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Gestational Diabetes Mellitus (GDM) : East

Coast Working Group Consensus

Guidelines for antenatal and intrapartum

care of Diabetes in pregnancy

Dr Norzaihan Hassan

Family Medicine Specialist

Klinik Kesihatan Pengkalan Chepa

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SECTION 2 ANTENATAL AND INTRA-PARTUM CARE OF

DIABETES IN PREGNANCY

2.1. Management of diabetes in pregnancy

2.1.1 Education2.1.2 Diet

2.1.3 Exercise

2.1.4 Management of co-morbidities

2.2

Blood glucose monitoring during pregnancy2.2.1 Blood glucose targets during pregnancy

2.2.2 Insulin therapy during pregnancy

2.3 Obstetric management of diabetes in pregnancy

2.3.1 Maternal surveillance

2.3.2 Fetal surveillance2.3.3 Timing and mode of delivery

2.3.4 Management of labor and delivery

2.3.5 Immediate post partum management

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2.0 Introduction

The aim of antenatal care for pregnant

diabetes patients are to achieve

normoglycaemia, prevent complications from

developing, stabilise existing complications,

maintain pregnancy to term (minimum 38

weeks) in order to improve as well as maintain

the health and well-being of mothers, babies,and families.

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2.0 Introduction

Pregnancies of women with diabetes are regarded ashigh-risk pregnancies. Therefore, these womenshould be advised that they will be offered morefrequent consultations in the combined antenatalclinic.

Studies have shown that pre-pregnancy care is

associated with improved glycaemic control in earlypregnancy with significant reductions in adversepregnancy outcomes (malformations, stillbirths plusneonatal deaths as well as very premature deliveries

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2.0 Introduction

In the case of patients with type 1 diabetes,pregnancy will affect the insulin treatment plan

whereby there is an increase in insulin requirement.

For person with type 2 diabetes, they are mostly on

oral anti diabetics to control blood glucose and

because the safety of using these during pregnancy

has not been established, the physician will probablyhave to switch to insulin right immediately.

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2.0 Introduction

For women with gestational diabetes, however

meal planning and exercise often works to

maintain blood glucose levels in control; however,

ifblood glucose levels are still high, insulin then

has to be started.

Maternal hyperglycaemia during the first few

weeks of pregnancy is strongly associated with

excess spontaneous abortions and major

congenital malformations2,3and the risk rises as

glucose levels worsen4,5,6.

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2.0 Introduction

Diabetic in pregnancy is also associated with

an increased risk of complications during

labour and delivery.

Close monitoring and prompt intervention

may improve outcomes for both the motherand her baby.
http://www.ncbi.nlm.nih.gov/books/n/nicecg63/glossary/def-item/glossary.g1-d96/http://www.ncbi.nlm.nih.gov/books/n/nicecg63/glossary/def-item/glossary.g1-d96/

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2.0 Introduction

For example, tight blood glucose control duringlabour reduces the risk of neonatal

hypoglycaemia and respiratory distress, thus

reducing the need for admission to a neonatal

intensive care unit.

It is therefore imperative that proper antenatal aswell as intra-partum care be delivered to pregnant

diabetes patients in order to obtain the best

possible outcome for the mother and baby.
http://www.ncbi.nlm.nih.gov/books/n/nicecg63/glossary/def-item/glossary.g1-d92/http://www.ncbi.nlm.nih.gov/books/n/nicecg63/glossary/def-item/glossary.g1-d92/

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Based on the evidence and guideline above the committee

recommends the following:

2.1 Management of diabetes in pregnancy

2.1.1 Education

All women with diabetes should receive education regarding :

the implications of diabetes in pregnancy for herself and her baby;

The role of diet and physical activity

The role of monitoring blood glucose levels

The possible need for insulin therapy

The need for increased maternal and fetal monitoring with diabetes inpregnancy10

Women should be encouraged, supported and provided with appropriate

information from the multidisciplinary team to make positive lifestyle

changes e.g. cessation of smoking and alcohol consumption

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2.1.2 Diet

All women with diabetes in pregnancy should receive

individualised nutritional advice by a qualified dietician11

Advice should be appropriate to glycaemic control and

gestational age

Diet should be balanced which includes vitamins (especiallyfolic acid) and minerals11

Calorie intake should be reduced if the patient is overweight

or obese11

Calorie intake should be increased if the patient is

underweight.

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2.1.2 Diet The amount of calorie intake would be depended on pre pregnancy

weight to aim for pregnancy weight as recommended by IOM

(Institute of Medicine Recommendation for weight gain in

pregnancy).

Women with normal BMI (19.8

26.0 kg/m2

) arerecommended to gain a total of 2535 lb (11.415.9 kg).

For overweight women (BMI 26.129.0 kg/m2), the

weight-gain recommendation is 1525 lb (6.811.4 kg).

