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Njm10/25/04

**ANMC Women's Health Service Diabetes Mellitus in Pregnancy Screening
and Management Guidelines**

**Page**

1.  Introduction 2

2.  Screening Procedures 2

3.  Diagnosis of Gestational Diabetes 3

4.  Management Categories of Gestational diabetes 3

5.  Management -- Class A-1 (diet controlled) 4

6.  Management -- Class A-2, pre-gestational, Class B and above 6

7.  Postpartum Management 9

8.  Family Planning and Future Pregnancy Consideration 10

9.  Preconception counseling 10

10. Care of the Newborn and child 11

11. Learn more and test your knowledge of diabetes in pregnancy 11 while
    you earn FREE CEU / CMEs

12. Summary of recommendations 11

13. Other recommendations 11

14. References 13

15. Appendix A: Alternative Options for Screening 15

16. Appendix B: Diabetes Predating Pregnancy White Classification 15

17. Appendix C: BMI table here 16

18. Appendix D: ANMC Pediatric Department Hypoglycemia Guidelines 16

19. Appendix E: Gestational Diabetes Traditional Foods Meal Plan with
    Milk 17

20. Appendix F: Exercise guidelines to improve glucose control 18

**ANMC Women's Health Service**

## Diabetes Mellitus in Pregnancy

# **Screening and Management Guidelines**

**[I.]{.underline}** **[Introduction]{.underline}**

> In the last 2 generations diabetes in pregnancy has increased
> significantly in Alaska Natives. Diabetes can be associated with
> morbidity and mortality for both the pregnant patient and her
> offspring. Management of diabetes in pregnancy offers a unique
> opportunity to positively impact both patients' lives.

**[II.]{.underline}** **[Screening Procedures]{.underline}**

A.  Patients with pre-gestational diabetes do not require gestational
    diabetes testing. Proceed directly to management plan. Do not
    perform glucose challenge testing.

B.  If the patient does not tolerate the standard glucose solution,
    there are several alternative modalities. (Appendix A)

> C. [Initial Screen, Average Risk Patients]{.underline}
>
> All patients should be screened at 24-28 weeks, (or at first visit, if
> after 28 weeks) as follows:
>
> 1\. Give a 50-gram oral glucose load, at any time of day, without
> regard to time of last food intake.
>
> 2\. Draw a venous blood sample one-hour later.
>
> 3\. A venous serum or plasma glucose level of 140 mg/dL or greater at
> one hour constitutes a [positive screen.]{.underline}
>
> D. Initial Screen, High Risk Patients
>
> 1\. High risk patients include those with the following factors:
>
> a\. history of infant over 8 lb.14oz. (4000 grams) at birth;
>
> b\. first degree family history of diabetes (parents or sibling);
>
> c\. initial visit BMI [\>]{.underline} 25 BMI = kg/m^2^ X 100 (see
> Appendix C)
>
> d\. past hx: stillbirth, habitual abortion, congenital anomaly
>
> e\. current pregnancy: unexplained polyhydraminos, persistent
> glycosuria
>
> f\. age \> 35 years;
>
> g\. prior history of gestational diabetes.

2.  Screen high risk patients on the first prenatal visit with a 50 gram
    oral glucose load.

3.  If the high risk screen is normal, repeat at 24 weeks

4.  If any screen is abnormal then repeat at 24-28 and 32 weeks.

5.  If the patient has one abnormal value on the OGTT, then the patient
    should have a repeat OGTT in 4 weeks. (See also MNT for one abnormal
    value, below)

6.  One-step testing is recommended in some American Indian / Alaska
    Native groups. One step testing could be completed with a 100 gm 3
    hr OGTT

**[III.]{.underline}** **[Diagnosis of Gestational
Diabetes]{.underline}**

All patients with a positive screen (one hour [\>]{.underline} 140
mg/dL) should be given a 3 hr OGTT

with a 8-14 hour fast after 3 days of unrestricted carbohydrate diet as
follows:

1.  Draw a fasting venous blood sample.

2\. Administer a 100 gram oral glucose load in 400 ml fluid.

3\. Draw venous blood samples at one, two, and three hours.

> B. [Two]{.underline} or more values at or above the following make the
> diagnosis of gestational diabetes.
>
> [time]{.underline} [plasma glucose mg/dL]{.underline}
>
> fasting [\>]{.underline} 105
>
> one hour [\>]{.underline} 190
>
> two hours [\>]{.underline} 165
>
> three hours [\>]{.underline} 145

Other diagnostic criteria have been suggested by various professional
organizations, e.g., Carpenter and Coustan criteria, but there is little
data to support that use of other criteria significantly improve
maternal or neonatal outcomes.

