Post on 02-Apr-2018
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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-d96/7/27/2019 gdm 050713
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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-d92/7/27/2019 gdm 050713
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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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2.2.2 Insulin therapy during pregnancy
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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2.2.2 Insulin therapy during pregnancy
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=Submit7/27/2019 gdm 050713
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