Responses – Gestational Diabetes Mellitus (GDM) and Preeclampsia
Response 1
Hello,
Great work with your post. Your discussion on gestational diabetes mellitus (GDM) is comprehensive and well-structured. Here are a few additional points and considerations to enhance your analysis:
Second-Line and Third-Line Treatments
If lifestyle measures, together with first-line pharmacological treatments like insulin, have proven to be ineffective, then more measures need to be taken into consideration. Some recent studies show that metformin can be used to treat GDM instead of insulin, especially for patients with insulin therapy issues (Tocci et al., 2023). Another second-line oral antidiabetic drug is glyburide, which is, however, not very popular for use due to the potential problem of neonatal hypoglycemia (Hardin & Jacobs, 2024).
Additional Considerations
Continuous Glucose Monitoring (CGM)
In some patients, CGM may be highly beneficial for achieving good glucose control as it offers real-time information and trends on glucose variation.
Postpartum Care
Follow-up should be done in the long term because T2DM is common among women with gestational diabetes. Dietary, exercise, and regular glycemic checkups have been identified to be critical in the management of T2DM (Björk Javanshiri et al., 2023).
Education and Support
Educating patients on the need to change their lifestyle and offering services such as dietitians and support groups are useful in enhancing results. Also, teaching patients about the signs and symptoms of hyperglycemia and hypoglycemia, as well as how to prevent and treat these conditions, will improve self-care knowledge (Garedow et al., 2023).
Follow-up Guidelines
Women with previous GDM need to be screened for T2DM by testing glucose levels at 6-12 weeks after childbirth, followed by testing every one to three years. This ensures that any of the complications that may arise are noticed early and managed appropriately.
References
Björk Javanshiri, A., Calling, S., & Modig, S. (2023). Follow-up and screening for type-2 diabetes mellitus in women with previous gestational diabetes in primary care. Scandinavian Journal of Primary Health Care, 41(1), 98–103. https://doi.org/10.1080/02813432.2023.2182632
Garedow, A. W., Jemaneh, T. M., Hailemariam, A. G., & Tesfaye, G. T. (2023). Lifestyle modification and medication use among diabetes mellitus patients attending Jimma University Medical Center, Jimma zone, southwest Ethiopia. Scientific Reports, 13(1). https://doi.org/10.1038/s41598-023-32145-y
Hardin, M. D., & Jacobs, T. F. (2024). Glyburide. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK545313/#:~:text=Although%20glyburide%20is%20one%20of
Tocci, V., Mirabelli, M., Salatino, A., Sicilia, L., Giuliano, S., Brunetti, F. S., Chiefari, E., De Sarro, G., Foti, D. P., & Brunetti, A. (2023). Metformin in gestational diabetes mellitus: To use or not to use, that is the question. Pharmaceuticals, 16(9), 1318. https://doi.org/10.3390/ph16091318
Response 2
Hello,
This is a great post. Your thorough overview of preeclampsia covers many crucial aspects. Here are some additional points and considerations to enhance your analysis:
Second-Line and Third-Line Treatments
For patients who do not respond adequately to initial treatments, alternative antihypertensive agents such as labetalol and nifedipine can be considered (Garovic et al., 2021). These medications are often used in conjunction with magnesium sulfate for seizure prophylaxis. In severe cases, a combination of different antihypertensives might be necessary to achieve blood pressure control.
Additional Considerations
Biomarkers and Prediction Models
New developments state that biomarkers like placental growth factor (PIGF) and soluble fms-like tyrosine kinase-1 (sFlt-1) can be used to forecast the development and the severity of preeclampsia (Aminuddin et al., 2022). All these biomarkers can be incorporated into clinical practice for better early diagnosis and intervention.
Nutritional Interventions
Research indicates that calcium and vitamin D may help lower the risk for preeclampsia, especially in cases of high-risk patients; it is advisable for gestational mothers (Giourga et al., 2023).
Education and Support
It is essential to offer patients proper enlightenment on the symptoms of preeclampsia and the value of prenatal appointments. Pregnant women suffering from preeclampsia should be encouraged to engage in support groups and counseling as they assist in the management of psychological stress in pregnancy (Chang et al., 2023). Instructing patients to adopt certain change standards and learning about lifestyles that offer better results can help enhance patients’ long-term health.
Follow-up Guidelines
Steady follow-up after delivery is important because preeclampsia may occur after delivery. Treatment of preeclampsia includes informing women about suitable lifestyle changes and frequent appointments with the healthcare provider in order to evaluate their cardiovascular status. The guidelines provided by Arntzen et al. (2023) include a lifelong approach to screening for risk factors such as hypertension, obesity, and diabetes that augment the risks for cardiovascular diseases in the later years.
