Sweet+Success

toc Written by the CCRMC Obstetrics Department based on California State Sweet Success Guidelines
 * CCRMC Guidelines for Management of Pregestational Diabetes and Gestational Diabetes in Outpatient Prenatal Care**

These are general guidelines—variation due to individual patient situation and new information will occur. Consultation is recommended with the Obstetrics Department or Consulting Perinatologist whenever management is uncertain.

Pregestational Diabetes
**Pre-conception**: All women with diabetes planning pregnancy should have an optimized HbA1C (ideally **<7**) using glucophage, glyburide, and insulin. TZD, ACEI, ARB, and diuretics should be avoided and stopped and/or converted to an alternative medication in the event of pregnancy. Routine pre-conception interventions apply including folic acid supplementation 1-4mg daily. Consultation may be indicated for optimal management, //especially// with Type 1 diabetes. **Glucophage, glyburide, and insulin should** __not__ **be interrupted when pregnancy is diagnosed and all women who might potentially get pregnant should be instructed** __NOT**__ to stop these medications if they become pregnant. When pregnancy is diagnosed the following steps are advised: 1. Expedited enrollment in Healthy Start and an urgent appointment with a physician comfortable with the management of pregestational diabetes in pregnancy. 2. Institution of standard glucose monitoring with FBS and 1 hour postprandial monitoring. 3. Consideration of switching to insulin immediately, especially if the FBSs are >120. 4. Outpatient management is usually most appropriate; however, inpatient management should be for women with very labile blood glucoses, or those less than 10 weeks gestation with glucoses >200 that cannot be expeditiously managed as outpatients with consultation with the Obstetrician on call.

Screening and Diagnosis of GDM (Gestational Diabetes Mellitus)

 * All patients will have a** HbA1C **drawn with initial labs to assess for GDM, undiagnosed DMII or control of known DMII.**

__HbA1C__ >__6.5 and not previously diagnosed with DM__. Diagnose DM2. Start glucometer and GDM teaching, and schedule urgent MD visit within one week. Perform random chemstick glucose check and if greater than 180, or appointment not available within one week, call MD on call to discuss starting medication prior to appointment.

__HbA1C: 5.7-6.4__ Indicates pre-gestational glucose intolerance; order 2 hr GTT to rule out early onset GDM. If negative be sure to repeat 2 hr GTT at 24-28 weeks EGA. Consider glucometer testing directly without 2 hour GTT if high risk or patient/provider prefers.

__HbA1c < 5.7 and multiple GDM risk factors.__ Consider early screening for GDM with either 50gm or 75gm GTT at 16- 20 weeks and repeat screening at 24-28 weeks if negative.


 * __If 50gm__ >****__200 or one abnormal value on pregnancy 2 hour GTT__**, start glucometer teaching. Provider may consider confirmatory 2 hour GTT if glucometer results are in the normal range and diagnosis based only on 50gm result.


 * Risk Factors to consider for early screening (<24 weeks) for GDM**
 * Age 30 or older
 * Non-caucasian ethnicity (Asian, Latina, African)
 * Family History of DM (1st degree relative with DM)
 * History of GDM, especially if on medication
 * Prior Fetal Macrosomia (>4000 gm)
 * Prior Fetal Demise of Undetermined Etiology
 * Elevated BMI (25 or greater)
 * Pre-diabetes on previous testing
 * Chronic use of medication that causes hyperglycemia (e.g. prednisone)

**Routine Screening for Gestational Diabetes**
All patients who **have not been** previously diagnosed with pregestational diabetes or GDM should have a 50 gram glucola administered at 24-28 weeks gestation or later in pregnancy if not done at 24-28 weeks.

