ANMC Womens Health Service Diabetes Mellitus in Pregnancy Screening and
Management Guidelines
Page
1 Introduction 2
2 Screening Procedures 2
3 Diagnosis of Gestational Diabetes 3
4 Management Categories of Gestational diabetes
3
5 Management - Class A-1 diet controlled
4
6 Management - Class A-2, pre-gestational, Class B and above
6
7 Postpartum Management 9
8 Family Planning and Future Pregnancy Consideration 10
9 Preconception counseling 10
10 Care of the Newborn and child 11
11 Learn more and test your knowledge of diabetes in pregnancy
11 while you earn FREE CEU / CMEs
12 Summary of recommendations 11
13 Other recommendations 11
14 References 13
15 Appendix
A: Alternative Options for Screening
15
16 Appendix B: Diabetes Predating Pregnancy White Classification
15
17 Appendix C: BMI table here 16
18 Appendix D: ANMC Pediatric Department Hypoglycemia Guidelines 16
19 Appendix E: Gestational Diabetes Traditional Foods Meal Plan with Milk
17
20 Appendix F: Exercise guidelines to improve glucose control
18
ANMC Womens Health Service
Diabetes Mellitus in Pregnancy
Screening and Management Guidelines
I Introduction
In the last 2 generations diabetes in pregnancy has increased
significantly 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 patients lives
II Screening Procedures
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
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-hour later
3 A venous serum or plasma glucose level of 140 mg/dL or
greater at one hour constitutes a positive screen
D Initial Screen, High Risk Patients
1 High risk patients include those with the following
factors:
a history of infant over 8 lb14oz 4000 grams at
birth;
b first degree family history of diabetes parents or
sibling;
c initial visit BMI 25 BMI kg/m2 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 high risk screen is normal, repeat at 24 weeks
4 If any screen is abnormal then repeat at 24-28 and 32
weeks
5 If the patient has one abnormal value on the OGTT, then the
patient should have a repeat OGTT in 4 weeks See also
MNT for one abnormal value, below
6 One-step testing is recommended in some American Indian /
Alaska Native groups One step testing could be completed
with a 100 gm 3 hr OGTT
III Diagnosis of Gestational Diabetes
All patients with a positive screen one hour 140 mg/dL should be
given a 3 hr OGTT
with a 8-14 hour fast after 3 days of unrestricted carbohydrate diet
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 or more values at or above the following make the diagnosis
of gestational diabetes
time plasma glucose mg/dL
fasting 105
one hour 190
two hours 165
three hours 145
Other diagnostic criteria have been suggested by various professional
organizations, eg, 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 have an increased risk of macrosomia In these patients,
Medical Nutrition Therapy MNT is suggested If the patient has
one abnormal value on the OGTT, then the patient should have a
repeat OGTT in 4 weeks
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, eg, intercurrent
illness
IV Management Categories of Gestational Diabetes
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
Class Fasting Glucose Level 2 hr Post prandial
Glucose
A-1 105 mg/dL and 120 mg/dL
A-2 105 mg/dL and/or 120 mg/dL
A Class A-1 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 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 Management - Class A-1 diet controlled
A Exercise:
The patient should receive an exercise consult In the meantime
the patient should be encouraged to exercise at least 3-4 times
weekly for 20 - 30 minutes per session Brisk walking is ideal
Please note this is a Level A Recommendation
Moderate exercise of 60-150 minutes per week
divided 3x / wk improves
glucose control See Appendix F: Exercise
guidelines to improve
glucose control
B Diet:
Please note: These are general recommendations
Your, or your nutrition counselor, should individualize these
recommendations
to the reality of each specific patients home environment
The 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 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
Traditional native diet include: muktuk, hooligan,
oogruk-
air-dried
bearded seal meat, oogruk oil, dried salmon, walrus
meat, walrus
skin, walrus fat, bowhead whale meat and fat
See Appendix E: Gestational Diabetes Traditional
Alaskan Foods
Meal Plan with Milk
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 25 not over 22 lbs
c these goals should be maintained without ketosis, if
ketones are
noted, have patient check urine QID x1-2 days and
report results;
d pregnancy is not the time for weight loss
7 Sugar substitutes are considered Generally safe in
pregnancy
C 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 this is a Level A
Recommendation
Moderate exercise of 60-150 minutes