C.  There is some data to suggest that patients with [one abnormal
    value]{.underline} have an increased risk of macrosomia. In these
    patients, Medical Nutrition Therapy (MNT) is suggested. If the
    patient has one abnormal value on the OGTT, then the patient should
    have a repeat OGTT in 4 weeks

D.  Note that glycosylated hemoglobin and finger-stick capillary blood
    values are not well enough standardized to be used for a definitive
    diagnosis of gestational diabetes.

E.  Patients who demonstrate an abnormal OGTT in the first trimester
    should be consider a pre-gestational diabetics, unless other medical
    circumstances suggest otherwise, e.g., intercurrent illness.

**[IV.]{.underline}** .**[Management Categories of Gestational
Diabetes]{.underline}**

These next two sections refer to diabetes diagnosed during pregnancy.

Please note there are later sections on pre-existing diabetes, Type I
DM, and Class B (and above) diabetes in pregnancy

[Gestational Diabetes Classification]{.underline}

[Class]{.underline} [Fasting Glucose Level]{.underline} [2 hr Post
prandial Glucose]{.underline}

A-1 \< 105 mg/dL and \< 120 mg/dL

A-2 ≥ 105 mg/dL and/or ≥ 120 mg/dL

A. [Class A-1]{.underline} patients are those who can achieve the above
glycemic control with diet alone. Patients in this class may deteriorate
to Class A-2. Management should then be changed accordingly.

B.  [Class A-2]{.underline} patients are those who require insulin or
    hypoglycemic therapy to achieve the above level of control. Prior to
    initiating insulin or hypoglycemic therapy, the patient should have
    been treated with at least 2 weeks of Medical Nutrition Therapy
    (MNT) after consultation with a skilled nutrition counselor.

**[V.]{.underline}** **[Management - Class A-1 (diet
controlled)]{.underline}**

A.  Exercise:

> The patient should receive an exercise consult. In the meantime the
> patient should be encouraged to exercise at least 3-4 times weekly for
> 20 -- 30 minutes per session. Brisk walking is ideal.
>
> [Please note]{.underline} this is a Level A Recommendation

Moderate exercise of 60-150 minutes per week divided 3x / wk improves

glucose control. (See Appendix F: Exercise guidelines to improve

glucose control)

B. Diet:

[Please note:]{.underline} These are general recommendations.

> Your, or your nutrition counselor, should individualize these
> recommendations
>
> to the reality of each specific patient's home environment.
>
> The following counseling should be reality based and allow enough
> leeway so
>
> the patient feels she is in control of this process.
>
> 1\. Nutrition consult:
>
> a\. initial to include diet recall.
>
> b\. periodic follow-up with nutritionist if possible.
>
> 2\. A diet of 30 kcal / kg, or 2,200 calories, is recommended for
> those patients whose initial BMI is \< 30.
>
> 3\. For those patients who have a BMI [\>]{.underline} 30 on their
> initial visit, a diet of 25 kcal / kg pre-pregnancy ideal body weight,
> can be calculated. In these patients, restrict carbohydrate to 35-40%
> of the total calories.
>
> 4\. In Medical Nutritional Therapy source of calories can be divided
> as:
>
> a\. 40% carbohydrates, especially complex unrefined carbohydrates

b.  20% protein

c.  40 % fat

> -less than 10% saturated fats;
>
> -up to 10% polyunsaturated fatty acids. The rest of the fats can
>
> come from mono-unsaturated sources.
>
> Traditional native diet include: muktuk, hooligan, oogruk- air-dried
>
> bearded seal meat, oogruk oil, dried salmon, walrus meat, walrus
>
> skin, walrus fat, bowhead whale meat and fat.
>
> (See Appendix E: Gestational Diabetes Traditional Alaskan Foods
>
> Meal Plan with Milk)
>
> 5\. Calories can be distributed as:
>
> a\. 10-15% breakfast

b.  5-10 % snack

c.  20-30 % lunch

> c\. 5-10% snack
>
> d\. 30-40% dinner
>
> e\. 5-10 % bedtime snack.
>
> 6\. The objectives for weight gain are:
>
> a\. BMI \< 25 22-28 lbs
>
> b\. BMI [\>]{.underline} 25 not over 22 lbs
>
> c\. these goals should be maintained [without ketosis]{.underline}, if
> ketones are
>
> noted, have patient check urine QID x1-2 days and report results;
>
> d\. pregnancy is not the time for weight loss.
>
> 7\. Sugar substitutes are considered \"Generally safe in pregnancy"
>
> C. Clinic Management:
>
> 1\. Frequency of visits

a\. at least weekly until glucose control established

> b\. every four weeks until 36 weeks gestation
>
> c\. weekly after 36 weeks gestation.

