DIABETES IN PREGNANCY MANAGEMENT PROTOCOL

DEPT OF OBSTETRICS AND GYNAECOLOGY

KORLE BU TEACHING HOSPITAL

1.0 INTRODUCTION

The prevalence of diabetes mellitus in pregnancy is increasing, parallel to the worldwide epidemic of
obesity. Diabetes confers significantly greater maternal and fetal risk largely related to the degree of
hyperglycemia but also related to chronic complications and comorbidities of diabetes.
Complications include spontaneous abortion, fetal anomalies, preeclampsia, fetal demise,
macrosomia, neonatal hypoglycemia, hyperbilirubinemia, and neonatal respiratory distress
syndrome. There is a large body of evidence that shows that good preconception and antenatal care
delivered by a dedicated medical/obstetric team can reduce the incidence of all these complications.

2.0 PRECONCEPTION PLANNING AND CARE FOR WOMEN WITH PRE-GESTATIONAL DIABETES
MELLITUS

• Counsel women that good glycaemic control before and throughout pregnancy reduces (but
does not eliminate) the risk of miscarriage, congenital malformation, stillbirth, and neonatal
death.
• Counsel women on the effect of diabetes on pregnancy and vise versa.
• Emphasize the importance of planning pregnancy and the use of contraception till they
achieve good blood glucose control.
• Advise women with BMI > 27kg/m2 to lose weight before pregnancy.
• Recommend folic acid 5mg daily till 12 weeks of gestation to reduce the risk of neural tube
defects.
• Recommend blood glucose meters for self-monitoring and offer monthly HbA1c
measurements.
• Advise women to target FBS 5-7mmol/l, other preprandials 4-7mmol/l, and HbA1c <6.5%.
• Advise women with HbA1c >10% to avoid pregnancy until HbA1c is lower. Offer appropriate
contraception.
• Women may be advised to use metformin as an adjunct or alternative to insulin in the
preconception period and during pregnancy. Replace all other oral hypoglycaemic agents
with insulin.
• Review antihypertensives for women with hypertension. Replace angiotensin-converting
enzyme inhibitors and angiotensin-II receptor blockers with alternatives that are safe in
pregnancy (eg. Nifedipine, Laetalol,Methyldopa). Women with proteinuria might derive
greater benefit from the renal protective effects of ACE inhibitors or ARBs by continuing
them until there is a positive pregnancy test.
• Stop statins and reinforce dietary and lifestyle management for dyslipidaemia.
• Refer for retinal assessment by an ophthalmologist if they haven’t had one in the last 6
months.
• Offer renal assessment and refer to a nephrologist if creatinine ≥ 120µmol/l or urinary
albumin:creatinine ratio > 30mg/mmol or estimated glomerular filtration rate (eGFR) < 45
ml/minute/1.73 m2.
• Offer thyroid function test. Manage thyroid disease appropriately if detected.
3.0 GESTATIONAL DIABETES MELLITUS

3.1 RISK ASSESSMENT

• Check for the following risk factors at booking:

o BMI > 30 kg/m2
o previous macrosomic baby weighing ≥4.0 kg
o previous gestational diabetes
o family history of diabetes (first degree relative with diabetes)
o high-risk race or ethnicity (African, Asian)
o hypertension
o women with polycystic ovary syndrome
• Offer oral glucose tolerance test (OGTT) to women with any of these risk factors.
• Do not use FBS, RBS, or HbA1c to assess the risk of developing gestational diabetes mellitus.

3.2 GLYCOSURIA DETECTED BY ROUTINE ANTENATAL TESTING

• Consider OGTT in women with the following dipstick results:

o Glycosuria ≥2+ on one occasion
o Glycosuria of 1+ on two or more occasions

3.3 TESTING

• For women with a previous history of gestational diabetes, offer a 75g 2-hour OGTT as soon
as possible after booking (whether in the first or second trimester). Repeat the OGTT at 24-
28 weeks if the results of the first one are normal.
• For women with any of the other risk factors, offer a 75g 2-hour OGTT at 24-28 weeks.

