Officers and Board of Directors - The Filipino Doctor Maternal Health (Diabetes... · Vice President Pilar Lagman Dy, M.D. Secretary Flerida L. Tan, M.D Treasurer Raul M. Quillamor,

Philippine Society of Maternal and Fetal Medicine Medical Arts Bldg. Room 327, St. Luke's Medical Center, 279 E. Rodriguez Sr. Avenue, Quezon CityTel. 723-0101 loc. 6327

President Sol Manarang Pangan, M.D. VicePresident Pilar Lagman Dy, M.D. Secretary Flerida L. Tan, M.D Treasurer Raul M. Quillamor, M.D. BoardofDirectors Mario Festin, M.D. Ramon Gonzales, M.D. Teresita Ortin, M.D.

Officers and Board of Directors

Diabetes in pregnancy cpM 6th eDitiOn

Diagnosis and Classification of Diabetes Mellitus in Pregnancycoma in pregnancy and might provoke instability of an occult diabetic’s diet and glycemic control.

Type II DM, possibly a pre-existing but occult type, is difficult to diagnose during pregnancy because of its many similar clinical characteristics with GDM. When GDM has been tentatively diagnosed in early pregnancy, it is not unusual to find overt type of diabetes after delivery. A first trimester HbA1c level > 8% is highly suspicious for pre-existing Type II DM. Definitive diagnosis though must be made after pregnancy using the WHO diagnostic criteria for diabetes mellitus. (See Table 2)

Proper management of diabetes mellitus during pregnancy requires careful and accurate diagnosis and classification. This aspect of high-risk pregnancy care has been plagued with confusion because of numerous opinions and classifications presented in various conferences and textbooks. It is the aim of this section to present the most commonly accepted norms and hopefully clarify some of the unclear aspects of classification and terminology.

In 1979, the National Diabetes Data Group (NDDG) of the U.S. National Institute of Health developed and presented a classification scheme for diabetes based on the pathophysiology of hyperglycemia. It categorizes patients into 3 groups, namely: Insulin-dependent diabetes mellitus (IDDM), Non-insulin-dependent diabetes mellitus (NIDDM) and Gestational diabetes mellitus (GDM). Features are summarized in table 1. This scheme is useful in that it categorizes patients by their underlying pathogenesis.

An alternative classification system, many obstetricians are more familiar with, is the system proposed by Priscilla White in 1932 and subsequently modified. It classifies patients based on the onset and duration of the disease and the presence of secondary vascular and other end-organ complications. Although it may be considered descriptive of risk and health status, it does not differentiate the underlying pathophysiology. For this reason, the NDDG classification is currently more favored.

Diagnostic Measures

Overt Diabetes

This refers to Type I and Type II DM in the NDDG classification. Type I DM is typically diagnosed during childhood and adolescence and rarely during pregnancy. During pregnancy, this type may manifest as unexpected

Gestational Diabetes (GDM)

Gestational diabetes is defined as “carbohydrate intolerance of variable severity with onset or first recognition during pregnancy”. GDM is definitely diagnosed via the Oral Glucose Tolerance Test (OGTT). This requires carbohydrate loading and overnight fast to provide maximum sensitivity. Pregnancy brings about changes in insulin sensitivity, degradation and activity, and it has been recognized that non-pregnant norms for oral glucose tolerance might not be valid during pregnancy.

In 1964, O’Sullivan and Mahan published their landmark study using a 3-hour, 100-gram oral glucose test, where they suggested specific hourly criteria for the definition of GDM. The requirement for two values to be abnormal was based on the desire to avoid “misclassification due to laboratory error, or occasional single high peaks resulting from unusually rapid absorption of glucose”. This criterion was widely used in the American continent probably because it was so thoroughly evaluated and was specific for pregnancy. In the late 1970’s, its use was recommended by the American College of Obstetricians and Gynecologists (ACOG) in 1978 and by both the National Diabetes Data

Table1.ClassificationofGlucoseIntolerance(NDDG)

nomenclature Old name clinical Features

type i Juvenile- Ketosis prone, Insulin-dependent onset DM insulin-deficient DM (IDDM)

type ii Adult- Ketosis-resistant, insulin- Non-insulin- onset DM resistant; Obesity, family dependent DM history & age are common (NIDDM) risk factors

type iii Gestational Occurs only during Gestational diabetes pregnancy; Established by diabetes (GDM) glucose tolerance test; Obesity and age are common risk factors

Diagnosis

Normal

ImpairedGlucose Tolerance

Diabetes

Fasting

<140 mg/dL(<7.8 mM)

<140 mg/dL(<7.8 mM)

>140 mg/dL(>7.8 mM)

2 Hours

<200 mg/dL(<11.1 mM)

>140 mg/dL and <200 mg/dL(>7.8 and <11 mM)

>140 mg/dL( >11.1 mM)

Table2. WHODiagnostic criteria for DiabetesMellitus(VenousPlasmaGlucose)

Note:For diagnosis of NIDDM after pregnancy, the NDDG requires a 1-hr value >200 mg/dL in addition to abnormal fasting and 2-hr values.

cpM 6th eDitiOn Diabetes in pregnancy

prevalent, this adaptation leads to the diagnosis of a higher proportion of pregnancies as “abnormal” than the other criteria. The WHO criteria were not developed specifically for use in pregnant women and neither were they validated by their ability to identify pregnancies at increased risk for adverse outcome. A major advantage of this criteria is that the 75-gram 2-hour test is used, the same as for non-pregnant individuals. It has been seen as simpler and more sensitive than the NDDG 100-gram 3-hour test.References:1. Carr SR: Screening for gestational diabetes mellitus.

Diabetes Care Volume 21 Suppl 2. Proceedings of the 4th International Workshop-Conference on Gestational Diabetes Mellitus, 1999.

2. Coustan DR and Carpenter MW: The diagnosis of gestational diabetes mellitus. Diabetes Care Volume 21 Suppl 2: Proceedings of the 4th International Workshop-Conference on Gestational Diabetes Mellitus, 1999.

3. Moore TR: Diabetes in Pregnancy in Maternal-Fetal Medicine (Creasy R and Resnik R (eds), WB Saunders Co. Inc, Phil, PA, 1999, pp. 969-973.

*ANMUM - IFD

Group (NDDG) and the First International Workshop-Conference on Gestational Diabetes Mellitus in 1979.

Owing to recent developments in laboratory techniques and methods, certain research groups opted to modify the hourly criteria originally set by O’Sullivan and Mahan’s 100-gram 3-hour OGTT. Since the work of O’Sullivan and Mahan utilized venous whole-blood samples and most laboratories subsequently shifted to plasma or serum samples, the NDDG in 1979 recommended conversion of the original criteria by an upward adjustment. Not only was there a shift in the samples analyzed, but technological advancements have led to a shift from the original Somogyi-Nelson technique of measuring glucose to the more modern specific enzymatic methods. Coustan and Carpenter have made recommendations as to the adjusted hourly criteria.