2.  Initial nutrition consult, then repeat prior to addition of insulin,
    or hypoglycemic

3.  Exercise therapy: [Please note]{.underline} this is a Level A
    Recommendation

Moderate exercise of 60-150 minutes per week divided 3x / wk improves

glucose control. (See Appendix F: Exercise guidelines to improve

glucose control)

> 4\. Home glucose monitoring should be taught to all women with GDM,
> and equipment (machine and strips) supplied. Frequency of monitoring
> should be QID (fasting, and either 1 hrs. or 2 hrs. after meals)
> initially. Individualize the schedule based on initial few days'
> results.

A.  Glucose goals

> Major goals of management should be maintenance of glucose at
>
> a\. fasting whole blood [\<]{.underline} 95 mg/dL,
>
> or
>
> b\. 1 hour post prandial whole blood [\<]{.underline} 130-140 mg/dL
>
> or
>
> c\. 2 hour post prandial whole blood [\<]{.underline} 120 mg/dL.

B.  Periodic lab work

> Women with BMI \> 30 treated [with diet restriction only]{.underline}

-ketone measurement may be helpful

Otherwise there is no role for routine urine testing

> 7\. Ultrasound for precise dating prior to 18 weeks in combination
> with careful clinical dating.

8\. Repeat ultrasound at 29-33 weeks to include abdominal circumference.
If

abdominal circumference \> 70 percentile, then consider insulin therapy.

> 9\. Daily fetal movement count - begin at 32 weeks.
>
> 10\. Consult OB-GYN if any of these factors are noted:
>
> a\. increased blood pressure
>
> b\. prior stillbirth
>
> c\. marked decrease in fetal movement
>
> 11\. When glucose control is good and no other complications
> supervene, there is no good evidence to support routine delivery
> before 40 weeks
>
> D. Intrapartum Management:
>
> Alaska Native Medical Center (ANMC) OB-GYN department recommends
> transfer of any pregnant woman with GDM at 37 weeks [not
> controlled]{.underline} within the above parameters. In situations
> where exceptions are made, specific consultation on labor management
> is advised

**[VI.]{.underline}** **[Management - Class A-2, pre-gestational, Class
B and]{.underline}**

**[above]{.underline}**

##### Classification

> -Patients with an abnormal OGTT should receive a 2-week trial of
> medical nutrition therapy (MNT).
>
> If after a trial of MNT, FBS [\>]{.underline} 105 mg/dL or 2 hour PPBS
> [\>]{.underline} 120 mg/dL, then they are considered **Class A-2** and
> their care should be discussed with ANMC Ob/Gyn about possible insulin
> or hypoglycemic therapy.
>
> -Patients with pre-existing diabetes should be classified by Type I
> and Type II.
>
> This can be supplemented with the White Classification. See Appendix.
>
> B. [The patient should be discussed with the ANMC OB/GYN prior to
> initiating insulin therapy]{.underline}. Following are the objectives
> to be met at the time of starting insulin.
>
> 1\. Education on the need for good control;
>
> 2\. Diet education. See previous discussion of Medical Nutrition
> Therapy (MNT)
>
> 3\. Learning to administer insulin and recognize signs and symptoms of
> hypoglycemia;
>
> 4\. Reviewing home glucose monitoring by finger-stick;
>
> 5\. Baseline physical assessment relating to diabetes in
> pre-gestational and above, especially:
>
> a\. creatinine clearance and 24 hour urine protein
>
> b\. ophthalmologic exam
>
> c\. Serum Creat and BUN
>
> 6\. If not yet done, ultrasound assessment of dates, fetal anatomy,
> and possible polyhydraminos.
>
> C. Insulin Therapy
>
> 1\. The goal is euglycemia. See previous glucose goals
>
> 2\. Human and DNA Recombinant Origin Insulin should be used.

4.  Split doses of short and intermediate fasting insulin should be
    given twice daily; two-thirds of the day's insulin is given before
    breakfast and one-third prior to supper. Each dose can be divided
    two-thirds intermediate and one-third short acting insulin.

> A common approach is to start with the following doses,
>
> based on actual body weight
>
> First trimester 0.8Units/ kg
>
> Second trimester 1.0 Units/ kg
>
> Third trimester 1.2 Units/ kg

5.  Another common formula for initiating therapy is:

-   20u NPH and 10u Regular insulin 30 minutes [before]{.underline}
    breakfast, or Lispro insulin [immediately before]{.underline}
    breakfast

-   5-10u Regular 30 minutes [before]{.underline}, or Lispro
    [immediately before]{.underline} meals,

-   7u NPH at supper.

-   Another helpful approach is to administer the NPH insulin at 9-10 pm
    to decrease fasting glucose.

-   Doses should be increased prn to keep glucose \< 95 mg/dL fasting
    and \< 120 mg/dL 2 hours post prandial

> 5\. The patient should monitor her own blood glucose with chemstrips
> with a portable glucometer. See glucose goals above. This regimen may
> be liberalized if stable as an outpatient. The patient should maintain
> a flow sheet.
>
> 6\. While tight control is the objective, hypoglycemia is a
> significant risk. If the patient has been admitted to initiate
> insulin, many feel it is best to discharge the patient as her control
> approaches but falls short of ideal. Fine tuning is then done on an
> outpatient basis under conditions of diet and exercise more normal for
> the patient.