3.4 DIAGNOSIS

Diagnose GDM if

• Fasting plasma glucose ≥5.1mmol/l or

• 1-hour plasma glucose ≥10.0mmol/l or
• 2-hour plasma glucose ≥8.5mmol/l

Diagnose Diabetes in Pregnancy if

• Fasting plasma glucose ≥ 7.0 mmol/l or

• 2-hour plasma glucose ≥ 11.1 mmol/ following a 75g oral glucose load or
• Random plasma glucose ≥ 11.1 mmol/l in the presence of diabetes symptoms

3.5 INTERVENTION

• Explain to women with gestational diabetes that their treatment includes diet changes and
exercise with or without medication
• Teach how to self-monitor blood glucose (see appendix I for blood glucose chart)
• Treatment targets are:
o FBS < 5.3mmol/l
o Preprandial <5.8mmol/l
o 1-hour postprandial <7.8mmol/l
o 2-hour postprandial <6.7mmol/l
o Bedtime <6.7mmol/L
 o 2- 6 am: 3.3 - 5.0mmol/L
▪ Do this to distinguish between Somogyi effect and Dawn Phenomenon.
▪ Somogyi effect: Rebound hyperglycaemia from counter-regulatory hormone
release following hypoglycaemia usually at night but can follow any
hypoglycaemic episode. Check blood sugar at 3:00am if there is early
morning hyperglycaemia to rule out Somogyi effect.
▪ Dawn phenomenon: Early morning hyperglycaemia due to the physiological
increase in Growth Hormone, Cortisol, and Catecholamines at night.
• Obtain blood glucose profile every 1-2 months (more frequently if control is poor).
• Tailor treatment to blood glucose profile.
• Offer advice about changes in diet and exercise. Refer to a dietician.
• For women with fasting plasma glucose <7mmol/l at diagnosis, offer a trial of diet changes
and exercise.
• If treatment targets are not met with diet changes and exercise within 1 to 2 weeks, add
metformin.
• If treatment targets are not met with diet and exercise changes plus metformin (maximum
dose of 2500mg) in a week, add insulin.
• For women with fasting plasma glucose ≥7mmol/l at diagnosis, offer immediate treatment
with insulin and diet and exercise changes, with or without metformin.
• For women with fasting plasma glucose 6.0-6.9mmol/l and complications such as
macrosomia and polyhydramnios, consider immediate treatment with insulin and diet and
exercise changes, with or without metformin.
• Total daily insulin = 0.7-1unit/kg (current weight). Intermediate:short-acting insulin ratio =
2:1 (eg. Premixed Insulin 30/70). Give 2/3 of the daily dose in the morning and 1/3 in the
evening.

4.0 ANTENATAL CARE FOR DIABETES IN PREGNANCY

• Advise pregnant women to maintain blood glucose within the treatment target.
• Recommend self-monitoring of blood glucose (SMBG).
• Measure HbA1c levels at booking for women with pre-gestational diabetes to determine the
level of risk for the pregnancy.
• On diagnosing gestational diabetes, measure HbA1c to identify women who may have pre-
gestational type 2 diabetes.
• Do not routinely use HbA1c levels to assess a woman's blood glucose control in the second
and third trimesters of pregnancy.
• Offer multidisciplinary care through joint diabetes and antenatal clinic. The multidisciplinary
team should comprise a consultant diabetologist, consultant obstetrician, midwives, diabetic
specialist nurse, and dietician.
• Refer women with diabetes in pregnancy to the High-Risk Diabetes/ Endocrine Clinic for such
multidisciplinary care.
• Women with diabetes are more vulnerable to experiencing psychological distress during
pregnancy than women without diabetes. Identify women with psychological challenges and
refer to the clinical psychologist.
4.1 RETINAL ASSESSMENT DURING PREGNANCY

• Offer retinal assessment to women with pregestational diabetes after their booking visit.
Repeat at 16-20 weeks for those with diabetic retinopathy.
• Offer another retinal assessment at 28 weeks.
• Diabetic retinopathy should be considered a contraindication to vaginal delivery.

4.2 RENAL ASSESSMENT DURING PREGNANCY

• Arrange a renal assessment at booking for women with pregestational diabetes if they
haven’t had one in the last 3 months.
• Consider referral to a nephrologist if:
o Serum creatinine >120µmol/l
o Urinary albumin:creatinine ratio >30mg/mmol
o Total protein >0.5g/day
• Do not use eGFR to measure renal function in pregnant women
• Consider thromboprophylaxis in nephrotic range proteinuria >5g/day (albumin:creatinine
ratio >220mg/mmol)

4.3 PREVENTING PRE-ECLAMPSIA

• Offer 75-150mg of aspirin daily from 12 weeks till delivery or 36 weeks.

