West Visayas State University – College of Medicine – Batch 2020

Block XVII
Module 2 Gestational Diabetes
Lecture 8
11/ 22/ 18
Dr. Mary Flor R. Gafate-Ong

TOPIC OUTLINE Commonly diagnosed in the 3rd trimester

I. Gestational Diabetes Mellitus Q: Can DM type 2 be diagnosed as GDM?
A. Implications A: Yes. Because mothers may not have undergone
B. Pathophysiology
C. Complication
any diagnostic test prior to pregnancy and they are
II. Screening only diagnosed with DM only during pregnancy
A. Recommendation Insulin resistance is related to the metabolic
B. Risk Factors changes of late pregnancy, and increased insulin
C. Diagnosis
III. Management requirement may lead to IGT (impaired glucose
A. Importance tolerance) or diabetes.
B. Recommendation GDM occurs in ~7% (range 2-10%) of pregnancies
C. Non-pharmacologic Treatment
in US; most women revert to normal glucose
D. Pharmacologic Treatment
E. Self-monitoring tolerance postpartum but have a substantial risk (35-
F. Glycemic Management during Labor and Delivery 60%) of developing DM in the next 10-20 years.
IV. Post-Partum Management
V. Follow-Up
A. IMPLICATIONS OF GDM
Review Questions
References • Associated with increased risk for gestational
Appendices hypertension and preeclampsia
• Untreated GDM leads to increased perinatal morbidity
LECTURER BOOK REFERENCE OLD TRANS Macrosomia – birth trauma (due to shoulder
dystocia and CS delivery)
Hyperinsulinemia – neonatal hypoglycemia
I. GESTATIONAL DIABETES MELLITUS Hyperbilirubinemia
• Multigenic condition that may involve abnormalities in Respiratory distress syndrome
genes of: • Increased genetic risk of developing obesity and T2DM
Insulin secretion in the offspring
Insulin or insulin signaling • Mother may develop DM afterwards
Lipid and glucose metabolism About 26-70% of patients with GDM will eventually
Other pathways develop T2DM 10-15 years after delivery
• GDM is defined as a condition of carbohydrate • Universal screening is recommended especially among
intolerance which is first recognized during pregnancy the developing countries, including Philippines and
• Advanced maternal age + obesity = increased risk for selective screening in low risk areas
GDM • Study shows improved maternal and fetal outcomes if
• Associated with adverse outcomes both in the mother DM is diagnosed and treated early
and the fetus Majority of mothers will not develop DM after
For many years, GDM was defined as any degree of delivery with proper lifestyle modifications.
glucose intolerance that was first recognized during Untreated GDM leads to increased natal and
pregnancy, regardless of whether the condition may perinatal mortality. Babies will have increased risk
have predated the pregnancy or persisted after the for obesity. As early as 10 years of age, babies may
pregnancy. This definition facilitated a uniform develop DM. Thus, proper monitoring is advised.
strategy for detection and classification of GDM, but it Some mothers will develop DM right after or a year
was limited by imprecision. after delivery.
Currently defined as diabetes diagnosed in the 2nd or
3rd trimester of pregnancy that is not clearly overt B. PATHOPHYSIOLOGY
diabetes • GDM is a condition involving not only carbohydrate
Overt diabetes – a woman with diabetes who became intolerance but also insulin secretion, insulin signaling,
pregnant/ women diagnosed during the first trimester as well as lipid and glucose metabolism.
