M A N A G E M E N T O F
Gestational Diabetes C a r e P r o c e s s M o d e l J U N E 2 0 1 7 This care process model (CPM) was developed by clinical experts from Intermountain Healthcare’s Women and Newborns Clinical Program and the Diabetes Workgroup of the Primary Care Clinical Program. Based on national guidelines and recent research, it recommends gestational diabetes screening, diagnosis, treatment, and follow-up processes to improve outcomes for pregnant women and their infants. Why Focus ON GESTATIONAL DIABETES? Gestational diabetes (GDM) warrants a clinical care management system for the following reasons: • GDM is common and increasing in prevalence. The prevalence of GDM in the United States has varied in different studies, from 1.4 % to 14 % of pregnancies.DAB Estimate variation depends on the diagnostic criteria used and the ethnicity of the study population. Overall, the prevalence has been increasing over time in women of all ethnic backgrounds, possibly related to increases in mean maternal age and weight.GET • GDM is associated with an increased risk of perinatal complications. Morbidity associated with GDM includes preeclampsia, polyhydramnios, and macrosomia; the latter is in turn associated with an increased risk for operative delivery and birth complication / trauma. GDM is also associated with neonatal metabolic complications such as hyperbilirubinemia and hypoglycemia. • GDM is also linked to long-term risk of metabolic problems for both mother and child. Both have a significantly higher risk of developing type 2 diabetes later in life along with cardiovascular and other long-term risks. • Good care may improve outcomes. Studies show that appropriate care of patients with GDM can improve pregnancy outcomes; it also offers an opportunity to Continue reading >>
Diabetes In Pregnancy (nice Clinical Guideline 3)
This guideline was produced by the National Collaborating Centre for Women’s and Children’s Health (NCC-WCH) on behalf of the National Institute of Health and Care Excellence (NICE). The guideline focuses on areas where additional or different care should be offered to women with diabetes and their newborn babies. Where the evidence supports it, the guideline makes separate recommendations for women with pre‑existing diabetes and women with gestational diabetes. Continue reading >>
Acog Guidelines At A Glance: Gestational Diabetes Mellitus
Committee on Practice Bulletins—Obstetrics ACOG Practice Bulletin 137: Gestational Diabetes Mellitus, August 2013 (Replaces Practice Bulletin Number 30, September 2001, Committee Opinion Number 435, June 2009, and Committee Opinion Number 504, September 2011). Obstet Gynecol. 2013;122:406-16. Full text of ACOG Practice Bulletins is available to ACOG members at _Bulletins_--_Obstetrics/Gestational_Diabetes_Mellitus. Gestational diabetes mellitus Gestational diabetes mellitus (GDM) is one of the most common medical complications of pregnancy. Debate continues to surround both the diagnosis and treatment of GDM despite several recent large-scale studies addressing these issues. The purpose of this document is to 1) provide a brief overview of the understanding of GDM, 2) provide management guidelines that have been validated by appropriately conducted clinical research, and 3) identify gaps in current knowledge toward which future research can be directed. Used with permission. Copyright the American College of Obstetricians and Gynecologists. By Haywood L. Brown, MD Dr. Brown is Roy T. Parker Professor and Chair, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Duke Medicine, Durham, NC. He is also a member of the Contemporary OB/GYN Editorial Board. Practice Bulletin 137 on gestational diabetes mellitus provides a rationale for current screening guidelines for a pregnancy population in which prevalence of obesity and Type 2 diabetes has increased over the past several decades. Review of the bulletin underscores several questions pertinent to diagnosis and management, which are reflected by and addressed similarly in the evidence-based recommendations in the document.1 Is GDM overdiagnosed or underdiagnosed? Obviously, the prevalence of gest Continue reading >>
Diabetes Mellitus In Pregnancy: Screening And Diagnosis
INTRODUCTION Pregnancy is accompanied by insulin resistance, mediated primarily by placental secretion of diabetogenic hormones including growth hormone, corticotropin-releasing hormone, placental lactogen, and progesterone. These and other metabolic changes ensure that the fetus has an ample supply of nutrients. (See "Maternal adaptations to pregnancy: Endocrine and metabolic changes".) Gestational diabetes develops during pregnancy in women whose pancreatic function is insufficient to overcome the insulin resistance associated with the pregnant state. Among the main consequences are increased risks of preeclampsia, macrosomia, and cesarean delivery, and their associated morbidities. The approach to screening for and diagnosis of diabetes in pregnant women will be reviewed here. Management and prognosis are discussed separately: Continue reading >>