Test Pre-requisites

A. Overnight fast of 8-14 hours B. Carbohydrate loading 3 days including >150 g

carbohydrate C. Unrestricted physical activity for 3 days D. Seated, not smoking during the test E. Two or more values must be met or exceeded

In much of the world outside of the U.S., gestational diabetes is diagnosed when the WHO criteria for diabetes outside of pregnancy, using a 75-g 2-hr oral glucose tolerance test, are satisfied. In some centers, the WHO criteria for impaired glucose tolerance test (IGT) are used to identify glucose intolerance in pregnancy. Two or more of the venous plasma concentration must be met or exceeded for a positive diagnosis. Criteria for this is as follows:

The same test prerequisites apply as in the test using the 100-g oral glucose load. Because IGT is highly

VenousPlasma Carpenter&Coustan

Fasting 105 mg/dL 95 mg/dL (5.3 mmol/L) 1Hour 190 mg/dL 180 mg/dL(10.0 mmol/L) 2Hour 165 mg/dL 155 mg/dL (8.6 mmol/L) 3Hour 145 mg/dL 140 mg/dL (7.8 mmol/L)

Note:FordiagnosisofNIDDMafterpregnancy,theNDDGrequiresa1-hrvalue>200mg/dL inaddition toabnormalfastingand2-hourvalues.

Table3. 100-gram3-hourGlucoseToleranceTestforgestational Diabetes

Table4.DiagnosisofGDMwitha75-goralglucoseload.

mg/dL mmol/L

Fasting 95 5.3 1Hour 180 10.0 2Hour 155 8.6


Introduction:Whyscreen?

The development of screening and diagnostic tests for GDM is a fascinating and much-debated topic. Consensus was initially reached with the adoption of O’Sullivan and Mahan’s study wherein criteria were based on the extrapolation of non-pregnant values to pregnant levels. Since then several changes have occurred especially along the lines of laboratory refinements such that new values are proposed. More recently, the original objective of screening rested mainly on its prediction of long-term type 2 diabetes mellitus and its complications and it is only now that the focus has shifted to the perinatal risks of GDM.

Proponents for screening have put forth the following arguments:

1. GDM is one of the most common medical problems in pregnancy (3-5%).

2. GDM is an in-utero risk factor for spontaneous abortions, prematurity, fetal malformations, macrosomia and metabolic derangements.

3. Risk for fetal macrosomia which leads to an increased risk for operative delivery by C/S, vacuum or forceps, and birth trauma (shoulder dystocia, clavicle fracture, peripheral nerve injury)

4. Neonatal risk factor for hypoglycemia, hypocalcemia, hyperbilirubinemia, respiratory distress syndrome, and congenital malformations.

5. Women with GDM are at increased risk for developing the following complications later in life: metabolic complications (NIDDM), coronary heart disease, CVA, polyneuropathy, blindness, non-traumatic amputations and end-stage renal disease.

Whom to Screen: Universal or SelectiveScreening?

Opinion is currently divided as to whether universal or selective screening for gestational diabetes should be done. Proponents for selective screening state that screening should be limited to women meeting at least one of the four criteria listed in Table 5.

GDM: Screening and DetectionPregnant women meeting none of these criteria are considered to be at a lower risk for the development of glucose intolerance during pregnancy and therefore it is likely not cost-effective to screen such patients. The American College of Obstetricians & Gynecologists (ACOG), the American Academy of Pediatrics (AAP) and the 4th International Workshop on Gestational Diabetes Mellitus (4th FIW-GDM) currently favor selective screening.

The ASEAN Study Group on Diabetes in Pregnancy (ASGODIP) lists the Philippines as having a 3-4% prevalence of GDM in low-risk patients but has a 38% prevalence rate of GDM in the high-risk groups, the highest among its member countries. This high prevalence rate statistic alone argues for mandatory or universal identification of high-risk groups (Table 6) among Filipino gravidas. Add to this statistic the previously-mentioned medical risks of GDM and the proposal for universal GDM screening for Filipinos seems more tenable not withstanding the problems of technology availability and cost of testing. The American College of Physicians and the American Diabetes Association currently favor universal screening.

WhentoScreen?

For women without the aforementioned risk variables, screening should be performed between the 24th and 28th weeks of gestation.

For women with risk factors, they are immediately screened at the first prenatal visit. If initial test results are normal, repeat tests are in order at 24-28 weeks and again later at 32-34 weeks due to increasing glucose sensitivity as pregnancy progresses.

* Historical risk factors * Past pregnancy - abnormal glucose tolerance macrosomia (BW = 8 lbs)

congenital malformations recurrent abortions unexplained intrauterine death

* Present pregnancy - family history (first degree relation)

maternal obesity (>180 lbs or BMI >27 kg/m2)

drugs affecting carbohydrate metabolism (steroids, betamimetics, etc.)

age > 30 years racial predilection (Indians)* Obstetric risk factors polyhydramnios macrosomic fetus fetal abnormality recurrent genital tract infections

Table 6. Identification of High Risk Groups for GDM(ASGODIP).

Table5.Riskfactorsforgestationaldiabetesmellitus

* >25 years of age* <25 years of age and obese (>20% over desired body

weight or BMI >27 kg/m2)* Family history of diabetes in first-degree relatives* Member of an ethnic / racial group with a high prevalence

of diabetes (Hispanic-American, Native American, Asian-American, African-American, or Pacific Islander)

4th International Workshop-Conference on Gestational Diabetes,1999


HowtoScreen?

Two-Step Testing / Normal Values

* The screening test should consist of a 50-g oral anhydrous glucose load followed by a plasma glucose determination 1 hour later; the patient need not be fasting before the glucose load. A value of >140 mg/dL (7.8 mmol/L) or >130 mg/dL (7.5 mmol/L) 1 hour after the 50-g load indicates the need for a full diagnostic 100-g 3-hour oral glucose tolerance test (OGTT) performed in the fasting state. The diagnosis of GDM requires any two of the four plasma glucose values obtained during the test to meet or exceed the values. A summary of clinically acceptable values is in Table 7.

summary and recommendations on Detection and Diagnosis

1. At the first prenatal visit, determine if the gravida is high risk or not based on historical and pregnancy risk factors.

2. If the gravida is low risk, screening should be performed between the 24th and 28th weeks of gestation but, if the woman is high risk, screening is immediately performed.

3. The screening tests should consist of a 50-g oral anhydrous glucose load followed by a plasma glucose determination 1 hour later. The patient need not be fasting before the glucose load. A value of >140 mg/dL (7.8 mmol/L) 1 hour after the 50-g load indicates the need for a full diagnostic 100-g 3-hr oral glucose tolerance test (OGTT) performed in the fasting state.

4. Diagnosis is based on results of the 100-g 3-hour OGTT interpreted according to the diagnostic criteria by Carpenter and Coustan. The diagnosis of GDM requires any two of the four plasma glucose values to meet or exceed the values.

5. Reclassification of maternal glycemic status should be performed at least 6 weeks after delivery and according to the guidelines of the “Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus”. If glucose levels are normal postpartum, reassessment of glycemia should be undertaken at a minimum of 3-year intervals. Women with IFG or IGT in the postpartum period should be tested at more frequent intervals.

References:1. Metzger BE, Coustan DR (Eds.): Proceedings of the

Fourth International Workshop-Conference on Gestational Diabetes Mellitus. Diabetes Care 21 (Suppl. 2): B1-B167, 1998.

2. American Diabetes Association: Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 22 (Suppl. 1): S5-S19, 1999.

3. Khandelwal M, Homko C and Reece EA: Gestational diabetes mellitus: controversies and current opinions. Curr Opinion Obstet Gynecol 11:157-165, 1999.

4. Naylor CD, et al: Selective screening for gestational diabetes mellitus. N Engl J Med 337: 1591-1596, 1997.

5. Weiss PAM, et al: Toward universal criteria for gestational diabetes: relationships between 75 and 100-gram glucose loads between capillary and venous glucose concentrations. Am J Obstet Gynecol 178:830-835, 1998.

