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2. Objectives
After completing this Module the participant
will be able to
• Discuss the benefit of self monitoring of blood
glucose (SMBG) when available
• Determine appropriate timing of SMBG depending
on availability of strips
• Decide on expected target values for fasting and
post prandial BG
• Discuss methods of fetal monitoring
2
4. How often should SMBG occur?
Daily monitoring provides immediate feedback to the
mother and is the ideal.
• Woman must know targets
• Must know how to respond to results out of target
range
When resources are limited
• Once weekly monitoring until targets reached
• When targets reached check once per month until
late in the 2nd trimester
• Then increase to every 1 - 2 weeks
Metzger, Buchanan et al 2007
Seshiah Balaji, 2006 4
6. HbA1C during pregnancy?
May be valuable in determining those who had
undiagnosed diabetes prior to pregnancy
May give indication of overall control during
pregnancy BUT
Not valuable for day-to-day management during
pregnancy
May give falsely low results
Other factors such as anemia make it unreliable
6
7. Fetal movement counting
The rationale - decreased fetal movements may signal
decreased oxygenation which often precedes fetal
demise
Reduction of activity associated with chronic fetal distress
Among inactive fetuses, approximately 50% are either
stillborn, tolerate labor poorly or require resuscitation at
birth
7
Lalor et al 2008
8. Fetal movement
• Inexpensive, involving the mother, easy to use
• Foetal movements related to maternal glucose
levels
• Patients taught generally from late third
trimester - after 35 weeks at routine ANC
• Reduced activity needs to be evaluated by
NST (non stress test)
8
9. Other parameters
Blood pressure – every visit
Values above 140/90 mm Hg are of concern
If > 140/90 re measure same day; If > 150/100 initiate
therapy
If BP > 140/90 check urine for albuminuria
Estimate Urine albumin / sugar dip stick
Though urine sugar not of value in a known GDM, albumin is
important as sometimes predates BP in preeclampsia
9
10. Ultrasound fetal measurement
Early pregnancy scan - 7-8 weeks
• Dating and viability
• Dating important to offer appropriate timing for
antenatal visits/ scans and delivery
• Accurate dating prevents iatrogenic prematurity
10
11. 11-13 week scan
• As for non- diabetic pregnancies
• Can pick up 60% of structural abnormalities –
value for women with suspected diabetes or
early gestational diabetes
11
12. 18-20 week target scan
• Detailed level 2/3 scan to ensure structural
normalcy
• Foetal echo for all DM and GDM detected early
in pregnancy
Reece CA 2004
12
13. Serial growth scan
• 28 weeks onwards, growth estimation is done
by ultrasound to monitor fetal growth and
identify both SGA and LGA babies.
• Scan to monitor growth is recommended every
4 weeks till 36 weeks.
• Growth plotted on growth charts to see centiles
13
Julie DL 2007, NICE 2008
15. Growth - macrosomia
• Macrosomia is common in GDM especially if there is
poor control
• If macrosomia is suspected, then additional
measurements that can be taken:
• include frontal truncal skin fat layer,
• skin thickness above the scapula,
• amniotic fluid index
• Post prandial blood sugars rather than fasting
sugars correlate better with birth weight and foetal
size
15
16. Growth - IUGR
IUGR seen in
- Women with vasculopathy
- Preeclampsia
- Diabetes with too strict glycaemic control
SGA babies(< 10th centile for GA) have an
increased risk of perinatal morbidity and mortality
16
18. Antenatal surveillance
From 36 weeks, CTG / modified BPP are tests of
fetal well being
No consensus or recommendation on when to
start such tests or the frequency of monitoring
In women who want to await spontaneous labour,
these tests are indicated weekly after 38 weeks
18Coustan 2009, NICE 2008
19. References
American Diabetes Association. Standards of Medical Care 2015. Diabetes Care 2015;38(suppl 1):
S77
Austin M.M., Haas L., Johnson T., Parkin C.G., Parkin C.L., Spollett G., Volpone, M.T. (2006). AADE
Position Statement: Self-monitoring of blood glucose: benefits and utilization. The Diabetes
Educator, 32:835-847.
Bode, B.W. (2007). Incorporating postprandial and fasting plasma glucose into clinical management
strategies. Insulin, 2:17-29.
Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes
Association 2013 Clinical practice guidelines for the prevention and management of diabetes in
Canada; Diabetes and pregnancy. Can J of Diabetes. 2013;37(suppl 1):S168-183.
Coustan D, Glob. libr. women's med. (ISSN: 1756-2228) 2009; DOI 10.3843/GLOWM.10162
Julie DL 2007
Lalor JG, Fawole B, Alfirevic Z, Devane D. Biophysical profile for fetal assessment in high risk
pregnancies. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.: CD000038. DOI:
10.1002/14651858.CD000038.pub2
Landon and Gabbe Antepartum surveillence in gestational diabetes Diabetes Supplement 2 50-54,
1985
McAndrew L., Schneider, S.H., Burns, E., Levethal, H. (2007). Does patient blood glucose monitoring
improve diabetes control? The Diabetes Educator, 33:991-1011.
Metzger, BE, Buchanan TA, Coustan DR, et al. Summary and recommendations of the Fifth
International workshop-Conference on Gestational Diabetes Mellitus. Diabetes Care.
2007;30(Supple 2):S251-260.
National Collaborating Centre for Women’s and Children’s Health. Diabetes in pregnancy. Revised
reprint July 200. London:RCOG Press. (www.nice.org.uk)
NICE 2008
Parkin C.G., Hinnen, D., Campbell, K., et al. (2009). Effective Use of Paired Testing in Type 2
Diabetes: Practical Applications in Clinical Practice, The Diabetes Educator, 35, 915.
