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Women with diabetes who are planning to become • Women with pre-existing diabetes mellitus must be
pregnant and their families should be offered information screened for diabetic end-organ damage (retinopathy,
on how diabetes affects pregnancy and how pregnancy nephropathy and cardiovascular disease)
affects diabetes. • Retinopathy screening is recommended at least twice
Discuss their plans for pregnancy and reinforce an appropriate during pregnancy (at first contact and at 28 weeks).
contraceptive method. Any type of contraception can be used • Women with serum creatinine >120 ~mol/litre or 24
except for women BMI > 25kg/m2 where DMPA should not hour urinary protein excretion exceeding 300mg must
be used. Pregnancy is contraindicated if the woman has be referred for renal specialist’s advice.
proliferative retinopathy, stage 2 or above chronic kidney
• Women with complicated diabetes should be managed
disease or major cardiac disease.
at a tertiary care institution by a multidisciplinary
All women with diabetes wishing to conceive MUST be team.
encouraged to seek specialist advice to ensure satisfactory
glycaemic control (HbA1c < 6.1%) before conception.
Ideally the decision to embark on pregnancy in known
Antenatal Appointments
diabetics should be decided on based on her HbA1. A • These women must be identified as high risk and
value of 6.1 or below would be ideal if safely achievable. managed almost entirely by a specialist Obstetrician
Women whose levels are above 10% should be strongly led team.
advised against conception until good glycaemic control • Public Health Midwife should visit such women once
is achieved, in view of higher risk of congenital anomalies. in every 2 weeks (refer guideline on domiciliary care
Stress that good planning and control will help to for high risk pregnancies).
achieve pregnancy outcome to be equivalent to that of • Review by the obstetric/diabetic team once every 2
a non-diabetic women. They should be informed that weeks throughout the pregnancy
establishing good glycaemic control before conception
and maintaining this throughout pregnancy will reduce • Anomaly scans at 18-20 weeks and Obstetric reviews
the risk of miscarriage, congenital malformation, still at 22-24, 28, 32 and 36-37 weeks with ultrasound
births and neonatal deaths. growth assessments.
Women who are using either metformin or insulin • If required, antenatal steroids for fetal lung maturity
for glycaemic control should be advised that these are may be used. Women should be admitted to hospital
safe for use during the peri-conception period and into for glycaemic control during therapy since glucose
their pregnancy. Self-testing of blood sugar should be levels rise in response to steroids.
encouraged wherever economically feasible. • More attention should be given to the woman with
Women must be encouraged to achieve a normal weight diabetes during antenatal preparation for breast
before becoming pregnant, especially those with a body feeding as they need to start and establish breast
mass index above 25 kg/m’- They must receive advice feeding quickly to prevent hypoglycaemia of
about reducing weight using lifestyle modification. newborn.
Known diabetics should be assessed for diabetic • Refer to dental surgeon for screening and maintenance
nephropathy and retinopathy before and during of oral hygiene.
4.3 Medical nutrition therapy (MNT) insulin combined with a single dose of basal insulin at bed
time is required. However, twice-daily dose of pre mixed
MNT is the cornerstone of the management of diabetes
30:70 insulin has better patient compliance with adequate
in pregnancy. Women must be referred to a dieticianj
control of blood sugar in most cases. If blood sugar is not
diabetic educator nurse where one is available.
controlled by this twice-daily regimen, adding metformin
Emphasise the importance of small frequent meals, food or soluble insulin to cover lunch is an alternative.
with low glycaemic index. Dietary advice should be
culture sensitive. Use of ACE inhibitors, statins and ARBs are
contraindicated during pregnancy
4.4 Exercise
5.2 Monitoring of glycaemic control
Exercise has an insulin-like action and women with
GDM and pre-existing diabetes complicating pregnancy. Self-monitoring of blood glucose (SM BG) with close liaison
Therefore, diabetic women must be encouraged to engage with the diabetic team is recommended for those who are
in regular exercise. able to afford a glucometer and test strips. (However,
in view of variable quality of glucometers women must
The intensity of exercise would depend on the woman’s
be advised to crosscheck the values occasionally with
level of fitness, presence of complications and familiarity
estimations made by a reliable laboratory.
with exercise.
