Objectives:

At the end of the session student should be able to

1.
2.
3.
4.
5.
Case

describe the principle of oral glucose tolerance test (OGTT).

interpret OGTT result and relates with gestational diabetes mellitus (GDM).
explain GDM and individual at risk.
explain how blood glucose homeostasis is maintained in the body.
describe how fatty acids are used and stored in the body.

A 35 year-old pregnant woman presented to maternity clinic for routine medical check
up. Her weight is 60 kg, and her blood pressure is 130/80 mmHg. Her family history reveals
that her mother has type 2 diabetes mellitus.
a.
She had been advised to do oral glucose tolerance test (OGTT). Explain the principle of
OGTT and give reason why she has to do OGTT.
-

Blood sugar measurements are expressed in either mmol/l or mg/dl

The ideal tests in diagnosis would be fasting blood glucose and random blood glucose levels.
A patient is considered,
Normal if
FBS is < 6.1 mmol/l (110 mg/dl)
RBS is less reliable
Uncertain of having
Diabetes if

FBS is in the range 6.1 - 7.0 mmol/l (110 126 mg/dl)

Diabetic if

FBS is > 7.0 mmol/l (126 mg/dl)

RBS is in the range 7.8 - 11.1 mmol/l (140 200 mg/dl)

RBS is > 11.1 mmol/l (200 mg/dl)

-

So a glucose tolerance test is useful in patients with a fasting or random blood sugar level
falling in the uncertain range, to diagnose / exclude diabetes.

The Oral Glucose Tolerance Test

Principle :
The Glucose Tolerance Test determines the degree and duration of hyperglycaemia after
an oral intake of a known amount of glucose. It is done to:
1. Check pregnant women for gestational diabetes mellitus (GDM). You have an
increased chance of developing gestational diabetes if you
a. Family history of diabetes mellitus, stillbirth, neonatal deaths, carry baby
with congenital anomalies, or has a bad reproductive history
b. Have had gestational diabetes during a previous pregnancy
c. Have previously given birth to a baby who weighed more than 4kg
d. Are younger than age 25 and were overweight before getting pregnant

2. Diagnosis of impaired glucose tolerance

3. For evaluation of patients with nephropathy, neuropathy or retinopathy that cannot be
explained (with random blood glucose of less than 7.0mmol/L)
4. Population study for epidemiologic data
5. Diagnose prediabetes and diabetes
Results :
Fasting Sugar Levels
> 7.0 mmol/l
( > 126 mg/dl)
6.1 7.0 mmol/l
(110 126 mg/dl)
< 6.1 mmol/l
( < 110 mg/dl)

Diabetes Mellitus
Impaired Glucosed Tolerance
Diabetes Unlikely

Sugar Levels after 2 hours

> 11.1 mmol/l
( > 200 mg/dl)
7.8 11.1 mmol/l
(140 200 mg/dl)
< 7.8 mmol/l
( < 140 mg/dl)

Interpretation :
Venous blood glucose level
Renal Threshold

Venous plasma glucose mmol/l (mg/dl)

Presence of Glucose in urine

13.8
(250)
11.1
(200)
8.3
(150)
5.5
(100)
2.7
(50)

Normal Curve

Renal glycosuria

Time
(hrs)

Venous plasma glucose mmol/l (mg/dl)

2
Time
(hrs)

13.8
(250)
11.1
(200)
8.3
(150)
5.5
(100)
2.7
(50)

Alimentary Glycosuria

Time
(hrs)

Diabetes Mellitus

2
Time
(hrs)

Impaired Glucose Tolerance

A smaller percentage of patients with impaired glucose tolerance develop diabetes later on in
their life. Therefore, dietary advice has to be given with regard to carbohydrate and simple sugar
intake. The same tests are repeated later on if indicated (if patient develops signs and symptoms
of diabetes). If the patient becomes pregnant, she is referred to a specialist for control of blood
sugar levels, as hyperglycaemia affects the foetus adversely.

b.

Below is her OGTT result.

Fasting blood glucose level

5.5 mmol/L (4.0-6.0 mmol/L)

1 hour

8.8 mmol/L (4.0-7.8 mmol/L)

2 hours

6.0 mmol/L (4.0-7.0mmol/L)

i. Interpret the above results

The blood sugar level increases one hour after meal and return to normal within 2 hours.

ii. Explain why the blood glucose level increases in the first one hour.
Glucose concentration in blood increases right after meal as carbohydrate is broken down
its base molecules which are sugar.

iii. Explain why the blood glucose level falls after it has reached its peak.
As the blood glucose level increases, insulin is released in response. Insulin is a hormone
which moves glucose from the blood into the muscles and fat cells for storage.

iv. What are the factors that influence the results of OGTT? Explain your answer.

c.

Explain gestational diabetes mellitus.

