Diseases of the Mother in Pregnancy Quiz

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Which management approach is most appropriate for gestational diabetes during pregnancy?

A Diet and exercise with glucose monitoring, adding metformin if ketonuria is detected on urine testing
B Diet and exercise with glucose monitoring, adding insulin if glycosuria is detected on urinalysis
C Diet and exercise with glucose monitoring, continuing oral glucose-lowering therapy after delivery
D Long-term oral hypoglycaemic therapy continued after pregnancy
E Diet and exercise with glucose monitoring, adding metformin and/or insulin if blood glucose targets are missed ✓

The answer is E: Diet and exercise with glucose monitoring, adding metformin and/or insulin if blood glucose targets are missed

Explanation

Why E is correct

See Management. Option E is correct. Gestational diabetes arises from insulin resistance in pregnancy, so that blood glucose rises (hyperglycaemia), and the aim of treatment is to keep glucose within target to protect the baby and the mother. The first step is diet and exercise, with the woman taught to monitor her own blood glucose, and often with a dietitian. For women whose fasting glucose at diagnosis is below 7 mmol/litre NICE advises a trial of diet and exercise first. If the targets are not met within 1 to 2 weeks, metformin (a tablet that lowers glucose) is offered, and insulin is added if metformin is not enough, or used instead if metformin is unsuitable. Glucose-lowering treatment is stopped immediately after the birth, because the condition usually settles when the placenta is delivered, but the woman remains at higher risk of type 2 diabetes later, so she is offered follow-up testing. The exam trap is to treat the diagnosis as a reason for early delivery or to assume no treatment is needed.

Stepwise treatment: diet, exercise and home glucose monitoring first, then metformin, then insulin if targets are missed.
Timing: metformin is offered if glucose targets are not met within 1 to 2 weeks.
After birth: glucose-lowering treatment stops, with follow-up testing for type 2 diabetes later.

Why the other options are incorrect

A. Diet and exercise with glucose monitoring, adding metformin if ketonuria is detected on urine testing: Adding metformin when urinary ketones are detected is not the criterion for starting drug treatment; metformin is introduced when blood glucose targets are not reached, not because ketones are present.
B. Diet and exercise with glucose monitoring, adding insulin if glycosuria is detected on urinalysis: Adding insulin for glycosuria is not the main determinant of treatment; therapy is adjusted to blood glucose readings, and urine glucose is not used to guide drug escalation in gestational diabetes.
C. Diet and exercise with glucose monitoring, continuing oral glucose-lowering therapy after delivery: Continuing oral glucose-lowering therapy after delivery is not current management; treatment is stopped immediately after birth because gestational diabetes usually resolves once the placenta has been delivered.
D. Long-term oral hypoglycaemic therapy continued after pregnancy: Blood glucose lowering treatment for gestational diabetes should be stopped immediately after birth, because the condition usually resolves once the placenta has gone. The woman is then followed up for diabetes later. This option would be right for a woman with type 2 diabetes that was known before pregnancy.

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More questions from this set. Start the quiz to answer them and see each explanation.

1
Which foetal outcome is most characteristically increased in pregnancies complicated by gestational diabetes?
2
At an antenatal booking appointment, which of the following features most strongly indicates an increased risk of gestational diabetes in the current pregnancy?

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