7.  Diet composition is the same as for Class A-1 but calories need to
    be spread among three meals and three or four snacks.

> 8\. Glyburide has been used as an oral hypoglycemic in the 2^nd^ and
> 3^rd^
>
> trimesters of pregnancy successfully in one randomized controlled
> trial at
>
> the time of this writing. ACOG states that further study is
> recommended
>
> before the newer oral hypoglycemic can be supported for use in
>
> pregnancy. Glyburide is being used onsite at ANMC in a monitored
>
> randomized and controlled manner.
>
> D. Indications for admission:
>
> 1\. The patient should be admitted for evaluation and control if any
> of the following conditions are noted:
>
> a\. poor adherence or persistent hyperglycemia;
>
> b\. pyelonephritis or severe infection;
>
> c\. ketoacidosis;
>
> d\. hypertension or pre-eclampsia.
>
> E. Clinical Management
>
> The insulin treated patient should be followed according to these
> guidelines:
>
> 1\. Frequency of visits
>
> a\. as often as daily until glycemic control as outpatient
> established;

b.  at least every month until 36 weeks, unless glucose control is

> poor, then q wk;

c.  weekly after 36 weeks.

d.  These visit intervals can be lengthened with good phone follow-up

> 2\. Labs each visit
>
> a\. the home flow sheet should be reviewed and a lab-done glucose
> obtained to verify control. This may be liberalized if village
> conditions warrant
>
> 3\. Periodic lab work
>
> a\. Serum quad testing should be offered at 15-20 weeks.
>
> b\. Fetal echocardiogram at 18-24 weeks.
>
> 4\. US to be repeated q 4-6 weeks to monitor fetal growth, e.g., AC \>
> 70th percentile
>
> 5\. Fetal well-being assessment
>
> a\. daily fetal movement count starting at 32 weeks;

b.  non-stress testing (NST) should be considered, though little data
    supports its benefit

> [Low risk:]{.underline} if good control, no hypertension or
> vasculopathy, no
>
> Stillbirth, then
>
> -NST weekly starting at 34 weeks,
>
> [High risk]{.underline} if poor control, hypertension, vasculopathy,
> previous
>
> stillbirth, then
>
> -NST twice weekly starting at 32 weeks
>
> 6\. Delivery
>
> Delivery recommendations need to be tailored to diabetic class on a
> case by case basis
>
> -Deliver in the 38th week, if good early dating
>
> -amniocentesis not necessary, if good glucose control and good
>
> dating
>
> -cesarean delivery not indicated for EFW \< 4,500 g

-For women with DM in pregnancy and an estimated fetal weight of

> 4,500 g or more, cesarean delivery may be considered because it may
>
> reduce the likelihood of permanent brachial plexus injury in the
> infant
>
> 7\. Intrapartum Insulin
>
> The goal of intrapartum insulin therapy is maternal and fetal
> euglycemia with a maternal glucose 60-90 mg/dL.
>
> If patient is in active labor, then a mainline of D5LR @ 125 cc/hr
> should be maintained. On morning of induction patient should arrive
> NPO, having [not]{.underline} taken her usual a.m. insulin dose.
> Obtain blood glucose q 1 hour in labor. The goal is to maintain
> glucose 60 --90 mg/dL to decrease neonatal hypoglycemia.
>
> Mix 125 units regular insulin in 250cc normal saline. (1u/2cc)
>
> [Blood glucose]{.underline} [Bolus]{.underline} [Insulin
> Drip]{.underline}
>
> \< 65 mg/dL \-\-\-\-- 0.0 unit insulin / hr
>
> 65-99 mg/dL \-\-\-\-- 0.5 unit insulin / hr
>
> 100-125 mg/L 2 unit 1 unit insulin /hr
>
> 126-150 mg/dL 3 unit 1 unit insulin hr
>
> \> 150 mg/dL 4 units 2 units insulin / hr
>
> Adjust drip to keep glucose between 60 -- 90 mg/dL
>
> **[VII.]{.underline}** **[Postpartum Management]{.underline}**

1.  The pre-gestational DM patient may undergo a transient 'honeymoon'

> period with euglycemia soon after delivery. The patient should be
>
> monitored closely prior to discharge and at home for impending
>
> hyperglycemia. The patient needs to be thoroughly evaluated for
>
> her insulin requirements at her 6-week postpartum check up.

2.  Nutrition consult.

3.  The patient should be encouraged to maintain the exercise or dietary

habits learned during pregnancy. The long-term goal should be to

maintain her ideal body weight. A significant percentage, e.g., 70%, of

GDM patients will become overtly diabetic, especially if \> BMI 27.