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Diabetes Acog 2017 | Gestational Diabetes | Diabetes Mellitus Type 2
Clinical Management Guidelines for ObstetricianGynecologists Number 180, July 2017 (Replaces Practice Bulletin Number 137, August 2013) Gestational diabetes mellitus (GDM) is one of the most common medical complications of pregnancy. However, debate continues to surround the diagnosis and treatment of GDM despite several recent large-scale studies address- ing these issues. The purposes of this document are the following: 1) provide a brief overview of the understanding of GDM, 2) review management guidelines that have been validated by appropriately conducted clinical research, and 3) identify gaps in current knowledge toward which future research can be directed. Background population or racial or ethnic group. Caucasian women generally have the lowest rates of GDM. There is an Definition and Prevalence increased prevalence of GDM among Hispanic, African Gestational diabetes mellitus is a condition in which American, Native American, and Asian or Pacific Islander carbohydrate intolerance develops during pregnancy. women (3). Gestational diabetes also increases with the Gestational diabetes that is adequately controlled with- same risk factors seen for type 2 diabetes such as obesity out medication is often termed diet-controlled GDM or and increased age (4). With a greater prevalence of obe- class A1GDM. Gestational diabetes mellitus that requires sity and sedentary lifestyles, the prevalence of GDM medication to achieve euglycemia is often termed class among reproductive-aged women is increasing globally. A2GDM. Because many women do not receive screening for diabetes mellitus before pregnancy, it can be chal- Maternal and Fetal Complications lenging to distinguish GDM from preexisting diabetes. Women with GDM have a higher risk of developing However, it has been es Continue reading >>
Guidelines For Gestational Diabetes Mellitus
Guidelines for Gestational Diabetes Mellitus Obstet Gynecol; ePub 2017 Jul; Caughey, et al The American College of Obstetricians and Gynecologists (ACOG) has issued clinical management guidelines for the diagnosis and treatment of gestational diabetes mellitus (GDM) in pregnancy. The document provides a brief overview of the understanding of GDM, reviews management guidelines that have been validated by appropriately conducted clinical research, and identifies gaps in current knowledge. Among the recommendations offered: Women in whom GDM is diagnosed should receive nutrition and exercise counseling, and when this fails to adequately control glucose levels, medication should be used for maternal and fetal benefit. When pharmacologic treatment of GDM is indicated, insulin is considered the first-line treatment for diabetes in pregnancy. All pregnant women should be screened for GDM with a laboratory-based screening test(s) using blood glucose levels. In women who decline insulin therapy or for those women whom the obstetrician or obstetric care provider believes the patient will be unable to safely administer insulin, metformin is a reasonable second-line choice. Glyburide treatment should not be recommended as a first-line pharmacologic treatment because, in most studies, it does not yield equivalent outcomes to insulin. Health care providers should counsel women of the limitations in safety data when prescribing oral agents to women with GDM. Women with GDM should be counseled regarding the risks and benefits of a scheduled cesarean delivery when the estimated fetal weight is 4,500 g or more. Gestational diabetes mellitus. Practice Bulletin No. 180. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2017;130:e1731. Continue reading >>
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Newly Published Acog Guidelines For The Diagnosis And Treatment Of Gestational Diabetes
Newly Published ACOG Guidelines for the Diagnosis and Treatment of Gestational Diabetes Posted On: January 12, 2018 By Daniel Saltzman, MD In July 2017, a new American Congress of Obstetricians and Gynecologists study was released on Gestational Diabetes Mellitus (GDM). This study contains important new information on both the management and treatment for GDM. Gestational diabetes that is adequately controlled without medication is often considered diet-controlled GDM or class A1GDM. Gestational diabetes mellitus that requires medication to achieve normal blood sugar levels is often called class A2GDM. It has been estimated that 69% of pregnancies are complicated by diabetes. Caucasian women generally have the lowest rates of GDM. There is an increased prevalence of GDM among Hispanic, African American, Native American, and Asian or Pacific Islander women. Gestational diabetes also increases with the same risk factors seen for type 2 diabetes such as obesity and increased age. With a greater prevalence of obesity and sedentary lifestyles, the prevalence of GDM among reproductive-aged women is increasing globally. Women with GDM have a higher risk of developing preeclampsia (9.8% in those with a fasting glucose less than 115 mg/dL and 18% in those with a fasting glucose greater than or equal to 115 mg/dL) and undergoing a cesarean delivery (25% of women with GDM who require medication and 17% of women with diet-controlled GDM underwent cesarean delivery versus 9.5% of controls). Furthermore, women with GDM have an increased risk of developing diabetes (predominantly type 2 diabetes) later in life. It estimated that up to 70% of women with GDM will develop diabetes within 2228 years after pregnancy. In 2014, the U.S. Preventive Services Task Force made a recommendation t Continue reading >>