Obese women with a BMI >29 kg/m2 need to gain 15 lb

(6.8kg)

The amount of carbohydrate intake should be restricted to 35-45% tocontrol blood glucose level.

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2.1.3 Exercise

All pregnant women should be physically active and perform

regular exercise but taking into consideration physical fitnessand stage of pregnancy11

It is recommended that pregnant women perform exercise or

moderate intensity physical activity that does not have a highrisk of falling or abdominal trauma, such as walking or doing

house chores a minimum of 30 minutes or more per day.

The minimal target of30 minutes daily can be divided into

three 10-minute sessions preferably after meals.

For women on insulin therapy, the management of

hypoglycaemic events resulting from physical activity should

be discussed11

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2.1.4 Management of co-morbidities1. Hypertension

- target 140/90mmhg- Arrange for PE profile (include platelet, renal profile, liver function

test)

- Medication Methyldopa, Nifedipine, Labetolol

2. Diabetes with complication:i) Retinopathy

Offer retinal assessment after the 1st contact in pregnancy if it hasnot been performed in the past 12 months.

At 28 weeks if the 1st assessment is normal

At 16-20 weeks if any diabetic retinopathy is present.

ii) Nephropathy

Referral to a nephrologist if serum creatinine is abnormal

(120mmol/L or more) or total protein excretion exceeds 2g/day

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2.2 Blood glucose monitoring during pregnancy

Self monitoring of blood glucose (SMBG) should be

recommended for all women with diabetes in pregnancy12

For women receiving insulin therapy, ideally self monitoring

of blood glucose (SMBG) should be performed 4

times a day pre meals plus one hour post for

all meals plus once before bed13,14but if 1hr postmeal is not possible then can do 2Hr post meal -

as long as postmeal is done.

Ideally the SMBG should be done every day but for practicalpurpose can do daily once but at different times so that after

a few days you can get the whole full day profile ie. today

prebreakfast, tomorrow postbreakfast, the next day prelunch

etc

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SMBG readings should be reviewed and treatment

adjusted as required

A baseline HbA1c measured at diagnosis of

diabetes and repeated every trimester or as

clinically indicated

Patients monitoring techniques must be checked to

ensure accuracy of results

2.2 Blood glucose monitoring during

pregnancy

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2.2.1 Blood glucose targets during pregnancy

The following target values are recommended for optimum

maternal and feotal outcome:

fasting blood glucose between 4 - 5 mmol/litre

premeal glucose level 4 -5 mmol/litre

1- hour postprandial blood glucose < 8 mmol/litre

2-hour postprandial blood glucose < 7 mmol/litre

0200 0400 H blood glucose > 4 mmol/L (if suspected

nocturnal hypoglycaemia)

*Achievement of post meal blood glucose target is a priority

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Insulin regime (basal / prandial / basal bolus) should be chosen

depending on blood glucose profile

Woman and her partner should be educated about insulin

therapy 14

Insulin should be initiated for GDM in these circumstances:

at diagnosis if fasting plasma glucose > 8 mmol/L and/or

2HPP > 10mmol/Lif patient failed to reach target after 1 to 2 weeks of diet

and exercise10

if ultrasound in 2nd or 3rd trimester suggests presence of

macrosomia (abdominal circumference above the 70th

percentile)10

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Ideally SMBG levels should be reviewed by clinic ortelephone contact at least once weekly to allow for

adjustment of treatment as required(depends on setting)

Further dietary education should be given whencommenced on insulin therapy

Over-treatment of GDM with insulin should be avoided

as the risk of small for gestational age babies is

increased15

OHA (Oral Hypoglycemic Agent) are not recommended.

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2.3.2 Fetal Surveillance

In all cases of suspected macrosomia, prompt

referral to the obstetrician should be made17

Women with diabetes in pregnancy should be

advised to monitorfoetal movements and the

women should report any concerns (i.e reduce

foetal movement) immediately to the healthcare

team16,18

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2.3.3 Timing and mode of delivery

Aim for delivery between 39-40 weeks in patientswith good glycaemic control and without

complications.19

Vaginal delivery is preferable unless obstetric ordiabetic complications necessitate caesarean

delivery

Clinical and sonographic estimation of foetalweight should be doneby 36 weeks onward to

decide mode of delivery.

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2.3.4 Management of Labor and Delivery

Continuous foetal monitoring throughout labour and delivery is

advised.20

Blood glucose should be monitored regularly (from onset of

labour and hourly) and maintained between 4-7 mmol/L. 20

For women with insulin treated diabetes in pregnancy :

Set up IV fluid with 5% Dextrose

Set up IV insulin infusion, adjust rate according to BS level.