19
20. Reece CA 2004
Roberts AB, Stubbs SM, Mooney R, et al. Fetal activity in pregnancies complicated by maternal diabetes mellitus. Br J
Obstet Gynaecol. 1980;87:845–849.
Seshiah V, Balaji V, et al. Gestational Diabetes Mellitus – Guidelines. J Assoc Physic of India. 2006;54:622-28.
The International Diabetes Federation Clinical Guidelines Task Force, in conjunction with the SMBG International
Working Group. Guideline on Self-Monitoring of Blood Glucose in Non-Insulin-Treated Type 2 Diabetes, 2009.
Vintzileos AM. Antenatal assessment for the detection of fetal asphyxia: an evidence-based approach using indication-
specific testing. Ann N York Acad Sci. 2000;900:137–150.
,
20
Editor's Notes
The International Diabetes Federation Clinical Guidelines Task Force, in conjunction with the SMBG International Working Group. Guideline on Self-Monitoring of Blood Glucose in Non-Insulin-Treated Type 2 Diabetes, 2009.
Austin M.M., Haas L., Johnson T., Parkin C.G., Parkin C.L., Spollett G., Volpone, M.T. (2006). AADE Position Statement: Self-monitoring of blood glucose: benefits and utilization. The Diabetes Educator, 32:835-847. McAndrew L., Schneider, S.H., Burns, E., Levethal, H. (2007). Does patient blood glucose monitoring improve diabetes control? The Diabetes Educator, 33:991-1011. Bode, B.W. (2007). Incorporating postprandial and fasting plasma glucose into clinical management strategies. Insulin, 2:17-29. Parkin C.G., Hinnen, D., Campbell, K., et al. (2009). Effective Use of Paired Testing in Type 2 Diabetes: Practical Applications in Clinical Practice, The Diabetes Educator, 35, 915.
Guidelines recommend that monitoring would ideally be done daily. In many countries women monitor before and after every meal. While this gives immediate feedback regarding levels however the value is limited if the woman does not know how to respond to the results, either adjusting intake or insulin.
Frequent testing may not be practical in many cases. Therefore in cases where good control is yet to be achieved, monitoring should be done more frequently. Once control is achieved then, One measurement per month up is sufficient up until the late second trimester and every 1 - 2 weeks thereafter. This way BG monitoring could be combined with visits to the clinic.
How many of your patients are able to monitor their own blood glucose?
How often can or do women come to the clinic to have their blood glucose monitored?
Metzger BE, Buchanan TA, Coustan DR, De Leiva A, Hadden DR, Hod M. Summary and recommendations of the fifth international workshop-conference on gestational diabetes mellitus, Diabetes Care. 2007; 30(suppl 2):S251-260.
Seshiah V, Balaji V, et al. Gestational Diabetes Mellitus – Guidelines. J Assoc Physic of India 2006;54:622-28.
These are the target levels for women once they are pregnant. Note they are slightly lower than target levels for non – pregnant people with diabetes. Targets are lower to protect the baby from exposure to too much glucose in the womb.
Metzger, BE, Buchanan TA, Coustan DR, et al. Summary and recommendations of the Fifth International workshop-Conference on Gestational Diabetes Mellitus. Diabetes Care. 2007;30(Supple 2):S251-260.
National Collaborating Centre for Women’s and Children’s Health. Diabetes in pregnancy. Revised reprint July 200. London:RCOG Press. (www.nice.org.uk)
American Diabetes Association. Standards of Medical Care 2015. Diabetes Care 2015;38(suppl 1): S77
Seshiah V, Balaji V, et al. Gestational Diabetes Mellitus – Guidelines. J Assoc Physic of India 2006;54:622-28.
Lalor JG, Fawole B, Alfirevic Z, Devane D. Biophysical profile for fetal assessment in high risk pregnancies. Cochrane Database Syst Rev.2008:CD000038. [PubMed]:
When Blood glucose is high the baby will move less, when low the baby may be very active.
Landon and Gabbe Antepartum surveillence in gestational diabetes Diabetes Supplement 2 50-54, 1985
Roberts AB, Stubbs SM, Mooney R, et al. Fetal activity in pregnancies complicated by maternal diabetes mellitus. Br J Obstet Gynaecol. 1980;87:845–849.
Vintzileos AM. Antenatal assessment for the detection of fetal asphyxia: an evidence-based approach using indication-specific testing. Ann N York Acad Sci. 2000;900:137–150.
Delayed conception sometimes see when ovulation is irregular in diabetes hence an accurate dating is a must – will help in interpretation of correct growth
for dating
Women with diabetes do not have an increased risk of numeric chromosomal anomalies such as Klienfelter
Some biochemical markers tend to be lower in women with type 1 diabetes than in women without diabetes.
Infants of mothers with diabetes are three times more likely than infants in general to manifest all types of birth defects. Cardiac, neural tube, and skeletal defects are most common, but a particular set of anomalies affecting the lower half of the body, the "caudal regression syndrome," is highly specific for diabetic pregnancy. (Reece CA 2004)
A fetal echo must be offered and done in a standardised detailed fashion, to all pregnant women with diabetes, given the increased incidence of anomalies. As some of the women with GDM / DM are obese, the timing of the scan and fetal echo may be pushed to 20 - 22 weeks for better visualisation.
It is important to plot the growth of the baby based on the scan to see progression.
BPD ??
HC Head circumference
AC Abdominal circumference
Rt F L – right femur length
EFW – Estimated Fetal Weight
