CommUnityCare Women s Health Brackenridge Professional Office Building

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1 Guidelines for Diabetes in Pregnancy Effective Date 7/1/11 *This document does not define a standard of care, nor is it intended to dictate an exclusive course of management. There are other accepted strategies for the management of diabetes in pregnancy. I. Screening for gestational diabetes mellitus (GDM) (from Metzger BE, et al. Diabetes Care 2010, 33: ) A. Universal screening at weeks. If pregestational diabetes is present by history, then screening is not necessary. Management will be with insulin. Further assessment as described in Appendix A. B. Selected screening early in pregnancy should be performed at the first prenatal visit. 1. Indications for select early screening: a. History of gestational diabetes in a prior pregnancy b. Previous macrosomic infant (>4000 gm) c. Family history of diabetes in first degree relative d. Obesity (BMI > 30) e. Unexplained stillbirth in previous pregnancy f. Maternal age at delivery to be > Diagnostic Criteria for overt diabetes (to be measured on high risk women described as above) First prenatal visit Measure AIC (this is the preferred method; others listed below) To diagnose overt diabetes in pregnancy Measure of glycemia FPG A1C Random plasma glucose Consensus threshold >7.0 mmol/l (126 mg/dl) >6.5% (DCCT/UKPDS standardized) >11.1 mmol/l (200 mg/dl) + confirmations * One of these must be met to identify the patient as having overt diabetes in pregnancy. sif a random plasma glucose is the initial measure, the tentative diagnosis of overt diabetes in pregnancy should be confirmed by FPG or A1C using DCCT/UKPDSstandardized assay 3. If overt diabetes is diagnosed, then treatment and follow-up as for preexisting diabetes. Refer to High Risk OB (HROB). 4. If results are not diagnostic of overt diabetes and fasting plasma glucose >5.1 mmol/l(92 mg/dl) but <7.0 mmol/l (126 mg/dl), then diagnose as GDM. Management as described in section II and III of this document. It the fasting plasma glucose is <5.1 mmol/l (92 mg/dl), test for GDM from 24 to 28 weeks gestation with a 75-g OGTT Pg. 18

2 G uid e li ne s f o r D ia b e tes i n P r e g na nc y (C o nti n u e d) C. If the early screen at first prenatal visit is negative (<5.1 mmol/1 or <92 mg/dl), then repeat at weeks. Screen with a 2hr 75gm oral glucose tolerance test (75gm OGTT) D. Screen with 75 gm oral glucose tolerance test: 1. Diagnostic Criteria: 1. Positive screen when any one or more values is elevated 2. Method: 1. At least 8 hours of fasting prior to 75gm glucose screen 1. Fasting blood glucose followed by a 2 hour 75gm oral glucose tolerance test 2. Plasma glucose at 1, and 2 hours after ingestion of glucose 3. Diagnosis of gestational diabetes: at least one abnormal value: Fasting > 92 mg/dl 1 hour > 180 mg/dl 2 hour > 153 mg/dl 4. Diagnosis of overt diabetes if fasting plasma glucose is > 126 mg/dl. Refer to HROB. Management with insulin and further assessment as described in Appendix A. II. Management A. Refer to Diabetes Education (see Appendix B for summary of education) B. Diet 1. Arrange Nutritional counseling 2. IDEAL body weight (IDBW): 5 ft= 100lb. + 5lb. for every inch >5 ft. 3. Caloric intake: 30K cal/kg/day if body weight is IDBW +/- 20%. This may be adjusted by dietician depending on body weight. 4. CHO, 40%; Protein, 20%- 30%; fat, 20%-30% Meals and 2-3 snacks daily. C. Glucose monitoring four times daily: Fasting and 2hr glucose after breakfast, lunch and dinner D. Issue Glucometer and give education. A glucose log must be kept by patients. Check fasting glucose and 2 hours after main meals (2 hr pc); four times daily. Record mean fasting and mean 2 hr pc values each visit in the progress note. E. If the mean fasting glucose is greater than 92 mg/dl, or the mean 2 hour post prandial glucose is greater than 120 mg/dl, refer the patient to the High Risk Obstetrics clinic within one week. F. If the mean fasting glucose is greater than 120 mg/dl or if 2 hour glucose mean is greater than 200 mg/dl then, this patient needs immediate evaluation. Consult with the UMCB faculty at Pg. 19