4.  Glucose tolerance should be re-evaluated at the six-week postpartum

> check-up and at a minimum of every 3 years thereafter.

5.  Pre-diabetes: Both Impaired Fasting Glucose (IFG) and Impaired

> Glucose Tolerance (IGT) should re-tested yearly and treated with MNT
>
> and exercise because of their high risk of developing Type II
> diabetes.

6.  The more sensitive test is a 75 gm 2 hour OGTT, but a fasting
    glucose

> can be diagnostic if elevated on two occasions
>
> The OGTT test requires the use of a glucose load containing the
>
> equivalent of 75 gm anhydrous glucose dissolved in water

7.  The patient may also be diagnosed with classic symptoms of DM and a

> casual (random) glucose [\>]{.underline} 200 mg/dL.

8.  Outside of pregnancy the laboratory criteria for diabetes mellitus

and pre-diabetes are:

**"Pre-diabetes"**

**Normal Impaired Fasting Diabetes**

**Glucose (IFG) mellitus\***

**or Impaired Glucose**

**Tolerance IGT)**

FPG \< 110 mg/dL FPG 100 -125mg/dL FPG [\>]{.underline} 126 mg/ dL

2-h PG \< 140 mg/dL 2-h PG 140-199 mg/dL 2-h PG [\>]{.underline} 200
mg/dL

\*A diagnosis of diabetes must be confirmed on a subsequent day by any
of the methods.

\* DM also can be diagnosed by symptoms of DM and casual plasma glucose
concentration ![](media/image2.png){width="7.291666666666667e-2in"
height="0.10416666666666667in"}200 mg/dl

<http://care.diabetesjournals.org/cgi/content/full/27/suppl_1/s5>

> **VII.** **[Family Planning and Future Pregnancy
> Consideration:]{.underline}**

1.  All contraceptive modalities are appropriate for the diabetic woman.

> Caveats include:
>
> -risk of weight gain with injectable medroxyprogesterone acetate and
>
> -increased insulin requirements with combination oral contraceptives.

2.  Family planning and six-week postpartum weight control, exercise,
    and diet considerations are the

same as for Class A-1 and pre-gestational DM patients.

**[VIII.]{.underline}** **[Preconception counseling]{.underline}**

> 1.) Weight loss and tight glycemic control should be in effect before
> conception of
>
> the next pregnancy. The teratrogenic effects of diabetes usually occur
> before
>
> the pregnancy is diagnosed.
>
> Euglycemia can prevent these effects.
>
> 2.) Pre-existing diabetic preconception goals
>
> Before meals (capillary blood glucose) 70 - 100 mg/dL
>
> 2 hours after meals \" \< 140 mg/dL
>
> Hgb A1C within lab
>
> normal range
>
> 3.) The GDM patient may prevent diabetes with her next pregnancy by
> achieving
>
> her ideal body weight prior to conception.
>
> 4.) Folic acid supplementation is particularly important for diabetic
> women who
>
> already at increased risk of malformations.
>
> -Patients with [no previous]{.underline} offspring with neural tube
> defects should take
>
> 0.4 -- 0.8 mg / day (1 mg might be easier) beginning at least 1 month
> prior to
>
> conception and continuing through the first trimester, to reduce the
> risk of
>
> neural tube defects
>
> -Those with a previous infant with neural tube defects should take 4
> mg.
>
> **[IX.]{.underline}** **[Care of the Newborn and child:]{.underline}**

1.  Hypoglycemia is the major risk.

2.  Early initiation of breast feeding / enteral milk (within 30-60
    minutes of birth)

3.  Maintenance of neutral thermal environment to minimize unnecessary
    energy expenditure

4.  Putting the infant to breast at the earliest sign of hunger (note:
    crying is a late hunger cue)

5.  See the 12/01 Pediatric Department Hypoglycemia guidelines (Appendix
    D)

6.  Enter "infant of diabetic pregnancy" on baby's problem list.

7.  The offspring of diabetic mothers are at increased risk for
    development of overweight or obesity, and glucose intolerance. The
    offspring should maintain their ideal body weight along appropriate
    growth curves and be followed for subsequent glucose intolerance on
    a periodic basis.

