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110 SECTION 3  Antenatal Care

CHAPTER 29  Gestational diabetes mellitus (GDM) IADPSG 2010

NICE 2008
Any degree of glucose intolerance with onset or first recognition during pregnancy

Universal early testing in populations with a high prevalence of

type 2 diabetes is recommended (e.g., South Asians).
Risk factor based
Screening Universal one-step 75 g OGTT for all women not known to be
diabetic at 24–28 weeks of gestation.

First prenatal visit.

• BMI > 30 kg/m2. Previous GDM.

• Previous macrosomic baby weighing ≥ 4.5 kg. FPG, A1C, or RPG on all or only high-risk women.
• Family history of diabetes (first-degree relative).
• Family origin with a high prevalence of diabetes − South
Asian, black Caribbean, Middle Eastern.
• Glycosuria 2+ or > 1 on one occasion or of ≥ 1+ on 2 or Overt DM – treat as pre-existing diabetes. Not diagnostic of overt DM.
more occasions.

FPG ≥ 5.1 mmol/l but < 7.0 FPG < 5.1 mmol/l
mmol/l – GDM. All these women.
OGTT at 24–28 weeks. Early self-monitoring of blood glucose OR
OGTT at 16–18 weeks, and a further OGTT at
28 weeks if the results are normal.
2-h 75-g OGTT: at 24–28 weeks.

2-hour 75 g OGTT by WHO criteria.

Overt diabetes if FPG ≥ 7.0 GDM if ≥ 1value equals or Normal if all values < thresholds
mmol/l. exceeds thresholds as given as given below:
Venous plasma glucose in mmol/l. below:
Fasting 2 hrs PP
< 6 < 7.8 NORMAL
> 5.6 > 7.8 Diabetes mellitus (DM)
To diagnose overt diabetes: To diagnose GDM:
FPG ≥ 7.0 mmol/l FPG 5.1 mmol/l
A1C ≥ 6.5% 1-h PP 10.0 mmol/l
RPG ≥ 11.1 mmol/l 2-h PP 8.5 mmol/l
Do not use FPG, RBG, HbA1c, glucose challenge test, or urine
analysis for glucose to assess risk of developing GDM.

It will result in a per pregnancy incidence of GDM over 16%

compared to current levels of 3.5%.
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GDM (NICE)

Prevalence and incidence Risks

• Diabetes is a disorder of carbohydrate metabolism.
• GDM – defined as carbohydrate intolerance that develops first time in the pregnancy.
• Approximately 650 000 women give birth in England and Wales each year, and 2–5% of Maternal
pregnancies involve women with diabetes. • Pre-eclampsia and preterm labour:
• Diabetes in pregnancy is seen in 2–5% of pregnancies – 87.5% are GDM, 7.5% due to type 1 • Increased monitoring and interventions during pregnancy and labour.
DM, and remaining 5% due to type 2 DM. • Likelihood of birth trauma, IOL, and CS.
• The prevalence of type 1 and type 2 diabetes is increasing. Type 2 diabetes is increasing in
minority ethnic groups (African, black Caribbean, South Asian, Middle Eastern, and Chinese
family origin).
Fetal
• The incidence of GDM is also increasing probably due to increasing rates of obesity.
• Risk factors – age, ethnicity, obesity, family history of DM, and past history of GDM. • Stillbirth, macrosomia, birth injury (shoulder dystocia), perinatal mortality, and postnatal
adaptation problems such as neonatal hypoglycaemia and admission to the neonatal unit.
• Obesity and/or diabetes in later life.