of pregnancy. In this case, they would be classified
as having Type 2 Diabetes rather than GDM. MATERNAL ADAPTATIONS
Any degree of glucose intolerance with onset or first • Increase the risk for GDM
recognition during pregnancy • B-cell hyperplasia in the Islets of Langerhans due to:

CCetC Group No. 2 1 of 7

MD 3 Alviar, Aportadera, Araneta
 Increased prolactin (5-10x) Preterm Labor
Presence of hPL (human placental lactogen) aka • Long Term
human chorionic somatomammotropin Type 2 DM
Estrogen ─ 26-70% develop within 10-15 years after
Cortisol delivery
─ Cause increased insulin secretion or
hyperinsulinemia FETAL
• There is increase in insulin production and secretion, • Macrosomia
during the 1st trimester of pregnancy leading to an early • Metabolic abnormalities in the newborn
increase in insulin sensitivity, followed by progressive • Immature lung maturation
insulin resistance during 2nd trimester (which is the time • Cardiac hypertrophy
to diagnose GDM) due to hormonal activity during
pregnancy state II. SCREENING
That’s why pregnancy is always referred as a • Filipinos are high risk for GDM. Therefore, universal
diabetogenic condition screening is applied for all
• There are additional factors for decreased insulin • Routine testing done during 24-28 weeks AOG
sensitivity and increased insulin resistance: High risk women should be screened at the
Decreased adinopectin soonest possible time (at the first prenatal visit,
Decreased leptin even before 24-28 weeks AOG)
Increase in Il-6 ─ Women with family history of DM, obese, and
Increase in TNF-α elderly primigravid
Adinopectin and Leptin act on insulin sensitivity • Testing for GDM should be carried out even beyond
while IL-6 and TNF-α act on insulin resistance 24-28 weeks AOG for patients at increased risk

FETAL ADAPTATIONS A. RISK FACTORS FOR GDM

• Fetal hormones promote insulin resistance
Table 1. Risk Factors for GDM from Different Sources. Source:
Increased hPGH (human placental growth
Doc’s slides
hormone)
ACOG ADA*
Increased CRH, leading to increased ACTH and
• History of GDM • History of GDM
cortisol
• BMI ≥ 30 • Marked Obesity
Increased human chorionic somatomammotropin
• Impaired glucose • Close family history
Increased progesterone metabolism of diabetes
Progesterone inhibits maximal transport of • Glycosuria
glucose as well as insulin binding CDA IDF*
Increased Tumor Necrosis Factor. • History of GDM • Previous GDM or
• BMI ≥ 30 macrosomic infant
• Prediabetes • Family History of
• Ethnicity with high diabetes mellitus (1st
prevalence degree relative)
• Age >35 years • Increasing maternal
• PCOS or acanthosis age and weight
nigricans • Ethnicity with high
• Corticosteroid use prevalence
• History of
macrosomic infant
• Current fetal
macrosomia or
polyhydramnios
NICE
• History of GDM
• Previous macrosomic Infant (≥4.5kg)
Figure 1. Glucose Homeostasis in Pregnancy. Source: Doc’s slides • BMI ≥ 30
• Family histoy of DM (1st degree relatives)
C. COMPLICATIONS • Ethnicity with high prevalence
MATERNAL ACOG – American Congress of Obstetricians and Gynecologists
• Immediate ADA – American Diabetes Association
CDA – Canadian Diabetes Association
Increased tendency for Cesarean Section
IDF – International Diabetes Federation
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NICE – National Institute for Health and Care Excellence • Women with a history of GDM found to have
*Doc emphasized the factors given by ADA and IDF
prediabetes should receive lifestyle interventions or
metformin to prevent diabetes. (A)
B. DIAGNOSIS
Table 2. Procedures for Screening and Diagnosis of GDM.
Source: Doc’s slides ADA 2015 Guidelines for Diagnosis of GDM
Indication Optimal Test Diagnostic ONE-STEP STRATEGY
gestation Criteria • Perform a 75-g OGTT, with plasma glucose
for testing measurement when patient is fasting and at 1 and 2h,
Clinical 75 g at 24-28 weeks of gestation in women not previously
Any time
suspicion OGTT diagnosed with overt diabetes. The OGTT should be
50 g 1 hr>140
Screening 24-28 wks performed in the morning after an overnight fast of at
GCT mg/dl
least 8 h. The diagnosis of GDM is made when any of
75 or
Confirmation the following plasma glucose values are met or
24-28 wks 100 g
of diagnosis exceeded:
OGTT
Fasting: 92 mg/dL (5.1 mmol/L)
CONFIRMATORY DIAGNOSIS 1h: 180 mg/dL (10.0 mmol/L)
• FBS 2h: 153 mg/dL (8.5 mmol/L)
Fast for 8 hours and then take blood sample
NV: < 92 mg/dl TWO-STEP STRATEGY
• 75g OGTT • Step 1: Perform a 50 g GLT (non-fasting), with plasma
This is the recommended screening test for glucose measurement at 1h, at 24-28 weeks of
gestational diabetes (Level 3, Grade B) gestation in women not previously diagnosed with
Take 75g glucose solution. Wait for 2 hours, then overt diabetes. If the plasma glucose level measured
take post glucose load blood sample 1h after the load is ≥ 140 mg/dL(7.8mmol/L), proceed
NV: < 140 mg/dl to a 100g OGTT.
