Mellitus: Management of Gestational 1. Purpose The Women s is committed to the provision of best practice evidence based multidisciplinary care for women with gestational diabetes. This Guideline outlines the requirement for the management of women with gestational diabetes (GDM) at the Women s. 2. Definitions GDM is any degree of glucose intolerance with the onset or first recognition during pregnancy. 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 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, dietitians and physiotherapists. For further information see the appendices: Appendix 1: Table 1 The criteria for transfer of women with GDM to Clinic. All other women are cared for within their Team. Appendix 2: Procedure following confirmation of GDM on a 75g OGTT Appendix 3: Clinic Care. 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 either in a group multidisciplinary session or if more appropriate, in one-to-one appointments. The education covers: The importance of GDM, its implications, need for management Education in self-blood glucose monitoring Initial dietary and exercise advice Long-term follow-up. All women with GDM will be provided a glucose meter, a diary in which to record their blood glucose levels (BGL s), written information about GDM and dietary information. They will need to register with the NDSS (National 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 small groups of up to 6 patients by a Credentialed Educator (CDE), a dietitian and a physiotherapist. GDM One to One Education Education is provided individually to non-english speaking women, women with special needs or women who are unable to attend the group session. These are a series of individual appointments with the Team CDE initially, with later appointments with a dietitian 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 Appendix 1: Table 1 Criteria for transfer of GDM to Clinic) which would indicate that their care should Uncontrolled document when printed Publication date (10/12/2012) Page 1 of 9
Mellitus: Management of Gestational be transferred to the Clinic. Note: women with GDM are ineligible for routine Shared Maternity Care. If a woman undertaking Shared Maternity Care is diagnosed as having GDM, the Shared Maternity Care Coordinator needs to be notified in order to notify the woman s Shared Care Provider. It is the responsibility of Team Leaders to ensure that women with GDM are seen by an appropriately experienced doctor. At each antenatal visit, a routine antenatal check should be performed. The woman s blood glucose diary should be examined to assess glycaemic control. The range of BGL s pre-breakfast and two hours after each meal should be recorded in the antenatal notes at each visit. In addition, the number of BGL s outside the target range at each time point each week should also be recorded. Women should also be asked about their current exercise/activity 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 BGL s 5.0mmol or 2 or more 2 hour postprandial BGL s 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 patient s diabetes management HbA 1 C 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 Dietitian Commence insulin or metformin Be reviewed by an endocrinologist (but remain in the Team Clinic) Be transferred to the Clinic. Note: A Team Obstetrician can seek a consultation by an endocrinologist for a woman with GDM-related issues; this does not necessitate 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 initial 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 should report their BGL s to the Educator weekly. Consider increasing the frequency of visits if there are other complications or risk factors, 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 BGL s four times a day. Fasting BGL s should be measured on waking in the morning. Postprandial BGL s should be measured 2 hours after the completion of a meal. The glycaemic targets are: Fasting : <5.0mmol Uncontrolled document when printed Publication date (10/12/2012) Page 2 of 9
Mellitus: Management of Gestational Postprandial: <6.7mmol HbA1c: within the normal range 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 patient s medical record as well as in their monitoring diary. 4.5 Maternal Investigations At the first antenatal visit following the diagnosis of GDM the following investigations are required: HbA 1 C Spot urine albumin/creatinine ratio The HbA 1 C is to be repeated at 36 weeks. Investigations should then be repeated according to clinical need. 4.6 Fetal surveillance Ultrasound An ultrasound to assess fetal growth is required in all women with GDM at approximately 32-34 weeks. This ultrasound should be booked at the first antenatal visit following the diagnosis of GDM by the clinician reviewing the patient in the Team Clinic. If the Estimated Fetal Weight (EFW) is above the 80 th centile at 32 34 weeks OR the Abdominal Circumference (AC) is above the 95 th 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 (CTG) Routine 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 Pre-labour, 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. Uncontrolled document when printed Publication date (10/12/2012) Page 3 of 9
Mellitus: Management of Gestational Glycaemic Control See Appendix 3: Clinic Care for the Management of gestational diabetes during labour and birthing. Women requiring postprandial insulin may require a sliding scale during labour. They should have 2 hourly BGL s throughout labour. This should be discussed with the CDE, obstetric medicine fellow or on-call endocrinologist. Management of GDM having LUSCS Usual insulin day and night prior Fast from midnight Withhold insulin morning of surgery; check blood glucose. 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 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 woman s GP should be notified as part of her discharge summary about the diagnosis of her GDM and asked to organise a follow-up 75g Glucose Tolerance Test (GTT) at 6-8 weeks postpartum using WHO non-pregnant criteria for impaired fasting glucose. 5. Evaluation, monitoring and reporting of compliance to this guideline Compliance with this Guideline will be monitored, evaluated and reported through the Team leader s management meeting. Outcomes will be measured by review of incidents, and / periodically auditing the compliance with the Guideline. Comprehensive data will be monitored for all GDM pregnancies. 6. Further reading/ References 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 in Pregnancy Society. Med J Aust 1998; 169: 93-97 http://www.mja.com.au/public/issues/jul20/hoffman/hoffman.html McIntyre HD, Cheung NW, Oats Jeremy JJ, Simmons D. 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 growthbased strategy to guide management of gestational giabetes in Caucasian women. 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? Care. 2011; 34: 39(5). Martin FIR for the Ad Hoc Working Party. The diagnosis of gestational diabetes. MJA 1991; 155: 112 7. Legislation/ Regulations related to this guideline No legislation or regulations related to the Guideline. Uncontrolled document when printed Publication date (10/12/2012) Page 4 of 9