**__Remember to repeat the Glucola at 24-28 weeks even if the initial screen done before 24 weeks was normal.__**

 * Administering the Screening 50gram GTT and Follow-up Testing**

50gm GTT does not need to be fasting, but a patient should be told not to consume carbohydrates during the test or take in a large carbohydrate load right before the test. The patient needs to be aware that once they drink the Glucola they must not eat/drink, smoke, or exercise. The blood glucose level is obtained __1 hour__ after start of Glucola ingestion. Normal Value for 1 hour Glucola (50gm) Screen: <130 A 2 hour 75gm GTT will be administered if the 1 hour 50gm GTTresult ranges from 130-199. A 1 hour GTT >199 will be used to diagnose GDM without a 2 hr GTT. //Alternatives to 2 hour GTT: a FBS > 91,or a random glucose > 199.// //If unable to do 2hr GTT begin glucometer testing and use best clinical judgement in making diagnosis of GDM.// <span style="display: block; font-family: arial,sans-serif;">Healthy Start will routinely order the 2 hour GTT if the 1 hour is >129 and <199. <span style="display: block; font-family: arial,sans-serif;">If a 50 gm Glucola is 200 or greater she will be diagnosed with GDM. If subsequent glucose monitoring is completely normal, a 2hour GTT can be considered by the provider to confirm diagnosis.
 * Administering the Confirmatory 2 Hour GTT**

<span style="display: block; font-family: arial,sans-serif;">The 2 hour Glucose Tolerance Test (100 gm) is administered FASTING. The normal values we are currently using for the 2 hour GTT are as follows:
 * <span style="display: block; font-family: arial,sans-serif;">Fasting **__<__ 92**
 * <span style="display: block; font-family: arial,sans-serif;">1 hour **__<__ 180**
 * <span style="display: block; font-family: arial,sans-serif;">2 hour **__<__ 153**

<span style="display: block; font-family: arial,sans-serif;">*1 abnormal value makes the diagnosis of GDM.*

Diagnosis and Initial Management
For all women diagnosed with GDM, Healthy Start should provide a glucometer and supplies, initiate glucometer teaching, glucose monitoring, dietary counseling, and make sure there is a clinician visit within 3-8 days. Sooner visits are indicated for first trimester diagnoses and higher blood glucoses. Women with mildly elevated levels and second and third trimester diagnoses can be followed up after a week of blood glucose measurements.

Both GDM is initially treated with diet and glucose monitoring 4 times a day--Fasting and 1 hour after the beginning of each meal. Women with GDM who have glucoses within range on diet should have the frequency of blood glucose monitoring decreased at the discretion of the provider.

Fasting target values are 60-90 and 1 hour postprandial are <130

Diet and Exercise
<span style="display: block; font-family: arial,sans-serif;">Dietary and Exercise Counseling Will Be Provided by the Healthy Start Personnel <span style="display: block; font-family: arial,sans-serif;">Important points for clinicians include: <span style="display: block; font-family: arial,sans-serif;">Although most women will be advised to eat more vegetables and more protein and fewer carbohydrates, at least 175 gms of carbohydrate per day divided into 3 meals and 3 snacks are required in pregnancy. <span style="display: block; font-family: arial,sans-serif;">Patients will be advised to avoid milk before 10 am due to increased blood glucoses in response to milk consumed in the morning. <span style="display: block; font-family: arial,sans-serif;">Regular exercise 30-60 minutes per day or 10-20 minutes TID are advised.

**Recommended Maternal Weight Gain**
<span style="display: block; font-family: arial,sans-serif;">Recent revisions of weight gain guidelines have lowered the recommended weight gains for women with higher BMIs. There is Sweet Success data supporting the safety of even lower weight gain in women with higher BMIs and GDM who have an improved diet during pregnancy. <span style="display: block; font-family: arial,sans-serif;">BMI < 18: 28-40 lbs <span style="display: block; font-family: arial,sans-serif;">BMI 18-25: 25-35 lbs <span style="display: block; font-family: arial,sans-serif;">BMI 25-30: 15-25 lbs <span style="display: block; font-family: arial,sans-serif;">BMI > 30: 11-20 lbs

Medication for GDM and Pregestational Diabetes
<span style="display: block; font-family: arial,sans-serif;">If approximately **//20%//** **//or more//** of the blood sugars are above the recommended range, despite diet and exercise, then medication is usually indicated. Three or more elevated FBS and/or 6 post-meal evaluations in one week can also be used as an indication for medication.

