Updates on gestational diabetes mellitus

The use of safe and effective oral agents may therefore offer advantages over insulin but has not yet been formally approved for GDM therapy in all countries[ 61 ]. A large randomized controlled trial was performed by Rowan et al[ 62 ] in which women with GDM at 20 to 33 wk of gestation were assigned to open treatment with metformin or insulin if lifestyle intervention had failed to achieve glycemic control. Three hundred and sixty-three women were assigned to metformin.

The authors concluded that metformin, alone or with supplemental insulin, was not associated with increased perinatal complications as compared with insulin. Thus the treatment with Metformin was considered safe and effective and moreover, the women preferred metformin to insulin treatment.

Further follow-up data are however necessary to establish long-term safety. Another randomized controlled trial included women between 11 and 33 wk of gestation with singleton pregnancies and GDM that required treatment and assigned them to either glyburide or insulin. All the women received dietary advice and eight women in the glyburide group required additional insulin therapy.

There were no significant differences between the glyburide and insulin groups regarding macrosomia, neonatal hypoglycemia, lung complications or foetal abnormalities and it was concluded that glyburide is a clinically effective alternative to insulin therapy[ 63 ]. Other studies show that both metformin and sulfonylurea have been increasingly and safely used in the treatment of GDM[ 64 ].

However, both glyburide and metformin cross the placenta and given the growing evidence of epigenetic foetal programming in utero, administration of drugs potentially affecting foetal metabolism is of major concern and as long term follow-up data on both mother and offspring are lacking oral antihyperglycemic agents should be used with caution.

The molecular and cellular mechanisms with respect to the interaction between vitamin D and GDM are only partly understood. However, it appears that vitamin D acts directly on pancreatic beta cells through expression of the vitamin D receptors as well as through the enzyme 25 OH Dalfa-hydroxylase by regulating intracellular calcium to increase insulin secretion and by attenuating systemic inflammation associated with insulin resistance[ 66 , 67 ].

As stated above lifestyle counseling concerning diet and exercise is one of the cornerstones in the treatment of GDM, but recently it was also reported that a healthful diet was associated with a lower risk of T2DM among women with a history of GDM[ 68 ].

Additionally, newly published results from a large prospective study indicate that increasing physical activity may help lower the risk of progression from GDM to T2DM[ 69 ]. Worldwide there has been a dramatic increase in the prevalence of overweight and obesity in women of childbearing age. Overweight and obese women have an increased risk of developing GDM leading to complications during pregnancy, birth and neonatally.

The clinical management of obese pregnant women and women with GDM is a challenge and puts additional stress on the healthcare system. In addition it seems more and more clear that maternal metabolic characteristics are crucial determinants of insulin resistance during pregnancy and in offspring and interventions, especially in the form of exercise, weight loss and a healthy diet before, during and after pregnancy might be a key to prevent the vicious circle that contributes to the epidemic of obesity, insulin resistance and T2DM.

Conflict-of-interest statement: Nothing to declare. Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. Peer-review started: August 31, First decision: December 26, Article in press: April 20, National Center for Biotechnology Information , U. Journal List World J Diabetes v. World J Diabetes. Published online Jul Author information Article notes Copyright and License information Disclaimer.

Published by Baishideng Publishing Group Inc. All rights reserved. This article has been cited by other articles in PMC. Abstract Gestational diabetes mellitus GDM is increasing in prevalence in tandem with the dramatic increase in the prevalence of overweight and obesity in women of childbearing age. Keywords: Gestational diabetes, Diagnostic criteria, Treatment, Complications. Gestational diabetes mellitus should be diagnosed at any time in pregnancy if one or more of the following criteria are met Fasting plasma glucose 5.

Open in a separate window. T2DM Women who have had GDM have a substantially increased risk for development of T2DM, even though most women return to a euglycaemic state shortly after delivery[ 34 - 36 ]. Footnotes Conflict-of-interest statement: Nothing to declare. References 1. Epidemiology of gestational diabetes mellitus and its association with Type 2 diabetes. Diabet Med.

The short- and long-term implications of maternal obesity on the mother and her offspring. Int J Gynaecol Obstet.