For women who cannot afford the cost of 5MBG,
Ideally this should be at least 30 minutes per day of an
monitoring with regular 6 point blood glucose monitoring
activity, which leaves her slightly breathless.
should be offered.
Women on insulin must be aware of the tendency to
The frequency of such monitoring should be decided by
hypoglycaemia and dehydration during exercise.
the overall glyceamic control, presence or absence of fetal
macrosomia and the period of gestation;: with at least four
weekly reviews in pregnancy two weekly reviews in late
5. Glyceamic control and Monitoring pregnancy.
5.1 Glyceamic Control Schedule ultrasound measurement of AC at 28, 32 and
5.1.1 The aim is to achieve optimum glycaemic control 36 weeks. If AC > 90 centile at any stage, consider insulin
throughout the day for the duration of the pregnancy therapy to target 2 hour PPBS to be less than 100mg/dl but
(avoiding hypoglycaemia) avoiding hypoglycaemia.
The target values for glycaemic control are given below: If crossing centiles or AC <10 centile, do AFI and request
obstetrician review.
Table 2. Target values in glycemic control Insulin requirements change throughout the pregnancy. If
Fasting and pre- 2 hour post meal requirements are falling (or maternal
meal hypoglycaemia occurs frequently) request early
Venous plasma 70 - 90 mgjdl (3.9 Below 120 mgjdl obstetrician review for fetal assessment.
- 5.0 mMol/L) (6 .7 mMol/L)
HbA1c< is not a reliable indicator of glycaemic control in
Capillary blood 80 - 103 mgjdl (4.4 118 mgjdl (6.5 the second and third trimesters.
- 5.7mMol/L) mMol/L)
(The equivalent capillary blood values were derived
using a conversion formula7) 6. Delivery and intra natal care
6.1 Timing of delivery
Refer the mother to a Diabetic Educator Nursing Officer For women with pre-pregnancy diabetes or who receive
(DENa) where one is available. insulin therapy, schedule obstetrician review at 36-37
At diagnosis, offer dietj lifestyle advice with a recorded weeks for planning their delivery at 38-39 weeks.
glycaemic assessment within 1-2 weeks. For women on diet control and/or women having optimal
Majority of these women can achieve optimal glycaemia glycaemic control and, carrying a normally grown baby,
with modest changes in diet and exercise. Consider insulin there is insufficient evidence to suggest the best time for
and /or metformin treatment if suboptimal glycaemia delivery.
persists despite diet and exercise modifications. The Diabetes alone is not an indication for a caesarean section.
choice of these treatments will depend on physician and The obstetrician should make the decision after discussing
patient preferences. with the woman.
Ideally the insulin regimen should be adjusted to Delivery should be arranged in the day time, when all
achieve targets: in most cases with moderate to severe supports are more easily available.
hyperglycaemia three doses of short acting pre prandial
andmanagement. Diabetes 1991;40(December (Suppl. Organization and National Diabetes Data Group
2)):18-24. procedures to detect abnormalities of glucose tolerance
5. Gough WW, Shack MJ, Bennett PH, Burch TA, Miller during pregnancy. Diabetes Care 1994;17(November
M.Evaluation of glucose in the Pima Indians by (11)):1264-8.
longitudinal studies. Diabetes 1970;19(Suppl. 1):388. 7. Haeckel R., Brinck U, Colic D. et aI., Comparability of
6. Pettitt DJ, Bennett PH, Hanson RL, Narayan Blood Glucose Concentrations Measured in Different
KM, KnowlerWC. Comparison of World Health Sample Systems for Detecting Glucose Intolerance.
Clinical Chemistry 2002.48: (6); 936-939