<span style="font-family: arial,sans-serif;">//**Insulin is still the Gold Standard, but glyburide or metformin are acceptable alternatives and in practice have become first line treatment.**//
<span style="display: block; font-family: arial,sans-serif;">Oral medication is generally used as first-line in patients with a FBS range from 95 to 120* or 1 hour postprandial range from 130 to 179. <span style="display: block; font-family: arial,sans-serif;">(*If only the FBS are elevated you may attempt to control with oral medication even if FBS is above 120. Be aware that sometimes just a small amount of NPH at bedtime will take care of the FBS.)
 * Metformin (Glucophage)**

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<span style="display: block; font-family: arial,sans-serif;">Begin with 500 mg once or twice a day with food or at bedtime (depending on the pattern of hyperglycemia). Increase every 3-7 days until good glucose control or maximum dose of 2500 mg/day is reached. <span style="display: block; font-family: arial,sans-serif;">As in the non-pregnant patient be aware of the GI effects, check a serum Cr if renal disease is suspected, and remember that it should be discontinued prior to major surgery/use of radiologic contrast agents. <span style="display: block; font-family: arial,sans-serif;">Drug Class Pregnancy : B Breastfeeding : Probably Safe


 * Glyburide**

<span style="display: block; font-family: arial,sans-serif;">Begin with 1.25 mg /day (maternal BW <200 lb) or 2.5 mg (maternal BW >200 lb) either in the AM or PM 60 minutes prior to meals. To control FBS, glyburide may be given at bedtime (10-11 PM). Increase by 1.25 to 2.5 mg every 3-7 days until target glucoses are attained or a maximum of 20 mg/day is reached. Note if you are up to 5 mg twice a day (10 mg/day) without the desired effect, you may not benefit from increasing to 10 mg BID. <span style="display: block; font-family: arial,sans-serif;">With this medication, it is essential that patients understand hypoglycemic prevention and management, adhere to meal and snack regimen. <span style="display: block; font-family: arial,sans-serif;">Drug Class Pregnancy: C Breastfeeding: Probably Safe

<span style="display: block; font-family: arial,sans-serif;">At this time, it is not standard in pregnancy to combine metformin and glyburide or insulin and glyburide in pregnancy. Metformin and insulin are sometimes combined.
 * Combining Medication**

Insulin
<span style="display: block; font-family: arial,sans-serif;">Insulin regimens generally combine the long-acting NPH and either a rapid-acting analog (Lispro, Novalog) or regular insulin. Longer acting agents (Lantus and Levemir) are not started in pregnancy and are only used if she is stable on this medication prior to pregnancy—usually with consultation. <span style="display: block; font-family: arial,sans-serif;">Insulin is usually prescribed by the prenatal provider who then refers the patient back to the Healthy Start personnel for instruction on the administration of insulin and monitoring and treatment of hypoglycemia. Sometimes OB Attendings start medications through Healthy Start before the patient is seen by the provider.

<span style="font-family: arial,sans-serif;">To calculate the total insulin need per day:
<span style="display: block; font-family: arial,sans-serif;">1-18 weeks GA 0.7 units/kg actual body weight in kg. <span style="display: block; font-family: arial,sans-serif;">18-26 weeks GA 0.8 units/kg actual body weight in kg. <span style="display: block; font-family: arial,sans-serif;">28-36 weeks GA 0.9 units/kg actual body weight in kg. <span style="display: block; font-family: arial,sans-serif;">36-40 weeks GA 1 unit/kg actual body weight in kg.


 * If using Regular/NPH Regimen:**

<span style="display: block; font-family: arial,sans-serif;">Take total daily insulin requirement and divide by 3 <span style="display: block; font-family: arial,sans-serif;">2/3 in AM and 1/3 in PM <span style="display: block; font-family: arial,sans-serif;">The AM 2/3 dose is divided into 2/3 dose NPH and 1/3 dose Regular to be given **//one hour prior//** to breakfast. <span style="display: block; font-family: arial,sans-serif;">The PM 1/3 dose is divided into ½ dose Regular **//one hour prior//** to dinner time and ½ dose NPH given at bedtime. Use of Insulin dose calculator: [] is recommended.