One-Step Testing / Normal Values

• Certain quarters (WHO, ASEAN) are advocating a one-step testing scheme. Basically, the anhydrous glucose load is 75 g, and only 1 blood sugar value measured 2 hours after glucose loading is taken. A value >140 mg % is considered abnormal and treatment is began.

• The Fourth International Workshop-conference on GDM proposed a scheme using 75 g load followed by the OGTT using the criteria of Carpenter and Coustan.

Post-Puerperium 100 Gm OGTT / Normal Values

Reclassification of maternal glycemic status should be performed at least 6 weeks after delivery according to the guidelines of the “Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus”. If glucose levels are normal postpartum, reassessment of glycemia should be undertaken at a minimum of 3-year intervals. Women with IFG or IGT in the postpartum period should be tested at more frequent intervals.

Table8.ReclassificationofMaternalGlycemiaStatus

normal iFg / igt Diabetes

FPG <110 mg/dL FPG > 110 mg.dL - FPG > 126 mg/dL < 126 mg/dl (IFG)

2hr PG < 140 mg/dL 2hr PG > 140 mg/dL - 2hr PG > 200 mg/dL < 200 mg/dL (IGT)

Table7.NormalvaluesforGCT/OGTT

Carpenter O’Sullivan& &Coustan Mahan/NDDG

GCT 130 mg/dL 140 mg/dLOGTT Fasting 95 mg/dL 105 mg/dL1 hour 180 mg/dL 190 mg/dL2 hour 155 mg/dL 165 mg/dL3 hour 140 mg/dl 145 mg/dL


Nutritional care in women with diabetes mellitus in pregnancy is the process of meeting the diabetic person’s changing nutritional needs. The type of care depends on the disease classification. The nutritional care process is carried out by the following steps:

• assessment of the individual’s nutritional status for identification of nutritional needs

• planning of objectives of nutritional care to meet these needs

• implementation of nutritional intervention activities, including education, necessary to meet the objectives

• evaluation of the nutritional care

assessment

Evaluation of nutritional status involves examination of the individual’s physical condition, growth and development, behavior, the urinary, blood or tissue levels of nutrients, and the quality of nutrient intake.

The gathering of adequate data base which includes anthropometric, biochemical, clinical, dietary and psychosocial information is important in the identification of the patient’s problems and needs. Each assessment must arrive at a conclusion upon which the plan is developed.

Dietary assessment is an important part of nutritional assessment, but it cannot be used alone to make a diagnosis of nutritional health. It is an aid in the interpretation of anthropometric, clinical and laboratory findings and provides a foundation for dietary counseling.

planning

After the identification of nutritional problems, the next step is to formulate a plan for dealing with each of them, with the greatest attention being paid to the problems of highest priority. If the nutrition information is not complete, the first objective would be to collect more of it. Based on the assessment: 1) reasonable objectives are set toward which the patient-client is willing to work; 2) ways are described to achieve the stated objectives; and 3) a plan is devised for evaluation of the results.

In addition, the objectives should be realistic, quantifiable and should take into consideration the educational level of the patient and the economic and social resources of the patient and his family.

implementationofNutritionalCare

Nutrition Management in Women with Diabetes Mellitus in Pregnancy

This part of the nutritional care process includes all of those activities or interventions that will enable the patient to meet the objectives already defined. Such activities include the diet prescription, nutritional counseling and education, provision of food and necessary nutritional supplements (if the patient is hospitalized) and vitamin and mineral medication.

Implementation means that the patient-client is able (independent) to plan his/her own menus, to prepare foods appropriate to the needed changes (or to supervise such preparation), and to consume the needed amounts. Available food in the market place are evaluated with respect to cost, information on labels, and so on. It means that the client applies each day those modifications of food behavior to which he or she is committed.

EvaluationofNutritionalCare

The last step is evaluation of the nutritional care provided. This step makes the nutritional care plan dynamic and responsive to the patient’s needs. If the objectives have been written in measurable behavioral terms, the evaluation becomes very easy, since present behavior is being measured against behavior already defined.

Each evaluation becomes, in effect, a reassessment or addition to the initial assessment. This may lead to revision of the plan, if needed, and then to changes in implementation. Sometimes the evaluation may show that an individual cannot be helped or does not want to be helped; this too should be recognized.

NutritionIntervention

Nutrition intervention is considered the cornerstone of treatment for all women with GDM. The American Diabetes Association advocates that all women with GDM receive nutrition counseling by a registered dietitian when possible. A summary of nutrition recommendations for women who have diabetes during pregnancy appears in Table 9. The registered dietitian’s most crucial and important goal is achieving normal blood glucose levels while maintaining appropriate nutritional status and adequate dietary intake for fetal growth and development.

The following points should be taken into consideration when prescribing appropriate diets:• The meal plan should promote normal glucose levels.

Whenever feasible, glucose monitoring should be encouraged throughout the pregnancy to assess blood glucose levels. When and how often the woman should be tested can be negotiated with her health care


practitioner.• The pattern of weight gain should be appropriate for

pregnancy. An adverse relationship has been found between pre-pregnancy body weight and average weight gain during pregnancy. Table 10 outlines weight gain recommendations for pregnancy based on body mass index. Weight changes should be noted at all follow-up visits. It is advisable that women measure ketone levels daily to ensure that adequate carbohydrate for energy requirements is being consumed. Weight loss without production of ketones represents a diuresis from lowered carbohydrate intake and increased intake of protein.

• The nutrient needs for pregnancy should be met. Routine assessment of dietary practices is recommended for all pregnant women to allow evaluation of the need for an improved diet or vitamin/ mineral supplementation. The Food and Nutrition Board advises against the use of routine vitamin/mineral supplements during pregnancy except for a daily low dose (30 mg) of ferrous iron.

• Individual diet and exercise habits should be taken into consideration.

energy prescriptions

The American Diabetes Association recommends an energy intake based on pre-pregnancy weight status. For women with desirable body weight, 30 kcal/kg per day (13.6 kcal/lb per day) is the suggested energy prescription. Women who are more than 120% of desirable weight need a lower energy intake, so 24 kcal/kg per day (10.9 kcal/lb per day) is the recommendation. Women who are underweight before pregnancy, less than 90% of desirable body weight, need more energy, and the range of 36 to 40 kcal/kg per day (16.3 to 18.2 kcal/lb per day) is suggested (See Table 11).

Hypocaloric diets have been used for obese woman with GDM. Risk of high levels of blood ketones and risk of sacrificing maternal nutritional status are higher in women who consume hypocaloric diets. Women placed on these diets should have the benefit of team management - including a diabetologist, an obstetrician, and a registered dietitian - to properly assess the effects of energy restriction.

Factorandreference Recommendation

Energy Consume energy necessary to maintain desirable weight gain during pregnancy Carbohydrate Percentage depends on individual eating habits and effect on blood glucose goals Sucrose and sweeteners Use depends on effect on blood glucose levels Fiber Daily consumption of 20 to 35 dietary fiber from a wide variety of food sources is recommended Protein Consume 10 g/day above the Recommended Dietary Allowance (i.e. a total of 60 g/day) Fat Percentage is based on nutrition assessment and treatment goals; less than 10% of energy should be

from saturated fat Alternative sweeteners Restrict use of saccharin. Use of aspartame and acesulfame K in moderation is acceptable Sodium Sodium restriction has not been found to be beneficial Alcohol Consumption is not advisable during pregnancy Caffeine Moderate use is acceptable Vitamins/minerals Institute of Medicine does not recommend routine use of multivitamin/ mineral supplementation.

