East coast working group GDM in pregnancy

DR MOHD SUKARNO SAUD KKB KOTA BAHRU KELANTAN

Introduction
Evidence of impairment of insulin secretion and

action with the of diagnosis of gestational diabetes. The dysglysecemia defect may persist with the risk of 16-20 % at 3 to 6 months post partum . A proper follow up programmed is outlined in this manual to detect this group of patient so that intervention can be given early to prevent the onset of overt diabetes.

Committee recommendation for postpartum follow up of gestational diabetes mother

1.At delivery
-Mother -Mother with GDM ,insulin therapy should be discontinued immediately postpartum -Blood sugar monitoring should be discontinued once blood glucose returns to normal level (4-7 mmol/l) -Baby -Neonate should be nursed at the mothers bedside unless admission to intensive care is necessary Early breast feeding (within 1 hours) should be encouraged Baby of GDM/Diabetic mother should be admitted to SCN for observation and assessment by neonatalogist esp if mother need insulin antenataly. Following delivery, neonatal blood glucose concentration fall quickly then rises and stabilized by approximately 2-3 hours of birth.

 At Discharge

-for mother Make sure all postnatal plan written in the POSTNATAL plan form Low risk mother -GDM on diet/insulin- OGTT at 6/52 High risk mother (tyep1 and type 2 dm with and without comorbidities) 6/52 reviewed at OG clinic/PPC -for baby Continue breast feeding and neonatal care Breast feeding has been shown to reduce the risk of obesity and type 2 Diabetes in later life in infants of mother with GDM

Appendix 2 POST NATAL PLAN FORM (to be created and inserted at the last page in the antenatal book)

POST NATAL PLAN Ex: Repeat MOGTT 6/52 to get date at local clinic 2) 3) 4)

Appendix 3: MOGTT RECORD BOOK - (need to keep in Health centre: Pre pregnancy clinic)
NO Name IC/RN Address No contact Appt. date for MOGTT Appt. date to review result Result plan

Fasting

2nd Hour

1.

2.

4.

5.

6.

Subsequent Follow up for GDM mother

The increase risk of developing T2DM in the

future should be emphasized and education in the post natal period should incorporate advice on : -Diet -Physical activity -Weight reduction/healthy weight maintenance -Other life style intervention

Risk factors for developing T2DM

Pre-pregnancy overweight/obesity High blood glucose level at diagnosis of

GDM High insulin requirement during pregnancy Early gestation at diagnosis of GDM The need of insulin treatment during pregnancy Preterm delivery An abnormal postpartum OGTT

MANAGEMENT AFTER OGTT

Normal OGTT- repeat OGTT/2HPP every 3 years.weight

loss and and physical activity as needed IGT/IF-Yearly assessment by OGTT /2HPP (Preferred) Life style intrevention should be emphasis including diet and moderate physical activity.This can reduce risk of T2DM by as much as 40-60%.weight management is the best strategy to prevent T2DM therefore woman should be encouraged to achieve and maintain a healthy body weight.physical activity should be encouraged as this will reduce insulin resistance. Breast feeding should be supported and encouraged

 At 6-8 weeks post partum

A 75 g OGTT using WHO criteria performed at

6 weeks postpartum
DIABETES

Fasting plasma glucose 2-H Plasma Glucose

Impaired Glucose Tolerance(IGT) Fasting Plasma Glucose 2 H plasma Glucose Impaired Fasting Glucose (IFG) Fasting Plasma Glucose

> Or 7.0 mmol/l > Or 11.1 mmol/l

7.8mmol/l -11.1 mmol/l

6.1-6.9 mmol/l

2 h Plasma Glucose

<7.8 mmol/l

Specific recommendation for patient with pre-gestational diabetes

General advice- mothers with diabetes should be offered an opportunity for skin to skin contact with their babies immediately after delivery .Paternal support is encouraged Early and frequent feeding should be encouraged to avoid neonatal hypoglycemia and to stimulate lactation