> **[X.]{.underline} [Learn more and test your knowledge of diabetes in
> ]{.underline}**
>
> **[pregnancy while you earn FREE CEU /CMEs]{.underline}**

Diabetes in Pregnancy: Screening and Diagnosis Module

<http://www.ihs.gov/MedicalPrograms/MCH/M/DP01.asp#top>

Diabetes in Pregnancy: Management and Postpartum Module

<http://www.ihs.gov/MedicalPrograms/MCH/M/DP21.asp#top>

###### Summary of recommendations

**[Whole Blood glucose monitoring recommendations]{.underline}**

Fasting glucose levels less than 95 mg/dL (Level C)

1 hour post prandial levels less than 130 mg/dL (Level B)

2 hour post prandial levels less than 120 mg/dL (Level C)

When medical nutritional therapy has not resulted in the above glucose
levels, then

Insulin or hypoglycemic therapy should be considered (Level C)

######### Other Recommendations

### Level A

(The following recommendation is based on good and consistent scientific
evidence)

-Regular moderate exercise of 150 minutes divided 3 times a week should
be

encouraged

-Fasting and post prandial glucose levels should be monitored, e.g., as
opposed to pre-

prandial levels

-All women planning pregnancy take a daily multivitamin or
multivitamin-multimineral

supplement containing folic acid at a dose of 0.4 - 0.8 mg, beginning at
least 1 month

prior to conception and continuing through the first trimester, to
reduce the risk of neural

tube defects.

### Level B 

> (The following recommendations are based on limited or inconsistent
> scientific evidence)
>
> -Laboratory screening should consist of a 50 g, 1-hour oral glucose
> challenge, which may
>
> be administered without regard to the time of the last meal.
>
> -The screening test should be performed on venous plasma or serum
> samples using well
>
> calibrated and well maintained laboratory instruments
>
> -Available evidence does not support a recommendation for or against
> moderate caloric
>
> restriction in patients with a BMI \> 30. However, if caloric
> restriction is used, the diet
>
> should be restricted by no more than 33% of calories.

-There is very little evidence to support either elective delivery or
expectant management

at term in pregnant women with insulin-requiring diabetes. Limited data
from a single

randomized controlled trial suggest that induction of labor in women
with gestational

diabetes treated with insulin reduces the risk of macrosomia.

-For women with GDM and an estimated fetal weight of 4,500 g or more,
cesarean

delivery may be considered because it may reduce the likelihood of
permanent brachial

plexus injury in the infant

-When medical nutritional therapy has not resulted in fasting glucose
levels less than 95

mg/dL or 1-hour postprandial values less than 130--140 mg/dL or 2-hour
postprandial

values less than 120 mg/dL, insulin should be considered

-Shoulder dystocia cannot be predicted or prevented because accurate
methods for

identifying which fetuses will experience this complication do not
exist.

-Elective induction of labor or elective cesarean delivery for all women
suspected of

carrying a fetus with macrosomia is not appropriate.

### Level C

(The following recommendations are based primarily on consensus and
expert opinion)

-Expert panels have supported two sets of diagnostic criteria. There is
no data from

clinical trials to change from the current criteria.

-There is insufficient evidence to determine the optimal antenatal
surveillance regimen for

women with GDM with relatively normal glucose levels on diet therapy and
no other risk

factors

-At present, there is not enough evidence from randomized trials to
evaluate the use of

biophysical profile as a test of fetal well-being in high risk
pregnancies.

-There are insufficient data for any reliable conclusions about the
effects of treatments for

impaired glucose tolerance on perinatal outcome.

-There appears to be no clear evidence of benefit from very tight
glycemic control for

pregnant diabetic women. Since very strict control may have a
substantial impact on

lifestyle, this suggests caution in advising such a degree of control

-Women who have had GDM are at high risk for subsequent diabetes or
glucose

intolerance, especially if they develop overweight, BMI \> 27. An OGTT
(75 gm, 2-h)

should be performed at 6 weeks post partum and every 3 years thereafter.
A fasting

plasma glucose can be substituted for the OGTT, if logistics dictate, or
if the initial OGTT

is normal.

-In patients with a history of shoulder dystocia, estimated fetal
weight, gestational age,

maternal glucose intolerance, and the severity of the prior neonatal
injury should be

evaluated and the risks and benefits of cesarean delivery discussed with
the patient.

-There is no evidence that any one maneuver is superior to another in
releasing an

impacted shoulder or reducing the chance of injury. However, performance
of the

McRoberts maneuver is a reasonable initial approach.

Revised September 2004 njm

Revised January 2002 njm

Revised November 1994 njm

September 1989

**[References]{.underline}**

> **-**Alfirevic Z, Neilson JP. Biophysical profile for fetal assessment
> in high risk pregnancies (Cochrane Review). In: *The Cochrane
> Library,* Issue 3, 2004. Chichester, UK: John Wiley & Sons, Ltd.
> (Level I) <http://www.update-software.com/clibng/cliblogon.htm>

-ACOG Practice Bulletin No. 30. Gestational Diabetes. American College
of Obstetricians

and Gynecologists. Obstet Gynecol 2001;98:525--538 (Level III)

ACOG Members

<http://www.acog.com/publications/educational_bulletins/pb030.cfm>

Non-ACOG Members

> <http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11547793&dopt=Abstract>
>
> -ACOG Practice Bulletin No. 40. Shoulder dystocia. American College of
> Obstetricians and Gynecologists. Obstet Gynecol 2002;100:1045--50.