Instead, it recommends that the nutritional adequacy of individual dietary habits be assessed to determine need for supplementation. Ferrous iron supplement (30 mg) is recommended to providefor the increased iron needs for pregnancy

Table9.NutritionRecommendationsforWomenwithGestationalDiabetes

Currentweight Dailycaloricintake

Less than 80 percent of 35 to 40 kcal per kg of presentideal body weight body weight

80 to 120 percent of 30 kcal per kg of presentideal body weight body weight

120 to 150 percent of 24 kcal per kg of presentideal body weight body weight

Greater than 150 percent of 12 to 15 kcal per kg ofideal body weight present body weight

Table 11.DailyCaloricRecommendations forPatientswithgestational Diabetes.

Table10.Recommendedtotalweightgainrangesforpregnantwomenbasedonpregnancybodymassindex(BMI)a

a Reprinted with permission from Nutrition during Pregnancy. Copyright 1990 by the National Academy of Sciences. Courtesy of the National Academy Press, Washington, D.C.

b BMI is calculated using metric units. BMI = [pregnancy weight (lb)/height (in)2] x 100.

c young adolescents and black women should strive for gains at the upper end of the recommended range. Short women (157 cm or 62 in) should strive for gains at the lower end of the range.

BMIb

<19.819.8-2626-29>29

Pregnancy

Weight

% Ideal

Body

Weight

<85100120>135

Recommended

total gainc

kg lb

12.5-18 28-4011.5-16 25-357.0-11.5 15-25at least at least

7.0 15

Diabetes in pregnancy cpM 6th eDitiOn Ketone testing

Maternal ketone testing is a useful indicator in determining adequacy of maternal carbohydrate and/or energy intake. Chez and Curcio concluded that ketonuria probably occurs sporadically in most pregnancies. However, two studies have indicated that ketonemia in the pregnant woman is associated with lower IQ in the offspring. These studies do not provide definitive data and more research is needed, but it appears prudent to avoid ketosis in pregnancy. The current recommendation is daily or periodic testing of the first voided specimen of urine for ketones. Dietary adjustments may be needed if trace or greater amounts of ketones persist. A ketone meter for measuring blood or serum ß-hydroxybutyrate is being tested, because urine ketone testing can prove unreliable in detecting high levels of blood ketones.

blood glucose Monitoring and Daily Food records

All cases of GDM require close surveillance of mother and fetus. The goal is to normalize blood glucose levels. Monitoring of maternal urinary glucose level is not adequate or sufficient to determine elevation in blood glucose levels. Self-monitoring of blood glucose level allows the woman to participate in the control of her glucose level and reinforces the modification in types and amounts of food choices recommended by the registered dietitian. Although self-monitoring of blood glucose level seems reasonable and logical, the costs and benefits for women who do not require insulin have not been universally accepted. The benefits of postprandial testing vs preprandial testing in reducing neonatal macrosomia are currently being studied.

The introduction of self-monitoring of blood glucose levels has resulted in self-induced lower carbohydrate intake among pregnant women with GDM. Unrefined, whole-grain breads, noninstant oatmeal, legumes, and lentils are encouraged because of their lower glycemic response. Self-monitoring of blood glucose level in conjunction with keeping daily food records will help determine individual glycemic responses to meals and food products.

The American College of Obstetricians and Gynecologists (ACOG) recommends checking of fasting and two-hour postprandial plasma glucose values at least weekly. The fasting value should be less than 105 mg per dL (5.8 mmol per L), and the two-hour postprandial levels should be less than 120 mg per dL 96.7 mmol per L). If either of these values is consistently abnormal, dietary therapy alone is not sufficient and insulin therapy should be instituted.

Recommendations about how carbohydrate should be distributed throughout the day vary among colleagues and programs treating women with GDM. Hollingsworth

and Ney recommend eliminating daytime snacks in obese women with GDM to avoid food-stimulated insulin release. Maternal hypersinsulinemia, with or without maternal hyperglycemia, is an important factor in fetal macrosomia. Jenkins, et al found that blood glucose and insulin concentrations were lower in patients with non-insulin-dependent diabetes mellitus who increased meal frequency. Their study indicates metabolic benefits for nibbling, that is, spreading the nutrient load over a longer period, vs the three-meals diet. A study by Peterson and Jovanovic-Peterson examined percentages of carbohydrate at meals and glycemic responses in women with GDM. The researchers determined that the percentage of carbohydrate in a meal and the glycemic response vary among persons. These studies show the need for daily food records and self-monitoring of blood glucose level to individualize dietary recommendations and make adjustments in meal plans throughout pregnancy.

Exercise

The registered dietitian plays an important role in assessing the current exercise habits of women with GDM. The major metabolic benefits of exercise are related to its ability to enhance insulin sensitivity. The dietitian can be influential in guiding women in an exercise program that will improve glucose control. Regular exercise sessions, rather than sporadic exercise, are effective in regulating blood glucose levels.

Patients should be encouraged to exercise at least three or four days a week, with each session lasting 15 to 30 minutes. The patient’s heart rate should not exceed 70 to 80 percent of her age-adjusted maximal heart rate (determined by subtracting the patient’s age in years from 220). For most pregnant patients, the maximal heart rate will fall between 130 to 160 beats per minute. Patients should avoid very strenuous activity and should not become overheated. If any signs of overexertion, hyperthermia, fetal distress or changes in the pregnancy occur, exercise should be discontinued immediately. (See Table 12).

At risk for premature labor Vaginal bleeding during pregnancy Placenta previa Anemia Cardiac disease Thyroid disease Hypertension Intrauterine growth retardation Malpresentation in the third trimester Excessive obesity Extreme underweight

Table12.ContraindicationsforExerciseinPregnancy


Other concerns

Nauseaandvomiting.Nausea and vomiting during pregnancy, classically known as “morning sickness,” affect 10% to 20% of all pregnant women to the end of their pregnancies. For the majority of women, it attenuates by week 17, often before the diagnosis of gestational diabetes is made. Ongoing morning sickness, however, may present eating difficulties, especially for women who require insulin. The registered dietitian needs to assess whether dietary nonadherence is the result of a lack of understanding of dietary instructions or of a physiologic need to eat certain foods at certain times to maintain gastrointestinal stability. Persons who are ill may eat foods that are not normally included in a meal plan for diabetes control, and liberalization to “sick day” meal guidelines needs to be considered.

nutrition counseling strategies

The registered dietitian plays an important role in the education of women with GDM. Dietary management of GDM in these women requires application of nutrition, medical obstetric, and behavioral knowledge. The behavioral changes that the dietitian is able to facilitate during pregnancy will also be important in the postpartum period, when the goal is often shifted to losing weight for prevention of future diabetes. Pregnancy offers a unique opportunity to begin educating pregnant women about the importance of a healthful diet and to enable them to see the results of proper dietary adherence.

During the initial instruction, survival skills are taught. The importance of three meals and two to three snacks daily, and the omission of concentrated sweets, are stressed.

Practical aspects of nutrition education that need to be covered at follow-up visits include measuring portion sizes, recognizing sugar as an ingredient in prepared food, and eating-out techniques. Visual aids such as food models, food labels, recipes, and fast-food exchanges are helpful to the learner.

