ACOG GDM Guidelines (Gestational Diabetes)

The most typical medical condition associated with pregnancy is gestational diabetes mellitus (GDM). Diabetes in pregnancy that can be well controlled without medication is frequently referred to as diet-controlled GDM or class A1GDM.

Class A2GDM refers to gestational diabetes mellitus that needs medication to control blood sugar levels normally.

According to estimates, diabetes complicates 6-9% of pregnancies. Women who are Caucasian typically have the lowest rates of GDM.

The same risk factors for type 2 diabetes, such as obesity and aging, also raise the risk of gestational diabetes. ACOG GDM guidelines have given information regarding the pros and cons of GDM.

Globally, the prevalence of GDM among women of reproductive age is rising due to rising rates of obesity and sedentary lifestyles.

Preeclampsia is more likely to occur in women with GDM (9.8% in those whose fasting glucose is less than 115 mg/dL and 18% in those whose fasting glucose is greater than or equal to 115 mg/dL).[Ref]

National Gestational Diabetes Mellitus Day

National gestational diabetes mellitus day is observed on the 10th of march every year. India was the first country to observe this day.

GDM Screening: One Step or Two Steps?

The ‘2 steps‘ strategy (24–28 weeks 1-hour venous glucose measurement after 50g oral glucose solution, followed by a 100g 3-hour oral glucose tolerance test (OGTT) if positive) is supported by ACOG (based on NIH consensus panel conclusions).

The 3-hour OGTT is used to diagnose GDM, and two abnormal readings must be present.

According to ACOG, there is not yet enough data to support the diagnosis of GDM with only one aberrant number. Patients with just one high value might need more monitoring.

A one-step method (75 g OGTT) on all women will accelerate the diagnosis of GDM, however, there are not yet enough prospective studies showing better outcomes.

ACOG does acknowledge that, if necessary given their demographic, some centers may choose to use “1 step.”

Who Needs to Undergo Early Screening for GDM? ACOG GDM Guidelines

The NIDDK/ADA recommendation on screening for diabetes and prediabetes, which takes into account both type 2 diabetes risk factors and previous pregnancy history, has been approved by ACOG. If any of the following apply during pregnancy:

The patient has a BMI of 25, which is overweight (23 for Asian Americans), and one of the following

• A lack of movement.
• Known dysfunctional glucose metabolism.
• History of:

1. • GDM in previous pregnancies
   • Childbirth weighing more than 4 kg (4000 g) in the past
   • Macrosomia
   • History of Stillbirth

• Hypertension (140/90 mm Hg or receiving treatment for it).
• HDL levels under 35 mg/dL (0.90 mmol/L).
• Triglycerides at fasting levels under 250 mg/dL (2.82 mmol/L).
• Morbid obesity, PCOS, acanthosis nigricans, nonalcoholic steatohepatitis, and other disorders linked to insulin resistance.
• Hgb impaired fasting glucose or reduced glucose tolerance, A1C 5.7% GCT/GTT is not necessary if A1C is greater than 6.5%, indicating pregestational diabetes.
• Cardiovascular disease.
• 1st-degree relative with a history of diabetes in the family (parent or sibling).
• Race of African, American Indian, Asian, Hispanic, Latino, or Pacific Islander descent.

What Are Glucose Target Levels?

The following goal levels are suggested by the guidelines of ACOG and ADA to lower the risk of macrosomia and GDM.

• Values of less than 95 mg/dL for fasting or premeal blood glucose.
• 140 mg/dL at one hour and 120 mg/dL at two hours post-meal.
• Review every week, however, revisions may be necessary depending on the level of glucose control.

Exercise and Diet for GDM according to ACOG guidelines

• Assessment and plan for nutrition

1. If accessible, registered dieticians or nutritional teams can provide counseling.
2. To reduce blood sugar swings, suggest complex carbohydrates, three meals, and two snacks.

• There is currently no consensus on the ideal caloric distribution between carbohydrates, fats, and proteins.
• 30 minutes of aerobic activity at a moderate level should be performed at least five days a week, or for a minimum of 150 minutes per week.
• Walking for 10-15 minutes after each meal has improved health.
• After implementing dietary suggestions, check blood sugar levels to ensure glycemic control.

Medical Care of Pregnant Women with GDM: ACOG GDM Guidelines

If glycemic control cannot be achieved with nonpharmacologic treatment, ACOG advises using insulin as the preferable option.

• A sizable portion of patients who began oral medication will need insulin while pregnant
  • Insulin treatment is initiated in a daily dose of 0.7-1.0 units/kg
  • Long-acting or intermediate-acting insulin should be used with short-acting insulin, and the dosage should be divided.
  • Individualize based on the glycemic profile of the patient
  • Due to their quicker onset, short-acting analogs (such as insulin Lispro and Aspart) are preferred to normal insulin.
  • NPH insulin is still utilized, however, there are other long-acting options such as insulin glargine and detemir.
• Metformin can be used if a patient refuses or is unable to take insulin [Ref].
• Glyburide should not be substituted for insulin due to research showing worse outcomes, such as macrosomia and birth defects.

Monitoring of Fetus

Starts fetal monitoring at 32 weeks on medication (A2GDM) with subpar control and no co-morbidities.

• If there are additional co-morbidities then start early.
• On the assumption that there may have been inadequate control at some point during the pregnancy, fetal testing for A2GDM is typically advised.
• Dietary management is good (A1GDM): No agreement since there isn’t enough evidence to show stillbirth risk and the need for fetal assessment might not exist.
• If monitoring of the fetus is performed, it is usually started later than A2GDM and can be based on local practice. Moreover, amniotic fluid volume assessment is included due to the risk of polyhydramnios.

Screening after Delivery: ACOG GDM Guidelines

• All pregnant women with gestational diabetes should undergo a screening for diabetes, impaired fasting glucose, or impaired glucose tolerance six to twelve weeks after giving birth.
• Women who undergo screening should be referred for preventive therapy if their findings are positive, and those who undergo screening negatively should undergo follow-up testing every three years.
• Postpartum screening can be done with either a fasting plasma glucose test or a 75-g, two-hour oral glucose tolerance test [Ref].