Gestational Diabetes Mellitus - Queensland Health

Queensland HealthQueensland HealthQueensland Clinical GuidelinesTranslating evidence into best clinical practiceGestational diabetes mellitus(GDM)Clinical Guideline Presentation v2.045 minutesTowards CPD Hours

References:Queensland Clinical Guideline: Gestational diabetes mellitus is the primary reference for this package.Recommended citation:Queensland Clinical Guidelines. Gestational diabetes mellitus clinical guideline education presentation E21.33-1-V2-R26.Queensland Health. 2021.Disclaimer:This presentation is an implementation tool and should be used in conjunction with the published guideline. This information doesnot supersede or replace the guideline. Consult the guideline for further information and references.Feedback and contact details:M: GPO Box 48 Brisbane QLD 4001 E: guidelines@health.qld.gov.au URL: www.health.qld.gov.au/qcgFunding: Queensland Clinical Guidelines is supported by the Queensland Health, Healthcare Improvement Unit.Copyright: State of Queensland (Queensland Health) 2021This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives V4.0 International licence. Inessence, you are free to copy and communicate the work in its current form for non-commercial purposes, as long as you attributeQueensland Clinical Guidelines, Queensland Health and abide by the licence terms. You may not alter or adapt the work in anyway. To view a copy of this licence, visit deed.enFor further information, contact Queensland Clinical Guidelines, RBWH Post Office, Herston Qld 4029, emailGuidelines@health.qld.gov.au For permissions beyond the scope of this licence, contact: Intellectual Property Officer, QueenslandHealth, GPO Box 48, Brisbane Qld 4001, email ip officer@health.qld.gov.au phone (07) 3234 1479.Images are property of State of Queensland (Queensland Health) unless otherwise cited.Queensland Clinical Guidelines: Gestational Diabetes Mellitus (GDM)2

ObjectivesIn relation to GDM outline: Risk factorsAppropriate screening and testing methodsClassification of types of diabetesRisks for mother and fetus/babyEducation and managementPharmacotherapy optionsIntrapartum carePost partum and discharge careQueensland Clinical Guidelines: Gestational Diabetes Mellitus (GDM)3

AbbreviationsACGIGlycaemic IndexGWGAustralasian Diabetesin Pregnancy SocietyGestational weightgainIOLInduction of labourBGLBlood glucose levelIOMInstitute of MedicineBMIBody mass indexLGACDECredentialleddiabetes educatorLarge for gestationalageMNTMedical dence intervalCSCaesarean sectionNDSSDIPDiabetes inpregnancyNational DiabetesServices SchemeOGTTGestational diabetesmellitusOral glucosetolerance testUSSUltrasound scanGDMQueensland Clinical Guidelines: Gestational Diabetes Mellitus (GDM)4

IntroductionGestational diabetes mellitus (GDM) is: One of the most common medicalcomplications of pregnancy Glucose intolerance firstrecognised in pregnancy Usually resolves postpartumDiabetes in pregnancy (DIP) if: Glucose level high enough to be diabetesmellitus diagnosis outside pregnancyQueensland Clinical Guidelines: Gestational Diabetes Mellitus (GDM)5

Prevalence In 2018 incidence: Queensland 13% Australia14% Rate has tripled since 2000–2001 Incidence increases with socio-economicdisadvantage (21% v 13%) In 2016/2017 32% required insulin 8% required oral hypoglycaemicQueensland Clinical Guidelines: Gestational Diabetes Mellitus (GDM)6

Risk factorsAssess all women early for risk factorsEthnicityAge 40 yearsPrevious elevated BGLPrevious GDMPrevious perinatal lossMultiple pregnancyBMI 30kg/m2Previous LGA babyFamily history of diabetes 1st degree relative with diabetes or sister with GDMMedications Corticosteroids, antipsychoticsPolycystic ovarian syndromeQueensland Clinical Guidelines: Gestational Diabetes Mellitus (GDM)7

Maternal risksShort termLong termPre-eclampsiaRecurrent GDMInduced labourIncreased risk of type 2 diabetesOperative birthCardiovascular diseaseCaesarean sectionRisk of glucose metabolism disorderPreterm labour and birthDevelopment of metabolic disorderHydramniosRenal diseasePostpartum haemorrhageDevelopment of cardiovasculardiseaseInfectionQueensland Clinical Guidelines: Gestational Diabetes Mellitus (GDM)8