Mellitus: Management of Gestational 8. Appendices Appendix 1: Table 1 The criteria for transfer of women with GDM to Clinic. All other women are cared for within their Team. Appendix 2: Procedure following confirmation of GDM on a 75g OGTT Appendix 3: Clinic Care Appendix 4: Management of Gestational During Labour and Birthing PGP Disclaimer Statement The Royal Women's Hospital Clinical Guidelines present statements of 'Best Practice' based on thorough evaluation of evidence and are intended for health professionals only. For practitioners outside the Women s this material is made available in good faith as a resource for use by health professionals to draw on in developing their own protocols, guided by published medical evidence. In doing so, practitioners should themselves be familiar with the literature and make their own interpretations of it. Whilst appreciable care has been taken in the preparation of clinical guidelines which appear on this web page, the Royal Women's Hospital provides these as a service only and does not warrant the accuracy of these guidelines. Any representation implied or expressed concerning the efficacy, appropriateness or suitability of any treatment or product is expressly negated In view of the possibility of human error and / or advances in medical knowledge, the Royal Women's Hospital cannot and does not warrant that the information contained in the guidelines is in every respect accurate or complete. Accordingly, the Royal Women's Hospital will not be held responsible or liable for any errors or omissions that may be found in any of the information at this site. You are encouraged to consult other sources in order to confirm the information contained in any of the guidelines and, in the event that medical treatment is required, to take professional, expert advice from a legally qualified and appropriately experienced medical practitioner. NOTE: Care should be taken when printing any clinical guideline from this site. Updates to these guidelines will take place as necessary. It is therefore advised that regular visits to this site will be needed to access the most current version of these guidelines. Uncontrolled document when printed Publication date (10/12/2012) Page 5 of 9
Appendix 1 Criteria for Transfer of GDM to Clinic Table 1 Criteria for transfer of GDM to Clinic Definite Diagnosis prior to 18 weeks HbA 1C>6.5% Women requiring high dose of insulin >40 units total daily dose and/or poor control Fasting BGL >7 or 2-hour post-prandial >11.1 on GTT 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 th 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 Educator, consider transfer to the Clinic or seeking a secondary consultation with an endocrinologist Uncontrolled document when printed Publication date (10/12/2012) Page 6 of 9
Appendix 2 Procedure Following Confirmation of GDM on a 75g GTT Procedure following confirmation of GDM on a 75g GTT RWH Pathology will forward all positive OGTT results to the Educators who will separate the results into each Team. The Educator attached to the individual Teams will follow up and action the results: Review the patient s future clinic appointments and ensure that the patient s next appointment is within two weeks and that the appointment is with a clinician within their own Team who has completed the Service GDM Training Program for health care professionals. Make an appointment for English-speaking women in the Friday GDM Group Education Session, or if non- English speaking, or with individual needs, a one-to-one session with the Team Nurse Educator, Dietitian and Physiotherapist. The Team Educator to phone the women and: Advise them of the positive GTT result and Their next appointment date/time. The Team Educator will notify the shared care coordinator if the woman has been diagnosed with GDM and no longer eligible for shared care. Credentialed 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 Dietitian Commence insulin Be reviewed by an endocrinologist (but remain in the Team) Be transferred to the Clinic. The management of these women (including indication for Endocrinology review or transfer to Clinic) will be guided by the CPG, Mellitus: Management of Gestational. The Team CDE will attend the Team Clinic Meeting, when possible, to facilitate multidisciplinary communication about complex patients. Dietitian Women who attend the group education session will also be given an appointment with their Team Dietitian for individualised diet counselling within 2 weeks of their initial education session. Uncontrolled document when printed Publication date (10/12/2012) Page 7 of 9
Appendix 3 Clinic Care Clinic Care The 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 seen in the 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 Clinic via the weekly Team meetings. Women with GDM who meet the criteria for care in Clinic should be referred by the Team Clinician (or Team CDE after consultation with the patient s 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 Clinic Coordinator is responsible for triaging referrals to the Clinic. New patients transferred to the Clinic will be seen by an obstetrician, endocrinologist, dietitian, and a multidisciplinary management plan devised. Initial Assessment of women with complex GDM in Clinic At the first visit following referral from a Team clinic, all complex GDM women will generally be reviewed by: Dietitian 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 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. Uncontrolled document when printed Publication date (10/12/2012) Page 8 of 9
Appendix 4 Management of Gestational During Labour and Birthing Management of gestational diabetes during labour and birthing Diet treatment for DGM - usual monitoring practices during labour GDM treated with insulin - overnight insulin: normal Protaphane dose prior to labour Usual monitoring during labour Pre-meal insulin: usual overnight insulin Morning: light breakfast, half usual insulin Usual management until in established labour ->2-hourly BG and sliding scale during labour Daily insulin dose <40 units Blood glucose mmol/l NovoRapid s/c 0-5.5 nil 5.6-7.0 2 units 7.1-10.0 4 units 10.1-13.0 8 units >13.0 8 units and call RMO Daily insulin dose >40 units Blood glucose mmol/l Novorapid s/c 0-5.5 Nil 5.6-7.0 4 units 7.1-10.0 6 units 10.1-13.0 8 units >13.0 10 units and call RMO Uncontrolled document when printed Publication date (10/12/2012) Page 9 of 9