4.4 ULTRASOUND SCAN SCHEDULE

• Offer scan at 12 weeks to confirm viability, date, screen for aneuploidy, and exclude
anencephaly.
• Offer a detailed scan of the spine and head contents at 16 weeks to screen for NTD.
• Offer fetal anatomy survey at 20 weeks, including examination of the fetal heart (4 chamber,
outflow tract, and 3-vessel views).
• Arrange serial growth scans (4-weekly) starting from 28 weeks and plot on a customized
growth chart.
• From 36 weeks, a weekly biophysical profile including NST should be considered if there is
fetal macrosomia.

5.0 INSULIN TREATMENT AND RISK OF HYPOGLYCAEMIA

• Advise women on insulin of the risks and symptoms of hypoglycaemia, and to always have
available a fast-acting form of glucose like cubed sugar or glucose-containing drinks.

6.0 KETONE TESTING AND DIABETIC KETOACIDOSIS Advise pregnant women with diabetes to
seek urgent medical care if they become hyperglycaemic or unwell.

• Test urgently for ketonuria if a pregnant woman with any form of diabetes presents with
hyperglycaemia or is unwell.
• Immediately admit or refer women with suspected diabetic ketoacidosis to a health facility
with critical care (HDU) services, where they can receive multidisciplinary medical,
anaesthetic, and obstetric care.
 • Beware of Precipitating factors: protracted vomiting, hyperemesis gravidarum, infections,
insulin non-compliance, medications precipitating diabetic ketoacidosis in pregnancy
including beta sympathomimetic agents and corticosteroids, insulin pump failure, and
conditions such as gastroparesis.
• Symptoms: polyuria, polydipsia, nausea, vomiting, abdominal pain, weakness, weight loss
• Signs: hyperventilation, ketotic breath, tachycardia, hypotension, dry mucous membranes,
disorientation, shock, coma, abnormal fetal heart tracing
• Diagnostic criteria: a triad of hyperglycaemia, ketonaemia/ketonuria and acidosis
o Blood glucose level > 11.0 mmol/l or known diabetes mellitus regardless of blood
glucose level (euglycaemic DKA)
o Blood ketone level ≥ 3.0 mmol/l or urine ketone level ≥ 2+
o Bicarbonate < 15.0 mmol/l and/or venous pH < 7.3

Management: (see appendix III for DKA protocol flow chart)

Using a perfuser

• 0.9% normal saline at 1l/hour x 1 hour, 500ml/hour x 4 hours, 250ml/hour x 8 hours, then
150ml/hour. Add 10% dextrose at 125ml/hr or 5% dextrose/dextrose saline at 250 ml/hr
when blood glucose <13-15mmol/l.
• Insulin infusion at a fixed rate of 0.1iu/kg/hr by a perfuser is the treatment of choice.
Increase by 1iu/hr if treatment target is not achieved. Women with pregestational diabetes
who are on basal insulin should not discontinue it.

Without a perfuser

• In the absence of a perfuser, resort to the use of modified Alberti’s regimes where 5-10 iu of
soluble insulin is given intramuscularly (IM) every hour with hourly monitoring of blood
glucose.
• 0.9% normal saline at 1l/hour x 1 hour, 500ml/hour x 4 hours, 250ml/hour x 8 hours, then
150ml/hour intravenously.
• When blood glucose <13-15mmol/l, switch to sliding scale. Add 10% dextrose at 125ml/hr or
5% dextrose/dextrose saline at 250 ml/hr while giving the soluble insulin subcutaneously
every 4 hours.

Other interventions

• Give 20mmol of KCl per litre of ongoing iv fluids if K+ ≤5.5mmol/l. Ensure adequate urine
output (0.5ml/kg/hr). If K+ <3.3mmol/l, correct hypokalaemia with 40mmol of KCl per litre of
ongoing iv fluids before starting insulin infusion.
• Identify and treat the cause.
• Monitor capillary glucose and blood ketones (or urine ketones if blood ketone testing not
available) hourly for the first 6hrs
• Monitor venous pH, bicarbonate, and serum potassium 2hrly for the first 6hrs

Treatment targets:

o Decrease in blood ketone levels by 0.5 mmol/l/h

o Increase in venous bicarbonate levels by 3 mmol/l/h
o Decrease in capillary glucose levels by 3 mmol/l/h

Switching to biphasic insulin (Premixed Insulin 30/70)

 • Insulin infusion should not be stopped until patients are able to eat and drink normally.
• Twice daily SC insulin should be started at least 1h before discontinuation of insulin infusion
(with rapid-acting insulin analogues you may stop sliding scale at the same time as starting
SC)

Recovery is defined as:

o Blood ketone level < 0.6mmol/l (or urine ketones ≤1+ if blood ketone testing not
available)
o pH > 7.3
o Serum bicarbonate > 15mmol/l
• For gestation ≥28 weeks, offer cardiotocograph to monitor fetal heart rate. Normalization of
fetal heart tracing may occur 4 to 8hrs after correcting DKA.
• The decision to deliver should be individualized and based on maternal status, gestational
age, fetal status, response to therapy, co-morbidities, and past obstetric history.
• Delivery for fetal indications should be reserved for fetal impairment that persists after
maternal resuscitation.
• Emergency Caesarean section before maternal stabilization should be avoided as it could
further aggravate the maternal condition.