 * If using Rapid-Acting Analog (Lispro or Novolog) with basal NPH Regiment:**


 * //In Pregestational Diabetics://**

<span style="display: block; font-family: arial,sans-serif;">You will take the total daily insulin requirement and divide by 6. <span style="display: block; font-family: arial,sans-serif;">You will start giving rapid-acting/NPH as follows <span style="display: block; font-family: arial,sans-serif;">1/6 of total as NPH + 1/6 of total as rapid-acting at breakfast <span style="display: block; font-family: arial,sans-serif;">1/6 of total as rapid-acting at lunch and 1/6 of total at dinner <span style="display: block; font-family: arial,sans-serif;">1/6 of total as NPH at bedtime (or at dinner) <span style="display: block; font-family: arial,sans-serif;">(So 5/6 of the total dose is what you will start with) <span style="display: block; font-family: arial,sans-serif;">Modify every 3 days according to blood sugars until good BS control

//**In Gestational Diabetics**////**:**//

<span style="display: block; font-family: arial,sans-serif;">Initiate 2-4 units of rapid-acting pre-breakfast, pre-lunch, and pre-dinner. <span style="display: block; font-family: arial,sans-serif;">Initiate NPH at bedtime using 0.1 to 0.2 units/kg actual body weight. <span style="display: block; font-family: arial,sans-serif;">Adjustment in dosing is based on BS values. <span style="display: block; font-family: arial,sans-serif;">Drug Class Pregnancy : B Breastfeeding : Probably Safe

Additional Testing in Pregnancies Complicated by Diabetes

 * Anatomy Ultrasound**

<span style="display: block; font-family: arial,sans-serif;">An anatomy screening ultrasound at 18-20 weeks is recommended for all women with pregestational or gestational diabetes. If possible, we recommend that this ultrasound is a level II scan for all women with pregestational diabetes and for women with GDM with suspected pregestational diabetes as determined by significantly elevated fasting blood sugars (consistently over 120) or HbA1C __>__ 6.5 early in pregnancy.


 * Fetal Echocardiography**

<span style="display: block; font-family: arial,sans-serif;">Women with a diagnosis of pregestational diabetes or GDM with suspected pregestational diabetes should be referred for fetal echocardiography in addition to level II anatomy screen if the __HbA1C is >8.0 or FBS is greater than 140__. This study is normally performed at about 22 weeks EGA.
 * Ultrasound for EFW**

<span style="display: block; font-family: arial,sans-serif;">A 38 week ultrasound for estimated fetal weight should be considered in women with GDM or DM, especially in pregnancies with FH above normal range, for excessive maternal weight gain, or when maternal size or body habitus precludes clinical assessment of fetal weight.


 * Maternal Screening Tests for Women withType I and Type II Diabetes**

<span style="display: block; font-family: arial,sans-serif;">Recommended maternal surveillance for diabetic complications include EKG for women over 35, ophthalmology exam, urine for microalbumin, hypertension screening and, if hypertension or microalbumin. a 24 hour urine for protein and creatinine clearance and baseline LFTs.