However, ACOG recommends a lower threshold of
Interpreting the 75g OGTT Results 135 mg/dL (7.5 mmol/L) in high-risk ethnic
Table 3. Threshold(s) for diagnosing GDM (mg/dL). Source: population with higher prevalence of GDM; some
Doc’s slides experts also recommend 130 mg/dL (7.2 mmol/L).
75-g IADPSG ADA ASGODI POGS* • Step 2: The 100g OGTT should be performed when
OGTT P& the patient is fasting. The diagnosis of GDM is made if
DIPSI
at least two of the following four plasma glucose levels
FBS 92 75 NA 92
(measured fasting and 1h, 2h, 3h after the OGTT) are
1-hour 180 180 NA NA
2-hour 140 met or exceeded.
153 155 140
3-hour NA 140 NA NA
*We use the Philippine Obstetrics and Gynecology Society criteria Table 4. Values for plasma glucose levels at different time
According to the POGS criteria, a >92 mg/dl of FBS intervals. Source: Upperclass notes
and >140mg/dl of 75g OGTT satisfies the diagnosis Carpenter/ NDDG
of GDM. 1 out of 2 criteria also confirms GDM. Coustan
Fasting 95 mg/dL 105mg/dL
SUPPLEMENTARY NOTES (5.3 mmol/L) (5.8mmol/L)
ADA 2015 Recommendations for Screening
1h 180mg/dL 190mg/dL
*for the evidences (A, B, etc.) please see appendix
(10.0mmol/L) (10.6mmol/L)
• Test for undiagnosed type 2 diabetes at the first
prenatal visit in those with risk factors, using standard 2h 155mg/dL 165mg/dL
diagnostic criteria. (B) (8.6mmol/L) (9.2mmol/L)
• Test for GDM at 24–28 weeks of gestation in pregnant
women not previously known to have diabetes. (A) 3h 140mg/dL 145mg/dL
• Screen women with GDM for persistent diabetes at 6– (7.8mmol/L) (8.0mmol/L)
12 weeks postpartum, using the OGTT and clinically NDDG – National Diabetes Data Group
appropriate non-pregnancy diagnostic criteria. (E)
• Women with a history of GDM should have lifelong III. MANAGEMENT
screening for the development of diabetes or A. IMPORTANCE OF MANAGING GDM
prediabetes at least every 3 years. (B) • Adequate control of blood sugar levels during
pregnancy, decrease the risk for preeclampsia

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• Decreased risk for development of excessive birth
weight (>4000 g)
• Decreased incidence of shoulder dystocia
• Reductions in:
Pre-eclampsia
Birth Weight > 4000g
Shoulder Dystocia
SUPPLEMENTARY NOTES
ADA 2015 Recommendations for Management
• Provide preconception counseling that addresses the
importance of tight control in reducing the risk of
congenital anomalies with an emphasis on achieving
A1C <7%., if this can be achieved without
hypoglycemia (B)
• Potentially teratogenic medications (ACE inhibitors,
statins, etc.) should be avoided in sexually active
women of childbearing age who aren’t using reliable
contraception (B)
• GDM should be managed first with diet and exercise,
and medications should be added if needed (A)
• Women with pre-gestational diabetes should have a
baseline ophthalmology exam in the first trimester and
then be monitored every trimester as indicated by
degree of retinopathy (B)
• Due to alterations in red blood cell turnover that lower
the normal A1C level in pregnancy, the A1C target in
pregnancy is <6%; if this can be achieved without
significant hypoglycemia.
• Medications widely used in pregnancy include insulin,
metformin, and glyburide; most oral agents cross the
placenta or lack long-term safety data.
B. NON-PHARMACOLOGIC TREATMENT
• Treatment of GDM is aimed at reducing the morbidity
associated with elevated glycemic levels.
• Dietary and lifestyle modifications are recommended
among all patients with GDM
MEDICAL NUTRITION THERAPY
• Initial management
• Goals:
Achieve normoglycemia
Prevent ketosis
Provide adequate weight
Contribute to the fetal well-being
• All women with GDM should receive nutritional
counseling for Medical Nutrition Therapy (MNT)
• Individualized MNT:
Adequate calories & nutrients for pregnancy
Consistent with maternal blood glucose goals
• Non-caloric sweeteners may be used in moderation
(Equal, Splenda)
• Advise patient to control diet, and do physical exercise
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• MNT is a primary therapy for 30-90% of women with
GDM (decrease HbA1c by 1%)
• Carbohydrate controlled meal plan that promotes
adequate nutrition with appropriate weight gain,
normoglycemia, and absence of ketosis.