7.0 CORTICOSTEROIDS FOR LUNG MATURITY

• For planned caesarean section before 37 weeks, prescribe corticosteroids (im

Dexamethasone 6mg 12 hourly x 4 doses).
• Increase all insulin doses by 50% 6 hours after the first dose of steroids.
• Maintain this increase until 24 hours after the last dose of steroids.
• Do blood glucose profile until 24 hours after the last dose.
• Test for ketones if blood glucose >10mmol/l. Recheck blood glucose after 1 hour.
• Commence variable rate insulin infusion or sliding scale if repeat blood glucose >10mmol/l.
• Reinstate the original insulin regimen 24 hours after the last dose.

8.0 TIMING AND MODE OF DELIVERY

• For women managed satisfactorily on diet and exercise, aim to deliver at 39+0 to 40+6 weeks.
• For women well controlled on metformin or insulin, aim to deliver at 39+0 to 39+6 weeks.
• For women poorly controlled on metformin or insulin, aim to deliver at 37+0 to 38+6 weeks.
• Counsel women with estimated fetal weight ≥4500g regarding the risks and benefits of
scheduled cesarean delivery.
• Document a clear delivery plan at 36 weeks of gestation.
9.0 INTRAPARTUM CARE

• A clear individualized plan of obstetric and diabetic intrapartum care and instructions for
care immediately following delivery should be documented in the case notes.
• Women coming in for induction of labour should have normal insulin and diet (can have
breakfast with usual insulin/metformin) in the morning.
• Once transferred to labour ward for artificial rupture of membranes, the woman should be
kept nil per os and glucose/sodium chloride/potassium/insulin variable rate (formerly GKI)
infusion commenced.
50 units of soluble insulin in 50mls of 0.9% Sodium Chloride in a separate syringe driver PLUS
500mls of 5% Glucose / 0.45% Sodium Chloride (1/2 strength dextrose saline) with 0.15%
(10mmol) of Potassium at a rate of 100ml/hr.
• Aim to achieve and maintain normal blood glucose levels during induction, labour, delivery,
and in the immediate postnatal period. Target blood glucose levels of 4-7mmol/l.
• Monitor blood glucose hourly and alter the infusion rate according to the sliding scale.
• Monitor urine output and test urine for ketones.
• For elective caesarean section, omit all medications on the day of surgery and commence
glucose/sodium chloride/potassium/insulin variable rate infusion.
• Elective caesarean section should be planned for the morning and should be first on the
theatre list.

10.0 POSTNATAL CARE

• Reduce insulin immediately after delivery and monitor blood sugar carefully to establish the
appropriate dose in women with pre-gestational diabetes.
• Women with gestational diabetes should stop diabetes medications immediately after
delivery.
• Monitor preprandial blood glucose for 24 hours following delivery. Discontinue monitoring if
levels remain within 4-9mmol/l.
• Breastfeeding mothers with type 2 diabetes can continue metformin but avoid other oral
hypoglycaemic agents.
• Offer contraception and advise on the need for preconception care when planning the next
pregnancy.
• Refer women with pre-gestational diabetes back to their routine diabetes care.
• Explain to women who were diagnosed with gestational diabetes about the risks of
recurrence in future pregnancies, and offer them diabetes testing when planning future
pregnancies.
• For women with gestational diabetes, offer OGTT at 6 weeks and interpret using non-
pregnant diagnostic criteria.
• Offer an annual HbA1c test to women with gestational diabetes who have a negative
postnatal test for diabetes.
REFERENCES

