Policy, Guideline and Procedure Manual

Diabetes Mellitus: management of gestational diabetes

1. Purpose
The Womens is committed to the provision of best practice evidence based multidisciplinary care to women with gestational diabetes. This guideline or procedure outlines the requirement for the management of women with gestational diabetes (GDM) at the Womens. GDM is a degree of glucose intolerance with the onset or first recognition during pregnancy.

2. Definition
GDM Group Education: Education provided to women diagnosed with GDM. This education is usually provided by a credentialed diabetes educator, dietitian and physiotherapist. GDM Training Program: A teaching / training program conducted by staff in the Diabetes Service to educate clinicians from the TeamCare teams about management of GDM

3. Responsibilities
Staff responsible for the care of women with gestational diabetes includes obstetricians, endocrinologists, diabetes educators, obstetric fellows, O & G registrars, midwives, dieticians and physiotherapists.

4. Guideline
4.1 GDM Education
All women with a new diagnosis of gestational diabetes (GDM) will be provided with education about management of the condition in either a group multidisciplinary session or if more appropriate in individual one to one appointments. The education covers: the importance of GDM, its implications, need for management education in home blood glucose monitoring initial dietary and exercise advice and long-term follow-up All women with GDM will be provided a glucose meter, a diary in which to record their blood glucose levels (BGLs), written information about GDM and dietary information. They will need to register with NDSS (National Diabetes Services Scheme) in order to purchase glucose strips and lancets at a discounted price.

GDM Group Education

GDM Group Education is scheduled every Friday morning. Women (and their partners) are seen in a small group of up to 6 patients by a Credentialed Diabetes Educator (CDE), a dietician and a physiotherapist.

GDM One to One Education

Education is provided to non-English speaking women, women with special needs or women who are unable to attend the group session. There are a series of individual appointments with the Team CDE, dietician and physiotherapist.

4.2 Antenatal Care in Team Clinics

Women with GDM will remain under the care of their Team unless they meet any of the high risk criteria (See Table 1 in Appendices) which would indicate that their care should be transferred to the Diabetes Clinic. Note women with GDM are ineligible for Shared Care. It is the responsibility of Team Leaders to ensure that women with GDM are seen by an appropriately experienced doctor or midwife. At each antenatal visit, a routine antenatal check should be performed. The womans blood glucose diary should be examined to assess glycaemic control.
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Diabetes Mellitus: management of gestational diabetes

The range of BGLs pre breakfast and two hours after each meal should be recorded in the antenatal notes at each visit and the number of BGLs outside of the target range at each time point each week. Women should also be asked about their current exercise and diet and whether they have had any contact with their team CDE since the last visit. The team CDE will be available to review the patient on the same day if: glycaemic control is sub-optimal (2 or more fasting BGLs 5.0mmol or 2 or more 2 hour postprandial BGLs 6.7 mmol in the past week) there is poor compliance with blood glucose testing the patient has other questions about GDM that cannot be answered by the clinician the clinician has any other concerns about the patients diabetes management HbA1c exceeds 6.0.

After consultation with the patient, the CDE will advise whether the patient should: continue their current management be reviewed by the team dietician commence insulin or metformin be reviewed by an endocrinologist (but remain in the Team Clinic) be transferred to the Diabetes Clinic.

Note: A team obstetrician can seek a consultation by an endocrinologist for a woman with GDM-related issues but does not necessitate a transfer to the diabetes services

4.3 Frequency of Team Clinic Visits

Women with GDM who do not require insulin will be seen fortnightly from the diagnosis of GDM until 38 weeks, then weekly until birthing. Women with GDM who require insulin should be seen weekly after 36 weeks. Prior to 36 weeks they need to report their BGLs to the diabetes educator weekly Consider increasing the frequency of visits if there are other complications, such as: Hypertension: pre-existing or gestational Fetal macrosomia Intrauterine growth restriction Poor glycaemic control Smokers

4.4 Glycaemic Control

All women with GDM will be instructed to monitor their BGLs four times a day. Fasting BGLs should be measured on waking in the morning. Postprandial BGLs should be measured 2 hours after the completion of a meal. The glycaemic targets are: Fasting : <5.0mmol Postprandial: <6.7mmol

In some cases, tighter or less tight glycaemic control will be advised (e.g. in the presence of IUGR or fetal macrosomia). This should be clearly documented in the patients medical record as well as in their monitoring diary.

4.5 Maternal Investigations

At the first antenatal visit following the diagnosis of GDM: o HbA1c o Renal function tests (creatinine, uric acid, U&E) o Spot urine albumin/creatinine ratio The HbA1c repeated at 36 weeks.
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Diabetes Mellitus: management of gestational diabetes

Investigations should then be repeated according to clinical need.