An intravenous fluids and insulin with hourly monitoring of

blood glucose

In the event of a planned caesarean section :

Delivery should be carried out early in the morning

Omit the morning dose of insulin.

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2.3.5 Immediate Post Partum Management

1. MotherCheck RBS

Reduce/ stop insulin 14,21

Monitor RBS regularly

2. Baby

SCN noted

Refer for neonatal management

Check RBS

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No STRATEGIC

ISSUE

ACTIVITY /ACTION RESPONSIBILITY

5 Insulin

therapy

duringpregnancy

The woman and her partner should be educated about insulin therapy

Insulin should be started for GDM:

- at diagnosis if fasting plasma glucose > 8 mmol/L and/or 2HPP > 10mmol/L- if patient failed to reach target after 1 to 2 weeks of diet and exercise

- if Ultrasound in 2nd or 3rd trimester suggests presence of macrosomia

(abdominal circumference above the 70th percentile)

Insulin regime (basal/prandial/basal bolus) should be chosen

depending on blood glucose profile.

SMBG levels should be reviewed by clinic or telephone contact at least

once weekly to allow for adjustment of treatment as required .

Further dietary education should be given when commenced on insulin

therapy

Over-treatment of GDM should be avoided as the risk of small for

gestational age babies is Increased.

Diabetic

educator/MO/FM

SMO/FMS/O&G

MO/FMS/O&G

DIABETIC

EDUCATOR/MO

/FMS/O&G

DIABETIC

EDUCATOR/

DIETITIAN/MO/

FMS/O&G

6 Maternal

Surveillance

Antenatal management should be a combined care between hospital and

primary health care centres. Blood pressure, body weight and urinalysis must be measured every

visit

Every patients with pre-existing diabetes should be monitored for

retinopathy and nephropathy every trimester

The risk of hypoglycaemia and hypoglycaemic unawareness in

pregnancy should be explained to all women on insulin treatment

JM,JK,PHN,KJ,KJKMO, FMS, O&G

JM,JK,PHN,KJ,KJK,

MO,FMS,O&G

No STRATEGI ACTIVITY /ACTION RESPONSIBILI

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No STRATEGI

C ISSUE

ACTIVITY /ACTION RESPONSIBILI

TY

7 Foetal

Surveillanc

e

The frequency and methods of foetal monitoring are determined by

maternal glycaemic control and the presence of other pregnancy

complications.

At First trimester, Ultrasound should be performed to confirmviability and gestational age

At second trimester-detailed ultrasound should be performed to

check for congenital foetal anomalies in women with pre-existing

diabetes or HbA1c >7%

At Third trimester ultrasounds should be performed monthly to

assess foetal wellbeing and growth

In cases suspected macrosomia, referral should be made to a obstetrician

Women with diabetes in pregnancy should be advised to monitor foetal

movements, and report any concerns immediately to the healthcare

team

Note: In complicated cases, patient must be referred early to obstetrician

MO,FMS,O&G

MO,FMS.O&G

MO,FMS,O&GMO,FMS

JM,JK,KJ,KJK,M

O,FMS,O&G

8 Timing

and mode

of delivery

Aim for delivery between 39-40 weeks in patients with good

glycaemic control without complications.

Vaginal delivery is preferable unless obstetric or diabetes

complications necessitate caesarean delivery

Clinical and Sonographic estimation of fetal weight should be done

by 36 weeks onward to decide on mode of delivery .

JM/SN/MO/

FMS/O&G

SN/MO/

FMS/O&G

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No STRATEGIC

ISSUE

ACTIVITY /ACTION RESPONSI

BILITY

9 Management

of labour and

delivery

Continuous foetal monitoring throughout labour and

delivery is advised.

Blood glucose should be monitored regularly ( from onset of

labour and hourly) and maintained between 4-7 mmol/L.

For women with insulin treated diabetes in pregnancy :

- Set up IV fluid with 5% Dextrose

- Set up iv insulin infusion , adjust rate according to BS level.

- an intravenous fluids and insulin with hourly monitoring ofblood glucose

In the event of a planned caesarean section :

- delivery should be carried out early in the morning

- Omit the morning dose of insulin.

