dL (78 mmol/L)
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Langer O et al A comparison of glyburide and insulin in women with gestational diabetes mellitus N Engl J Med 2000 Oct 19;343(16):1134 8 [PMID: 11036118]
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Overall, 5% of maternal deaths are due to heart disease Most heart disease complicating pregnancy in the United States is congenital heart disease Normal pregnancy causes a faster pulse, an increase of cardiac output of more than 30%, and a rise in plasma volume greater than red cell
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Class I Class II Class III Ordinary physical activity causes no discomfort (perinatal mortality rate about 5%) Ordinary activity causes discomfort and slight disability (perinatal mortality rate 10 15%) Less than ordinary activity causes discomfort or disability; patient is barely compensated (perinatal mortality rate about 35%) Patient decompensated; any physical activity causes acute distress (perinatal mortality rate over 50%)
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hydramnios, preeclampsia-eclampsia, infections, and prematurity is increased even in carefully managed diabetic pregnancies Diabetes is an inherently unstable disease characterized by fluctuations of blood glucose levels, particularly late in pregnancy The risk of fetal demise in the third trimester (stillbirth) and neonatal death increases with the level of hyperglycemia Consequently, pregnant women with diabetes must receive regular antepartum fetal testing (nonstress testing, contraction stress testing, biophysical profile) during the third trimester The timing of delivery is dictated by the quality of diabetic control, the presence or absence of medical complications, and fetal status The goal is to reach 39 weeks (38 completed weeks) and then proceed with delivery Confirmation of lung maturity is necessary only for delivery prior to 39 weeks Cesarean sections are performed for obstetric indications Because 15% of patients with gestational diabetes require insulin during pregnancy and because the infants of gestational diabetics have some risks similar to those of infants of diabetic mothers (particularly macrosomia), screening of women for glucose intolerance has been recommended between the 24th and 28th weeks of pregnancy (Table 18 3) Patients with gestational diabetes should be evaluated 6 8 weeks postpartum by a 2-hour oral glucose tolerance test (75 g glucose load)
ACOG Practice Bulletin Clinical Management Guidelines for Obstetrician-Gynecologists Number 60, March 2005 Pregestational diabetes mellitus Obstet Gynecol 2005 Mar;105(3): 675 85 [PMID: 15738045] Crowther CA et al; Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS) Trial Group Effect of treatment of gestational diabetes mellitus on pregnancy outcomes N Engl J Med 2005 Jun 16;352(24):2477 86 [PMID: 15951574]
mass with relative hemodilution Vital capacity and oxygen consumption rise only slightly For practical purposes, the functional capacity of the heart is the best single measurement of cardiopulmonary status In general, patients with class I or class II functional disability (80% of pregnant women with heart disease) do well obstetrically, with four-fifths of maternal deaths due to heart disease occurring in women with class III or class IV disability Congestive failure is the usual cause of death Most deaths occur in the early puerperium Pregnancy is contraindicated in Eisenmenger s complex, in primary pulmonary hypertension, in severe mitral stenosis with secondary pulmonary hypertension, and in Marfan s syndrome, in which the aorta is prone to dissection and rupture In addition, pregnancy is poorly tolerated in patients with aortic stenosis, aortic coarctation, tetralogy of Fallot, and active rheumatic carditis Therapeutic abortion and elective sterilization should be offered to patients with significant cardiac disease Cesarean section should be performed only for obstetric indications Women with valvular heart disease, mitral valve prolapse associated with mitral insufficiency, or idiopathic hypertrophic cardiomyopathy should receive appropriate antibiotic prophylaxis against infective endocarditis during labor and delivery or termination of pregnancy
Earing MG et al Congenital heart disease and pregnancy: maternal and fetal risks Clin Perinatol 2000 Oct 19;343(16): 1134 8 [PMID: 16325669] Elkayam U et al Valvular heart disease and pregnancy: Part II: Prosthetic valves J Am Coll Cardiol 2005 Aug 2;46(3):403 10 [PMID: 16053950]
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