per week divided 3x / wk improves
glucose control See Appendix
F: Exercise guidelines to improve
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
A Glucose goals
Major goals of management should be maintenance of
glucose at
a fasting whole
blood 95 mg/dL,
or
b 1 hour post prandial whole blood 130-140
mg/dL
or
c 2 hour post prandial whole blood 120 mg/dL
B Periodic lab work
Women with BMI 30 treated with diet restriction only
-ketone measurement may be helpful
Otherwise there is no role for
routine urine testing
7 Ultrasound for precise dating prior to 18 weeks in
combination with careful clinical dating
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
D Intrapartum Management:
Alaska Native Medical Center ANMC OB-GYN department recommends
transfer of any pregnant woman with GDM at 37 weeks not
controlled within the above parameters In situations where
exceptions are made, specific consultation on labor management
is advised
VI Management - Class A-2, pre-gestational, Class B and
above
Classification
-Patients with an abnormal OGTT should receive a 2-week trial of
medical nutrition therapy MNT
If after a trial of MNT, FBS 105 mg/dL or 2 hour PPBS 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 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
c Serum Creat and BUN
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
4 Split doses of short and intermediate fasting insulin
should be given
twice daily; two-thirds of the days
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
A common approach is to start with the following
doses,
based on actual body weight
First trimester 08Units/ kg
Second trimester 10 Units/ kg
Third trimester 12 Units/ kg
5 Another common formula for initiating therapy is:
- 20u NPH and 10u Regular insulin 30 minutes before
breakfast, or Lispro insulin immediately before
breakfast
- 5-10u Regular 30 minutes before, or Lispro immediately
before meals,
- 7u NPH at supper
- Another helpful approach is to administer the NPH
insulin at 9-10 pm to decrease fasting glucose
- Doses should be increased prn to keep glucose 95 mg/dL
fasting and 120 mg/dL 2
hours post prandial
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 2nd and 3rd
trimesters of pregnancy 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
randomized and controlled manner
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 month 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
3 Periodic lab work
a Serum quad testing should be offered at 15-20 weeks
b Fetal echocardiogram at 18-24 weeks
4 US to be repeated q 4-6 weeks to monitor fetal growth,
eg, AC 70th percentile
5 Fetal well-being assessment
a daily fetal movement count starting at 32 weeks;
b non-stress testing NST should be considered, though
little data supports its benefit
Low risk: if good control, no hypertension or
vasculopathy, no
Stillbirth, then
-NST weekly starting at 34 weeks,
High risk if poor control, hypertension,
vasculopathy,
previous
stillbirth, then
-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
-For women with DM in pregnancy 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
7 Intrapartum Insulin
The goal of intrapartum insulin therapy is maternal and
fetal euglycemia with a maternal glucose 60-90 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 taken her usual am
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 Bolus Insulin Drip
65 mg/dL —– 00 unit insulin /
hr
65-99 mg/dL —– 05 unit insulin /
hr
100-125 mg/L 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 Postpartum Management
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, eg, 70, of
GDM patients will become overtly
diabetic, 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 Pre-diabetes: 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 Type II
diabetes
6 The more sensitive test is a 75 gm 2 hour OGTT, but a
fasting glucose
can be diagnostic if elevated on two occasions
The OGTT test requires the use of a glucose load
containing the
equivalent of 75 gm anhydrous glucose dissolved in
water
7 The patient may also be diagnosed with classic symptoms
of DM and a
casual random glucose 200 mg/dL
8 Outside of pregnancy the laboratory criteria for
diabetes mellitus
and pre-diabetes are:
Pre-diabetes
Normal Impaired Fasting Diabetes
Glucose IFG mellitus
or Impaired Glucose
Tolerance IGT
FPG 110 mg/dL FPG 100 -125mg/dL FPG 126 mg/ dL
2-h PG 140 mg/dL 2-h PG 140-199 mg/dL 2-h PG 200 mg/dL
A diagnosis of diabetes must be confirmed on a subsequent day by any of
the methods
DM also can be diagnosed by symptoms of DM and casual plasma glucose
concentration 200
mg/dl
http://carediabetesjournalsorg/cgi/content/full/27/suppl_1/s5
VII Family Planning and Future Pregnancy Consideration:
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 Preconception counseling
1 Weight loss and tight glycemic control should be in