• National Institute for Health and Care Excellence. (2020). Diabetes in pregnancy:
management from preconception to the postnatal period. NICE, February, 2–65.
http://www.ncbi.nlm.nih.gov.ez.srv.meduniwien.ac.at/pubmed/25950069
• ACOG. (2018). Gestational diabetes mellitus. ACOG Practice Bulletin No. 190. American
College of Obstetricians and Gynecologists. Obstetrics and Gynecology, 131(2), e49–e64.
• Mohan, M., Baagar, K. A. M., & Lindow, S. (2017). Management of diabetic ketoacidosis in
pregnancy. The Obstetrician & Gynaecologist, 19(1), 55–62.
https://doi.org/10.1111/tog.12344
• Care, D., & Suppl, S. S. (2020). Management of diabetes in pregnancy: Standards of medical
care in diabetes-2020. Diabetes Care, 43(January), S183–S192.
https://doi.org/10.2337/dc20-S014
• Berger, H., Gagnon, R., & Sermer, M. (2019). Guideline No. 393-Diabetes in Pregnancy.
Journal of Obstetrics and Gynaecology Canada, 41(12), 1814-1825.e1.
https://doi.org/10.1016/j.jogc.2019.03.008
APPENNDIX I
APPENDIX II

KORLE-BU TEACHING HOSPITAL

FETAL KICK COUNT CHART

NAME: AGE: WARD:

HOW TO COUNT
KICKS
1. Choose a time
when baby is
usually active.

2. Assume the
position. Sit
comfortably or lie
on your side.

3. Start to count:
- The first time the
baby moves,
write the down
the time and
mark the first
stroke.
- Count and mark
each movement
until the baby has
moved 10 times
and write down
the end time.

Ideally you want to

feel the 10
movements within 12
hours.
APPENDIX III
KORLE-BU TEACHING HOSPITAL
DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
DKA IN PREGNANCY MANAGEMENT PROTOCOL
Test urgently for ketonuria or ketonaemia if a pregnant woman with any form of DM presents
with hyperglycaemia (blood glucose > 11.0mmol/l) or is unwell (even if normoglycaemic)

Urine ketones ≥ 2+ or blood ketones ≥ 3.0mmol/l Urine ketones < 2+ or blood ketones < 3.0mmol/l

Test for venous pH and/or bicarbonate DKA excluded

Venous pH < 7.3 or bicarbonate < 15.0mmol/l Venous pH ≥ 7.3 or bicarbonate ≥ 15.0mmol/l

DKA Not DKA. Investigate

and manage for other
Immediately admit to HDU (Recovery Ward) and send consult to Physicians, Anaesthesia and causes of ketonuria/
Maternal Fetal Medicine ketonaemia

Infuse (with perfuser or dorsiflow)
0.9% NS at: 1l/h for 1hour
500ml/h for next 4 hours
250ml/h for next 8hours
150ml/h subsequently
Add 10% Dextrose at 125ml/h
or 5% Dextrose at 250ml/h
when blood sugar < 13mmol/l
Infuse soluble insulin at 0.1 iu/kg/hr Give 20mmol of KCl per litre
using a perfuser. of ongoing iv fluids if
↑ by 1iu/hr if treatment target* is not K+<5.5mmol/l. Ensure
achieved. adequate urine output.
You may reduce rate to 0.05iu/kg/hr If K+ <3.3mmol/l, correct
when blood sugar < 13mmol/l hypokalaemia with 40mmol
KCl per litre of iv fluids
Do not discontinue basal insulin in
before starting insulin
women with pregestational DM

Identify and treat cause of DKA¶

¶ Precipitating factors:
Monitor capillary glucose and blood Monitor venous pH, bicarbonate, and
ketones hrly for the first 6hrs serum K+ 2hrly for the first 6hrs protracted vomiting, hyperemesis gravidarum,
infections, insulin non-compliance, medications
precipitating diabetic ketoacidosis in pregnancy
including beta sympathomimetic agents and
corticosteroids, insulin pump failure, and conditions
Switch to sc biphasic insulin (premixed insulin 30/70) or basal bolus regime when
such as gastroparesis
there is recoveryϮ from DKA, and patient can eat and drink normally

Start twice daily sc insulin or basal bolus regime at Monitor blood glucose
least 1hr before discontinuation of insulin infusion 4 hourly * Treatment targets:
(overlap not necessary if using analogue
↓ in blood ketones by 0.5mmol/l/h
subcutaneous insulin)
↑ in venous bicarbonate by 3mmol/l/h
For gestation ≥28 weeks, offer cardiotocograph to monitor fetal heart rate.
↓ in capillary glucose by 3mmol/l/h
Normalization of fetal heart tracing may occur 4 to 8hrs after correcting DKA

The decision to deliver should be individualized and based on maternal status,

gestational age, fetal status, response to therapy, co-morbidities, and past obstetric
history
Ϯ Recovery:

Delivery for fetal indications should be reserved for fetal impairment that persists after • Blood ketones <0.6mmol/l
maternal resuscitation or urine ketones ≤1+
• pH >7.3
• Bicarbonate >15mmol/l
Emergency Caesarean section before maternal stabilization should be avoided as it could
further aggravate the maternal condition
APPENDIX IV

KORLE-BU TEACHING HOSPITAL

DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
DIABETES IN PREGNANCY CLINIC
WORKFLOW CHART

Arrival at the clinic/ registration

Vital signs PLUS

Urine dipstick for glucose, ketones, and proteins

Group diabetes education

with emphasis on lifestyle
changes and self-monitoring
of blood glucose

Preconception Antenatal care Postnatal care

care

Refer to Refer to section 4 on Refer to

section 2.0 on antenatal care, section section
preconception 3.5 on interventions 10.0 on
care in the and section 8.0 on postnatal
DM in timing and mode of care in the
Pregnancy delivery in the DM in DM in
protocol Pregnancy protocol Pregnancy
protocol
APPENDIX V

DM CLINIC BASELINE DATA

SOCIO-DEMOGRAPHIC INFORMATION

1. Name: …………………………………………………………………. Tel: …………………………………………

2. Hospital number: …………………………………………………
3. Place of abode: ……………………………………………………
4. Level of education: a. None [ ] b. Basic school [ ]
c. Senior High School [ ] d. Tertiary [ ]
5. Occupation: ………………………………………………………...
6. Marital status: a. Single [ ] b. Married [ ] c. Co-habiting [ ]

d. Divorced/ Separated [ ] e. Widowed [ ]

7. Religion: a. Christianity [ ] b. Islam [ ]

c. Traditional d. Other (specify)

CLINICAL PROFILE

8. Age: ……………… years

9. Family history of DM: a. Yes [ ] b. No [ ]
10. Previous history of DM in pregnancy: a. Yes [ ] b. No [ ]
11. Previous macrosomia: a. Yes [ ] b. No [ ]
12. Previous unexplained IUFD: a. Yes [ ] b. No [ ]
13. Multiple gestation in current pregnancy: a. Yes [ ] b. No [ ]
14. Polyhydramnios in current pregnancy: a. Yes [ ] b. No [ ]
15. Booking weight: ………………..kg

DIAGNOSTIC CRITERIA

16. Pre-gestational DM: a. Yes [ ] b. No [ ]

17. If yes: a. Type 1 [ ] b. Type 2 [ ]
c. Other (specify)……………………………………….. d. Unspecified
18. Gestational DM: a. Yes [ ] b. No [ ]
19. OGTT at diagnosis of GDM: FBS: ……………………………….mmol/l
 1HPP: …………………………….mmol/l
2HPP: …………………………….mmol/l

TREATMENT MODALITIES

20. Medical diet therapy and exercise alone: a. Yes [ ] b. No [ ]

21. Metformin: a. Yes [ ] b. No [ ] c. If yes, daily dose: ………………………….mg
22. Insulin: a. Yes [ ] b. No [ ]
23. Premixed insulin: a. Yes [ ] b. No [ ] c. If yes, daily dose: ……………..……IU
24. Basal bolus insulin: a. Yes [ ] b. No [ ] c. If yes, daily dose: .………………….IU
25. Good blood glucose profile? a. Yes [ ] b. No [ ]
26. If yes, after what duration of therapy? ………………………………………… days
27. Patient acceptance of therapy: a. Wholly accepts [ ] b. Reluctantly accepts [ ]
c. Unacceptable [ ]
28. Compliance to therapy: a. Full compliance [ ] b. Poor compliance [ ]
29. Number of admissions: ………………………………………
30. Reasons for admissions: a. Blood glucose profile [ ] b. Delivery [ ]
c. Other (specify): …………………………………………..
31. Cumulative duration of admissions: …………………………………. days
32. Estimated cost of admission: ……………………………………