TYPE 1 DIABETES Post partum insulin regime (similar to the pre-pregnancy dose of insulin) should be prescribed prior to delivery if possible and this should commence immediately following the third stage of labour. Blood sugar monitoring should be performed in the post partum period and insulin regime adjusted by by physcian/endoncrinologist to maintain blood glucose between 4-7 mmol/l. Close contact with the diabetes team is essential in the postpartum period to allow for assessment of glycemic control and adjustment of insulin dose. Multi disciplinary (obstetrician /physcian and dietian) management must be reemphasized. Women should be advised regarding risk of hypoglycemia while breast feeding and should be encouraged to monitor blood sugar levels closely to allow for correct insulin dose adjustment. Mother may require less insulin due to the calories expended with the breast feeding and may require a carbohydrate snack before or during breast feeding. Medication which were discontinue for safety reasons in the preconception period or antenatal period should continue to be avoided during lactation

 Type 2 Diabetes
Following delivery women with T2DM may be switched from insulin therapy to OHA . Careful consideration of the type of agent is needed in the lactating mother .Glipizide Glyburide,Metformine and Acarbose are considered compatible with breast feeding. Blood sugar monitoring should be done in post partum period and insulin regime adjusted by physician/endocrinologist to maintain blood sugar between 4-7 mmol/l.

Close contact with the diabetes team is essential in the postpartum period period to allow for assessment of glycaemic control and adjustment of insulin dose.
Multidisciplinary team (obstetrician/physcian,dietician) management must be emphasized.

Breast feeding should be actively encouraged in women with preexisting diabetes ,not only for the proven benefit offered to the general population but also for the protective effects against type 2 diabetes in the offspring in later life.
Medications which were discontinued for safety reasons in the preconceptual or antenatal period should continue to be avoided during lactation.

DR MOHD SUKARNO SAUD KKB KOTA BHARU KELANTAN

Is Pre-pregnacy counseling improved out come for mother with pre-gestational Diabetes ?
A study by Murphy et al in women with type 2 diabetes showed significant improvements that helped to reduce overall adverse outcomes8. For women with type 2 diabetes, the congenital malformation rate fell from 12.3 to 4.4%, perinatal mortality fell from 6.2 to 0.9%, and any serious adverse outcome fell from 16.4 to 5.3%, whereas in all these subcategories, there was very little change for women with type 1 diabetes. The importance of the reported study is that it shows that access to pre-pregnancy counseling and care does indeed reduce adverse pregnancy outcomes by approximately 80%8.
.

CARE PLAN
Optimal timing of pregnancy Optimally compliant and informed patient Optimized therapeutics Planned pregnancy

Desired outcome:
Well informed patient Where risks identified and risk reduction strategized. Periconception optimization of disease and therapeutics Planned conception

ADVICE AND CARE PLAN FOR PREGESTATIONAL

Discussion with the patient about future plan for pr contraceptive advise, Educate the patient about the effect of diabetic on pregnancy and pregnancy on diabetic. Women with diabetes who wish to conceive should of the need to establish good glycaemic control p to conception with the aim of HbA1c <6.5%6or FBS Advice about increase risks associated with unplann pregnancies and advocate for early antenatal care.

ADVICE AND CARE PLAN FOR PREGESTATIONAL

Screening for complications of diabetes for all women who plan to get pregnant9 Substituted the medications with known teratogenic effects with appropriate medication prio to conception9.(ACEI,ARB,Statin,Fibrate,Diuretic) Prescribing high dose folic acid (5mg) as part of pre-pregnancy care to prevent neural tube

Advice and care plan (cont)

OHA medication (metformin / glibenclamide) can be continue however insulin therapy has to be started in order to achieve glycemic control Aim to change to total insulin treatment before conception in type 2 Diabetes . Optimized control in type 1 Diabetes. Offering dietary advice to women with diabetes who are planning to become pregnant9. Offering effective family planning method until the optimum glycaemic controlled achieved . In the presence of vascular complications of diabetes or other contraindications, the combined oestrogen-progestogen pill should be avoided and other methods discussed (WHO MEC).