Suggested Antepartum Testing

 * <span style="display: block; font-family: arial,sans-serif;">DIAGNOSIS || <span style="display: block; font-family: arial,sans-serif;">GESTATIONAL AGE TO BEGIN || <span style="display: block; font-family: arial,sans-serif;">RECOMMENDED TESTING || <span style="display: block; font-family: arial,sans-serif;">FREQUENCY ||
 * <span style="display: block; font-family: arial,sans-serif;">GDMA1 Diet-controlled. Monitoring criteria the same as for low risk pregnancy || <span style="display: block; font-family: arial,sans-serif;">41 weeks. May start at 40 wks per provider preference || <span style="display: block; font-family: arial,sans-serif;">NSTAFI || <span style="display: block; font-family: arial,sans-serif;">Biweekly;Weekly ||
 * <span style="display: block; font-family: arial,sans-serif;">GDMA2: Well controlled on low dose of medication || <span style="display: block; font-family: arial,sans-serif;">32 weeks || <span style="display: block; font-family: arial,sans-serif;">NSTAFI || <span style="display: block; font-family: arial,sans-serif;">Weekly until 36 wks, then biweekly; Weekly ||
 * <span style="display: block; font-family: arial,sans-serif;">GDMA2 difficult to control or requiring insulin || <span style="display: block; font-family: arial,sans-serif;">32 weeks || <span style="display: block; font-family: arial,sans-serif;">NSTAFI || <span style="display: block; font-family: arial,sans-serif;">Biweekly;Weekly ||
 * <span style="display: block; font-family: arial,sans-serif;">Pregestational Diabetes || <span style="display: block; font-family: arial,sans-serif;">32 weeks || <span style="display: block; font-family: arial,sans-serif;">NSTAFI || <span style="display: block; font-family: arial,sans-serif;">Biweekly;Weekly ||
 * <span style="display: block; font-family: arial,sans-serif;">Pregestational Diabetes with vasculopathy or significant hypertension || <span style="display: block; font-family: arial,sans-serif;">Consult. May start as early as 28 weeks or need additional studies. || <span style="display: block; font-family: arial,sans-serif;">NSTAFI || <span style="display: block; font-family: arial,sans-serif;">Biweekly;Weekly ||

=Delivery Plan=

<span style="display: block; font-family: arial,sans-serif;">Infants born to women with diabetes, particularly if not well-controlled, are at increased risk for fetal lung immaturity at later gestational ages, macrosomia, and other complications of labor and delivery. If the EFW is >4500, an elective cesarean should be considered. Altermatove delivery plan may be necesary for EFW 4000-4500 and history of difficulty delivery, or relatively large fetal abdominal circumference. Consult with OB Attending.
 * Delivery timing, assuming reliable dates:**

<span style="display: block; font-family: arial,sans-serif;">Women with GDM A1 (well-controlled on diet) are normally induced or delivered by 41-42 weeks EGA. <span style="display: block; font-family: arial,sans-serif;">Women with GDM A2 (medication indicated) are normally induced or delivered by 40 weeks EGA <span style="display: block; font-family: arial,sans-serif;">Consultation regarding timing of delivery is recommended for women with uncertain dates or more severe or poorly controlled diabetes


 * Postpartum Screening and Management**

<span style="display: block; font-family: arial,sans-serif;">All women diagnosed with GDM should be considered at risk for the subsequent development of DMII. If pregestational diabetes is suspected, glucometer monitoring should be continued postpartum to evaluate for Type II diabetes. <span style="display: block; font-family: arial,sans-serif;">If Type II diabetes is not suspected, screening is typically performed with a 2 hour GTT at 3-6 weeks postpartum and then annually with FBG, HbA1C, or 2 hour GTT.

The 2 hour GTT used postpartum has only a FBS and a 2 hour value and uses the ADA criteria for diagnosing DM or Glucose intolerance in contrast to the 2 hr GTT used during pregnancy. Postpartum 2 hr GTT results:
 * Fasting value: <100 normal
 * 100-125 impaired glucose tolerance
 * >125 Diabetes
 * 2 Hour result: <140 normal
 * 140-199 impaired glucose tolerance
 * >199 Diabetes
 * Normal: fasting <100 normal and 2 hour <140
 * IGT: fasting 100-125 or 2 hour 140-199
 * DMII: fasting >125 or 2 hour >199

Women should also be educated to maintain their diet, minimize weight gain, continue to exercise, and utilize their glucometers occasionally to self-screen for diabetes, especially in the absence of on going access to health care.

<span style="display: block; font-family: arial,sans-serif;">Breastfeeding should be encouraged. Blood glucose goals for women with diabetes who are breastfeeding are FBS < 100, and 1 hour PP < 150. <span style="display: block; font-family: arial,sans-serif;">Women with diabetes in pregnancy are at increased risk for postpartum depression and should be screened postpartum.