Information on weight gain during pregnancy, passage of nutrients from the mother to the fetus, the physiology of GDM, rationale for the diet, and goals for blood glucose levels also need to be covered.


insulin is initiated in GDM when the mother’s fasting plasma glucose and/or post-prandial plasma glucose are above the recommended goals on two or more occasions while the mother is on medical nutrition therapy and physical activity for two weeks. The current guidelines for excellent plasma glucose control during pregnancy are:

Fasting or pre-meal plasma glucose of below 95 mg% (<5.3 mmol/L)

One hour post-prandial plasma glucose of below 140 mg% (<7.8 mmol/L)

Two hours post-prandial plasma glucose of below 120 mg% (<6.7 mmol/L)

Mean plasma glucose levels of 90-100 mg%

Plasma glucose levels above these goals were reported to be associated with a three-fold increase in macrosomia, increased risk for large for gestational age babies and intrauterine deaths in both lean and obese GDM mothers. Delaying insulin therapy in these mothers is therefore ill-advised.

Self-MonitoringofthePlasmaGlucose(SMBG)is the most effective means of identifying mothers who fail to achieve the appropriate level of glycemic control and will therefore need exogenous insulin. The present recommendations are: SMBG four to six times a day; (fasting, one or two hours after breakfast, lunch and supper, at bedtime, and at three o’clock in the morning on certain occasions).

As of this writing, there is no concensus as to whether the one hour or two hours post-meal plasma glucose value is the better value, provided target goals are achieved. Recent studies have shown that the use of glucose reflectance meters with memory are superior over the visually read glucose strips in producing a significant reduction in observed adverse pregnancy outcomes. Glucose reflectance meters with memory are useful in verifying data that would reflect true levels of plasma glucose and therefore glycemic control.

hbaic levels are not helpful here because they are not sensitive enough to pick up minor elevations of plasma glucose levels and are not helpful in immediate decision-making especially with insulin adjustments.

UrineSugars have not been found to be useful during pregnancy. However, one should check for fasting urinary ketones at least once a week or when the patients is on a low calorie-nutrition or when plasma glucose levels are 250 mg% or greater.

Insulin Therapy and Glucose Monitoring in Gestational Diabetes Mellitus

insulin types, Dose adjustments

The least immunogenic insulins, preferably HUMAN INSULINS are used during pregnancy because these insulins rarely stimulate antibody formation and do not even cross the placenta. The dose of insulin ranges from 0.7 to one unit per kilogram body weight per day with the patient requiring higher doses as pregnancy progresses from 24 weeks to term. Conveniently, two-thirds of the computed dose is given subcutaneously before breakfast, and one-third of the dose is given subcutaneously before supper. Since we are not deal-ing with an emergency situation, the choice of insulin is an intermediate-acting insulin or a pre-mixed insulin (a combination of short-acting and intermediate-act-ing insulin). Insulin injections are given SUBCUTA-NEOUSLY. (The thigh is a convenient area to start injections for demonstration).

To enhance compliance and emotional adjustment, we recommend the use of newer insulin delivery systems, such as insulin pens, which are convenient, practical, accurate and safe.

It is appropriate to increase the dose of insulin needed to achieve near normal glycemic levels without fear of giving too much insulin. The main concern should be BLOOD GLUCOSE CONTROL rather than the total dose of insulin per day. The insulin dose differs from patient to patient and doses as high as 75-100 units per day have been reported to be safe. Caution should be exercised to prevent hypoglycemia, hence the need for frequent self-monitoring of the blood glucose (SMBG).

During Labor:

1. The last insulin dose is given subcutaneously the night before or that morning

2. Monitor plasma glucose every 1-4 hours3. Give short-acting insulin via IV infusion at a dose

of 0.5-1 unit per hour for plasma glucose above 120 mg%

4. Targets of control during labor are: Plasma Glucose 80-120 mg% (4.4-6.7 mmol/L) Capillary Glucose 70-110 mg% (3.9-6.1 mmol/L)5. Discontinue IV insulin immediately prior to

delivery

For C.S. Patients:

1. The last insulin dose is given subcutaneously the night before

2. Determine random plasma glucose immediately prior


to C.S.3. Infuse short acting insulin (0.5-1 unit per hour) if

plasma glucose is above 120 mg% (see targets as above)

4. Discontinue IV insulin immediately prior to delivery

5. Check plasma glucose 2 hours post C.S. up to 24 hours

In the immediate post-partum period1. Monitor plasma glucose every 4-6 hours for 24

hours2. Administer insulin subcutaneously when indicated

During Lactation:

1. Monitor plasma glucose 4 times a day2. Give insulin subcutaneously when indicated

Summary:

Frequent self monitoring of the plasma glucose (SMBG), liberal use of insulin and stringent control of the plasma glucose during the entire length of gestation should improve fetal outcomes in our GDM patients.Rsferences:1. Langer O. Maternal Glycemia - Criteria for Insulin

Therapy in Gestational Diabetes Mellitus. Annual Review of Diabetes, 1999.

2. Treatment of Hyperglycemia in Pregnancy. Is there more than Insulin? Symposium on Gestational Diabetes: Council on Diabetes in Pregnancy. 59th Annual Meeting, American Diabetes Association, San Diego, California, USA June 19-20, 1999.

3. Type 2 Diabetes. Practical Targets and Treatments. 2nd edition, Asian-Pacific Type 2 Diabetes Policy Group. (IDF-WPR) International Diabetes Federation-Western Pacific Region 1999.

4. Homkoc CJ, Sivan E, Reece EA. Is Self-Monitoring of Blood Glucose Necessary in the Management of Gestational Diabetes Mellitus? Proceedings of the Fourth International Workshop Conference on Gestational Diabetes Mellitus. Diabetes Care Vol. 21 Supplement 2 August 1998.

5. Book of Abstracts. 34th Meeting European Association of the Study of Diabetes EASD, Barcelona, Spain, September 8-12, 1998.

6. Standards of Medical Care for Patients with Diabetes Mellitus, American Diabetes Association. Diabetes Care


Fetal Monitoring techniques

It is well established that fetal antepartum tests should address three important goals:

1. to help prevent perinatal morbidity and mortality.2. to detect fetal health compromise as accurately and

effectively as possible.3. to provide appropriate guidance for obstetric

intervention or justifiable continuation of pregnancy.

A. Perceived Fetal Movement

Charting of maternal perception of fetal movement is the oldest and simplest method of monitoring fetal well-being in the second half of pregnancy. Studies have shown a positive correlation between the number of combined torso and lower extremity movements perceived and those confirmed by ultrasound. The “count to 10” method is the most commonly used since it requires little time and can be performed at any time. Limitations of monitoring fetal movement include the inability to detect malformations, multiple gestations, and growth abnormalities, or to anticipate stillbirths.

The amount of fetal activity perceived may depend on many factors, including maternal glucose levels. Maternal hypoglycemia, although generally believed to be associated with decreased fetal movement, has been reported to stimulate fetal activity.

A woman’s overall perception of decreased fetal activity is important and the same evaluation should be done as for patients who report perceiving less than 10 movements in 2 hours. With advances in fetal survival at earlier gestational ages, the timing of the initiation of testing has changed. Fetal kick-counting monitoring is begun at 26 to 28 weeks in diabetic pregnancies.