Fetal and baby risks from GDMShort termLong termMacrosomiaImpaired glucose toleranceHypoglycaemiaType 2 diabetesIncreased weight and adiposityOverweight and besityPolycythaemiaPrematurityBirth traumaRespiratory distressHypocalcaemiaJaundiceCardiac anomaliesQueensland Clinical Guidelines: Gestational Diabetes Mellitus (GDM)9

ScreeningIf risk factors OGTT (75 g) (or HbA1c) in first trimester withfirst antenatal bloods If normal, OGTT at 24–28 weeks gestationIf maternal medications Do not perform OGTT within one week ofsteroids If having steroids monitor BGLs Metformin (for PCOS) may affect OGTT resultQueensland Clinical Guidelines: Gestational Diabetes Mellitus (GDM)10

ScreeningIf no risk factors and not diagnosed withGDM OGTT at 24–28 weeks gestation If testing is declined consider fastingplasma glucoseQueensland Clinical Guidelines: Gestational Diabetes Mellitus (GDM)11

Previous bariatric surgeryIf previous bariatric surgery 1st trimester fasting PGL and HbA1c 2nd trimester fasting BGL at 24–28 weeks If 4.6–5 mmol/L fasting and postprandial selfmonitoring BGL for 1–2 weeks 3rd trimester if evidence of fetalhyperinsulinaemia on USS repeat testingQueensland Clinical Guidelines: Gestational Diabetes Mellitus (GDM)12

GDM diagnosisTimeFasting1 hour2 hourPlasma glucose level (one or more)5.1–6.9 mmol/L 10.0 mmol/L8.5–11.0 mmol/L1st trimester onlyHbA1c 41 to 48 mmol/molQueensland Clinical Guidelines: Gestational Diabetes Mellitus (GDM)13

Diabetes in pregnancyTimeFasting1 hour2 hourRandomHb1AcPlasma glucose level (one or more) 7.0 mmol/LA one hour level is not used 11.1 mmol/L 11.1 mmol/L (confirm diagnosis withadditional standardised testing 48 mmol/mol1st trimester onlyHbA1c 48 mmol/molQueensland Clinical Guidelines: Gestational Diabetes Mellitus (GDM)14

Antenatal care Individualise care for each woman Collaborative model with midwiferycontinuity of care gives best outcomes Education and dietician advice within oneweek of diagnosis Individualise schedule of contact–increasefrequently if suboptimal BGLs or othercomplications If diagnosed 16 weeks increase contactQueensland Clinical Guidelines: Gestational Diabetes Mellitus (GDM)15

Education at GDM diagnosis May be group or individual session Individualise considering culturalbackground, learning style, family andsocial circumstances Encourage partner or support person toattend Provide psychosocial support and adviceQueensland Clinical Guidelines: Gestational Diabetes Mellitus (GDM)16

Initial education Overview of GDM and effects for womanand baby Dietary, physical activity and lifestylerecommendations Self-monitoring and BGL targets Registration with National DiabetesScheme Service (NDSS) by CDE or doctor Dietician inputQueensland Clinical Guidelines: Gestational Diabetes Mellitus (GDM)17

Self monitoring BGL Hand washingTargets and interpretation of BGLsMeter useTarget BGLTime(mmol/L)Times to testFasting 51 hour postprandial 7.42 hourspostprandial 6.7 Lancet device use and safe disposalQueensland Clinical Guidelines: Gestational Diabetes Mellitus (GDM)18

Medical nutrition therapy Food choices for optimal nutrition formaternal and fetal health Promotes: Appropriate GWG Target BGLs Absence of ketones Includes: Minimum 175 g carbohydrates per day Low GI dietQueensland Clinical Guidelines: Gestational Diabetes Mellitus (GDM)19

MNT (continued) Individualise eating plan–use food diary Culturally appropriate Discuss: Carbohydrate food and influence on BGLGlycaemic indexPortion sizeSafe foods and label reading GWG–weight loss not recommendedQueensland Clinical Guidelines: Gestational Diabetes Mellitus (GDM)20

Physical activity Helpful adjunctive therapy Assess current activity level Consider exercise snacking for 10 minuteperiods Suggest aerobic exercise– Walking, exercise bike, swimming, otheraquatic activities, prenatal exercise classesQueensland Clinical Guidelines: Gestational Diabetes Mellitus (GDM)21