Diabetes Management Guidelines
Source: American Diabetes Association. Standards of medical care in diabetes—2016. Diabetes Care. 2016;39(suppl 1):S1-S106. Available here. Refer to source document for full recommendations, including class of recommendation and level of evidence. Jump to a topic or click back/next at the bottom of each page Diabetes in Pregnancy (Gestational Diabetes) Glycemic Targets in Pregnancy Pregestational diabetes Gestational diabetes mellitus (GDM) Fasting ≤90 mg/dL (5.0 mmol/L) ≤95 mg/dL (5.3 mmol/L) 1-hr postprandial ≤130-140 mg/dL (7.2-7.8 mmol/L) ≤140 mg/dL (7.8 mmol/L) 2-hr postprandial ≤120 mg/dL (6.7 mmol/L) ≤120 mg/dL (6.7 mmol/L) A1C 6.0-6.5% (42-48 mmol/L) recommended <6.0% may be optimal as pregnancy progresses Achieve without hypoglycemia Recommendations for Pregestational Diabetes Pregestational type 1 and type 2 diabetes confer greater maternal and fetal risk than GDM Spontaneous abortion Fetal anomalies Preeclampsia Intrauterine fetal demise Macrosomia Neonatal hypoglycemia Neonatal hyperbilirubinemia Diabetes in pregnancy may increase the risk of obesity and type 2 diabetes in offspring later in life Maintain A1C levels as close to normal as is safely possible Ideally, A1C <6.5% (48 mmol/L) without hypoglycemia Discuss family planning Prescribe effective contraception until woman is prepared to become pregnant Women with preexisting type 1 or type 2 diabetes Counsel on the risk of development and/or progression of diabetic retinopathy Perform eye exams before pregnancy or in first trimester; monitor every trimester and for 1 year postpartum Management of Pregestational Diabetes Insulin is the preferred medication for pregestational type 1 and type 2 diabetes not adequately controlled with diet, exercise, and metformin Insulin* management during pre Continue reading >>
Acog Releases Updated Guidance On Gestational Diabetes
SUMMARY: ACOG has released updated guidance on gestational diabetes (GDM), which has become increasingly prevalent worldwide. Highlights and changes from the previous practice bulletin include the following: Fetal Monitoring Screening for GDM – One or Two Step? ACOG (based on NIH consensus panel findings) still supports the ‘2 step’ approach (24 – 28 week 1 hour venous glucose measurement following 50g oral glucose solution), followed by a 3 hour oral glucose tolerance test (OGTT) if positive Note: While the diagnosis of GDM is based on 2 abnormal values on the 3 hour OGTT, ACOG states, due to known adverse events, one abnormal value may be sufficient to make the diagnosis 1 step approach (75 g OGTT) on all women will increase the diagnosis of GDM but sufficient prospective studies demonstrating improved outcomes still lacking ACOG does acknowledge that some centers may opt for ‘1 step’ if warranted based on their population Who Should be Screened Early? ACOG has adopted the NIDDK / ADA guidance on screening for diabetes and prediabetes which takes in to account not only previous pregnancy history but also risk factors associated with type 2 diabetes. Screen early in pregnancy if: Patient is overweight with BMI of 25 (23 in Asian Americans), and one of the following: Physical inactivity Known impaired glucose metabolism Previous pregnancy history of: GDM Macrosomia (≥ 4000 g) Stillbirth Hypertension (140/90 mm Hg or being treated for hypertension) HDL cholesterol ≤ 35 mg/dl (0.90 mmol/L) Fasting triglyceride ≥ 250 mg/dL (2.82 mmol/L) PCOS, acanthosis nigricans, nonalcoholic steatohepatitis, morbid obesity and other conditions associated with insulin resistance Hgb A1C ≥ 5.7%, impaired glucose tolerance or impaired fasting glucose Cardiovascular disea Continue reading >>
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Resources: Diabetes In Pregnancy
Within this page are a variety of resources and links to downloads that you can use professionally and to assist your patients. First are items from SSEP,including archieved newsletters, see the product websitepage for professional and patient materials. Second, many resources (both for porfessionals and patients) fromCDAPP (California Diabetes and Pregnancy Program) are listed. To follow next arepublished standards in the care of Diabetes and Pregnancy. Finally, there are numerous free resources and patient materials on a variety of subjects. These are listed alphabetically by the resource group or subject. Direct website links and download linksare provided when available: click onunderlined or buttons below. Diabetes & Pregnancy Self-Study Modules - 40 CE Credits. Online format - [email protected] Details for all professional and patient resourceson