effect 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 GDM patient 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
04 - 08 mg / day 1 mg might be easier beginning
at least 1 month prior to
conception and continuing through the first
trimester, to reduce the risk of
neural tube defects
-Those with a previous infant with neural tube
defects should take 4 mg
IX Care of the Newborn and child:
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 babys 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
X Learn more and test your knowledge of diabetes in
pregnancy while you earn FREE CEU /CMEs
Diabetes in Pregnancy: Screening and Diagnosis Module
http://wwwihsgov/MedicalPrograms/MCH/M/DP01cfmtop
Diabetes in Pregnancy: Management and Postpartum Module
http://wwwihsgov/MedicalPrograms/MCH/M/DP21cfmtop
Summary of
recommendations
Whole Blood glucose monitoring recommendations
Fasting glucose levels less than 95 mg/dL Level C
1 hour post prandial levels less than 130 mg/dL Level
B
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
-Regular moderate exercise of 150 minutes divided 3 times a week
should be
encouraged
-Fasting and post prandial glucose levels should be monitored, eg,
as opposed to pre-
prandial levels
-All women planning pregnancy take a daily multivitamin or
multivitamin-multimineral
supplement containing folic acid at a dose of 04 - 08 mg,
beginning at least 1 month
prior to conception and continuing through the first trimester, to
reduce the risk of neural
tube defects
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
-When medical nutritional therapy has not resulted in fasting glucose
levels less than 95
mg/dL or 1-hour postprandial values less than 130-140 mg/dL or 2-hour
postprandial
values less than 120 mg/dL, insulin should be considered
-Shoulder dystocia cannot be predicted or prevented because accurate
methods for
identifying which fetuses will experience this complication do not
exist
-Elective induction of labor or elective cesarean delivery for all
women suspected of
carrying a fetus with macrosomia is not appropriate
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 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
-There are insufficient data for any reliable conclusions about the
effects of treatments for
impaired glucose tolerance on perinatal outcome
-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
-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
-In patients with a history of shoulder dystocia, estimated fetal
weight, gestational age,
maternal glucose intolerance, and the severity of the prior neonatal
injury should be
evaluated and the risks and benefits of cesarean delivery discussed
with the patient
-There is no evidence that any one maneuver is superior to another in
releasing an
impacted
shoulder or reducing the chance of injury However,
performance of the
McRoberts maneuver is a reasonable initial approach
Revised September 2004b njm
Revised January 2002 njm
Revised November 1994 njm
September 1989
References
-Alfirevic Z, Neilson JP Biophysical profile for fetal assessment in
high risk pregnancies Cochrane Review In: The Cochrane Library,
Issue 3, 2004 Chichester, UK: John Wiley Sons, Ltd Level I
http://wwwupdate-softwarecom/clibng/cliblogonhtm
-ACOG Practice Bulletin No 30 Gestational Diabetes American College
of Obstetricians
and Gynecologists Obstet Gynecol 2001;98:525-538 Level III
ACOG Members
http://wwwacogcom/publications/educational_bulletins/pb030cfm
Non-ACOG Members
http://wwwncbinlmnihgov/entrez/queryfcgi?cmdRetrievedbPubMedli
st_uids11547793doptAbstract
-ACOG Practice Bulletin No 40 Shoulder dystocia American College of
Obstetricians and Gynecologists
Obstet Gynecol 2002;100:1045-50
ACOG Members
http://wwwacogorg/publications/educational_bulletins/pb040cfm
Non-ACOG Members
http://wwwncbinlmnihgov/entrez/queryfcgi?cmdRetrievedbpubmeddo
ptAbstractlist_uids12578001
-American Diabetes Association: 2004 Clinical Practice Guidelines
Level III
http://carediabetesjournalsorg/content/vol27/suppl_1/
-Buchanan TA, Kjos SL Diabetes Mellitus Clinical Updates in Womens
Health Volume 1 No 4 Fall 2002 American College of Obstetricians
and Gynecologists Level III
http://wwwacogcom/
-Gabbe SG, Graves CR Management of diabetes mellitus complicating
pregnancy tet Gynecol 2003 Oct;1024:857-68 Level III
http://wwwncbinlmnihgov/entrez/queryfcgi?cmdRetrievedbPubMedli
st_uids14551019doptAbstract
-Meltzer S, Leiter L, Daneman D, Gerstein HC, Lau D, Ludwig S, Yale
JF, Zinman B, Lillie D Canadian Medical Association Expert Committee
Clinical Guidelines for management of diabetes in Canada CMAJ 1998;
159Suppl 8:S1-S29 Level III
http://wwwncbinlmnihgov/entrez/queryfcgi?cmdRetrievedbPubMedli
st_uids9834731doptAbstract
-Tuffnell DJ, West J, Walkinshaw SA Treatments for gestational
diabetes and
