Gestational Diabetes and Pregnancy Bleeding
Screening and management; bleeding in the first and second half
Gestational diabetes: screening at 24–28 weeks
Earlier testing if high risk. Two accepted approaches:
| One-step | 75 g 2-hour OGTT (fasting). Positive if any: fasting ≥92, 1 h ≥180, 2 h ≥153 mg/dL |
| Two-step | 50 g 1-hour screen (no fasting); if ≥130–140 → 100 g 3-hour OGTT. Diagnosis needs ≥2 abnormal values |
An abnormal 1-hour screen is not a diagnosis: it leads to the 3-hour test.
Management
- Targets: fasting <95; 1 h after meals <140; 2 h <120 mg/dL.
- Nutrition therapy, carbohydrate spread across meals and snacks, regular activity.
- Insulin is the preferred drug (doesn't cross the placenta). Metformin and glyburide cross the placenta: second-line.
- Risks: big baby, shoulder dystocia, preeclampsia, newborn hypoglycemia, stillbirth.
- 75 g OGTT 4–12 weeks postpartum; lifelong type 2 diabetes risk, so screen every 1–3 years.
Bleeding in early pregnancy
| Condition | Clues | Care |
|---|---|---|
| Miscarriage | Cramping, bleeding; threatened (closed cervix) → inevitable/incomplete (open) | Support; monitor bleeding; Rh immune globulin per protocol |
| Ectopic pregnancy | One-sided pelvic pain, spotting; shoulder pain, dizziness, hypotension = rupture | Stable and unruptured: methotrexate (no alcohol, folic acid or NSAIDs; follow hCG). Ruptured: emergency surgery |
| Molar pregnancy | Very high hCG, uterus larger than dates, severe vomiting, early preeclampsia, dark brown bleeding | Evacuation; follow hCG to zero; reliable contraception during follow-up |
Bleeding in later pregnancy
| Placenta previa | Placental abruption | |
|---|---|---|
| What | Placenta over or near the cervix | Placenta separates early from the uterine wall |
| Pain | Painless | Painful, tender |
| Blood | Bright red | Dark; may be hidden (concealed) |
| Uterus | Soft, relaxed | Rigid, board-like |
| Risks | Previous cesarean, multiparity, multiples | Hypertension, cocaine, smoking, trauma |
| Nursing | No vaginal exams until previa is ruled out by ultrasound; cesarean birth | Emergency: fetal distress, shock, DIC |
DIC labs
↓ platelets, ↓ fibrinogen, prolonged PT/aPTT, ↑ D-dimer. Bleeding from IV sites, gums, petechiae. Treat the cause; blood products.
Priority
Any second-half bleeding: left side, monitor FHR and vital signs, IV access, notify, and no vaginal exam until the placenta's location is known.