Antenatal care
Joint diabetes and antenatal clinic – within 1 week

There is a continuous linear relationship between maternal BG and fetal growth. Good glycaemic
control throughout pregnancy will reduce the risk of fetal macrosomia, trauma during birth, IOL or
CS, neonatal hypoglycaemia, and perinatal death.
Monitoring
Maternal
Lifestyle advice – weight control, diet and exercise – most women respond to it.
•  D iet – carbohydrates from low glycaemic index sources, lean proteins including oily • Diabetes care team for assessment of glycaemic control every 1–2 weeks throughout
fish, and a balance of polyunsaturated fats and monounsaturated fats. pregnancy.
•  If pre-pregnancy BMI is > 27 kg/m2 – advise to restrict calorie intake (to 25 kcal/kg/ • Self-monitoring of blood glucose (BG) levels.
day or less) and to take moderate exercise (of at least 30 minutes daily). • FBG and BG levels 1 hour after every meal.
•  Folic acid 5 mg/day. • Aim to keep FBG 3.5–5.9 mmol/l and 1-hour PP BG < 7.8 mmol/l; 2-hour PP 6.4 mmol/l.
• Women with insulin-treated diabetes – to test BG levels before going to bed at night.
Oral hypoglycaemic agents – 10–20% will need oral hypoglycaemic agents if:
• Do not use HbA1c routinely for assessing glycaemic control in the 2nd and 3rd trimesters
*  Diet and exercise fail to maintain BG targets during a period of 1–2 weeks. of pregnancy.
*  USS suggests incipient fetal macrosomia (AC > 70th percentile) at diagnosis.
•  Start treatment with oral hypoglycaemic agents but often insulin is needed to ensure adequate
glycaemic control.
• Both glibenclamide and metformin are effective treatments for GDM. Fetus
• Offer metformin if blood sugar not controlled with changes in diet and exercise
• USS monitoring of fetal growth and amniotic fluid volume every 4 weeks from 28 weeks.
within 1–2 weeks.
• 38 weeks – start regular tests of fetal wellbeing in women who are awaiting spontaneous
• Need for insulin is in about 20–30% of patients who were initially started on
labour weekly.
glibenclamide and metformin. Agents – regular insulin, rapid-acting insulin
• Risk of IUGR (macrovascular disease and/or nephropathy) – use an individualized
analogues.
approach to monitor fetal growth and wellbeing.

111 CHAPTER 29  Gestational diabetes mellitus (GDM)

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112 SECTION 3  Antenatal Care

Time and mode of delivery

• Normally grown fetus – IOL or ELCS if indicated, after 38 completed weeks. Preterm labour
• USS diagnosed macrosomic fetus – discuss the risks and benefits of vaginal birth, IOL, and CS.
• Women with insulin-treated diabetes who are receiving steroids for fetal lung
• During labour and birth, monitor capillary BG hourly and maintain it between 4 and 7 mmol/l.
maturation – give additional insulin and closely monitor.
Commence IV dextrose & insulin infusion if BG is not maintained at 4–7 mmol/l.
• Do not use betamimetic drugs for tocolysis.
• Diabetes is not a contraindication for VBAC.

Postnatal care

Maternal Neonatal

• Discontinue hypoglycaemic treatment immediately after birth.
• BG to exclude persisting hyperglycaemia before women are transferred to community care.
• Warn women of the symptoms of hyperglycaemia.
• Lifestyle advice (including weight control, diet, and exercise).
• Discuss contraception.
• Feed ASAP after birth (within 30 minutes) and then at frequent intervals (every
2–3 hours) until feeding maintains pre-feed blood glucose levels at a minimum of
2.0 mmol/litre. Test BG routinely at 2–4 hours after birth.
• Do not transfer babies to community care until they are at least 24 hours old,
and not before they are maintaining BG levels and are feeding well.

• If one or more of these criteria are met:

* BG < 2.0 mmol/litre on 2 consecutive readings.
* If there are abnormal clinical signs.
Follow-up * If the baby will not feed orally effectively.

• FPG (but not an OGTT) at the 6-week postnatal check and annually thereafter.
• Inform of risks of GDM in future pregnancy (including those with ongoing impaired glucose
regulation) and offer women screening (OGTT or FPG) for diabetes when planning future
pregnancy. • SCBU – tube feeding or intravenous dextrose.
• Offer early self-monitoring of BG or an OGTT in future pregnancies (including those with ongoing
impaired glucose regulation). Offer a subsequent OGTT if the test results in early pregnancy are
normal.
• Remind of the importance of contraception and the need for pre-conception care when planning
future pregnancies.
What not to do
• Betamimetic drugs for tocolysis.
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Guideline comparator