Do not starve your patients!
• Nutrition therapy + SMBG (self-monitoring of blood
glucose) = positive impact on maternal and infant
outcomes
DIETARY RECOMMENDATIONS
• Breakfast matters
Eat smaller amounts
• Avoid fruit juice
• Strictly limit sweets and desserts
• Use artificial sweeteners (Equal or Splenda)
• Keep food records
• Distribute between 3 meals and 2-3 snacks / day
• Eat reasonable portions of starch
• Drink one cup of milk at a time
• Limit fruit portions
• Do not eat fruit that had been canned in syrup
• Carbohydrate is limited to 40% of total calories
• Weight used for caloric computation is the current
pregnancy weight and not the baseline weight
NUTRITION
• Diet based on ideal pre-pregnancy weight
30 kcal/kg for average weight
35 kcal/kg for underweight
25 kcal/kg for overweight
• Generally, 2000-2200 calories per day
• Avoid concentrated sweets – utilize complex, high-fiber
carbohydrates
Recommended to take 5-6 meals a day
(breakfast, snacks, lunch, snacks, dinner, snacks)
Small, frequent meals rather than 3 large meals
• Consume reasonable amounts of starch and limit fruit
portions because fruits are also sources of sugar
Instructed not to eat canned fruits in syrup
CALORIC DISTRIBUTION OF MEALS
• 40-45% of total calories for Carbohydrates
• 20-25% of total calories for Protein
• 35-40% of total calories Fat
CALORIC REQUIREMENTS
• Normal caloric requirement for patients with GDM is 30
kcal/kg/day
• If overweight: 22-25 kcal/kg/day
• Morbidly obese: 12-14 kcal/kg/day
• Underweight: 35-40 kcal/kg/day
PHYSICAL ACTIVITY
• Usually plain and simple brisk walking
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• Circuit resistance training may also be recommended
• For women with GDM and no medical or obstetrical
contraindications to physical activity
e.g. if high risk for premature labor
• Exercise is an adjust to MNT
• Monitor fetal activity & blood glucose levels
• Limit physical activity to 15-30 mins
• GDM patients to walk briskly or do arm exercises while
seated in a chair for at least 10 min after each meal
accomplishes this goal
C. PHARMACOLOGIC TREATMENT
• If MNT fails – reevaluate after 2 weeks
• There is NO approved oral diabetic medication for
pregnant women
• Giving of insulin is still recommended
Insulin is the only recommended pharmacologic
treatment for patients with GDM
Oral hypoglycemic agents are not recommended
TOTAL INSULIN DOSE
• Insulin dosage is increased as the pregnancy comes to
term
• Doubles in twin gestation
• TOTAL INSULIN is divided into:
50% of the dosage is taken as long acting insulin
50% is taken as pre-prandial rapid acting insulin
injected before meals – 3 doses
Inject 30-45 mins before meals
All in all, 4 injections per day.
Table 5. Insulin dosage depending on AOG. Source: Doc’s
slides
Week (AOG) Insulin Dosage
0-12 weeks 0.7 u/kg (starting dose)
13 – 26 weeks 0.8 u/kg
26 – 36 weeks 0.9 u/kg
36 – 40 weeks (term) 1.0 u/kg
• In severely obese patients, increase the initial insulin
dose to 1.5-2.0u/kg
Due to higher insulin resistance
ORAL ANTI-DIABETIC MEDICATIONS
• Controversial
• Glyburide – already given in other countries. Has
conflicting results. Should be used with caution.
• Metformin – recommended for use during the 2nd and
3rd trimester. Patients taking Metformin require
supplemental insulin doses.