Gestational diabetes mellitus (GDM) is defined as any degree of glucose intolerance with
onset or first recognition during pregnancy. Gestational diabetes develops during
pregnancy (gestation). Like other types of diabetes, gestational diabetes affects how your
cells use sugar (glucose). Gestational diabetes causes high blood sugar that can affect
your pregnancy and your baby's health.

Any pregnancy complication is concerning, but there's good news. Expectant moms can
help control gestational diabetes by eating healthy foods, exercising and, if necessary,
taking medication. Controlling blood sugar can prevent a difficult birth and keep you and
your baby healthy.
In gestational diabetes, blood sugar usually returns to normal soon after delivery. But if
you've had gestational diabetes, you're at risk for type 2 diabetes. You'll continue
working with your health care team to monitor and manage your blood sugar.

d.

Explain the consequences of insulin resistance that occur in this patient.

In insulin resistance, muscle, fat, and liver cells do not respond properly to insulin and
thus cannot easily absorb glucose from the bloodstream. As a result, the body needs
higher levels of insulin to help glucose enter cells.
The beta cells in the pancreas try to keep up with this increased demand for insulin by
producing more. As long as the beta cells are able to produce enough insulin to overcome
the insulin resistance, blood glucose levels stay in the healthy range.
Over time, insulin resistance can lead to type 2 diabetes and prediabetes because the beta
cells fail to keep up with the bodys increased need for insulin. Without enough insulin,
excess glucose builds up in the bloodstream, leading to diabetes, prediabetes, and other
serious health disorders.

e.

Explain the risks for getting GDM.

Women with GDM are at increased risk for the development of diabetes, usually type 2,
after pregnancy. Obesity and other factors that promote insulin resistance appear to
enhance the risk of type 2 diabetes after GDM, while markers of islet celldirected
autoimmunity are associated with an increase in the risk of type 1 diabetes. Offspring of
women with GDM are at increased risk of obesity, glucose intolerance, and diabetes in
late adolescence and young adulthood.

f.

Explain how gestational diabetes can affect fetal development.

Diabetes can affect the developing fetus throughout the pregnancy. In early pregnancy, a
mother's diabetes can result in birth defects and an increased rate of miscarriage. Many of
the birth defects that occur affect major organs such as the brain and heart.
During the second and third trimester, a mother's diabetes can lead to over-nutrition and
excess growth of the baby. Having a large baby increases risks during labor and delivery.

For example, large babies often require planned or emergency caesarean deliveries, and if
he or she is delivered vaginally, they are at increased risk for complications such as
trauma to the baby.
In addition, when high blood sugar from the mother causes high insulin levels
(hyperinsulinemia) in the baby, the baby's blood sugar can drop very low after birth,
because it won't be receiving the high blood sugar.
However, with proper treatment, you can deliver a healthy baby, despite having diabetes.
Other
If you have gestational diabetes, your baby may be at increased risk of:
Excessive birth weight. Extra glucose in your bloodstream crosses the placenta, which
triggers your baby's pancreas to make extra insulin. This can cause your baby to grow too
large (macrosomia). Very large babies those that weigh 9 pounds or more are more
likely to become wedged in the birth canal, sustain birth injuries or require a C-section
birth.
Early (preterm) birth and respiratory distress syndrome. A mother's high blood sugar
may increase her risk of early labor and delivering her baby before its due date. Or her
doctor may recommend early delivery because the baby is large.
Babies born early may experience respiratory distress syndrome a condition that
makes breathing difficult. Babies with this syndrome may need help breathing until their
lungs mature and become stronger. Babies of mothers with gestational diabetes may
experience respiratory distress syndrome even if they're not born early.
Low blood sugar (hypoglycemia). Sometimes babies of mothers with gestational
diabetes develop low blood sugar (hypoglycemia) shortly after birth because their own
insulin production is high. Severe episodes of hypoglycemia may provoke seizures in the
baby. Prompt feedings and sometimes an intravenous glucose solution can return the
baby's blood sugar level to normal.
Type 2 diabetes later in life. Babies of mothers who have gestational diabetes have a
higher risk of developing obesity and type 2 diabetes later in life.
Untreated gestational diabetes can result in a baby's death either before or shortly after
birth.

g.

The doctor advised her to take food in small portion but frequent.
i. Explain your reason.

ii. Explain the consequences if she takes high quantity of food at one time.

h.

Explain the complication of GDM.

Gestational diabetes may also increase the mother's risk of:
-

High blood pressure and preeclampsia. Gestational diabetes raises your risk of high
blood pressure, as well as, preeclampsia a serious complication of pregnancy that
causes high blood pressure and other symptoms that can threaten the lives of both mother
and baby.
Future diabetes. If you have gestational diabetes, you're more likely to get it again
during a future pregnancy. You're also more likely to develop type 2 diabetes as you get
older. However, making healthy lifestyle choices such as eating healthy foods and
exercising can help reduce the risk of future type 2 diabetes.