3 G uid e li ne s f o r D ia b e tes i n P r e g na nc j ( C o nti n ue d) III. Therapy women needing therapy other than diet should be referred to HROB. A. Insulin (Humulin) Initial calculation for total dose:.8 units/kg/ibw daily first trimester.9 units/kg/ibw daily second trimester 1.0 units/kg/ibw daily third trimester 2/3 AM (3/4 NPH, ¼ breakfast 1/3 PM (1/2 NPH, ½ Humalog) supper; bedtime snack B. Oral Agent Therapy see Appendix C. In general this is reserved for gestational diabetes only. Overt or pre- existing diabetes should be managed with insulin in almost all cases. IV. Antenatal Testing A. A1 diabetes Fetal movement chart at 36 weeks NST twice weekly at 40 weeks B. A2 diabetes (uncomplicated) Fetal movement chart at 28 weeks NST weekly at 32 weeks; twice weekly at 36 weeks C. Pregestational or overt diabetes (uncomplicated) Fetal movement chart at 28weeks NST twice weekly at 32 weeks D. Diabetes complicated by hypertension, other evidence of vascular disease, renal or eye involvement, or other significant medial or obstetric complications. Fetal movement chart at 28 weeks NST twice weekly at 28 weeks E. Other interventions and testing as indicated by clinical finding V. Delivery A. Al diabetes at 4l weeks B. Medically managed or insulin dependent diabetes 38.5 to 40 weeks depending on control and patient reliability C. Delivery prior to 38.5 week may require amniocentesis for pulmonary maturity, unless an absolute indication for delivery based on maternal or fetal condition exists. There is considerable controversy surrounding this issue. Pg. 20

4 A p p e nd ix A Early Assessment (< 20 weeks) - Overt or Pregestational Diabetes MATERNAL Physical Exam Evaluate for: Possible Tests Recommendation HTN Retinopathy EKG Retinal evaluation Ophthalmology Consult Goiter Nephropathy T4, TSH 24 hr urine Collection for Cr. Cl. Consult with appropriate Medical or MFM consult if and total protein, and required urine culture Obesity Nutritional Counseling regarding obesity Glucometer (test 4 times daily) Glycemic Control Hb A1C Diabetic Counseling Nutritional Counseling Dietician consult FETA L Gestational Age Assessment Physical Exam Early ultrasound if possible Anatomic Assessment Appropriate fetal screening MFM Consult in all cases (1 st or 2 nd trimester ultrasound for dating) MS-AFP at 15 0/7 (even if they had a 1 st trimester screening) This is valid through 20 0/7 weeks Targeted ultrasound at weeks for anatomy Fetal echocardiogram at 24 weeks Pg. 21

5 A p p e nd ix B Guidelines for Diabetes Education 1. Patients new to the OB Diabetic Clinic are provided education on Mondays, in a class setting. Education is provided in the client s primary language. The template is for 3 classes of 4 patients each at 8:30am, 10:00 am and 11:30 am. Patients are instructed on importance of good control of blood sugar during pregnancy, as well as possible complication with poor control. Patients are encouraged to walk for exercise, unless medically prohibited. They are also instructed on exercise precautions. They are instructed on use of the glucose log, timing of testing for fasting and 2 hours after meals, and glucose logs. MAP patients are provided with a Contour Meter and instructed in its use as well as in the use of the control solution. Documentation is recorded in NextGen. 2. Patients are counseled on a 2000 calorie Gestational Diabetes meal plan of 3 meals and 3 snacks. Reference materials are provided for the meal plan, food safety, risk reduction of Type 2 Diabetes (when applicable) and healthy food habits for infants and children. Food models are used to demonstrate sample meals, snacks and food portion sizes and patients are evaluated on their knowledge of foods high in carbohydrates. Patients are also provided with a 1 week food log to record their intake and are asked to return it at their next clinic visit. The dietitian will review the food log with the patient and provide feedback. Documentation is recorded in NextGen. 3. Tuesdays, the dietitian and nurse educator are available in the clinic to follow up on patients taught the previous week in class, to teach patient needing Glyburide or insulin and to see any patients referred by the physician. We like to follow up with any patients who have been discharged from the hospital. 4. Please order insulin dose in increments of 2. We try to teach all patients needing insulin on the 1 cc insulin syringes which are marked only in 2 s, so even numbers of insulin can confusing to our clients. Pg. 22

6 Hyperglycemia Not Controlled by Diet and requiring Therapy CommUnityCare Women s Health A p p e nd ix C Oral Agent Therapy for Gestational Diabetes (NEJM 2OOO: 343:1134-8) Physician review. Decision to start Glyburide Start Glyburide 2.5 mg q. a.m. Follow up in One Week Patient Experiencing Hypoglycemia Yes Consider decreasing oral agent and change food plan No Blood Glucose Improving Yes Patients remains on oral as expected agent. Oral Agent (Glyburide) No Increase Recommended Dose Adjustments (mg) Increase once weekly Up to 6 week period Start Next Next Next Max a.m. a.m. am-pm am-pm am-pm 2.5 mg 5 mg 5mg/lOmg lomg/5mg lomg/lomg Glucose control achieved? Yes No Continue dose Switch to insulin am = before breakfast pm = bedtime Pg. 23