SUPPLEMENTARY NOTES
Insulin Dose
• 0.7-2.0 u/kg of present pregnancy weight
• If FBS is high:
Give 0.2 u/kg of insulin at bedtime
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Monitor blood glucose level
• If there is an increase in the Postprandial Blood
Glucose (PPBG)
Give short acting insulin every before meals
Breakfast – 1.5u/10g of CHO to control PP
hyperglycemia
Lunch and Dinner – 1u/10g of CHO
• If both FBS and PPBG are persistently high:
Take 6 injections of insulin per day
Intermediate Acting Insulin (IAI) - before breakfast,
before dinner, and at bedtime. (3)
Rapid Acting Insulin (RAI) – before meals (3
meals)
Insulin Use in Pregnancy
• Insulin: preferred agent for management of diabetes in
pregnancy because of the lack of long-term safety data
for noninsulin agents.
• Insulin management during pregnancy is complex
• The physiology of pregnancy requires frequent titration
to match changing requirements
• Referral to specialized center is recommended if this
resource is available.
All insulins are pregnancy category B except for
glargine and glulisine which are labelled C
Metabolic physiology of pregnancy is characterized
by fasting hypoglycemia due to insulin-independent
glucose update by the placenta, post prandial
hyperglycemia, and carbohydrate intolerance as a
result of diabetogenic placental hormones. In
addition, insulin resistance increases exponentially
during the second trimester and levels off toward the
end of the third trimester.
Management: In the first trimester, there is often a
decrease in total daily dose of insulin. In the second
trimester, rapidly increasing insulin resistance
requires weekly or biweekly increase in insulin dose
to achieve glycemic targets.
In general, a small proportion of the total daily dose
should be given as basal insulin and a greater
proportion as prandial insulin.
D. SELF-MONITORING
PLASMA GLUCOSE
• Patients are instructed to monitor their Blood Sugar
levels at home
• Done at least 4X a day every before injection
• Glucose Targets according to ADA and ACOG are:
FBS < 95mg/dL
1hr PPBG <140mg/dL
─ suggestive if at risk of developing a macrosomic
baby
2hr PPBG <120mg/dL
─ if increased, possible full blown T2DM
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WEIGHT GAIN
Table 6. Gestational Weight Gain. Source: Doc’s slides
BMI Total Weight Total weight
Gain (kg) gain (lb)
< 18.5 12.5 – 18.0 26 – 40
18.5 – 24.9 11.5 – 16.0 25. – 35
25.0 – 29.9 7.0 – 11.5 15 – 25
> 30 5.0 – 9.0 11 – 20
Data is for recommended rate of weight gain and total
weight gain according to pre-pregnancy BMI and
singleton pregnancies
SUPPLEMENTARY NOTES
• Decrease monitoring (number of BS per day) if BSs are
normal after several days of testing
• If readings do not coincide with these results, insulin
dose should be reassessed and be increased.
• The dose of insulin is adjusted according to the needs
of the patient.
Concerns Related to Type 1 Diabetes in Pregnancy
• Increased risk of hypoglycemia in the first trimester
• Frequent hypoglycemia → IUGR
• Rapid implementation of tight glycemic control in the
setting of retinopathy → worsening of retinopathy
• Insulin resistance drops rapidly with delivery of the
placenta → become very insulin sensitive → Require
less insulin than in the prepartum period.
Concerns Related to Type 2 Diabetes in Pregnancy
• Often associated with obesity
• Glycemic control is often easier to achieve in T2DM
than in T1DMes, but hypertension and other
comorbidities often render pre-gestational T2DM as
high or higher risk than pre-gestational T1DM
E. GLYCEMIC MANAGEMENT DURING LABOR AND
DELIVERY
• Keep maternal blood glucose between 72-120mg/dL to
reduce risk of neonatal hypoglycemia
• Women should receive adequate glucose during labor
in order to meet the high energy requirements
IV. POST-PARTUM MANAGEMENT
• ~15% of women with GDM have impaired glucose
tolerance or diabetes after delivery
• Greater likelihood if:
Obese
GDM diagnosed early in pregnancy
Treatment required (insulin therapy)
• ADA stated that all women with GDM be evaluated
postpartum for diabetes
• Post-partum follow-up should be done between 6wks to
6mo
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• Interval periodic screening for high risk pts done yearly
& 2-3 years interval for low risk pts
• Various screening methods may be utilized for follow-
up (OGTT, FBS, HbA1c)
• Infant blood glucose should be monitored very closely
• Maternal insulin requirement may decrease
significantly a few hours after delivery and continue to
decline
POST-PARTUM GDM MANAGEMENT CHECKLIST
• Encourage breastfeeding
To avoid neonatal hypoglycemia
Continued for at least 3mos postpartum to prevent
childhood obesity & reduce risk of maternal
hypoglycemia
• Discuss increased long-term risk of diabetes
• Importance of returning to pre-pregnancy weight
SUPPLEMENTARY NOTES
ADA Recommendations for Post-partum Care
• All women should be supported in attempts to nurse
their babies, given immediate nutritional and
immunological benefits of breastfeeding for the baby;
there may also be a longer-term metabolic benefit to
both mother and offspring
• Women with GDM should be screened for persistent
diabetes or prediabetes for 6-12 weeks postpartum
using nonpregnancy criteria and every 1-3 years
thereafter depending on other risk factors.