References
Aminuddin, N. A., Sutan, R., Mahdy, Z. A., Rahman, R. A., & Nasuruddin, D. N. (2022). The feasibility of soluble Fms-like tyrosine kinase-1 (sFLT-1) and placental growth factor (PlGF) ratio biomarker in predicting preeclampsia and adverse pregnancy outcomes among medium to high-risk mothers in Kuala Lumpur, Malaysia. PloS One, 17(3), e0265080. https://doi.org/10.1371/journal.pone.0265080
Arntzen, E., Jøsendal, R., Sandsæter, H. L., & Horn, J. (2023). Postpartum follow-up of women with preeclampsia: Facilitators and barriers — A qualitative study. BMC Pregnancy and Childbirth, 23(1). https://doi.org/10.1186/s12884-023-06146-8
Chang, K.-J., Seow, K.-M., & Chen, K.-H. (2023). Preeclampsia: Recent advances in predicting, preventing, and managing the maternal and fetal life-threatening condition. International Journal of Environmental Research and Public Health, 20(4), 2994. https://doi.org/10.3390/ijerph20042994
Garovic, V. D., Dechend, R., Easterling, T., Karumanchi, S. A., McMurtry Baird, S., Magee, L. A., Rana, S., Vermunt, J. V., & August, P. (2021). Hypertension in pregnancy: Diagnosis, blood pressure goals, and pharmacotherapy: A scientific statement from the American Heart Association. Hypertension, 79(2). https://doi.org/10.1161/hyp.0000000000000208
Giourga, C., Papadopoulou, S. K., Voulgaridou, G., Karastogiannidou, C., Giaginis, C., & Pritsa, A. (2023). Vitamin D deficiency as a risk factor of preeclampsia during pregnancy. Diseases, 11(4), 158. https://doi.org/10.3390/diseases11040158
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Question 
PEER RESPONSE 1:
Etiology
Gestational diabetes mellitus (GDM) is a disorder characterized by glucose intolerance with onset or first recognition during pregnancy (Sweeting et al., 2020). The first prognosis is based on the concept of genetic vulnerability and precipitating factors. In pregnancy, the levels of the lactogenic hormones estrogen and cortisol, which are derived from the placenta, contribute to insulin resistance, a significant factor in the generation of GDM.
Gestational Diabetes Mellitus (GDM) and Preeclampsia
Epidemiology
GDM affects 7–10% of pregnancies worldwide, depending on demographics, diagnostic criteria, and screening (Behboudi-Gandevani et al., 2019). African, Hispanic, Native American, and Asian Americans are more likely to have it. Risk factors include advanced maternal age, obesity, diabetes, GDM, and polycystic ovarian syndrome (Behboudi-Gandevani et al., 2019).
Pathophysiology
The pathophysiology of GDM involves an imbalance between insulin resistance and insulin secretion. Insulin resistance rises throughout pregnancy to deliver glucose to the fetus. Women with GDM have hyperglycemia because the pancreas cannot produce enough insulin to overcome insulin resistance (Sweeting et al., 2020). Mothers and newborns can develop macrosomia, preeclampsia, and cesarean birth from chronic hyperglycemia.
Clinical Manifestations
GDM is frequently asymptomatic and is typically identified through routine screening. When symptoms do occur, they may include excessive thirst, frequent urination, fatigue, nausea, and blurred vision (Sweeting et al., 2020). These symptoms are nonspecific and can overlap with ordinary pregnancy experiences, making screening and diagnostic testing essential.
Work-up
The diagnosis work-up for GDM comprises screening by the oral glucose tolerance test (OGTT) in 24-28 weeks of pregnancy (Maor-Sagie et al., 2023). The most common approach is the two-step method: an abnormal glucose challenge test is to undergo a 50-gram glucose challenge test and, subsequently, a 100-gram oral glucose tolerance test if impaired. Others employ a one-step procedure with the 75-gram OGTT (Maor-Sagie et al., 2023).
Nonpharmacological Management
Nonpharmacological GDM treatment requires lifestyle changes. This includes medical nutrition therapy with a balanced diet of complex carbohydrates, fiber, lean proteins, reduced simple sugars, and refined carbohydrates (Sweeting et al., 2020). Regular walking or swimming improves insulin sensitivity. Blood glucose self-monitoring is also helpful.
Pharmacological Management
When lifestyle adjustments fail to control blood glucose, medication is taken. Insulin is the standard treatment because it does not cross the placenta and has an extended safety and efficacy history (Raets et al., 2023). Metformin and glyburide are oral hypoglycemics; however, placental transfer and long-term safety issues limit their use.
Education
Patient education is crucial to GDM management. Glycemic control, nutrition, exercise, and untreated GDM should be taught to women. If needed, teach insulin administration and blood glucose self-monitoring.
Follow-up
Blood glucose levels require close monitoring and therapy adjustments. GDM women are more likely to have T2DM later in life, so postpartum follow-up is essential. Normal glycemic levels should be checked 6-12 weeks postpartum with a glucose tolerance test and diabetes monitoring.
PEER RESPONSE 2:
Preeclampsia
Preeclampsia is a hypertensive disorder that occurs during pregnancy. Approximately 2-8% of pregnancies worldwide are affected by preeclampsia (Ives et al., 2020). This disorder causes a significant morbidity and mortality rate amongst the maternal and perinatal populations. The only known treatment for preeclampsia is the delivery of the fetus.