the product page. Birth Defect Research for Children, Inc. (BDRC) is a 501(c)(3) non-profit organization that provides parents and expectant parents with information about birth defects and support services for their children. BDRC has a parent-matching program that links families who have children with similar birth defects. The Compliance Scale developed by Susan Rasmussen, RN and Colleen Johnson, RD who manage the Perinatal Outpatient Services/Sweet Success Program at Sierra Vista Regional Medical Center in San Luis Obispo, California, may be downloaded and copied. The objective of this compliance scale is to provide the Healthcare Provider with accurate and measurable information regarding a patient's participation in the program. For more information, contact Susan directly [email protected] Promotes the benefits of public cord blood banking and provides the latest up-to-date information Down Continue reading >>
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New Figo Guidelines On Gestational Diabetes [24p]
New FIGO Guidelines on Gestational Diabetes [24P] Gestational diabetes mellitus is one of the most common medical disorders found in pregnancy. Clinical recognition of GDM is important because timely intervention by dietary measures or insulin and fetal surveillance can reduce the well described associated maternal and fetal complications. This observational study was done over a period of one year. Single step test using 75 gms oral glucose was used as screening and diagnostic test for GDM. A total of 500 pregnant women attending antenatal clinic were selected randomly for the study at less than 16 weeks POG. All the selected women were given a 75 gm anhydrous glucose powder dissolved in a glass of water, to be consumed over 5 minutes, irrespective to the time of last meal. A venous blood sample was collected at 2 hours for estimating plasma glucose by the glucose oxidase peroxidase (GOD-POD) method. GDM was diagnosed if 2 hrs plasma glucose is >140 mg/dl. Prevalence of GDM was found to be 7% in present study. Age 25 years, obesity, multigravidity and family history of diabetes mellitus were major risk factors for developing GDM. Maternal and fetal outcomes were poor in GDM group as compared to the control group. In GDM group common maternal complications were polyhydramnios and recurrent vaginal infections. Present study concurs with the WHO recommendation of 2-hr 75 gms OGTT as single step procedure for both screening as well as diagnosis of GDM. Hence we suggest the adaptation of 75 gms glucose single step test for screening and diagnosis of GDM. Financial Disclosure: The authors did not report any potential conflicts of interest. 2017 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved. Continue reading >>
Acog Issues New Practice Bulletin On Gestational Diabetes
ACOG Issues New Practice Bulletin on Gestational Diabetes The American College of Obstetricians and Gynecologists (ACOG) has issued a new practice bulletin on the management of gestational diabetes mellitus. The document "primarily serves as an update, to incorporate new clinical trials and whether or not they shed any additional light or would change management," says one of the authors, Wanda K. Nicholson, MD, from the University of North Carolina at Chapel Hill. The bottom line is that there is "no change on what was previously recommended," she told Medscape Medical News. "The new studies that have been done since the last bulletinreconfirm what the management has been, but we also identify areas or gaps in our knowledge for future studies," she noted. The bulletin is published in the August issue of Obstetrics & Gynecology. Diagnosing Gestational Diabetes: Keep 2-Step Approach Approximately 7% of the 4 million women who give birth each year in the United States develop gestational diabetes. The condition is increasing as obesity and older age at pregnancy become more common. Other risk factors include having a family history of type 2 diabetes or belonging to an ethnic group at increased risk for the condition (such as Hispanic, Native American, South or East Asian, African American, or Pacific Islands descent). Women with gestational diabetes are at higher risk for gestational hypertension, preeclampsia, and cesarean delivery and associated potential morbidities, and, of note, have a 7-fold increased risk of developing diabetes later in life. The offspring of women with gestational diabetes are also at increased risk for macrosomia, neonatal hypoglycemia, hyperbilirubinemia, operative delivery, shoulder dystocia, and birth trauma. The new ACOG bulletin, together Continue reading >>
The Emerging Role Of Metformin In Gestational Diabetes Mellitus