• Women with a history of GDM have a greatly increased
risk of conversion to Type 2 Diabetes over time.
• Interpregnancy or postpartum weight gain is associated
with increased risk of adverse pregnancy outcomes in
subsequent pregnancies and earlier progression to
Type 2 Diabetes.
• Both metformin and intensive lifestyle invention prevent
or delay progression to diabetes in women with a
history of GDM.
• For patients with Type 1 Diabetes: Insulin sensitivity
increases in the immediate postpartum period and then
returns to normal over the following 1-2 weeks, and
many women will require significantly less insulin at
this time than during the prepartum period. Breast-
feeding may cause hypoglycemia, which may be
ameliorated by consuming a snack (such as milk) prior
to nursing. Diabetes self-management often suffers in
the postpartum period.
• For patients with Type 2 Diabetes: If the pregnancy has
motivated the adoption of a healthier diet, building on
these gains to support weight loss is recommended in
the postpartum period.
V. FOLLOW-UP
• Patients usually revert back to normoglycemia after
delivery
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• Despite this, reassessment after delivery is necessary Care in Diabetes d2015. Diabetes Care
since they are of high-risk Diabetes Mellitus 2015;38(Suppl. 1):S8–S16
• American Diabetes Association. Management of
Table 7. Metabolic Assessments Recommended for GDM. diabetes in pregnancy. Sec. 12. In Standards of
Source: Doc’s slides Medical Care in Diabetes d2015. Diabetes Care
Time Test Purpose 2015;38 (Suppl. 1):S77–S79
1-3 days post- FBS, RBS Detect persistent or
partum development of APPENDIX
overt Diabetes FDA PREGNANCY CATEGORIES
• Category A: Well-controlled studies in humans show
Early 75g /2hr Postpartum
no risk to the fetus
postpartum OGTT classification of
• Category B: No well-controlled studies have been
(6wks glucose
conducted in humans; animal studies show no risk to
postpartum) metabolism
the fetus.
1 year 75g/2hr Assessment of
postpartum OGTT glucose • Category C: No well-controlled studies have been
metabolism conducted in humans; animal studies have
Annually FBS/Fasting Assessment of demonstrated an adverse effect on the fetus.
thereafter Plasma glucose • Category D: Evidence of human risk to the fetus
Glucose metabolism exists; however, benefits may outweigh risks in certain
*Done most especially in patients with a family history of GDM. situations
• Category X: Controlled studies in animals or humans
REVIEW QUESTIONS demonstrate fetal abnormalities; the risk in pregnant
1. Acdg to POGS, what is the threshold value of FBS in
women clearly outweighs any possible benefit.
the diagnosis of GDM?
a. > 90mg/dL
b. > 91mg/dL
c. > 92mg/dL
d. > 93mg/dL
2. (T/F) The diagnosis of GDM is made if at least two of
the following four plasma glucose levels (measured
fasting and 1h, 2h, 3h after the OGTT) are met or
exceeded.
3. Which of the ff are not the goals of medical nutrition
therapy in managing GDM?
a. Achiveve normoglycemia
b. Promote ketosis
c. Provide adequate weight
d. Contribute to fetal well-being
4. (T/F) Women should receive adequate glucose during
labor in order to meet the high-energy requirements.
5. The ff are factors that decreases insulin sensitivity
except:
a. Increased adinopectin
b. Increased IL-6
c. Increasedd TNF-a
d. Decreased leptin
6. (T/F) Filipinos are mid-risk for GDM. Therefore,
universal screening does not need to be applied for all.

Answers: c,T,b,T,a,F

REFERENCES
• Doc’s slides
• Adeos notes
• American Diabetes Association. Classification and
diagnosis of diabetes. Sec. 2. In Standards of Medical
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