Pharmacological therapy If not achieving optimal BGLs with lifestylechanges Metformin or insulin Decision to commence based on: Degree and pattern of hypoglycaemiaMaternal choiceGestational ageFetal growthQueensland Clinical Guidelines: Gestational Diabetes Mellitus (GDM)22

Metformin Improves insulin resistancePreferred by womenMay also need insulin addedMaximum dose–2500 mg SR or 2000 mgXR orally per day Titrate based on BGLs Review BGLs within 3 days ofcommencingQueensland Clinical Guidelines: Gestational Diabetes Mellitus (GDM)23

Insulin therapyIndications: BGLs above targets Sub-optimal BGLs with metformin Maternal preference Metformin not tolerated Fetal macrosomiaQueensland Clinical Guidelines: Gestational Diabetes Mellitus (GDM)24

Insulin therapy Consult with expert clinician about doseand type Individualise regimen Titrate every 2–3 days with increments of2–4 units Education: Clinician trained in teaching women toself-administer Hypoglycaemia managementQueensland Clinical Guidelines: Gestational Diabetes Mellitus (GDM)25

Insulin typeIndicationElevated fasting glucoseInsulin type Intermediate acting atbedtimePostprandial hyperglycaemia Rapid acting at mealtimesFasting and postprandial Basal bolus regimeno Rapid acting at meal timeshyperglycaemiaand intermediate acting atbedtime oro Mixed twice daily (if womanreluctant to have injectionfour times per day)Queensland Clinical Guidelines: Gestational Diabetes Mellitus (GDM)26

Birthing GDM well managed with no complications Expectant management If estimated fetal weight: 4000 g vaginal birth usually appropriate 4000–4500 g consider other factors (e.g.maternal stature and history) 4501 g consider CS Document birth and pharmacotherapyplansQueensland Clinical Guidelines: Gestational Diabetes Mellitus (GDM)27

Metformin as birth approachesBirthActionSpontaneous onset Cease when in established labourIOL Cease when in established labourCS Cease evening before elective CSQueensland Clinical Guidelines: Gestational Diabetes Mellitus (GDM)28

Insulin as birth approachesBirthActionSpontaneous onset Titrate insulin according toBGLs during labourIOL (morning) Eat early morning breakfast Usual rapid acting insulin Omit morning dose of longor intermediate insulin Cease all insulin when inestablished labourCS Usual rapid, long orintermediate insulin nightbefore Fast for six hours Omit morning insulin doseQueensland Clinical Guidelines: Gestational Diabetes Mellitus (GDM)29

Intrapartum BGL monitoring Aim to maintain BGL 4–7 mmol/L (optimal)BGL 7.0 mmol/L 4.0 mmol/LQueensland Clinical Guidelines: Gestational Diabetes Mellitus (GDM)ActionConsider stage oflabour/imminency of birthRepeat BGL in 1 hourConsider insulin infusionCease insulin therapyTreat if symptomaticRepeat BGL30

Postpartum careTherapyRecommendationNonpharmacologicalCease BGLsPharmacological Cease metformin and insulin immediately afterbirth BGLso Check for 24 hours pre-prandial andbefore bedo If all are 4–8 mmol/L cease after 24 hourso If elevated: Medical review Continue BGLs If indicated (rarely) lower dose than inpregnancyQueensland Clinical Guidelines: Gestational Diabetes Mellitus (GDM)31

Breastfeeding Discuss short and long term benefits forwoman and baby Encourage all women to breastfeed Offer early skilled lactation support andassistanceQueensland Clinical Guidelines: Gestational Diabetes Mellitus (GDM)32

Discharge planning Discuss: Optimal postpartum and inter-pregnancyweight Contraception OGTT at 6–12 weeks postpartum Lifestyle interventions–weight management,eating patterns, physical activity Early screening in future pregnancies Lifelong diabetes screeningQueensland Clinical Guidelines: Gestational Diabetes Mellitus (GDM)33

Gestational diabetes mellitus (GDM) 45 minutes Towards CPD Hours. Clinical Guideline Presentation v2.0 . References: Queensland Clinical Guideline: Gestational diabetes mellitus is the primary reference for this package. Recommended citation: Queensland Clinical Guidelines. Gestational diabetes mellitus clini