Etiology/Epidemiology
According to the Centers for Disease Control (CDC), hypertensive disorders of pregnancy (HDP) are accountable for approximately 7% of all maternal deaths (Bisson et al., 2023). Preeclampsia is one of the hypertensive disorders of pregnancy. According to the American College of Obstetrics and Gynecology (ACOG), risk factors for the development of preeclampsia include diabetes, chronic hypertension, kidney disease, advanced maternal age, multifetal gestation, a history of preeclampsia, obesity, and autoimmune disease (Bisson et al., 2023). Women of African descent or black race have higher rates of preeclampsia compared to White women. HELLP syndrome is a more severe form of preeclampsia that includes elevated liver enzymes, low platelets, and hemolysis. This syndrome results in increasingly high rates of mortality and negative outcomes for the mother and fetus. The most life-threatening and severe form of preeclampsia is called eclampsia. Eclampsia is when patients with preeclampsia develop new-onset seizures.
Pathophysiology
According to Bisson et al. (2023), the pathophysiology of preeclampsia is not fully understood. However, placental dysfunction and immunologic changes contribute to poor uteroplacental perfusion. A combination of inflammation, placental pathology, and changes in angiogenesis results in preeclampsia, which contributes to adverse health outcomes in pregnant and postpartum women.
Clinical manifestations
Most patients with preeclampsia present with elevated blood pressure. During prenatal visits, the patient’s blood pressure is usually checked and documented for review of the patient’s trend. Patients who have an increase in their blood pressure throughout the pregnancy should be evaluated for preeclampsia. Other symptoms of preeclampsia include headache, vision changes, and right upper quadrant pain. Patients who complain of new-onset lower extremity edema should be evaluated. Not all patients with preeclampsia present with symptoms; therefore, laboratory results that may indicate preeclampsia should lead to further evaluation.
Workup/Diagnosis
The workup for preeclampsia includes blood pressure evaluation and labs, including a 24-hour urine collection and protein/creatinine ratio. There are two main forms of preeclampsia: preeclampsia without severe features and preeclampsia with severe features. The diagnostic criteria for preeclampsia without severe features involve elevated blood pressures greater than or equal to 140/90 that are evaluated more than four hours apart after 20 weeks of gestation. The lab values diagnostic of preeclampsia without severe features include protein in the urine, also known as proteinuria. Proteinuria is defined as at least 300 mg of protein in a 24-hour urine collection specimen or a protein/creatinine ratio greater than or equal to 0.3 (Bisson et al., 2023). The diagnostic criteria for preeclampsia with severe features differ from that of preeclampsia without severe features. The diagnostic criteria for preeclampsia with severe features include elevated blood pressures greater than or equal to 160/110 that are taken more than four hours apart after 20 weeks of gestation. Also, elevated blood pressures greater than 140/90 with or without symptoms are also indicative of preeclampsia with severe features. This form of preeclampsia includes lab values of thrombocytopenia, transaminitis, and/or acute kidney injury. Preeclampsia with severe features includes symptoms of pulmonary edema, severe right upper quadrant pain, intractable headache, and/or persistent vision changes (Bisson et al., 2023).
Treatment/Management
Antihypertensive therapy is used as palliation in the management of patients with preeclampsia. Antihypertensive agents help prevent intracranial bleeding and manage blood pressure. Intravenous magnesium sulfate is a more effective treatment for preeclampsia and is used to prevent seizure activity. Although magnesium sulfate is safe when used appropriately, an overdose can lead to life-threatening effects such as respiratory distress and cardiac failure (Burton et al., 2019). The American College of Obstetricians and Gynecologists, the United States Preventive Services Task Force, and the International Society for the Study of Hypertension in Pregnancy recommend daily aspirin for high-risk women after 12 weeks of gestation (Ives et al., 2020). Aspirin is believed to lower the risk of preeclampsia by inhibiting cyclooxygenase-1 and cyclooxygenase-2. Despite the effective management of preeclampsia with antihypertensives and magnesium sulfate, delivery of the fetus is the most effective way to treat the disorder (Ives et al., 2020).
Education and Follow-Up
Preeclampsia significantly impacts cardiac health and increases the risk for future cardiovascular disease. It can also develop in the postpartum period. There should be an emphasis on postpartum follow-up appointments to monitor any signs and symptoms of preeclampsia and other postpartum complications. Postpartum women should be educated on the importance of monitoring signs and symptoms of preeclampsia, such as new-onset headaches, vision changes, and right upper quadrant pain. Patients must be advised to seek emergent medical help if any of those symptoms occur. Healthcare providers must emphasize prevention strategies for cardiac disease development. Implementation of adequate physical activity, a heart-healthy diet, and maintaining an appropriate weight are recommendations that healthcare providers can help decrease the risk of cardiac disease in patients (Bisson et al., 2023). The International Society for the Study of Hypertension in Pregnancy recommends exercise for the prevention of preeclampsia (Ives et al., 2020). These recommendations are also appropriate for patients who have a history of preeclampsia and other hypertensive disorders of pregnancy.