# PROBLEM: Diabetes Mellitus in Pregnancy (outpatient management)

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| **Gestational DM Class A-1**                                          |
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| [Definition]{.underline}: Diet controlled diagnosed during pregnancy  |
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|  Nutrition Consult                                                   |
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| -   Exercise physiologist consult                                     |
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| -   Home glucose monitoring (fasting and two hour postprandial)       |
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| [Ultrasound]{.underline}                                              |
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| -   18-20 weeks                                                       |
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|  29-33 weeks (Consider Insulin if abdominal circumference \> 70^tth^ |
| percentile)                                                           |
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| [Monitoring]{.underline}                                              |
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|  Kick counts at 32 weeks                                             |
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| [Prenatal visits]{.underline}: Every 4 weeks until 32 weeks, then     |
| every 2 weeks until 36 weeks, then weekly                             |
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| [Delivery:]{.underline} 40 weeks if in good control Date:             |
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| ## Gestational DM Class A-2                                           |
|                                                                       |
| [Definition]{.underline}: Unsuccessful control of blood glucose       |
| levels following two weeks of nutritional counseling                  |
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| -   Ongoing nutritional counseling                                    |
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| -   Exercise physiologist consult                                     |
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| -   Home glucose monitoring                                           |
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| -   Insulin therapy                                                   |
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|  Refer to MFM or N. Murphy for possible Glyburide                    |
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| [Ultrasound]{.underline}                                              |
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| -   18-20 weeks                                                       |
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|  At diagnosis and then every 4 weeks                                 |
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| [Monitoring]{.underline} (complete pink sheet)                        |
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|  Kick counts at 32 weeks                                             |
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| -   Low risk (good control no HTN, stillbirth Hx, vasculopathy): NST  |
|     weekly at 34 weeks                                                |
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| -   High risk (poor control no HTN, stillbirth Hx, vasculopathy): NST |
|     twice weekly                                                      |
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| [Prenatal visits]{.underline}: After glycemic control then every 4    |
| weeks until 32 weeks, then every 2 weeks until 36 weeks, then weekly  |
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| Poor control -- weekly visits                                         |
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| [Delivery]{.underline}: If good control then deliver at 38 weeks      |
| Date:                                                                 |
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| ## Pregestational Diabetes Mellitus                                   |
|                                                                       |
| -   Insulin therapy                                                   |
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| -   Ongoing nutritional counseling                                    |
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| -   Exercise physiologist consult                                     |
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| -   Ophthalmologic exam                                               |
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| -   Fetal echo - 18-24 weeks                                          |
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| ###                                                                   |
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| [Admission criteria]{.underline}                                      |
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| poor adherence or persistent hyperglycemia, ketoacidosis              |
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| pyelonephritis or severe infection, hypertension or pre-eclampsia     |
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| [Labs]{.underline}: Baseline -- CBC, Cr, 24 hour urine (protien &     |
| CrCl)                                                                 |
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| 15-20 weeks -- triple test                                            |
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| [Ultrasound]{.underline} [Monitoring]{.underline} (complete pink      |
| sheet)                                                                |
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| -   Early first trimester  Kick counts                               |
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| -   18-20 weeks  Low-risk -- Weekly NST starting at 34 weeks         |
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| -   Every 4 -- 6 weeks  High-risk -- NST twice a week starting at 32 |
|     weeks                                                             |
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| [Prenatal visits]{.underline}: daily visits or frequent phone f/u     |
| until glycemic control is achieved; every 2-4 weeks to 36 weeks, then |
| weekly                                                                |
|                                                                       |
| [Delivery]{.underline}: (tailor to Diabetes class)                    |
|                                                                       |
| Deliver at 38 weeks if good control Date:                             |
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  Lab Results                         Ultrasound Results

                                      
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