ACOG Members

> <http://www.acog.org/publications/educational_bulletins/pb040.cfm>

Non-ACOG Members

> <http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12578001>

-American Diabetes Association: 2004 Clinical Practice Guidelines (Level
III)

> <http://care.diabetesjournals.org/content/vol27/suppl_1/>
>
> -Buchanan TA, Kjos SL. Diabetes Mellitus. Clinical Updates in Women\'s
> Health. Volume 1 No. 4 Fall 2002 American College of Obstetricians and
> Gynecologists. (Level III)
>
> <http://www.acog.com/>
>
> -Gabbe SG, Graves CR. Management of diabetes mellitus complicating
> pregnancy. tet Gynecol. 2003 Oct;102(4):857-68. (Level III)\
> <http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14551019&dopt=Abstract>
>
> -Meltzer S, Leiter L, Daneman D, Gerstein HC, Lau D, Ludwig S, Yale
> JF, Zinman B, Lillie D. Canadian Medical Association Expert Committee.
> Clinical Guidelines for management of diabetes in Canada. CMAJ 1998;
> 159(Suppl 8):S1-S29. (Level III)

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9834731&dopt=Abstract>

**-**Tuffnell DJ, West J, Walkinshaw SA. Treatments for gestational
diabetes and

impaired glucose tolerance in pregnancy (Cochrane Review). In: *The*

*Cochrane Library,* Issue 3, 2004. Chichester, UK: John Wiley & Sons,
Ltd.

(Level I) <http://www.update-software.com/clibng/cliblogon.htm>

###  -U.S. Preventive Services Task Force 1996 Chapter 42. Screening for Neural Tube 

###  Defects \-- *Including Folic Acid/Folate Prophylaxis* (Level III)

<http://hstat.nlm.nih.gov/hq/Hquest/db/local.gcps.cps/screen/Browse/s/40763/cmd/HF/action/GetText?IHR=CH42CINT>

-Walkinshaw SA. Very tight versus tight control for diabetes in
pregnancy

(Cochrane Review). In: *The Cochrane Library,* Issue 3, 2004.
Chichester, UK:

John Wiley & Sons, Ltd.. (Level I)

<http://www.update-software.com/clibng/cliblogon.htm>

**[American Indian and Alaska Native References and/or
Screening]{.underline}**

-Bergus GR, Murphy NJ. Screening for gestational diabetes mellitus:
Comparison of a

glucose polymer and a glucose monomer test beverage. J Am Board Fam
Pract 1992;

5:241-7. (Level II-1)

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=1580171&dopt=Abstract>

-Boyd KL, Ross EK, Sherman SJ. Jelly beans as an alternative to cola
beverage

containing fifty grams of glucose. Am J Obstet Gynecol 1995;
173:1889-92. (II-2)

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8610782&dopt=Abstract>

-Kim C, Newton KM, Knopp RH.Gestational diabetes and the incidence of
type 2

diabetes: a systematic review. Diabetes Care 2002 Oct;25(10):1862-8
(Level III)

> <http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12351492&dopt=Abstract>

-Lamar ME et al. Jelly beans as an alternative to fifty-gram glucose
beverage for

gestational diabetes screening. Am J Obstet Gynecol 1999; 181:1154-7.
(Level I)

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10561636&dopt=Abstract>

-Murphy NJ, Meyer BA, O\'Kell RT, Hogard ME. Carbohydrate sources for
gestational

diabetes screening: A comparison. J Reprod Med 1994; 39:977-81. (Level
I)

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=7884757&dopt=Abstract>

For other American Indian and Alaska Native References go here:

<http://www.ihs.gov/MedicalPrograms/MCH/M/DP36.asp#top>

or here:

<http://www.ihs.gov/MedicalPrograms/MCH/M/DP13.asp#top>

######## Appendix A

**[Alternative Options for Screening]{.underline}**

[Regional center based screening]{.underline}

A.  Give 50 g of Polycose solution. Polycose is the best tolerated,
    e.g., no nausea, bloating, or lightheadedness and most reproducible.

> Polycose can be prepared ahead of time in the Pharmacy in the
> following manner:
>
> 50 g of Polycose\*, 50 mL of unsweetened club soda, and 1.5 gm of
> unsweetened lemon-lime Kool-Aid mix. Use standard blood glucose
> screening cut-off.
>
> \* This can be easily prepared in the Pharmacy: Polycose 50 g = 100 mL
> of 43% polymer solution
>
> (2 cal / mL)

B.  Give either 28 each Brach, No. 110, or 18 each of the Brach 150
    jellybeans per pound. Use

> standard blood glucose screening cut-off.
>
> Please note: This has poor sensitivity compared to Polycose.