PREGNANCY OUTCOMES

33. Hypertension: a. Yes [ ] b. No [ ]

34. Pre-eclampsia: a. Yes [ ] b. No [ ]
35. Macrosomia (EFW > 90th centile): a. Yes [ ] b. No [ ]
36. Polyhydramnios: a. Yes [ ] b. No [ ]
37. Congenital anomalies: a. Yes [ ] b. No [ ]
c. If yes, specify: …………………………………………………………………
38. IUFD: a. Yes [ ] b. No [ ]
39. Daily dose of metformin by time of delivery ……………………………………… mg
40. Daily dose of insulin by time of delivery ……………………………………… IU
41. Gestational age at delivery: ………………………………………
42. Mode of delivery: a. Vaginal [ ] b. Caesarean [ ]
43. Condition of baby: a. Live birth [ ] b. Fresh SB [ ] c. Macerated SB[ ]
44. Apgar score at 1 minute: ………………………………………….
45. Apgar score at 5 minutes: …………………………………………
46. Birth weight: ………………………… kg
47. OGTT at 6 weeks postpartum: FBS: ……………………………….mmol/l
1HPP: …………………………….mmol/l
2HPP: …………………………….mmol/l
48. Referral to Physicians after puerperium: a. Yes [ ] b. No [ ]
49. Overall patient satisfaction with management: a. Very satisfied [ ]
b. Satisfied [ ] c. Somewhat satisfied [ ] d. Dissatisfied [ ]
APPENDIX VI

KORLE BU TEACHING HOSPITAL

DM IN PREGNANCY/ ENDOCRINE CLINIC

PATIENT EDUCATION LEAFLET

What is diabetes?

• Diabetes happens when there is not enough insulin in your body.

• Insulin is a hormone that helps move sugar (glucose) from your blood into your cells. All the
cells in your body need sugar to work normally.
• If there is not enough insulin, or if the body stops responding to insulin, sugar builds up in
the blood. That is what happens to people with diabetes.
• Both type 1 and type 2 diabetes may be present before pregnancy, but diabetes can also
develop during pregnancy. This is known as gestational diabetes.

How should I prepare for pregnancy if I have diabetes?

• If you want to get pregnant, it is very important that you talk to your doctors before you
start trying to get pregnant. The doctors can make sure that you do everything possible to
have a healthy baby.
• Before you start trying to get pregnant, you will need to work closely with your healthcare
team to get your blood sugar as close to normal as possible. That might mean using more
insulin or metformin if you already use it.
• Normal blood sugar levels help prevent miscarriages and birth defects.
• You should also talk to your doctors about all medicines you take, including any supplements
or herbal medicines. If you use any medicines that are not safe to take during pregnancy,
you might need to switch or go off them.
• You need to take folic acid supplements in the months preceding pregnancy, preferably
starting 3 months before you become pregnant.

Will I need any tests before I start trying to get pregnant?

Yes. You will need these tests before pregnancy if you have diabetes:

• An eye exam (if you have not had one in the last 12 months). Pregnancy can increase your
chances of getting an eye disease called diabetic retinopathy, and it can make the condition
worse if you already have it. If you have severe diabetic retinopathy, you might need to treat
the condition before you get pregnant.
• Blood and urine tests to check the health of your kidneys – People with diabetes are at risk
for kidney disease. Pregnancy can worsen kidney disease that already exists.
• Blood pressure measurements – Having high blood pressure during pregnancy can cause
problems for you and your baby. If your blood pressure is too high, your doctors might give
you medicines to treat it. But they will choose medicines that are safe to use during
pregnancy.
 • Blood tests to measure thyroid hormone levels – Having normal thyroid hormone levels is
very important for you and a developing baby. If your tests show that your thyroid hormone
levels are too high or too low, you might need treatments to get them back to normal.
• Urine tests to check for infection – People with diabetes can have bladder or kidney
infections and not know it. It's important to treat these before pregnancy.

What is gestational diabetes?

• Gestational diabetes, like "regular" diabetes, is a disorder that disrupts the way your body
uses sugar.
• Gestational diabetes is a form of diabetes that affects some people when they are pregnant.
It happens because pregnancy increases the body's need for insulin, but the body cannot
always make enough.
• Gestational diabetes usually starts in the middle or towards the end of pregnancy.

What problems can gestational diabetes cause?

Many of the problems that can happen are related to having high blood sugar levels. For example:

• The baby can get too big (heavier than 4.0kg). That is a problem, because a big baby can get
hurt if it cannot fit easily through the birth canal. A big baby can also damage the mother's
body during delivery. Sometimes, a c-section is needed (surgery to get the baby out). Babies
born to mothers with gestational diabetes might also be at higher risk for being overweight
later in life.
• Right after birth, the baby can have blood sugar levels that are too low. They can sometimes
have other health problems, too.
• Gestational diabetes also increases the risk that a woman will have a life-threatening
problem during pregnancy called preeclampsia. (Preeclampsia causes high blood pressure,
among other things.)

Do I have risk factors for gestational diabetes?

