management of gestational diabetes

Seek specialist advice. The main themes of diabetic management in pregnancy is the maintenance of good control of the diabetes, and regular ultrasound examination of the foetus. The management of the pregnant diabetic is best undertaken using a team approach. Some general principles concerning the management of a diabetic patient are outlined below: health care team - members include: obstetrician midwife physician general practitioner A summary of the NICE guidance regarding management gestational diabetes (1) is included below: screening for gestational diabetes using fasting plasma glucose, random blood glucose, glucose challenge test and urinalysis for glucose should not be undertaken the 2-hour 75 g oral glucose tolerance test (OGTT) should be used to test for gestational diabetes and diagnosis made using the criteria defined by the World Health Organization . If a woman has had gestational diabetes in a previous pregnancy then she should be offered early self-monitoring of blood glucose or an OGTT at 16-18 weeks, and a further OGTT at 28 weeks if the results are normal. Women with any of the other risk factors for gestational diabetes should be offered an OGTT at 24-28 weeks risk factors for development of gestational diabetes body mass index above 30 kg/m2 previous macrosomic baby weighing 4.5 kg or above previous gestational diabetes family history of diabetes (first-degree relative with diabetes) family origin with a high prevalence of diabetes: - South Asian (specifically women whose country of family origin is India, Pakistan or Bangladesh) - black Caribbean - Middle Eastern (specifically women whose country of family origin is Saudi Arabia, United Arab Emirates, Iraq, Jordan, Syria, Oman, Qatar, Kuwait, Lebanon or Egypt) women with any one of these risk factors should be offered testing for gestational diabetes inform women with gestational diabetes that good glycaemic control throughout pregnancy will reduce the risk of fetal macrosomia, trauma during birth (to themselves and the baby), induction of labour or caesarean section, neonatal hypoglycaemia and perinatal death advise women with gestational diabetes to choose, where possible, carbohydrates from low glycaemic index sources, lean proteins including oily fish and a balance of polyunsaturated fats and monounsaturated fats women with gestational diabetes whose pre-pregnancy body mass index was above 27 kg/m2 should be advised to restrict calorie intake (to 25 kcal/kg/day or less) and to take moderate exercise (of at least 30 minutes daily) hypoglycaemic therapy: should be considered for women with gestational diabetes if diet and exercise fail to maintain blood glucose targets during a period of 1-2 weeks should be considered for women with gestational diabetes if ultrasound investigation suggests incipient fetal macrosomia (abdominal circumference above the 70th percentile) at diagnosis hypoglycaemic therapy for women with gestational diabetes (which may include regular insulin, rapid-acting insulin analogues [aspart and lispro] and/or oral hypoglycaemic agents [metformin and glibenclamide]) (see notes) should be tailored to the glycaemic profile of, and acceptability to, the individual woman if insulin then: healthcare professionals should be aware that the rapid-acting insulin analogues (aspart and lispro) have advantages over soluble human insulin during pregnancy and should consider their use women with insulin-treated diabetes should be advised of the risks of hypoglycaemia and hypoglycaemia unawareness in pregnancy, particularly in the first trimester during pregnancy, women with insulin-treated diabetes should be provided with a concentrated glucose solution and women with type 1 diabetes should also be given glucagon; women and their partners or other family members should be instructed in their use during pregnancy, women with insulin-treated diabetes should be offered continuous subcutaneous insulin infusion (CSII or insulin pump therapy) if adequate glycaemic control is not obtained by multiple daily injections of insulin without significant disabling hypoglycaemia target ranges for blood glucose during pregnancy individualised targets for self-monitoring of blood glucose should be agreed with women with diabetes in pregnancy, taking into account the risk of hypoglycaemia if it is safely achievable, women with diabetes should aim to keep fasting blood glucose between 3.5 and 5.9 mmol/litre and 1-hour postprandial blood glucose below 7.8 mmol/litre during pregnancy HbA1c should not be used routinely for assessing glycaemic control in the second and third trimesters of pregnancy diabetes UK has previously suggested that (2): insulin should be commenced if: capillary fasting whole blood glucose is >5.3 mmol/l (plasma glucose >5.8 mmol/l) 1-hourly postprandial whole blood glucose is >7.8 mmol/l (plasma glucose >8.6 mmol/l) monitoring blood glucose and ketones during pregnancy women with diabetes should be advised to test fasting blood glucose levels and blood glucose levels 1 hour after every meal during pregnancy women with insulin-treated diabetes should be advised to test blood glucose levels before going to bed at night during pregnancy women with type 1 diabetes who are pregnant should be offered ketone testing strips and advised to test for ketonuria or ketonaemia if they become hyperglycaemic or unwell screening for congenital malformations women with diabetes should be offered antenatal examination of the four-chamber view of the fetal heart and outflow tracts at 18-20 weeks monitoring fetal growth and well-being pregnant women with diabetes should be offered ultrasound monitoring of fetal growth and amniotic fluid volume every 4 weeks from 28 to 36 weeks routine monitoring of fetal well-being before 38 weeks is not recommended in pregnant women with diabetes, unless there is a risk of intrauterine growth restriction women with diabetes and a risk of intrauterine growth restriction (macrovascular disease and/or nephropathy) will require an individualised approach to monitoring fetal growth and well-being preterm labour in women with diabetes diabetes should not be considered a contraindication to antenatal steroids for fetal lung maturation or to tocolysis women with insulin-treated diabetes who are receiving steroids for fetal lung maturation should have additional insulin according to an agreed protocol and should be closely monitored betamimetic drugs should not be used for tocolysis in women with diabetes timing and mode of birth pregnant women with diabetes who have a normally grown fetus should be offered elective birth through induction of labour, or by elective caesarean section if indicated, after 38 completed weeks diabetes should not in itself be considered a contraindication to attempting vaginal birth after a previous caesarean section pregnant women with diabetes who have an ultrasound-diagnosed macrosomic fetus should be informed of the risks and benefits of vaginal birth, induction of labour and caesarean section Notes: NICE state with respect to the use of metformin and glibenclamide in pregnancy (3): metformin is used in UK clinical practice in the management of diabetes in pregnancy and lactation. There is strong evidence for its effectiveness and safety, which is presented in the full version of the guideline (3) . This evidence is not currently reflected in the SPC (July 2008). The SPC advises that when a patient plans to become pregnant and during pregnancy, diabetes should not be treated with metformin but insulin should be used to maintain blood glucose levels. Informed consent on the use of metformin in these situations should be obtained and documented glibenclamide is used in UK clinical practice in the management of diabetes in pregnancy and lactation. There is strong evidence for its effectiveness and safety, which is presented in the full version of the guideline (3). This evidence is not currently reflected in the SPC (July 2008). The SPC advises that glibenclamide is contraindicated in pregnancy. Informed consent on the use of glibenclamide in pregnancy should be obtained and documented