B. Contraction Stress Test (CST)

The CST was the first biophysical test used for antepartum surveillance in pregnancies complicated by diabetes. The CST is a test of fetal well-being in response to stress denoted by uterine contractions. Increased myometrial pressure during a contraction causes occlusion of the spiral arteries and interrupts the flow of oxygenated blood into the villous space decreasing the partial pressure of fetal oxygen. If the fetus has a baseline oxygen deficit, late decelerations will be apparent with the contractions. As a primary surveillance method, the CST has the advantage, over the NST or BPP, of detecting subtle compromise better, by detecting hypoxia prior to the onset of acidosis.

InterpretingCSTFindings:

Negative CST - no late decelerations with adequate uterine contractions (three contractions within 10

Antepartum Fetal Surveillance in Diabetic Pregnancyminutes)

Positive CST - persistent late decelerations with adequate uterine contractions (three contractions within 10 minutes).

The incidences of abnormal perinatal outcome including mortality, fetal distress in labor, low apgar score and reduced birth weight are higher in patients with a positive CST. The frequency of a positive CST requiring delivery in diabetic pregnancy ranges from 1 - 10% of patient tests.

Ray, et al evaluated 31 insulin-dependent and 7 gestational diabetic patients with CST. Eight insulin-dependent patients and one gestational diabetic patient with severe preeclampsia had positive CSTs. In these nine patients, 2 intrauterine fetal deaths occurred and 3 neonates had low 5 minute apgar score.

Gabbe and co-workers observed no intrauterine deaths within 1 week of a negative CST in 211 insulin-dependent diabetic patients. Four additional studies of 282 insulin-dependent diabetic women confirmed that a negative CST predicts fetal well being in metabolically stable patients for one week.

A negative CST result in insulin-dependent diabetics predicts fetal well-being in a metabolically stable patient for 1 week. Up to 50% of positive CST results are ultimately considered false-positive.

C. Nonstress Test (NST)

The NST is a recording of fetal heart rate and maternal uterine activity. The NST is based on the assumption that

PositiveTest No.ofPatients Comments

Gabbe 16 242 7 fetal distressKitzmiller 12 109 2 low ApgarCoustan 1 72 low ApgarFadel 2 23 —Lavin 5 60 3 SGA, 2 low Apgar

Table 13. Positive Contraction Stress Test in Diabetic

No.ofPatients Stillbirth

Gabbe 211 0Kitzmiller 134 0Coustan 72 0Fadel 21 0Lavin 55 0

Table14.FrequencyofStillbirthinInsulin-DependentDiabeticPregnancy(NegativeContractionStressTest)


a nonacidotic, nonneurologically depressed fetus will produce heart rate accelerations as it moves. Absence of accelerations associated with fetal movement may result from fetal sleep cycles or an abnormality, such as fetal acidosis, CNS depression, or congenital abnormalities. The absence of these accelerations in the resting FHR may be a sign of fetal compromise.

InterpretingNST:

Reactive - two accelerations of the FHR, rising 15 beats above baseline, lasting 15 seconds within 20 minutes. The tracing may be continued up to 40 minutes if criteria are not met. Acoustic stimulation of a nonacidotic fetus may elicit FHR accelerations.

Non-reactive - none of the criteria for reactive test was met.

Its ease of performance and absence of contraindications make the NST a popular antepartum test. Because the predictive values of a reactive NST appears equal to that of a negative CST, the NST has now become the preferred antepartum fetal heart rate test for screening fetal condition in diabetic pregnancies. It is recommended that NST be done twice weekly in insulin-dependent diabetics being tested beyond 32 weeks AOG based on data from several published series.

clinical management should be based not only on the absolute score, but also on the score composition and clinical context.

Golde, et al observed that 430 of 434 BPPs done after a reactive NST in a diabetic population were associated with reassuring scores of 8 or greater. Of 25 BPPs done after a nonreactive NST, 21 had scores of 8; 4 were below 8. The BPP did not appear to add more information about fetal condition if the NST was reactive, but a score of 8 based on ultrasound parameters was as reliable in predicting good fetal outcome as was a reactive NST. In a study of 98 insulin-dependent diabetic patients, a normal BPP was confirmed as predicting normal apgar scores in 99% of patients; only 2.9% of 978 BPPs were abnormal. Ten patients had an abnormal BPP just before delivery; in 6 of these cases, neonatal asphyxia or depression was present.

Johnson, et al described twice-weekly tests on 50 insulin-dependent diabetic women and weekly BPPs in 188 GDMs. There were no stillbirths in this series. The incidence of abnormal BPPs was low — 3.3% (8 of 238 tests), however, 37.5% had significant neonatal morbidity. Although this study did not demonstrate the superiority of the BPP over the NST alone, it did establish that the BPP may also be used for fetal surveillance with few unnecessary interventions, thereby allowing prolongation of pregnancy beyond 37 weeks in most of the patients studied.

E. Detecting Macrosomia

Obstetricians are motivated to predict macrosomia before birth because of the potential for trauma and other related morbidity. For clinical purposes, macrosomia is defined as a fetal weight in excess of 4,000 or 4,500 g, with an incidence of 16-45%. Others believe that birth weight above the 90th percentile for gestational age is a more meaningful practical definition of macrosomia than absolute birth weight.

Landon, et al found that AC growth was accelerated after 32 weeks’ gestational age in a group of LGA fetuses of diabetic gravidas. An abdominal girth change of > 1.2 cm/week detected LGA fetuses with 84% sensitivity and 85% specificity. Elliot and associates detected macrosomia by determining the difference between the fetal trunk diameter and the BPD. Using 1.4 cm as the threshold between macrosomia and nonmacrosomia, they were able to detect 87% of such fetuses, with a false-positive rate of 39%.

When the AC values were greater than the 90th percentile, macrosomia can be correctly predicted in 78% of cases, while estimated fetal weights exceeding the 90th percentile correctly predicted macrosomia in 74% of cases. When both the AC and EFW exceeded the 90% percentile, macrosomia was diagnosed correctly

In addition, NSTs performed by a patient at home and transmitted to a hospital for interpretation are satisfactory for interpretation and also cost-effective. When a test is found to be nonreactive, a back-up test such as CST or BPP is employed.

D. Biophysical Profile (BPP)

The BPP combines the NST with four ultrasound observations: (1) fetal breathing movements (FBM) of 30 seconds duration, (2) three or more body movements, (3) fetal tone with an extremity going from extension to flexion or vice versa, and (4) AF1 >5 cms. Each of the 5 components is scored as a 0 (does not meet criteria) or 2 (meets criteria), with a maximum score of 10. The BPP is a measure of the probability of acute and chronic fetal hypoxia and asphyxia; NST, fetal breathing, fetal movements, and fetal tone markers monitor acute asphyxia, while AFI is the marker for chronic asphyxia. The normal fetus will have a score of 8 or 10; a fetus that may be compromised will have a score of 6 or less. Although each component is weighted equally,

Table15.WeeklyReactiveNSTinInsulin-DependentDiabetics

No.ofPatients No.ofFetalDeaths

Barrett (7) 426 6Lavery (13) 10Miller & Horger 49 3

Diabetes in pregnancy cpM 6th eDitiOn in 88% of cases. Of clinical importance, cesarean delivery rate for disproportion in fetuses predicted to be macrosomic was 28.3% (vs. 10.7% in fetuses predicted not to be macrosomic).

Using the BPD and AC, the best-fit equation for estimating fetal weight was: EFW = 0.02597 AC + 0.2161BPD - 0.1999 (ACxBPD) / 1000 + 1.2659 which is the formula used to target LGA fetuses with reports of statistically significant reduction in random error of birth weight estimation. However, even if all infants destined to be macrosomic at birth could be identified correctly, only about 50% of all shoulder dystocias would be obviated.