You are more likely to get gestational diabetes if you:

• Had it before
• Have previously given birth to a baby weighing 4.0kg or more

• Are overweight (your body mass index (BMI) is higher than 30)
• Have diabetes in your family
• Are older than 25, and especially if you are older than 40
• Are of African, South Asian, or Middle Eastern origin

Some habits might reduce your risk of gestational diabetes. These include:
 • Losing weight before pregnancy if you are overweight,
• Eating a healthy diet,
• Exercising regularly, and
• Not smoking.

Should I be tested for gestational diabetes?

• Yes. All pregnant women are tested for gestational diabetes.

• Most people should be tested when they are about 6 or 7 months pregnant. (That's the
same as 24 to 28 weeks pregnant.) But people at high risk for diabetes might need to be
tested earlier in pregnancy.
• The test used to diagnose gestational diabetes is the oral glucose tolerance test (OGTT).
• An OGTT involves fasting overnight (not eating or drinking anything apart from water):
o In the morning, before breakfast, you will have a blood test. You are then given a
glucose drink.
o The blood test is repeated 1 and 2 hours later to see how your body reacts to the
glucose drink.
• If you have had gestational diabetes in a previous pregnancy, you will be offered an OGTT in
early pregnancy. If this is normal, you will be offered an OGTT again at 24–28 weeks.
• During your routine pregnancy care, your urine is tested for glucose. If glucose is present in
your urine, then your healthcare team may recommend that you have an OGTT.

How is gestational diabetes treated?

• To treat your gestational diabetes, you will need to check your blood sugar often. This is
something you can learn how to do on your own with an easy-to-use machine.
• Most people can keep their blood sugar level in the normal range by changing their diet.
Some people also need insulin shots or other diabetes medicines.

How should I change my diet?

• The most important treatment for gestational diabetes is a healthy eating plan and
exercising regularly.
• A dietitian can tell you how to change your diet. Everyone is different, so there is no single
diet that is right for everyone.

Do I need to exercise?

• Yes. Exercising (e.g., walking) for 30 minutes a day helps with controlling your blood glucose
levels.

How do I monitor my blood sugar?

 • After you have been diagnosed with gestational diabetes, you will be shown how to check
your blood glucose levels and told what your ideal level should be.
• If it does not reach this level with healthy eating and exercise, or if an ultrasound scan shows
that your baby is larger than expected, you may need to take tablets or give yourself insulin
injections.
• If your glucose level is very high at the time of diagnosis, then you may be offered treatment
straight away, in addition to making changes to your diet and exercise.

What are the risks to my baby?

The risks to your baby are:

• Congenital malformations (especially if you had diabetes before pregnancy)

• being bigger than average
• shoulder dystocia (where your baby’s shoulder gets stuck during birth)
• stillbirth or the baby dying at or around the time of birth.
• needing additional care once they have been born, possibly in a neonatal unit
• being at greater risk of developing obesity and developing type 2 diabetes in later life

Controlling your levels of blood glucose during pregnancy and labour reduces the chances of these
complications for your baby.

Can I have a normal delivery?

• The general aim is to have vaginal delivery at 38 to 39 weeks of pregnancy.

• If your blood sugar levels have been close to normal, chances are good that you will have a
normal delivery.
• If your blood glucose levels are high, the chances of you having an induced labour or a
caesarean birth are increased.
• During delivery, your doctor or nurse will check your blood sugar to make sure that it is not
too high.

What happens after I give birth?

• Your baby will stay with you unless they need extra care. Occasionally they may need to be
looked after in a neonatal unit (NICU) if they are unwell or need extra support.
• Your baby should have their blood glucose level tested a few hours after birth to make sure
that it is not too low.
• Your diabetes will probably go away, and your blood sugar will probably go back to normal.
• If you were taking insulin or another medicine, you probably will not need it anymore.
• Even so, your doctor or nurse should check your blood sugar to make sure your levels get
back to normal and stay that way.
• People who have gestational diabetes are at very high risk of getting "regular" diabetes later
in life.
• You should get checked for diabetes 6 weeks after you give birth, then every few years for
the rest of your life.
What do I need to know about future pregnancies?

• Having a healthy weight, eating a balanced diet, and taking regular physical exercise before
you become pregnant can reduce your risk of developing gestational diabetes again.
• As soon as you find out you’re pregnant, contact your healthcare team for advice about your
antenatal care as there is a chance you may develop gestational diabetes again (more than 1
in 3 women will get gestational diabetes again).

Emotional support

• Having tests or treatment can be a stressful time. If you are feeling anxious or worried in any
way, please speak to your healthcare team who can answer your questions and help you get
support.
• The support may come from healthcare professionals. We have a team of Clinical
Psychologist who can help you in this regard.