From the Guidelines
Uteroplacental insufficiency in gestational diabetes mellitus (GDM) can be prevented with tight glycemic control, and the primary management approach should include lifestyle modifications and insulin therapy as the first-line treatment. In GDM, the risk of uteroplacental insufficiency increases with progressive maternal hyperglycemia, and therefore, all women should be tested for GDM as outlined in the standards of medical care in diabetes 1. The management of GDM should focus on achieving glycemic targets, with target blood glucose levels being fasting <95 mg/dL and 1-hour postprandial <140 mg/dL or 2-hour postprandial <120 mg/dL.
Initial management includes dietary modifications, such as carbohydrate counting and portion control, and regular exercise. If lifestyle changes are insufficient after 1-2 weeks, medication therapy is indicated, with insulin being the preferred medication for treating hyperglycemia in GDM 1. Insulin therapy should typically start with basal insulin (NPH or detemir) at 0.2 units/kg/day, with prandial insulin (regular or rapid-acting analogs) added if needed.
Some key points to consider in the management of GDM include:
- Regular fetal monitoring, including kick counts, non-stress tests, and ultrasound assessment of fetal growth and amniotic fluid volume every 3-4 weeks
- The use of oral agents like metformin may be considered in some cases, but insulin is the first-line pharmacological treatment 1
- Uteroplacental insufficiency occurs because maternal hyperglycemia causes fetal hyperinsulinemia, which increases oxygen consumption while placental vascular changes reduce oxygen delivery, creating a mismatch that can lead to fetal hypoxia and growth restriction or macrosomia depending on the timing and severity
- GDM is characterized by increased risk of large-for-gestational-age birth weight and neonatal and pregnancy complications, as well as an increased risk of long-term maternal type 2 diabetes and offspring abnormal glucose metabolism in childhood 1
Recent studies have also highlighted the importance of lipid metabolism in the development of GDM and uteroplacental insufficiency, with elevated levels of triglycerides and total cholesterol being associated with an increased risk of GDM 1. However, the primary focus of management should remain on achieving tight glycemic control to prevent uteroplacental insufficiency.
From the Research
Uteroplacental Insufficiency in Gestational Diabetes
- Uteroplacental insufficiency is a condition where the placenta does not function properly, leading to a decrease in oxygen and nutrient transfer to the fetus 2.
- Gestational diabetes mellitus (GDM) is a disease characterized by glucose intolerance and first diagnosed in pregnancy, which can lead to an anomalous placental environment and aberrant placental vascular function 3.
- GDM-associated hyperglycemia can change the placenta structure, leading to abnormal development and functionality of the placenta 3.
- Insulin therapy is used to treat GDM, but it may cause alterations in the placenta and umbilical vessels, as well as the fetus and newborn, in addition to those seen in pregnant women with GDM treated with diet 3.
Effects of Insulin Therapy on Uteroplacental Insufficiency
- Insulin therapy can restore maternal glycaemia, but this beneficial effect is not reflected in the fetus and newborn metabolism, suggesting that other factors than d-glucose may be involved in the pathophysiology of GDM 3.
- The use of insulin in pregnancy has been shown to have minimal harms associated with its effects, and the choice to use insulin or oral anti-diabetic pharmacological therapies may be down to physician or maternal preference, availability, or severity of GDM 4.
- Newer insulin preparations have been developed to mimic the physiologic release of endogenous insulin, which can be administered safely and achieve tighter glycemic control while reducing episodes of hypoglycemia 5.
Importance of Personalized Approach to Insulin Regimens
- A personalized approach to insulin regimens is necessary due to individual heterogeneity in defects of insulin secretion or sensitivity in liver and muscle, unique genetic influences on pregnancy glycemic regulation, and variable cultural and lifestyle behaviors 5.
- Educating and empowering patients to learn how their glucose responds to insulin, portion and content of meals, and physical activity can increase personal engagement in therapy, flexibility in eating patterns, and improved glycemic control 5.