Revised 1/2/02njm

**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 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 patient's 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[-]{.underline}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\. 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 screen is normal, repeat at 24 weeks and 32 weeks.

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

A.  All patients with a positive screen (one hour [\>]{.underline} 140
    mg/dL) should be given a 3 hr GTT after a 8-14

> hour fast 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.

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} [Post prandial
Glucose Level]{.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. 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.

This 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.
>
> 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.

B.  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.

> 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.

5.  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.

6.  Periodic lab work

> -urine dipstick for protein after 36 weeks
>
> -ketone measurement may be helpful in women with BMI \> 30 treated
> with diet restriction

7.  Ultrasound for precise dating prior to 18-24 weeks, Careful clinical
    dating is important as

> well.

8.  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
>
> C. Intrapartum Management:
>
> Alaska Native Medical Center (ANMC) OB-GYN department recommends
> transfer of any pregnant woman at 37 weeks not controlled 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 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
>
> 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.
>
> 3\. 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.

4.  One common formula for initiating therapy is:

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

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

-   7u NPH at supper.

-   Another helpful approach is to administer the NPH insulin at 9-10 pm
    to

> decrease fasting glucose.
>
> 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

9.  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
    prospective manner

    with an OB/GYN consultation.

> 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 two weeks 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;
>
> b\. urine for ketones, glucose, and protein. Note all three results in
> chart each visit.
>
> 3\. Periodic lab work
>
> a\. for women with diabetes predating pregnancy (Type I or Type II) a
> glycosylated hemoglobin should be obtained on the first visit.
> Counseling regarding risk of congenital anomalies should be provided
> based on result;
>
> d\. Serum triple testing should be offered at 15-20 weeks.
>
> e\. Fetal echocardiogram at 18-22 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 28 weeks;

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

> [Low risk:]{.underline} good control, no hypertension or vasculopathy,
> no stillbirth
>
> -NST twice weekly starting at 34 weeks,
>
> [High risk]{.underline} poor control, hypertension, vasculopathy,
> previous stillbirth
>
> -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
>
> 7\. Intrapartum Insulin
>
> The goal of intrapartum insulin therapy is maternal and fetal
> euglycemia with a maternal glucose less than 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 \-\-\-\-- 0.5 unit insulin / hr
>
> 65-99 mg/dL \-\-\-\-- 1 unit insulin / hr
>
> 100-125 mgdL 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 of these patients will become overtly diabetic within 15
> years, 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.  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
>
> diabetes.

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

> and may be logistically easier. This test requires the use of a
> glucose load containing the
>
> equivalent of 75 gm annhydrous glucose dissolved in water

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

> glucose [\>]{.underline} 200 mg/dL.

8\. Outside of pregnancy the laboratory criteria for diabetes mellitus
are:

**Normoglycemia** **Impaired** **Impaired** **Diabetes**

**Fasting glucose (IFG) Glucose tolerance (IGT) mellitus**

FPG \< 110 mg/dL FPG 110 -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.

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

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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 effected 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 gestational diabetic 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 offspring with neural tube defects should
> take 0.4 mg / day
>
> -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.

###### 

###### 

###### 

###### 

###### Summary of recommendations

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

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

1 hour post prandial levels less than 140 mg/dL (Level A)

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)

-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

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

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

### 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

### 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 not enough evidence to evaluate the use of primary dietary
therapy for women who show

impaired glucose metabolism during pregnancy.

-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.

-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.

September 1989

Revised November 1994 njm

Revised January 2002 njm

**[References]{.underline}**

-ACOG Practice Bulletin. Gestational Diabetes. American College of
Obstetricians and Gynecologists.

No. 30, September 2001 (Level III)

-Alfirevic Z, Neilson JP. Biophysical profile for fetal assessment in
high risk pregnancies (Cochrane

Review). In: *The Cochrane Library,* Issue 4, 2001. Oxford: Update
Software. (Level I)

-American Diabetes Association. Gestational Diabetes. Clincial
PracticeRecommendations. Diabetes

Care(Suppl 1):S77-S79. (Level III)

-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)

-Boulvain M, Stan C, Irion O. Elective delivery in diabetic pregnant
women (Cochrane Review). In: *The*

*Cochrane Library,* Issue 4, 2001. Oxford: Update Software. (Level I)

-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)

-Buchanan TA, Kjos SL. Diabetes Mellitus. Clinical Updates in Women\'s
Health. American College of

Obstetricians and Gynecologists. (In Press) (Level III)

-Canadian Medical Association Expert Committee. Clinical Guidelines for
management of diabetes in

Canada. CMAJ 1998; 159(Suppl 8):S1-S29. (Level III)

-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)

-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)

-Walkinshaw SA. Dietary regulation for \'gestational diabetes\'
(Cochrane Review). In: *The Cochrane*

*Library,* Issue 4, 2001. Oxford: Update Software (Level I)

-Walkinshaw SA. Very tight versus tight control for diabetes in
pregnancy (Cochrane Review). In: *The*

*Cochrane Library,* Issue 4, 2001. Oxford: Update Software. (Level I)

### 

######## 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.

####### 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

### Appendix D

ANMC Pediatric Department Hypoglycemia 12/01Guidelines here