SN/MO/O&G

SN/MO/O&G

10 Immediate

post operativemanagement

1. Mother

- Check RBS- Reduce/ stop insulin

- Monitor RBS regularly

- 2. Baby

- - SCN noted

- - refer for neonatal management

- - check RBS

References

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References

1. Rosemary C. Temple, Vivien J. Aldridge, Helen R. Murphy. Prepregnancy Care and Pregnancy Outcomes in Women with Type

1 Diabetes. Diabetes Care. 2006 Aug;29(8):1744-9.

2. Kitzmiller JL, Buchanan TA, Kjos S, Combs CA, Ratner RE: Pre-conception care of diabetes, congenital malformations, and

spontaneous abortions (ADA Technical Review). Diabetes Care 19:514541, 1996

3. Ray JG, O'Brien TE, Chan WS: Preconception care and the risk of congenital anomalies in the offspring of women with

diabetes mellitus: a meta-analysis. QJM 94:435444, 2001

4. Kitzmiller JL, Block JM, Brown FM, Catalano PM, Conway DL, Coustan DR, Gunderson EP, Herman WH, Hoffman LD, Inturrisi

M, Jovanovic LB, Kjos SI, Knopp RH, Montoro MN, Ogata ES, Paramsothy P, Reader DM, Rosenn BM, Thomas AM:

Management of Preexisting Diabetes and Pregnancy. Alexandria, Virginia, American Diabetes Association, 2008

5. Suhonen L, Hiilesmaa V, Teramo K: Glycemic control during early pregnancy and fetal malformations in women with type 2

diabetes mellitus. Diabetologia 43:7982, 2000

6. Nielsen GL, Moller M, Sorensen HT: HbA1C in early pregnancy and pregnancy outcomes: a Danish population-based cohort

study of 573 pregnancies in women with type 1 diabetes. Diabetes Care 29:26122616, 2006

7. Parretti E, Mecaci F, Papini M, Cioni R, Carignani L, Mignosa M, La Torre P, Mello G: Third-trimester maternal blood glucose

levels from diurnal profiles in nondiabetic pregnancies: correlation with sonographic parameters of fetal growth. Diabetes Care

24:13191323, 2001

8. Mosca A, Paleari R, Dalfra MG, Di Cianni G, Cuccuru I, Pellegrini G, Malloggi L, Bonomo M, Granata S, Ceriotti F, Castiglioni

MT, Songini M, Tocco G, Masin M, Plebani M, Lapolla A: Reference intervals for hemoglobin A1C in pregnant women: data from

an Italian multicenter study. Clin Chem 52:11381143, 2006

9. Jovanovic L, Knopp RH, Kim H, Cefalu WT, Zhu X-D, Lee YJ, Simpson JL, Mills JL, for the Diabetes in Early Pregnancy Study

Group: Elevated pregnancy losses at high and low extremes of maternal glucose in early normal and diabetic pregnancy:

evidence for a protective adaptation in diabetes. Diabetes Care 28:11131117, 2005

10. Hoff man L, Nolan C, Lison J, Oats J, Simmons D. Gestational diabetes mellitus: management.The Australasian Diabetes inPregnancy Society. Med J Aust. 1998 Jul 20;169(2):93-7
http://care.diabetesjournals.org/search?author1=Rosemary+C.+Temple&sortspec=date&submit=Submithttp://care.diabetesjournals.org/search?author1=Vivien+J.+Aldridge&sortspec=date&submit=Submithttp://care.diabetesjournals.org/search?author1=Helen+R.+Murphy&sortspec=date&submit=Submithttp://www.ncbi.nlm.nih.gov/pubmed/?term=Rosemary+C.+Temple%2C+Vivien+J.+Aldridge%2C+Helen+R.+Murphy.+Prepregnancy+Care+and+Pregnancy+Outcomes+in+Women+with+Type+1+Diabeteshttp://www.ncbi.nlm.nih.gov/pubmed/?term=Hoff+man+L%2C+Nolan+C%2C+Lison+J%2C+Oats+J%2C+Simmons+D.+Gestational+diabetes+mellitus%3A+managementhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Hoff+man+L%2C+Nolan+C%2C+Lison+J%2C+Oats+J%2C+Simmons+D.+Gestational+diabetes+mellitus%3A+managementhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Rosemary+C.+Temple%2C+Vivien+J.+Aldridge%2C+Helen+R.+Murphy.+Prepregnancy+Care+and+Pregnancy+Outcomes+in+Women+with+Type+1+Diabeteshttp://www.ncbi.nlm.nih.gov/pubmed/?term=Rosemary+C.+Temple%2C+Vivien+J.+Aldridge%2C+Helen+R.+Murphy.+Prepregnancy+Care+and+Pregnancy+Outcomes+in+Women+with+Type+1+Diabeteshttp://www.ncbi.nlm.nih.gov/pubmed/?term=Rosemary+C.+Temple%2C+Vivien+J.+Aldridge%2C+Helen+R.+Murphy.+Prepregnancy+Care+and+Pregnancy+Outcomes+in+Women+with+Type+1+Diabeteshttp://care.diabetesjournals.org/search?author1=Helen+R.+Murphy&sortspec=date&submit=Submithttp://care.diabetesjournals.org/search?author1=Vivien+J.+Aldridge&sortspec=date&submit=Submithttp://care.diabetesjournals.org/search?author1=Rosemary+C.+Temple&sortspec=date&submit=Submit

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