F. Doppler Studies

Because women with insulin-dependent diabetes are at increased risk for the development of preeclampsia and fetal growth restriction, Doppler ultrasound could be helpful. In a study on 25 patients with vasculopathy, Bracero, et al. found a significant positive correlation between umbilical artery systolic/diastolic (S/D) ratio and serum glucose levels. Landon and Gabbe, in 291 studies in 35 insulin-dependent diabetic patients, umbilical artery waveforms were abnormal in 50% of fetuses of women with vascular disease compared with 12% of those without hypertension or nephropathy. Increased placental resistance as shown by elevated umbilical artery S/D ratio in Doppler studies may be helpful in the early detection of fetal growth retardation in diabetic patients with vasculopathy.

summary

Antepartum surveillance is the standard of care in diabetic pregnancies, with either twice-weekly NSTs or weekly CST. A study that reported on twice-weekly NST and amniotic fluid evaluation showed that these assessment methods were successful in preventing stillbirth. Absence of FHR reactivity and the presence of decelerations were predictive of the diagnosis of fetal distress in labor requiring C/S delivery. No differences were observed between various classes of diabetics; 85% of the tests were reactive and 12% had decelerations. No differences in AFI were seen between diabetic classifications, thus this study does not support the use of routine amniotic fluid assessment in the well-controlled term diabetic. Since they commonly have elevated AFI, monitoring those patients for a decline in volume is not helpful.

At some institutions, the CST is used as primary surveillance because this test provides a constant marker of uteroplacental reserve. Class R or F diabetic patients with a small-for-gestational-age fetus or a concomitant diagnosis of hypertension may require commencement of testing as early as 26 weeks’ gestation. However,

the incidence of false-positive CSTs range from 40% to 60%; therefore, intervention in the preterm diabetic should occur when either several tests suggest fetal compromise or pulmonary maturation is documented.

Maternal fetal kick counting is started at 28 weeks for all diabetic gravidas. Because well-controlled class A1 diabetics are at low risk for in-utero fetal death, antepartum surveillance may begin at 40 weeks, with weekly NSTs. Those with complications like hypertension, previous stillbirth, preeclampsia, class A2, and all progestational diabetics should begin antenatal testing at 32 weeks, with twice-weekly NSTs.

References:1. Barrett JM, Salyer SI, Boehm FH. The nonstress test: an

evaluation of 1,000 patients. Am J Obstet Gynecol 1981; 141:153.

2. Bracero I, Sculman H, Fleischer A, et al. Umbilical artery velocimetry in diabetes and pregnancy. Obstet Gynecol 1986; 68:654.

3. Diamond MP, Vaughn WK, Salyer S, et al. Antepartum fetal monitoring in insulin-dependent diabetic pregnancies. Am J Obstet Gynecol 1985; 153:528.

4. Dicker D, Feldberg D, Yeshaya A, et al. Fetal surveillance in insulin-dependent diabetic pregnancy: predictive value of the biophysical profile. Am J Obstet Gynecol 1988; 159:800.

5. Ellito JP, Garite TJ, Freeman RK, et al. Ultrasonic prediction of fetal macrosomia in diabetic patients. Obstet Gynecol 1982; 60:159.

6. Gabbe SG, Mestman JH, Freeman RK, et al. Management and outcome of pregnancy in diabetes mellitus, classes B to R. Am J Obstet Gynecol 1977; 129:723.

7. Golde SH, Montoro M, Good-Anderson B, et al. The role of nonstress tests, biophysical profile, and contraction stress tests in the outpatient management of insulin-requiring diabetic pregnancies. Am J Obstet Gynecol 1984; 148:269.

8. Johnson JM, Lange IR, Harman CR, et al. Biophysical profile scoring in the management of the diabetic pregnancy. Obstet Gynecol 1988;72:841.

9. Landon MB, Gabbe SG. Antepartum fetal surveillance in gestational diabetes mellitus. Diabetes 1985; 34:50.

10. Landon MB, Gabbe SG, Brunner JP, et al. Doppler umbilical artery velocimetry in pregnancy complicated by insulin-dependent diabetes mellitus. Obstet Gynecol 1989; 73:961.

11. Landon MB, Gabbe SG. Fetal surveillance in the pregnancy complicated by diabetes mellitus. Clin Obstet Gynecol 1991; 34:535.

12. Landon MB, Mintz MC, Gabbe SG. Sonographic evaluation of fetal abdominal growth: predictor of the large-for-gestational-age infant in pregnancies complicated

False-negative False-positive (per1,000)

CST 0.4 >50%NST 3.2 50%BPP 0.6 40%

Table16.False-NegativeandFalse-PositiveRatesforAntepartumtests


by diabetes mellitus. Am J Obstet Gynecol 1989; 160:115.

13. Lavery JP. Nonstress fetal heart rate testing. Clin Obstet Gynecol 1982; 25:689.

14. Miller JM, Horger EO. Antepartum heart rate testing in diabetic pregnancy. J Reprod Med 1985:30:515.

15. Nyland L, Lubell NO. Uteroplacental blood flow in diabetic pregnancy: measurements with indium 113 m and a computer-linked gamma camera. Am J Obstet Gynecol 1982; 144:298.

16. Ray M, Freeman R, Pine S. Clinical experience with the oxytocin challenge test. Am J Obstet Gynecol 1972; 114:1.

17. Sabbagha RE, Minogue J, Tamura RK, Hungerford SA.


i. Metabolic Management During Labor and Delivery

Objective: to provide calories for fasting, laboring patients and to avoid maternal hyperglycemia, which may worsen neonatal hypoglycemia.

During spontaneous labor, when the last meal and insulin dose occured within 5 hours, glucose levels should be monitored at 1-3 hour intervals. A dextrose infusion (5-7 g/hr) should be started about 5 hours after the last meal, provided that the circulating glucose concentration is less than 120 mg/dL.

Patients in labor for more than 5 hours after eating and those for induction of labor should have dextrose infusion. Blood sugar is measured every 1-3 hour intervals. Many laboring patients maintain glycemia between 60-120 mg/dL without exogenous insulin at an initial rate of 20% of 0.5 u/kgBW/hr, increasing the insulin rate by 0.5-10 u/hr at 1-3 hour intervals to achieve the desired glycemia.

Patients for cesarean section generally are fasting and about to undergo a short operation. If maternal glucose levels are 120 mg/dL or less, no specific glucose or insulin is required. Insulin IV is given for higher glucose levels before surgery. Dextrose containing solutions should not be used for volume management in diabetic women.

The insulin resistance of late pregnancy dissipates rapidly after delivery. The rigorous glycemia requirements of late pregnancy no longer apply once the baby has been delivered. Insulin infusion is reduced or discontinued at the time of delivery. Patients with type I diabetes are given smaller doses of insulin, less than pre-pregnancy requirements, subcutaneously at 4-6 hour intervals, with frequent capillary glucose monitoring to avoid hypoglycemia. Insulin requirements may not return to pre-pregnancy levels until several weeks after delivery. Patients with NIDDM generally do not require insulin in the immediate postpartum period; most return to their pre-pregnancy therapy within 4-8 weeks of delivery. Oral hypoglycemic agents are not recommended for women who breast-feed.

Maternal and Fetal Intrapartum Monitoring

II.ObstetricIntrapartumManagementofgDM patients

A. Management Based on Age of Gestation:

N.B. The presence of documented poor metabolic control duringpregnancyshouldindicateearlydeliveryoncefetalpulmonarymaturitycanbedocumented.