The emerging role of metformin in gestational diabetes mellitus School of Pharmacy, The University of Queensland, Brisbane, Australia Mater Pharmacy Services, Mater Health Services, Brisbane, Australia Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia School of Pharmacy, The University of Queensland, Brisbane, Australia Department of Pharmacy, Xinhua College of Sun Yatsen University, Guangzhou, China Correspondence Professor Peter J. Little PhD, MSc, BPharm, School of Pharmacy, The University of Queensland, Pharmacy Australia Centre of Excellence, 20 Cornwall Street, Woolloongabba, QLD 4102, Australia.Email: School of Pharmacy, The University of Queensland, Brisbane, Australia Mater Pharmacy Services, Mater Health Services, Brisbane, Australia Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia School of Pharmacy, The University of Queensland, Brisbane, Australia Department of Pharmacy, Xinhua College of Sun Yatsen University, Guangzhou, China Correspondence Professor Peter J. Little PhD, MSc, BPharm, School of Pharmacy, The University of Queensland, Pharmacy Australia Centre of Excellence, 20 Cornwall Street, Woolloongabba, QLD 4102, Australia.Email: Please review our Terms and Conditions of Use and check box below to share full-text version of article. I have read and accept the Wiley Online Library Terms and Conditions of Use. Use the link below to share a full-text version of this article with your friends and colleagues. Learn more. Get access to the full version of this article.View access options below. You previously purchased this article through ReadCube. View access options below. Logged in as READCUBE_USER. Log out of ReadCube . Metformin use during pregnancy is controversial and there is disparity i Continue reading >>
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Updated Guidelines On Screening For Gestational Diabetes
1Department of Medicine, Government Medical College and Hospital, Chandigarh, India; 2Bharti Hospital, Karnal, Haryana, India; 3Excel Center, Guwahati, Assam, India; 4Saket City Hospital, New Delhi, India Abstract: Gestational diabetes mellitus (GDM) is associated with an increased risk of complications for both mother and baby during pregnancy as well as in the postpartum period. Screening and identifying these high-risk women is important to improve short- and long-term maternal and fetal outcomes. However, there is a lack of international uniformity in the approach to the screening and diagnosis of GDM. The main purpose of this review is to provide an update on screening for GDM and overt diabetes during pregnancy, and discuss the controversies in this field. We take on debatable issues such as adoption of the new International association of diabetes and pregnancy study groups criteria instead of the Carpenter and Coustan criteria, one-step versus two-step screening, universal screening versus high-risk screening before 24 weeks of gestation for overt diabetes, and, finally, the role of HbA1c as a screening test of GDM. This discussion is followed by a review of recommendations by professional bodies. Certain clinical situations, in which a pragmatic approach is needed, are highlighted to provide a comprehensive overview of the subject. Keywords: pregnancy, guidelines, IADPSG, GDM, Carpenter and Coustan criteria Gestational diabetes mellitus (GDM) has classically been defined as any glucose intolerance first identified during pregnancy.1 Recently, the American Diabetes Association (ADA) defined it as “Diabetes diagnosed in the second or third trimester of pregnancy that is not clearly overt diabetes”.2 However, as per IADPSG (International association of diabete Continue reading >>
Acog Issues Clinical Practice Guidelines For Gestational Diabetes Mellitus
The American College of Obstetricians and Gynecologists (ACOG) has issued clinical practice guidelines for the diagnosis and treatment of gestational diabetes mellitus (GDM). Although prevalence of GDM is directly proportional to prevalence of type 2 DM in a given population, it is estimated that GDM accounts for 90% of cases diabetes in pregnancy. The prevalence of DM in pregnancy is around 6-9%. The prevalence of GDM globally is on the rise because of increasing obesity, delayed childbearing and sedentary lifestyle. The document provides a brief overview of GDM, one of the most common complication of pregnancy, identifies the disease process, its diagnosis and management based on current research and identifies the lacunae for future research. Screening for GDM is done by various methods and there is still no standardized method. ACOG supports the two-step process most commonly used in USA. It involves first screening with the administration of a 50-g oral glucose solution followed by a 1-hour venous glucose determination. Women whose glucose levels meet or exceed an institution’s screening threshold then undergo a 100-g, 3-hour diagnostic OGTT. Gestational diabetes mellitus is most often diagnosed in women who have two or more abnormal values on the 3-hour OGTT. Other institutions and private practitioners use International Association of Diabetes and Pregnancy Study Group (IADPSG) recommended one step, universal 75-g, 2-hour OGTT to diagnose GDM. The summary of recommendations by ACOG: Recommendations based on good scientific evidence (Level A): All women diagnosed with GDM should first be treated with adequate nutritional and exercise counselling, before starting any pharmacological treatment. If lifestyle modifications fail to control glucose levels, Insulin is Continue reading >>