Ferrara A. Increasing prevalence of gestational diabetes mellitus: a public health perspective. Diabetes Care. Gestational diabetes mellitus: results from a survey of country prevalence and practices.

J Matern Fetal Neonatal Med. Gestational diabetes mellitus in Africa: a systematic review. PLoS One. Diabetes Atlas International Diabetes Federation. American Diabetes Association. Standards of medical care in diabetes HbA1c levels are significantly lower in early and late pregnancy. Establishing diagnosis of gestational diabetes mellitus: Impact of the hyperglycemia and adverse pregnancy outcome study.

Semin Fetal Neonatal Med. Hyperglycemia and adverse pregnancy outcomes. N Engl J Med. Gestational diabetes: infant and maternal complications of pregnancy in relation to third-trimester glucose tolerance in the Pima Indians. Adverse pregnancy outcome in women with mild glucose intolerance: is there a clinically meaningful threshold value for glucose? Acta Obstet Gynecol Scand. Impact of increasing carbohydrate intolerance on maternal-fetal outcomes in women without gestational diabetes.

Am J Obstet Gynecol. International association of diabetes and pregnancy study groups recommendations on the diagnosis and classification of hyperglycemia in pregnancy. World Health Organization. Diagnostic criteria and classification of hyperglycaemia first detected in pregnancy: a World Health Organization Guideline. Diabetes Res Clin Pract. Cellular mechanisms for insulin resistance in normal pregnancy and gestational diabetes. Adiponectin in human pregnancy: implications for regulation of glucose and lipid metabolism.

Pedersen J. The pregnant diabetic and her newborn. Problems and management. Arch Dis Child. TNF-alpha is a predictor of insulin resistance in human pregnancy. Am J Epidemiol.

Ethnicity modifies the effect of obesity on insulin resistance in pregnancy: a comparison of Asian, South Asian, and Caucasian women. J Clin Endocrinol Metab. Gestational diabetes mellitus - an analysis of risk factors. Endokrynol Pol. Universal vs. A preliminary review. Insulin requirements in type 1 diabetic pregnancy: do twin pregnant women require twice as much insulin as singleton pregnant women?

Gestational diabetes mellitus: a risk factor for non-elective cesarean section. J Obstet Gynaecol Res. Shoulder dystocia: an analysis of risks and obstetric maneuvers. Gestational diabetes and perinatal mortality rate. Screening and diagnostic practices for GDM are inconsistent across the world.

This narrative review includes data from 87 observational studies and randomized controlled trials RCTs , and aims to give an overview of the current evidence on screening strategies and diagnostic criteria for GDM. Screening in early pregnancy remains controversial and studies show conflicting results on the benefit of screening and treatment of GDM in early pregnancy. This is called contra-insulin effect, which usually begins about 20 to 24 weeks into the pregnancy. As the placenta grows, more of these hormones are produced, and the risk of insulin resistance becomes greater.

Normally, the pancreas is able to make additional insulin to overcome insulin resistance, but when the production of insulin is not enough to overcome the effect of the placental hormones, gestational diabetes results. Although any woman can develop GDM during pregnancy, some of the factors that may increase the risk include the following:. Age women who are older than 25 are at a greater risk for developing gestational diabetes than younger women. Although increased glucose in the urine is often included in the list of risk factors, it is not believed to be a reliable indicator for GDM.

The American Diabetes Association recommends screening for undiagnosed type 2 diabetes at the first prenatal visit in women with diabetes risk factors. In pregnant women not known to have diabetes, GDM testing should be performed at 24 to 28 weeks of gestation. In addition, women with diagnosed GDM should be screened for persistent diabetes 6 to 12 weeks postpartum.

It is also recommended that women with a history of GDM undergo lifelong screening for the development of diabetes or prediabetes at least every three years. Treatment for gestational diabetes focuses on keeping blood glucose levels in the normal range.

Treatment may include:. Unlike type 1 diabetes, gestational diabetes generally occurs too late to cause birth defects. Birth defects usually originate sometime during the first trimester before the 13th week of pregnancy. The insulin resistance from the contra-insulin hormones produced by the placenta does not usually occur until approximately the 24th week.

Women with gestational diabetes mellitus generally have normal blood sugar levels during the critical first trimester.