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

SECTION 2 ANTENATAL AND INTRA-PARTUM CARE OF DIABETES IN PREGNANCY

2.1. 2.1.1 2.1.2 2.1.3 2.1.4 2.2 2.2.1 2.2.2 2.3 2.3.1 2.3.2 2.3.3 2.3.4 2.3.5 Management of diabetes in pregnancy Education Diet Exercise Management of co-morbidities Blood glucose monitoring during pregnancy Blood glucose targets during pregnancy Insulin therapy during pregnancy Obstetric management of diabetes in pregnancy Maternal surveillance Fetal surveillance Timing and mode of delivery Management of labor and delivery Immediate post partum management

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.

2.0 Introduction
Pregnancies of women with diabetes are regarded as high-risk pregnancies. Therefore, these women should be advised that they will be offered more frequent consultations in the combined antenatal clinic. Studies have shown that pre-pregnancy care is associated with improved glycaemic control in early pregnancy with significant reductions in adverse pregnancy outcomes (malformations, stillbirths plus neonatal deaths as well as very premature deliveries

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 probably have to switch to insulin right immediately.

2.0 Introduction
For women with gestational diabetes, however meal planning and exercise often works to maintain blood glucose levels in control; however, if blood 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 malformations2,3 and the risk rises as glucose levels worsen4,5,6.

2.0 Introduction
The relation of maternal glucose to pregnancy outcome is a continuum, and ideal results are achieved when maternal glucose concentrations are within normal limits7,8 but not excessively low9.

Therefore subcutaneous insulin administration is the mainstay of intensified therapy for preexisting diabetes in pregnancy.
It is recommended to patients to practise SMBG before and after meals and occasionally at nighttime in order to evaluate their response to therapy and assess whether glycaemic targets are being achieved.

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 mother and her baby.

2.0 Introduction
For example, tight blood glucose control during labour 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 as well as intra-partum care be delivered to pregnant diabetes patients in order to obtain the best possible outcome for the mother and baby.

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 in pregnancy10
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

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 (especially folic 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.

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 (19.826.0 kg/m2) are recommended 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% to control blood glucose level.

2.1.3

Exercise

All pregnant women should be physically active and perform regular exercise but taking into consideration physical fitness and stage of pregnancy11 It is recommended that pregnant women perform exercise or moderate intensity physical activity that does not have a high risk of falling or abdominal trauma, such as walking or doing house chores a minimum of 30 minutes or more per day.

The minimal target of 30 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

2.1.4 Management of co-morbidities

1. 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 has not 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

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 post meal 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 practical purpose 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

2.2 Blood glucose monitoring during pregnancy

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

2.2.1 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

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/L if 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

2.2.2Insulin therapy during pregnancy

Ideally SMBG levels should be reviewed by clinic or telephone contact at least once weekly to allow for adjustment of treatment as required(depends on setting) Further dietary education should be given when commenced 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.

2.3 Obstetric management of diabetes in pregnancy

2.3.1 Maternal surveillance
Antenatal management should be a combined care between hospital and primary health care. Blood pressure, body weight and urinalysis should be measured at each visit11 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

2.3.2

Fetal Surveillance

The frequency and methods of fetal monitoring should be determined by maternal glycaemic control and the existence of other pregnancy complications. At first trimester, ultrasound should be performed to confirm viability and gestational age16 At second trimester, detailed ultrasound should be performed to check for congenital foetal anomalies in women with pre-existing diabetes or HbA1c >7% 15 At third trimester ultrasound, should be performed monthly to assess fetal wellbeing and growth16

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 monitor foetal movements and the women should report any concerns (i.e reduce foetal movement) immediately to the healthcare team16,18

2.3.3

Timing and mode of delivery

Aim for delivery between 39-40 weeks in patients with good glycaemic control and without complications.19

Vaginal delivery is preferable unless obstetric or diabetic complications necessitate caesarean delivery
Clinical and sonographic estimation of foetal weight should be done by 36 weeks onward to decide mode of delivery.

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.

2.3.5 Immediate Post Partum Management 1. Mother Check RBS Reduce/ stop insulin 14,21 Monitor RBS regularly

2. Baby SCN noted Refer for neonatal management Check RBS

SOP for antenatal and intrapartum care of diabetes in pregnancy

No STRATEGIC ISSUE ACTIVITY /ACTION RESPONSIBILITY

At diagnosis

All women with GDM should receive individualised nutritional advice by a dietician Advice should be appropriate to glycaemic control and gestational age. HbA1c should be obtained if the test is available

DIETITIAN/DIA BETIC EDUCATOR/SN /MO/FMS

Treatment Diet of GDM - The amount of calorie intake would be depended on pre pregnancy weight to aim for pregnancy weight as recommended by IOM (1). - Women with normal BMI (19.826.0 kg/m2) will be recommended 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% to control blood glucose level. Insulin - Insulin regime (basal / prandial / basal bolus) should be chosen depending on blood glucose profile OHA (Oral Hypoglycemic Agent) are generally not recommended.

