NOTE: This article was made possible by an unrestricted educational grant from Sanofi, which had no control over content.
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1. The criteria for the diagnosis of gestational diabetes includes which of the following:
2. In women with pre-existing DM, what is the recommended target HbA1c during pre-conception?
3. In gestational diabetes, which therapies are preferred:
4. Glibenclamide can be used as it is safe, but may result in:
5. In gestational diabetes, which is the preferred oral agent:
6. In gestational and diabetic pregnancy, what target fasting blood levels are recommended:
7. In diabetic pregnancy, what blood glucose level should be targeted 2 hours post-prandially?
Case Study 1
Patient: 25-year-old female, period of gestation – first trimester (P0G1)
- T1DM for 8 years, on basal bolus insulin therapy
- Glargine as basal 26 units at supper, Apidra at mealtimes 12 units with adjustments made depending on food intake and exercise
- Well-controlled with average HGM 4.5-6.8mmol/L pre-pregnancy
- HbA1c 7.2%, BMI 24, weight 66kg
- Planned pregnancy with good compliance to diet and exercise
- Prone to hypoglycaemia but tests regularly, good hypo awareness
- No complications at present with eye consult recently by an ophthalmologist, no retinopathy
- She has a normal blood pressure, no microalbuminuria.
Patient presents at 8 weeks of pregnancy for advice and guidance.
8. What are the parameters you would set for her diabetic control through the pregnancy?
9. How would you adjust her insulin dosages in the third trimester?
10. What are the pitfalls in the peripartum period including method of delivery?
11. What advice would you give her concerning breastfeeding, insulin adjustment?
Case Study 2
Patient: 34-year-old female
- A family history of DM on the maternal side presents for a follow-up visit with her obstetrician at 24 weeks of pregnancy
- Obstetrician performs an OGTT with the recommended glucose load of 75g
- Diagnosed with a fasting glucose level of 8.6mmol/L and 2-hour postprandial of 10.7mmol/L
- She has been tested for DM before and was always in a non-diabetic range
- Her HbA1c at this visit is 8.2%
- The patient is then referred for management to yourself in collaboration with the obstetrician
- BMI 32; BP 122/76mmHg
- Cigarette smoker.
At 32 weeks she is found to have developed proteinuria and is now hypertensive (156/98mmHg). She has significant swelling of her legs and she feels very uncomfortable. She is concerned that the baby is not moving well. Her average glucose levels remain >7.0mmol/L.
12. What are your concerns, how do you manage the insulin adjustments in this situation?
13. How would you educate this young patient regarding the management of her glucose levels, choice of treatment, monitoring and lifestyle adjustment?
14. Closer to the delivery date, if all seems well on a non-stress test for the baby, how would you advise glucose control and especially around the actual delivery/caesarean section?
15. How would you follow this patient postnatally and what would be her risk of developing diabetes in the following 5 years?
- American Diabetes Association. Standards of medical care in diabetes – 2017. Diabetes Care 2017; 40(S1): S114-S119.
- The 2017 SEMDSA Guidelines for the Management of Type 2 Diabetes. JEMDSA 2017; 22(1): S99-103.
- Hebert MF, Ma X, Naraharisettti SB, et al. Are we optimizing gestational diabetes treatment with glyburide? The pharmacologic basis for better clinical practice. Clin Pharmacol Ther 2009; 85(6): 607-614.
- Balsells M, Garcia-Patterson A, Sola I, et al. Glibenclamide, metformin, and insulin for the treatment of gestational diabetes: a systematic review and meta-analysis. BMJ 2015; 350: h102.
- Jiang YF, Chen XY, Ding T, et al. Comparative efficacy and safety of OADs in management of GDM: network meta-analysis of randomized controlled trials. J Clin Endocrinol Metab 2015; 100(5): 2071-2080.
- Blum AK. Insulin Use in Pregnancy: An Update. Diabetes Spectrum 2016; 29(2): 92-97.
- Daniels M, Grobbelaar L. Nutrition in pregnancy. SA J of Diabetes 2015; 8: 19-23.
- The 2017 SEMDSA Guidelines for the Management of Type 2 Diabetes. JEMDSA 2017; 22(1): S103-106.