B. Management Based on Estimated Fetal Weight:

EFW

>4,500 gramsCesarean Section

4 , 0 0 0 - 4 , 4 9 9 gramsIndividualize

<4,000 gramsTrial of Labor

Recommendations based on POGS Committee on Nationwide Statistics reports: 1. Fetal weight of 3,500 - 4,000 grams Ratio of 1 C/S per 6 vaginal deliveries 2. Fetal weight of >4,000 grams: Ratio of 1 C/S per 4 vaginal deliveries

Cautions for Trial of Labor:

1. E x t r a c a r e f o r s h o u l d e r d y s t o c i a a n d polyhydramnios.

2. Electronic fetal monitoring during labor or during induction of labor.

3. Regional anesthesia must be carefully administered because maternal hypotension has been associated with more profound fetal acidosis.

Poor fetal surveillancePoor maternal surveillance

DeliverAntenatal steroids

Deliver

AOG

<38 weeks >38 weeks

Fetal surveillance Maternal surveillance

Poor fetal surveillanceGood maternal surveillance

Good fetal surveillanceGood maternal surveillance

Good fetal surveillancePoor maternal surveillance

Treat poor maternal conditionAntenatal steroids

Pulmonary maturity

Delivery at 38 weeksindividualize

Delivery by Induction


iii. Macrosomia and shoulder Dystocia

Shoulder Dystocia Incidence:• Swarts (1960) 1. 0.15% for fetus weighing more than 2,500 grams 2. 1.7% for fetus weighing >4,000 grams • Spellacy (1985) 1. 0.3% for fetus weighing 2,500 - 3,499 grams 2. 7.3% for fetus weighing 4,500 - 4,999 grams 3. 14.6% for fetus weighing >5,000 grams • Johnsons (1987) - Maternal Obesity 1. 0.6% for pregnant women weighing <200 lbs. 2. 5.1% for pregnant women weighing >250 lbs.

Prediction of Shoulder Dystocia:• Eliot (1982)Transthoracic diameter for an infant of a diabetic mother of 1.4 cm. greater than the biparietal diameter served as a predictor of significant fetomaternal disproportion and correlated with the possibility of a shoulder dystocia.

With such measurements among fetuses likely to develop shoulder dystocia, choices of management are:

1. Cesarian section2. If vaginal delivery is planned, the following

conditions should be met: a. A physician experienced in the management of

shoulder dystocia should attend the delivery. b. Appropriate anesthesia support personnel should

be present for the delivery. c. Pediatric support personnel should be present in

order to minimize the sequelae of a potentially traumatic delivery.

Fetal Consequences:• Benedetti and Gabbe (1978)Of 19 neonates with shoulder dystocia, 5 had fractured humerus and clavicle, 3 had Erb’s palsy and 1 had abnormal neurological examination.• Mc Call (1962)Among 105 cases of shoulder dystocia, there were 8 perinatal deaths, 7 brachial plexus injury and 21 asphyxia. Of 46 survivors traced, 2 were mentally retarded, 5 were slow learners and 2 had speech defect.

Maternal Consequences:Reduced interval of time from delivery of the head to delivery of the body is of great importance to survival but over-vigorous traction on the head or neck or excessive rotation of the body may cause serious damage to the infant. A large medio-lateral episiotomy and anesthesia is needed.

Techniques:

1. Suprapubic Pressure - Resnik (1980) Use consists of removing the woman’s legs from

the stirrups and sharply flexing them from her abdomen. This straightens the sacrum relative to the lumbar vertebrae with accompanying rotation of the symphysis pubis toward the patient’s head and

a decrease in the angle of pelvic inclination. The cephalic rotation of the pelvis frees the impacted anterior shoulder. Pollack (1985) had successful use in 24 of 25 cases.

3. Woods’ Corkscrew Manuever (1943) By progressively rotating the posterior shoulder 180

degrees in a corkscrew fashion, the impacted anterior shoulder could be released.

The delivery of the posterior shoulder consists of carefully sweeping the posterior arm of the fetus across the chest followed by delivery of the arm. The shoulder girdle then is rotated into one of the oblique diameters of the pelvis with subsequent delivery of the anterior shoulder.

4. Rubin’s Manuever (1964) The fetal shoulders are rocked from side to side by

applying force to the mother’s abdomen. If this is not successful, the most easily accessible fetal shoulder is pushed toward the anterior surface of the fetus chest. This often results in abduction of both fetal shoulders. This in turn produces a smaller shoulder-to-shoulder diameter and displacement of the anterior shoulder from behind the symphysis pubis.

5. Deliberate Fracture of the Clavicle Pressing the anterior clavicle against the ramus of the

pubis can be done to free the shoulder impaction. The fracture will heal rapidly and is not nearly as serious as a brachial nerve injury, asphyxia or death.

References:1. Burrow, G., Ferris, T., Diabetes Mellitus pp. 29-61 Medical

Complications During Pregnancy 4th edition 1995.2. Kurjak, A. Diabetes in Pregnancy pp. 1912-1918 Textbook

of Perinatal Medicine vol. 2 1998.3. Coustan, O., Diabetes in Pregnancy pp. 479-580 Clinical

Obstetrics and Gynecology.4. Kruppel, R., Durkker, J. Diabetes Mellitus in Pregnancy

pp. 518-538 High Risk Pregnancy, a Team Approach 1993.

5. Hod, M., Bar, J., Antepartum Management Protocol, Timing and Mode of Delivery in GDM, Diabetes Care 1998 Aug. 21 Suppl 2: b 113-7.

6. Cunningham, G., MacDonald, P., Diabetes pp. 1202-1222 William’s Obstetrics 20th Edition, 1998.

7. Carr, S. M.D. Screening for Gestational Diabetes Mellitus vol. 21, Supplement 2. Proceedings of the Fourth International Workshop - conference of Gestational Diabetes Mellitus.

8. Gabbe, S. The Gestational Diabetes Mellitus Conference vol. 21, Supplement 2. Proceedings of the Fourth International Workshop - Conference of Gestational Diabetes Mellitus.

9. Kitzmiller, J., Elixhauser, A. Assessment of Costs and Benefits of Management of Gestational Diabetes Mellitus vol. 21, supplement 2. Proceedings of the Fourth International Workshop Conference on Gestational Diabetes Mellitus.

10. Jovanovic, L., M.D. Therapeutic Interventions American Diabetes Association’s Fourth International Workshop - Conference on Gestational Diabetes Mellitus.

11. Cunningham G, McDonald P, Gant N. Dystocia due to Abnormalities in Presentation, Position, or Develop-ment of the Fetus pp. 365-369 William’s Obstetrics 18th Edition, 1989.


Drugs Mentioned in the Treatment Guideline

Insulin Actrapid HM Humalog Humulin 70/30 Humulin N (NPH) Humulin R (Regular) Humulin Ultralente Insulatard HM Mixtard 30 HM Ultratard HMEnteral/Nutritional Products Anmum Plain Anmum Chocolate Enfamama Gerber for Mom Mamacare

This index lists drugs/drug classifications mentioned in the treatment guideline. Prescribing information of these drugs can be found in PPD reference systems.

Documents

Officers and Board of Directors - The Filipino Doctor Maternal Health (Diabetes... · Vice President Pilar Lagman Dy, M.D. Secretary Flerida L. Tan, M.D Treasurer Raul M. Quillamor,