4.6 Fetal surveillance

Ultrasound:
An ultrasound to assess fetal growth in all women with GDM at approx 32-34 weeks. (This ultrasound should be booked at the first antenatal visit following the diagnosis of GDM by the clinician reviewing the th patient in the Team Clinic. If the estimated fetal weight (EFW) is above the 80 centile at 32 34 weeks th OR the abdominal circumference (AC) is above the 95 centile, an additional scan at 36-37 weeks may be indicated to assist with the decision regarding timing and mode of birthing (unless an elective Caesarean section is already planned due to other factors) (see below). More frequent ultrasound examination, including umbilical artery blood flow measurement, may be indicated if there are additional complicating factors including intrauterine growth restriction, pre-eclampsia or hypertension.

Cardiotocography
Cardiotocography should be performed weekly from 40 weeks gestation in the absence of complicating factors. Earlier and more intensive fetal monitoring (more frequent CTG, Doppler flow studies, biophysical profiles) may be indicated in the presence of the above complication or a reduction in fetal movements Fetal movements: Women should be asked about fetal movements at every visit and advised to present to hospital if there are concerns about fetal movements.

4.7 Labour and birth

Timing
In patients with optimal glycaemic control and no complicating factors (see above) birthing should be considered at 40-41 weeks, with the mode depending on obstetric factors. Insulin of itself is not an indication for earlier birthing. If an elective Caesarean section is to be performed, this should be at 39 weeks. Patients with one of the complicating factors mentioned above should be delivered at 38-39 weeks, or earlier if indicated.

Birthing Mode
If the estimated fetal weight at the time of birthing is <4,000 g, vaginal birthing is usually appropriate unless there are other obstetric indications for Caesarean section. If the estimated fetal weight at the time of birthing is >4,250 g, elective Caesarean section should be strongly considered because of the risk of shoulder dystocia. If the estimated fetal weight at the time of birthing is 4,000 - 4,250 g, the decision about the route of birthing should be discussed with the patient taking into account the risks for the particular patient.

Glycaemic Control
Women with GDM not requiring insulin should continue to have their blood glucose measured 4 hourly intrapartum. Women requiring postprandial insulin may require a sliding scale during labour. They should have 2 hourly BGLs throughout labour. This should be discussed with the CDE, obstetric medicine fellow or on-call endocrinologist.

4.8 Postnatal Care

Cease all insulin immediately following birth. Blood glucose monitoring should continue twice daily (either fasting or 2 hour postprandial measurements) for 48 hours. If fasting blood glucose is <6 and 2hr post prandial blood glucose is <8, cease monitoring. If blood
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Diabetes Mellitus: management of gestational diabetes

glucose levels exceed these targets, the Team CDE should be contacted. The infant of a woman with GDM should be managed according to the infant GDM Clinical Guideline.

4.9 Follow-up
A standard 75g Oral Glucose Tolerance Test (OGTT) should be performed 6-8 weeks postnatally, using WHO non-pregnant criteria for diagnosis of impaired glucose tolerance or diabetes mellitus.

5. Evaluation, monitoring and reporting of compliance to this guideline

Compliance with this guideline will be monitored, evaluated and reported through the team leaders management meeting. Compliance may be measured by review of incidents, and / periodically auditing the compliance with the guideline. Comprehensive data will be monitored of all GDM pregnancies.

6. Further reading
Crowther CA, Hiller JE, Moss JR, et al. Effect of treatment of gestational diabetes on pregnancy outcomes. N Engl J Med 2005; 352:2477-2486 http://content.nejm.org/cgi/content/full/352/24/2477 Hoffman L, Nolan C, Wilson JD, et al. Gestational diabetes mellitus management guidelines. The Australasian Diabetes in Pregnancy Society. Med J Aust 1998; 169: 93-97 http://www.mja.com.au/public/issues/jul20/hoffman/hoffman.html McIntyre H David, Cheung N Wah, Oats Jeremy J N, David Simmons. Gestational diabetes mellitus: from consensus to action on screening and treatment Med J Aust 2005; 183 (6): 288-289. [Editorials] http://www.mja.com.au/public/issues/183_06_190905/mci10646_fm.html RANZCOG. Diagnosis of gestational diabetes mellitus, 2006 http://www.ranzcog.edu.au/publications/statements/C-obs7.pdf Schaefer-Graf UM, Kjos SL, Fauzan OH, et al. A Randomized Trial Evaluating a Predominately Fetal Growth Based Strategy to Guide Management of Gestational Diabetes in Caucasian Women. Diabetes Care. 2004; 27: 297-302. Schaefer-Graf UM, Wendt L, Sacks DA, et al. How many sonograms are needed to reliably predict the absence of fetal overgrowth in gestational diabetes mellitus pregnancies?. Diabetes Care. 2011; 34: 39(5). Wrath: 1991 MJA article by FIR Martin