No STRATEGIC ISSUE 3 Blood glucose monitoring during pregnancy

ACTIVITY /ACTION

RESPONSIBILITY
JM/SN/DIABETIC EDUCATOR/MO/ FMS/O&G

Self monitoring of blood glucose (SMBG) is recommended for all women with diabetes in pregnancy. For women receiving insulin therapy, 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 bed SMBG readings should be reviewed and treatment adjusted as required at every clinic visit A baseline HbA1c may be measured at diagnosis of diabetes and repeated as clinically indicated Patients monitoring techniques must be checked to ensure accuracy of results Blood glucose The following target values are recommended for optimum targets during maternal and foetal outcome: pregnancy - 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.

MO/FMS/O&G

No STRATEGIC ISSUE
5 Insulin therapy during pregnancy

ACTIVITY /ACTION
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. 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

RESPONSIBILITY

Diabetic educator/MO/FM S MO/FMS/O&G MO/FMS/O&G DIABETIC EDUCATOR/MO /FMS/O&G DIABETIC EDUCATOR/ DIETITIAN/MO/ FMS/O&G

Maternal Surveillance

JM,JK,PHN,KJ,KJK MO, FMS, O&G JM,JK,PHN,KJ,KJK, MO,FMS,O&G

No STRATEGI ACTIVITY /ACTION C ISSUE

7 Foetal The frequency and methods of foetal monitoring are determined by Surveillanc maternal glycaemic control and the presence of other pregnancy e complications. At First trimester, Ultrasound should be performed to confirm viability 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 Timing Aim for delivery between 39-40 weeks in patients with good and mode glycaemic control without complications. of delivery 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 .

RESPONSIBILI TY
MO,FMS,O&G MO,FMS.O&G MO,FMS,O&G MO,FMS JM,JK,KJ,KJK,M O,FMS,O&G

JM/SN/MO/ FMS/O&G SN/MO/ FMS/O&G

No STRATEGIC ISSUE
9 Management of labour and delivery

ACTIVITY /ACTION

RESPONSI BILITY

10

Continuous foetal monitoring throughout labour and SN/MO/O&G delivery is advised. SN/MO/O&G 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 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. Immediate 1. Mother post operative - Check RBS management - Reduce/ stop insulin - Monitor RBS regularly - 2. Baby - SCN noted - refer for neonatal management - check RBS

References
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11. Kitzmiller JL, Block JM, Brown FM, Catalano DR, Gunderson EP. et al Managing Preexisting Diabetes and Pregnancy, Summary of evidence and consensus recommendations for care. Diabetes Care 2008; 31: 1060-1079. 12. American Diabetes Association. Preconception Care of Women with Diabetes. Diabetes Care 2004; 27:S76-S78. 13. Griffi th J. Conway DL. Care of diabetes in pregnancy. Obstetrics and Gynaecology Clinics of North America 2004; 31:243-256. 14. NICE clinical guidelines 63. Diabetes in pregnancy: management of diabetes and its complications from pre-conception to the postnatal period. Available from: www.nice.org.uk/CG063 15. Metzger B.E. and Associates. Summary and Recommendations of the Fifth International Workshop-Conference on Gestational Diabetes Mellitus. Diabetes Care 2007; 30:S251-S260. 16. Conway DL. Obstetric Management in Gestational Diabetes. Diabetes Care 2007; 30:S175-S179. 17. Confi dential Enquiry into Maternal and Child Health. Diabetes in pregnancy: are we providing the best care? Findings of a national enquiry: England, Wales and Northern Ireland. London: CEMACH; 2007 guidelines. The Australasian Diabetes in Pregnancy Society. MJA 1998; 169:937. 18. Moore TR, Piacquadio K. A prospective evaluation of fetal movements screening to reduce the incidence of antepartum fetal death. Am J Obstet Gynecol 1989; 160:1075-1080. 19. Kjos SL, Berkowitz K, Xiang A. Independent predictors of caesarean delivery in women with diabetes. J Matern-Fetal Med 2004; 15:61-67. 20. Scottish Intercollegiate Guidelines Network. Management of diabetes. A national clinical guideline. Edinburgh: SIGN; 2001. 21. IDF Clinical Guidelines Task Force. Global Guideline on Pregnancy and Diabetes. Brussels: International Diabetes Federation, 2009.

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