C.  **[50 gram Breakfast load]{.underline}**

Menu

Two scrambled eggs (3 oz)

Two slices toast or one English muffin

Two pats of butter or margarine

8 oz orange juice

8 oz whole or skim milk

One cup coffee or tea (no sugar)

Contents

Carbohydrate 52 gm (210 kcal)

Protein 28 gm (110 kcal)

Fat 31 gm (280 kcal)

D. **100 Gram Carbohydrate Test Breakfast**

On the morning of the test, your breakfast must follow one of the three
breakfast

menus listed below [exactly]{.underline}. The right amount of
carbohydrate is needed for

accurate test results. Take no more than half an hour to eat breakfast.
Eat nothing

more until the test is over, and do not take a nap. The blood sample
must be

drawn exactly two hours after you began to eat, so note the time you
started

eating. Example: If you started eating breakfast at 8:00 am, be at the
lab at 9:30 am

to have your blood drawn by 10:00 am. Choose one of the menus below:

Breakfast #1 Breakfast #2

½ cup cold cereal 10 gms 4 (4" across) pancakes 30 gms

(not sugar coated) 2 ½ tablespoons syrup 30 gms

1 cup milk 12 gms 1 cup milk 12 gms

2 slices toast 30 gms 1 cup orange juice or

1 tablespoon jelly 15 gms one small banana 30 gms

1 teaspoon sugar 5 gms Total: 102 gms

1 cup orange juice or

one small banana 30 gms Breakfast #3 "Lemonade" Mix:

Total: 102 gms ¼ cup lemon juice 4 gms

½ cup sugar 96 gms

1 cup water \-- Total 100 gms

If you are unable to eat the types or amounts of foods indicated,
contact your WH-

PCC clinic for help with substitutions.

####### Village clinic based screening

A.  A variety of methods are being tried. The most accurate, is to send
    a glucola drink to the health aide to be administered in clinic. A
    gray top tube is drawn at 1 hour and the plasma separated off within
    2-3 hours, refrigerated, and sent in.

B.  Other options include:

> 1\. Have the health aide obtain a capillary random glucose value by
> using a portable glucometer. If a value of 120 mg/dL or greater is
> found, then consult the referral physician.
>
> 2\. Send a Standard 100 gram glucose drink to the health aide and have
> him/her administer half of it, followed by a 1 hour capillary glucose.
> If a value of 120 mg/dL or greater is found, then consult the referral
> physician.

3.  Have the health aide give a simulated glucola drink, made by
    dissolving four tablespoons table sugar in eight ounces of water.
    Flavor with some lemon juice, if possible. Follow with a 1 hour
    glucose determination. If a value of 120 mg/dL or greater is found,
    then consult the referral physician.

> [Please note]{.underline}: sucrose is metabolized differently than
> glucose. This
>
> method is better than nothing, but sending out a glucola bottle is far
>
> superior.

### Appendix B

#### **Diabetes Predating Pregnancy White Classification**

Age of Onset Duration

[Class]{.underline} [(year)]{.underline} [(year)]{.underline} [Vascular
Disease]{.underline} [Therapy]{.underline}

A Any Any 0

A-1, Diet only

A-2, Insulin

B \> 20 \< 10 0 Insulin

C 10-19 or 10-19 0 Insulin

D 10 or 20 Benign retinopathy Insulin

F Any Any Nephropathy Insulin

R Any Any Proliferative retinopathy Insulin

> H Any Any Heart Disease
>
> Insulin

### Appendix C

**[BMI table here]{.underline}**

<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/PresidentChallenge0102BMI.pdf>

### Appendix D

**[ANMC Pediatric Department Hypoglycemia Guidelines]{.underline}**

**[Appendix E]{.underline}**

**[Gestational Diabetes Traditional Foods Meal Plan with
Milk]{.underline}**

![](media/image3.wmf){width="5.997222222222222in"
height="8.063194444444445in"}

**[Appendix F]{.underline}**

# **[Exercise guidelines to improve glucose control]{.underline}**

Type of activities:

Aerobic activities such as walking, stationary cycling, or swimming

Frequency:

At least 3 days per week

Duration:

20-45 minutes per session

Intensity:

Moderate. The "talk-sing test" may be used -- the patient should be able
to talk while

exercising; if she can sing, the pace can be increased. If using rating
of perceived

exertion (RPE) exertion level should feel "fairly light" to "somewhat
hard".

Patient should warm-up before and cool down after exercise, drink plenty
of water, and

have snacks nearby if needed.

Initial exercise consult:

> Assessment of current physical activities and level of readiness for
> exercise
>
> Education/Information on exercise and GDM
>
> Individualized exercise plan

Supervised exercise:

> Measure blood glucose pre and post exercise
>
> Exercise on treadmill and/or recumbent cycle
>
> Monitor perceived exertion
>
> Monitor blood pressure and/or heart rate as needed