South
Dakota
Gestational Diabetes Care Guidelines
Antepartum Surveillance
-
Initiate daily fetal movement determinations (kick counts) at 28 weeks in all patients with GDM.
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Antepartum surveillance includes a twice weekly nonstress test (NST) or a weekly Biophysical Profile or Contraction Stress Test.
- If euglycemic with diet only, then initiation of antepartum testing may be delayed until 40 weeks.
- If insulin is not required, but euglycemia has not been documented, then initiate antepartum testing at 36 weeks.
- If insulin therapy is required, then initiate antenatal testing at 32-34 weeks.
Intrapartum/Delivery Management
- All patients should have a clinical or ultrasound estimate fetal
weight (EFW) within 2 weeks of estimated delivery date. Decisions
regarding route of delivery need to involve appropriate counseling
regarding risks and consequences of shoulder dystocia as well as risks
associated with cesarean delivery.
- If EFW > 4500 grams, then delivery by cesarean section without a trial labor is reasonable.
- If EFW 4000-4500 grams, then clinical pelvimetry, obstetrical history, and fetal growth pattern should be used to counsel the patient regarding trial of labor.
- If EFW < 4000 grams, then the patients should be managed according to standard obstetric practice.
- Monitor fingerstick blood glucose (FSBG) every 1 to 2 hours in labor with the goal of maintaining whole blood glucose levels between 70 and 100 mg/dl.
- If labor is anticipated to exceed 6 hours duration, then maintenance intravenous fluids containing 5% dextrose should be initiated. Bolus fluids should not contain glucose.
- Initiate an insulin drip during labor if FSBGs are > 120. If they are between 100 and 120 mg/dl, then the decision to initiate an insulin drip will depend on the expected time interval to delivery; the longer the interval the more beneficial the use of an insulin drip.
- This is one of many insulin drip regimens. Mix 25 units of regular human insulin in 250cc of normal saline (concentration 1 unit/10 cc Normal Saline). Initiate infusion at 10 cc/hour (1 unit insulin/hour). Adjust rate hourly based on hourly FSBG results. If patient has been requiring large doses of insulin to achieve euglycemia antenatally, a higher initial infusion rate may be appropriate. Consultation is recommended if the primary obstetrical provider is not prepared to manage an intrapartum insulin drip.
- Each institution should have a consistent protocol for intrapartum glucose monitoring and insulin use.
Postpartum Follow-up
- Discontinue insulin therapy after delivery.
- Obtain a casual (random) blood glucose on postpartum day 1-3; if it is normal (<200 mg/dl), then blood glucose monitoring is not required during the postpartum period.
- Obtain a 2-hour 75 g OGTT 6 to 8 weeks postpartum if:
- Patient required insulin during pregnancy
- Patient diagnosed with GDM prior to 24 weeks gestation
- Patient had a value >200 mg/dl on the 1-hour 50 g GCT
- Patient had a fasting result of >95mg/dl on the 3-hour 100 g OGTT
2-hour 75 gram GCT |
||
---|---|---|
Any single abnormal value is diagnostic |
Serum/Plasma Glucose Values for Diagnosis of Pre-Diabetes (mg/dl) |
Serum/Plasma Values for Diagnosis of Type 2 Diabetes (mg/dl) |
Fasting |
100-125 |
> or equal to 126 |
1-hour |
> or equal to 200 |
|
2-hour |
140-199 |
> or equal to 200 |
- Alternatively, these patients can be tested with a casual or fasting serum/plasma glucose; however, the result will not be as sensitive.
Casual or fasting serum/plasma glucose |
||
---|---|---|
Any single abnormal value is diagnostic |
Serum/Plasma Glucose Values for Diagnosis of Pre-diabetes |
Serum/Plasma Glucose Values for Diagnosis of Type 2 Diabetes (mg/dl) |
Fasting |
100-125 |
> or equal to 126 |
Casual |
> or equal to 200 |
- Refer patients diagnosed with Pre-diabetes, Type 2 DM, or Impaired Fasting Glucose to a primary care provider.
- Fasting blood glucose should be obtained annually on all patients with history of GDM. Communicating this to patients and primary care providers is important.
- All patients with GDM should be strongly encouraged to have a consultation with a diabetes educator and Diabetes Education following discharge regarding the long-term implication of a history of GDM.
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