Case Study: A 34-Year-Old Woman in

Her Second Pregnancy at 24 Weeks

Gestation
StevenG.Gabbe,MD

Presentation
A34yearoldHispanicAmericanwomanwhoisinhersecondpregnancyandhashadonelive
birthandnoabortionsisseenforprenatalcareat24weeksgestation.Herweightis220lb,and
herbloodpressureis130/80mmHg.Uterinesizeisappropriateforgestationalage.Thepatient's
pastobstetrichistoryincludesthespontaneousvaginaldeliveryofa9lb,8oz.maleinfantat40
weeksgestation,8yearsagoinMexico.Thepatientreportsthatthechildisdoingwell.Her
familyhistoryrevealsthathermotherhastype2diabetesmellitus.Aurinedipstickshows3+
glycosuriaandnegativeketones.

Questions

1.Whattestsshouldbedonetoevaluatethepatient'sglucosetolerance?1hourglucosetest,if
failsgoesto3hourglucose.Treatmentregularprenatalcare,nutritionalconsult,countingcarbs,
checkingBS.
2.Howisthediagnosisofgestationaldiabetesmellitus(GDM)established?
3.Whatwouldbethebesttreatmentandfollowupstrategy?

Commentary
ThispatientpresentswithseveralriskfactorsforGDM,definedascarbohydrateintoleranceof
varyingdegreesofseveritywithonsetorfirstrecognitionduringpregnancy,regardlessof
whetherinsulinisusedfortreatmentortheconditionpersistsafterpregnancy.Sheisover30
yearsofage,fromanethnicgroupatincreasedriskfortype2diabetesmellitus,isobese,andhas
afirstdegreerelativewithtype2diabetes.

Thefindingsofsignificantglycosuriashouldprompttheperformanceofaglucosedetermination
beforethepatientleavestheclinic.Theusualapproachtoscreeningwouldbea50goralglucose
loadadministeredtothepatientbetween24and28weeksgestationwhenthe"diabetigenic
stress"ofpregnancyispresent.Apositivetestisavenousplasmaglucosevalue1hourlater
of>140mg/dl.Thiswouldleadtoa100gmoralglucosetolerancetest(OGTT)withthe
diagnosisofGDMmadeiftwoofthefollowingvaluesaremetorexceeded:fasting,95mg/dl;1
hour,180mg/dl;2hour,155mg/dl;and3hour,140mg/dl.Thesecutoffvaluesarethose
proposedbyCarpenterandCoustanandrecommendedmostrecentlybytheFourthInternational
WorkshopConferenceonGestationalDiabetesMellitusandtheAmericanDiabetesAssociation.

Thepatient'scapillaryglucosereading,performedintheclinic,was193mg/dl.Shewas
instructedtoreturnthenextmorningforafastingvenousplasmaglucose,whichwas143mg/dl.
Giventhisfinding,thediagnosisofGDMwasestablished.Whileitislikelythatthepatienthad
diabetesbeforepregnancy,giventhesignificantelevationofherfastingglucoselevel,thisis
GDMbecauseitsfirstrecognitionwasduringpregnancy.Thereisnoneedtoperformfurther
testinginthispatient.Asingleelevatedfastingglucoseof>126mg/dlobviatesfurthertesting.A
glycohemglobincouldbeperformed,and,ifelevated,supportsthelikelihoodofpreexisting
diabetesmellitus.

Thepatientwasbegunonbothdietaryandinsulintherapyasanoutpatient.Herdietincluded25
kcal/kgactualbodyweightdividedintothreemealsandabedtimesnack.Thedietemphasized
complexcarbohydrateswiththeavoidanceofsimplecarbohydrates.Inaddition,shewas
instructedonselfmonitoringofbloodglucose,performingtestswhilefastingand2hoursafter
eachmeal.Thetargetsfortherapywereafastingvalueof<95mg/dlandvaluesnohigherthan
140mg/dlat1hourornohigherthan120mg/dlat2hoursaftereating.Shewasstarted
empiricallyon20UofNPHand10Uofregularinsulinadministeredinthemorning,tobe
adjustedafterreviewingherglucoselogsheets.Thepatientwasseeneachweek.Giventhe
significantelevationofherfastingglucoselevel,atrialofdietonlywasnotadvisable.

Thepatientdidwellonthisregimen,maintaininggoodcontroluntil30weeksgestation,when
hertotalinsulindosewasincreasedby20%.At28weeks,thepatientwasinstructedindaily
fetalmovementcountingtoassessfetalwellbeing,andat32weeksgestationantepartumfetal
heartratetestingwithnonstresstestswasbeguntwiceweekly.Anultrasoundexaminationat37
weeksrevealedthefetustobegrowingnormallywithanestimatedweightof7lb,1oz.At39
weeks,thepatientstartedspontaneouslaborandunderwentthevaginaldeliveryofan8lb,1oz
boy.Theinfantwasevaluatedforbutdidnotdemonstratehypoglycemiaorothermorbidities.

Postpartum,thepatientbreastfedherinfantand,withherpartner,decidedonabarriermethodof
contraception:foamandcondoms.Sixweeksafterdelivery,shereturnedtotheclinicforan
evaluationofherglucosetolerance.Herfastingplasmaglucosewas128mg/dl.Shereturnedthe
nextday,andarepeatfastingplasmaglucosewas132mg/dl.Giventhesefindings,thediagnosis
ofdiabetesmellituswasmade,anda75gOGGTtestwasnotneeded.

ClinicalPearls

1. WhenpatientspresentwithsignificantriskfactorsforGDM,earlyscreeningforGDM,before
20weeksgestation,mightbeundertaken.

2.Thefindingofglycosuriashouldpromptarandomcapillaryglucoseperformedimmediately
andafollowupfastingvenousplasmaglucose.
3.Givenanelevatedfastingvenousplasmaglucose,suchpatientsshouldbestartedimmediately
ondietandinsulintherapyandfollowedwithselfmonitoringofbloodglucoseusingthecriteria
recommendedbytheFourthInternationalWorkshopConferenceonGestationalDiabetes
Mellitus.

4.Patientstreatedwithnotonlydietbutalsoinsulinareatincreasedriskforanintrauterinefetal
death,andforthatreason,antepartumfetaltestingwithnonstresstestsshouldbeperformed.

5.Forsuchpatientswhodonotenterspontaneouslabor,inductionoflaborat39weeksis
appropriate.

6.Postpartum,thispatientwasfoundtohaveanelevatedfastingplasmaglucoseandthe
diagnosisofdiabetesmellituswasmade.Thatdiabetespersistedafterdeliveryisnotsurprising
giventhatthediagnosisofGDMwasmaderelativelyearlyinpregnancy,thatthefastingplasma
glucoseexceeded140mg/dl,andthatthepatientwasobese.