7. Legislation/Regulations related to this guideline

No legislation or regulations related to the guideline

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Diabetes Mellitus: management of gestational diabetes

8. Appendices
Appendix 1: Table 1 Criteria for transfer of GDM to Diabetes Clinic
Definite Diagnosis prior to 18 weeks HbA1c >6.5% Women requiring high dose of insulin >40 units total daily dose and poor control Fasting BGL >7 or 2-hour post-prandial >11.1 on OGTT Previous adverse outcomes related to GDM (e.g. otherwise unexplained FDIU or intrapartum stillbirth in women with GDM; previous significant shoulder dystocia in macrosomic baby in GDM pregnancy) Relative Macrosomic baby in current pregnancy (EFW >95 centile) consider referral Clinician concerns: The presence of GDM with any other complicating factor should be considered by the clinician and, if deemed appropriate after discussion with Diabetes Educator, consider transfer to the Diabetes Clinic or seeking a secondary consultation with an endocrinologist
th

Appendix 2: Procedure following confirmation of GDM on a 75g OGTT

RWH Pathology will forward all positive OGTT results to the diabetes educators who will separate the results into each team. The diabetes educator attached to the individual teams will follow up and action the results: Review the patients future clinic appointments and ensure that the patients next appointment is within two weeks and that the appointment is with a clinician within their own Team who has completed the Diabetes Service GDM Training Program for health care professionals.. Make an appointment for English speaking women in the Friday GDM Group Education Session, or if not English speaking, or individual needs, a one-to-one session with the Team Diabetes Nurse Educator, dietician and physiotherapist. The team diabetes educator to phone the women and o advise them of the positive OGTT result o and of their next appointment date/time Credentialed Diabetes Educator (CDE) At the initial education session, all women will be provided with the contact details and best contact time, of their Team CDE and asked to ring her/him within one week to discuss their self-blood glucose testing results. A CDE will be available to take calls from all women with GDM at any time during business hours but women are encouraged to ring on the day that their Team CDE is available to receive telephone calls. The CDE will be available on Team Clinic day to support clinicians and patients in the management of their GDM, including advice to continue current management be reviewed by the Team dietician commence insulin be reviewed by an endocrinologist (but remain in the Team) be transferred to the Diabetes Clinic.

The management of these women (including indication for Endocrinology review or transfer to Diabetes Clinic) will be guided by the CPG, Diabetes Mellitus: Management of Gestational Diabetes.
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The Team CDE will attend the Team Clinic Meeting, when possible, to facilitate multidisciplinary communication about complex patients. Dietician

Women who attend the group education session will also be given an appointment with their Team dietician for individualised diet counselling within 2 weeks of their initial education session. Appendix 3: Diabetes Clinic Care
The diabetes clinic is a multidisciplinary clinic and is specifically designed for the management of women with pre-gestational diabetes during pregnancy and women with complex GDM. Women who are seen in the Diabetes Clinic remain affiliated with their Team for inpatient and postnatal care. The Team CDE will provide regular feedback to Teams about women who are seen in the Diabetes Clinic via the weekly Team meetings. Women with GDM who meet the criteria for care in Diabetes Clinic should be referred by the Team clinician (or Team CDE after consultation with the patients primary Team clinician or Medical team leader) using the internal referral form. The team CDE is available to discuss the appropriateness of transfers at all times. The Diabetes Clinic Co-ordinator is responsible for triaging referrals to the Diabetes Clinic. New patients transferred to the Diabetes Clinic will be seen by an Obstetrician, Endocrinologist, Dietician, and a multidisciplinary management plan devised.

Initial Assessment of women with complex GDM in Diabetes Clinic At the first visit following referral from a team clinic, all complex GDM women will generally be reviewed by: Dietician Endocrinologist Obstetrician.

A routine antenatal check will be performed and a clinical consultation regarding her diabetes. The need for insulin or a more intensive treatment regimen will be determined by the multidisciplinary team. The frequency of subsequent visits will be tailored to the clinical need. Women with early onset GDM (diagnosed prior to 18 weeks) should undergo more regular fetal growth surveillance (i.e. every 3-4 weeks during the third trimester). Frequency of visits The frequency of visits for women who require Diabetes Clinic multidisciplinary care will vary according to the gestation at diagnosis and complexity but in general will be 3 weekly until 30 weeks, fortnightly until 34 weeks and weekly thereafter.

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