ACOG SOGC

• Screen all pregnant women for GDM, whether by patient history, clinical risk factors, or
a 50 g 1 hour GTT.
• The diagnosis of GDM can be made by 100 g 3 hour OGTT, for which there is evidence
that treatment improves outcome.
• Diagnosis of GDM based on ‘one-step screening and diagnosis test’ as outlined by
IADPSG (2010) is not recommended at this time because there is no evidence that
diagnosis using these criteria leads to clinically significant improvements in the maternal
or neonatal outcomes and it would lead to a significant increase in health care costs.
• Insulin therapy for women receiving medical/nutritional therapy whose FBG > 5.35; 1-h
PP BG level > 7.75; or 2-h PP BG level > 6.65 mmol/l.
• Insulin is the first-line therapy. Most insulin regimens include intermediate-acting
insulins, such as isophane (NPH), and short-acting insulins, such as regular recombinant
(Humulin R), and the insulin analogues aspart (Novolog) and lispro (Humalog).
• American Family Physician guidelines – metformin (Glucophage) may be another option.
• The ADA – screen for congenital anomalies in women with GDM who present with
evidence of pre-existing hyperglycaemia, such as an A1C level > 7%, a FBG > 6.65
mmol/l or a diagnosed GDM in the first trimester. Women with these findings are more
likely to have unrecognized pre-gestational diabetes and are therefore at higher risk of
fetal malformation from exposure to hyperglycaemia during organogenesis.
• ACOG – women with GDM who are on insulin or who have poor glucose control have
the same antenatal monitoring as women with pre-gestational DM.
• If the estimated fetal weight exceeds 4500 g, CS may reduce the likelihood of brachial
plexus injury in the infant.
• Postpartum – an OGTT at 3-year intervals has been shown to be a cost-effective strategy
for screening.
• A single approach of testing for GDM cannot be recommended at present as there is not
enough evidence proving the beneficial effect of a large screening programme.
• Each of the following approaches is acceptable.
* Routine screening of women at 24–28 weeks with the 50 g glucose challenge test
(GCT), using a threshold of 7.8 mmol/l except in the women who are low risk.
* Maternal age < 25.
* Caucasian or other ethnic group with low prevalence of diabetes.
* Pregnant BMI ≤ 27.
* No previous history of GDM or glucose intolerance.
* No family history of diabetes in first-degree relative.
* No history of GDM-associated adverse pregnancy outcomes.
• The diagnostic test can be the 100 g OGTT or the 75 g OGTT, according to the American
Diabetes Association (ADA) criteria. Use of the WHO criteria will approximately double
the number of women diagnosed with GDM without an apparent clinical benefit.
* Women at high risk for GDM – diagnostic test as early in pregnancy as possible and
repeat it at 24–28 weeks if initial results are negative.
• Until evidence is available from large RCTs that show a clear benefit from screening for
glucose intolerance in pregnancy, the option of not screening for GDM is considered
acceptable. Conversely, there are no compelling data to stop screening when it is practised.
• Reassess glucose tolerance with a 75 g OGTT 6–12 weeks postpartum in order to identify
women with persistent glucose intolerance.

Diabetes in Pregnancy: Management of Diabetes and its Complications from Pre-conception to the Postnatal Period; NICE CGN 63, March 2008. Please refer
to updated guideline from February 2015.
International Association of Diabetes and Pregnancy Study Groups Recommendations 2010.
SOGC. Clinical Practice Guidelines: Screening for Gestational Diabetes Mellitus. J Obstet Gynaecol Can 2002;24(11):894–903.
ACOG Committee opinion. Screening and Diagnosis of GDM; No. 504, 2011.
ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists. Number 30, September 2001; Gestational diabetes. Obstet Gynecol.
2001 Sep;98(3):525–538.
David C. Serlin and Robert W. Lash. Diagnosis and management of gestational diabetes mellitus. Am Fam Physician. 2009 Jul 1;80(1):57–62.
RCOG. Diagnosis and Treatment of Gestational Diabetes Scientific Advisory Committee Opinion Paper 23; January 2011.

113 CHAPTER 29  Gestational diabetes mellitus (GDM)