GENERAL EDUCATION FOR PREGESTATIONAL DIABETES DURING PRECONCEPTION PERIOD

The need for assessment and treatment of any complications of diabetes prior to conception and during pregnancy. The increase risk of congenital defects, neonatal morbidity and perinatal mortality associated with diabetes and pregnancy10,12. The risk of possible transient exacerbation of pre-existing retinopathy9 or nephropathy. The risk of hypoglycaemia and of hypoglycaemia unawareness in pregnancy13

The following capillary glucose targets are recommended in the pre-conception period:
Fasting 4.0 6.0 mmol/L RBS: 4.0 8.0 mmol/L6 HbA1c levels should be < 6.5%9. Follow-up of patients are individualized and hypoglycaemia should be avoided. Expected glycaemic targets should be discussed with the women and realistic individualized goals should be agreed HbA1c care does indeed reduce adverse pregnancy outcomes by approximately 80%8. levels should be measured 3 monthly during the preconception period6

DIABETES COMPLICATION : REVIEW AND MANAGEMENT IN THE PRECONCEPTION PERIOD

Preexisting complications of diabetes need to be

evaluated as complications may accelerate and alter the outcome of the pregnancy In the presence of advanced complications of diabetes Specialist advice should be sought from an endocrinologist ,to evaluate the individualized risk of pregnancy in that patient

 Retinal assessment in the preconception period: Presence of any retinopathy on fundus camera examination

should be referred to ophthalmologist The risk of advancement of retinopathy should be discussed. Renal assessment in the preconception period Women should be offered microalbminuria/albuminuria assessment serum creatinine and e-GFR assessment . If serum creatinine is abnormal or e-GFR is less than 45 mmol/l the patient should be referred to nephrologists. Assessment of autonomic neuropathy in the preconception period Gastroparesis,urinary retention, hypoglycemia unawareness or orthostatic hypotension may seriously complicate the management of diabetes in pregnancy.

 Cardiovascular assessment in the preconception period Hypertensive women with diabetes who are contemplating

pregnancy or who are at risk of becoming pregnant should be prescribed antihypertensive medication appropriate to pregnancy. Specifically ,ACE inhibitors should be avoided where possible in this group. ECG should be done for those women age > 35 (Diabetic Care 2008).Pre-existing or suspected coronary artery disease warrants cardiology review before conception Thyroid assessment in the preconception period Thyroid function should be measure in patient with type 1 Diabetes at initial physical assessment as both hypothyri0dism and hyperthyroidism can adversely affect pregnancy outcome if left untreated

Diabetic women with HbA1c >10% and impaired renal function with serum creatinine >0.2 mmol/l ( 180 umol/l )are advice not to get pregnant

Preconception Advice and care for previous GDM and IGT patients
Achieving and maintaining and ideal body weight (BMI 18-27 kg/m2) Healthy lifestyle which include diet and physical activity Assessment of self care ability should be undertaken and any

shortcoming addressed. The need to stop medication with teratogenic effect and possible need of insulin prior to conception The necessity of commencing folic acid ( 5 mg) as part of prepregnancy care to prevent neural tube defect. Important of early booking should and unplanned pregnancy occurred. For IGT patient advice for good control by diet and monitor their blood glucose 3-6 months before conception For previous GDM mother or having risk factors of GDM repeat OGTT at once to asses the glycaemic control.

Process of care PPC in Health Clinics and Hospitals

Health Clinics
MCH: Family Planning Child Health services Postnatal services Womens health

Klinik Bandar
OPD: NCD Wellness services Premarital screening Thalasemia screening Adolescent services MMT/NSEP

Hospital
Specialist clinics: MOPD SOPD O&G Orthopaedic Cardiology Nephrology

OPD: NCD Wellness services Premarital screening Thalasemia screening Adolescent services MMT/NSEP

Women in reproductive age of 15-55 years Risk Factor?

Women in reproductive age of 15-55 years Present Pre-pregnancy care (integrated) PPC in O& G Hospital History taking by screening format Physical examination Laboratory investigation

Absent Counseling Health education Family Planning Preparation for next pregnancy

History taking by screening format Physical Examination Laboratory investigation

Refer MO/FMS *Referral Follow up

Follow up

Pregestational Diabetes,Previous GDM and IGT

General advice in preconception period -general education Safety of medication Health promotion Dietary advice Physical activity education

Plan For Pregnancy Yes No

IGT
-optimized glucose control 3-6 months Before conception

CONFIRM DIABETES
H/O GDM or with risk factors
GDM Repeat OGTT at once to asses the glycaemiac control -Counseling -off contraception -start folic -target bsp -preexistinjg complioation assessment Continue NCD folloow up DM surveilance

T1 DM -Advice SMBG -OPTIMIZED CONTROL -HBA1C

Type 2DM -Change to insulin -For SMBG -Optimized control -Hba1c