impaired glucose tolerance in pregnancy Cochrane Review In: The
Cochrane Library, Issue 3, 2004 Chichester, UK: John Wiley Sons,
Ltd
Level I http://wwwupdate-softwarecom/clibng/cliblogonhtm
-US Preventive Services Task Force 1996 Chapter 42 Screening
for Neural Tube
Defects — Including Folic Acid/Folate Prophylaxis Level III
http://hstatnlmnihgov/hq/Hquest/db/localgcpscps/screen/Browse/s/40
763/cmd/HF/action/GetText?IHRCH42CINT
-Walkinshaw SA Very tight versus tight control for diabetes in
pregnancy
Cochrane Review In: The Cochrane Library, Issue 3, 2004
Chichester, UK:
John Wiley Sons, Ltd Level I
http://wwwupdate-softwarecom/clibng/cliblogonhtm
American Indian and Alaska Native References and/or Screening
-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
http://wwwncbinlmnihgov/entrez/queryfcgi?cmdRetrievedbPubMedli
st_uids1580171doptAbstract
-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
http://wwwncbinlmnihgov/entrez/queryfcgi?cmdRetrievedbPubMedli
st_uids8610782doptAbstract
-Kim C, Newton KM, Knopp RHGestational diabetes and the incidence of
type 2
diabetes: a systematic review Diabetes Care 2002 Oct;2510:1862-8
Level III
http://wwwncbinlmnihgov/entrez/queryfcgi?cmdRetrievedbPubMedli
st_uids12351492doptAbstract
-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
http://wwwncbinlmnihgov/entrez/queryfcgi?cmdRetrievedbPubMedli
st_uids10561636doptAbstract
-Murphy NJ, Meyer BA, OKell RT, Hogard ME Carbohydrate sources for
gestational
diabetes screening: A comparison J Reprod Med 1994; 39:977-81 Level
I
http://wwwncbinlmnihgov/entrez/queryfcgi?cmdRetrievedbPubMedli
st_uids7884757doptAbstract
For other American Indian and Alaska Native References go here:
http://wwwihsgov/MedicalPrograms/MCH/M/DP36asptop
or here:
http://wwwihsgov/MedicalPrograms/MCH/M/DP13asptop
Appendix A
Alternative Options for Screening
Regional center based screening
A Give 50 g of Polycose solution Polycose is the best tolerated,
eg, 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 15 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
C 50 gram Breakfast load
Menu
Two scrambled eggs 3 oz
Two slices toast or one English muffin
Two pats of butter or margarine
8 oz orange juice
8 oz whole or skim
milk
One cup coffee or tea no sugar
Contents
Carbohydrate 52 gm 210 kcal
Protein 28 gm 110 kcal
Fat 31 gm 280 kcal
D 100 Gram Carbohydrate Test Breakfast
On the morning of the test, your breakfast must follow one of the
three breakfast
menus listed below exactly The right amount of carbohydrate is
needed for
accurate test results Take no more than half an hour to eat
breakfast Eat nothing
more until the test is over, and do not take a nap The blood sample
must be
drawn exactly two hours after you began to eat, so note the time you
started
eating Example: If you started eating breakfast at 8:00 am, be at
the lab at 9:30 am
to have your blood drawn by 10:00 am Choose one of the menus below:
Breakfast 1 Breakfast 2
cup cold cereal 10 gms 4 4 across pancakes
30 gms
not sugar coated 2 tablespoons syrup 30 gms
1 cup milk 12 gms 1 cup milk 12 gms
2 slices toast 30 gms 1 cup orange
juice or
1 tablespoon jelly 15 gms one small banana 30 gms
1 teaspoon sugar 5 gms Total: 102 gms
1 cup orange juice or
one small banana 30 gms Breakfast 3 Lemonade Mix:
Total: 102 gms cup lemon juice 4 gms
cup sugar 96 gms
1 cup water –
Total 100 gms
If you are unable to eat the types or amounts of foods indicated,
contact your WH-
PCC clinic for help with substitutions
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: 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 year year Vascular Disease
Therapy
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
http://wwwihsgov/MedicalPrograms/MCH/M/MCHdownloads/PresidentChallenge0102
BMIpdf
Appendix D
ANMC Pediatric Department Hypoglycemia Guidelines
Appendix E
Gestational Diabetes Traditional Foods Meal Plan with Milk
Appendix F
Exercise guidelines to improve glucose control
Type of activities:
Aerobic activities such as walking, stationary cycling, or swimming
Frequency:
At least 3 days per week
Duration:
20-45 minutes per session
Intensity:
Moderate The talk-sing test may be used - the patient should be
able to talk while
exercising; if she can sing, the pace can be increased If
using
rating of perceived
exertion RPE exertion level should feel fairly light to somewhat
hard
Patient should warm-up before and cool down after exercise, drink
plenty of water, and
have snacks nearby if needed
Initial exercise consult:
Assessment of current physical activities and level of readiness for
exercise
Education/Information on exercise and GDM
Individualized exercise plan
Supervised exercise:
Measure blood glucose pre and post exercise
Exercise on treadmill and/or recumbent cycle
Monitor perceived exertion
Monitor blood pressure and/or heart rate as needed
———————–
Source:ihs.gov
