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Glucose intolerance with onset or first Insulin resistance begins in mid pregnancy and
recognition during pregnancy progresses through the third trimester
A result of maternal adiposity and effects of placental
Characterized by -cell function that is hormones
unable to meet the bodys insulin needs
1
GDM represents a state of chronic -cell Prevalence
dysfunction in the face of insulin The prevalence of GDM is estimated to be 10-
resistance 16.9% in pregnant women depending on the
diagnostic criteria used.
Insulin resistance and insulin levels are different
prior to pregnancy in women who develop GDM Prevalence also varies by region and ethnicity.
and those who do not Highest prevalence is in South East Asia
Lowest in North America and the Caribbean
Changes in insulin sensitivity are similar in both
groups during pregnancy Prevalence higher
in less physically active women.
However in GDM women, insulin secretion does In older women
In women with higher BMI
not increase adequately In those with a strong family history of diabetes
WHO, 2013
Buchanan, Wiang, Kjos, Watanabe 2007 IDF, 2013
1
2
Is Hypertension a risk factor? Why diagnose and treat GDM?
Hypertension prior to pregnancy or during Short term risks for the mother
1st trimester doubled the risk of GDM Development of gestational hypertension, worsening essential
hypertension or development of preeclampsia
independent of maternal weight Operative delivery - related to macrosomia
Polyhydramnios
Premature labour
Hence all women with hypertension should
be screened for GDM Long term risks for the mother
Development of type 2 diabetes in next ~10 years (30-60%
depending on population)
Development of cardiovascular disease
CDA, 2013
Hedderson, Ferrara, 2008 Metzger, Buchanan, et al. 2007
Short term risks for the baby Long term follow up studies have shown
Macrosomia that most women with GDM will develop
Neonatal hypoglycemia diabetes within the first decade after the
Jaundice pregnancy
Preterm birth
Birth injury
Hypocalcemia/ hypomagnesimia Testing after pregnancy is important - more
Respiratory distress syndrome
about this later
Long term risks for the baby
Obesity
Type 2 diabetes Kim, Newton, Knopp 2002
3
Who to screen
Screening
Some guidelines recommend screening all
women at the first visit to rule out pre -
- Whom to screen existing type 2 diabetes
4
Center-to-center differences occur in GDM frequency
and relative diagnostic importance of fasting, 1-h, and
2-h glucose levels. This may impact strategies used for
V. Seshiah, V. Balaji, Madhuri S Balaji, A Paneerselvam, Manjula Datta, Diabetes Research In
the diagnosis of GDM
Frequency of gestational diabetes mellitus at collaborating centers based on IADPSG
Clinical Practice: 2007. Sept; 77(3): 482-4 consensus panel-recommended criteria: the Hyperglycemia and Adverse Pregnancy
Outcome (HAPO) Study.
Sacks DA. etal. Diabetes Care 2012 Mar;35(3):526-8
Diagnostic criteria
Crowther CA. Hiller JE, Moss JR. et al. Effect of treatment of gestational diabetes
mellitus. N Engl J Med 2005: Vol. 352. No. 24. 2477-86.
Gayle C. Germain S. Marsh Ms. et al. Comparing pregnancy outcomes for intensive
versus routine antenatal treatment of GDM based on a 75 gm OGTT 2 - h blood
glucose (>140 mg / dl). Diabetologia. 2010. Vol. 53. Suppl. No. 1, S435.
Paul W. Franks, Helen C. Looker, Sayuko Kobes, Lesite Touger, P. Antonio Tataranni, Robert I. Hanson, and
Willliam C. Knowler. Diabetes 2006 55: 460-465. Jitendra Singh et al. Prevalence of Gestational Diabetes Mellitus (GDM) and its
Seshiah V, Balaji V, Arjalakshi C, Madhuri S Balaji, et al. A Single test procedure to diagnose GDM. Outcomes in Jammu. JAPI (59): April 2011.
Acta Diabetologica 46 (1) : 51-54, March 2009
Balaji V, Madhuri Balaji, Anjalakshi C, Cynthia A, Arthi T. Seshiah V. (2011). Diagnosis
Diabetes Care 2015, WHO 2013 of gestational diabetes mellitus in Asian-Indian women. India J Endocrinol Metab.
July 2011, Vol. 15, Issue 3, pp. 187-190
5
How to screen Venous or capillary
Key considerations for screening in low resource
countries The venous plasma is the gold standard
Low cost
No requirement for elaborate preparation
High sensitivity and specificity Where laboratory facilities or technicians are not
Short turn-around time available, capillary glucose estimations may be done
Be administered by health workers with minimal training
using a hand held glucose meter.
Need little maintenance, calibration, or refrigeration
6
7
Insulin Therapy
Pregnant Woman with GDM
MNT for 2 weeks
2 hr PPPG
120 mg/dl 2 hr PPPG < 120 mg/dl
FBG <95mg/dl & 2 hrs PPPG FBG <95mg/dl & 2 hrs PPPG FBG <95mg/dl & 2 hrs PPPG
<120 mg/dl <120 mg/dl <120 mg/dl
Continue same dose of Increase dose of Insulin Give Inj. Insulin 2 doses
Insulin + MNT by 2 U + MNT pre breakfast - by 4 U
Repeat FBG & 2 hr PPPG every 3rd day till dose of Insulin adjusted
v
Repeat FBG & 2 hr PPPG every 3rd day
v
Adjust dose of Insulin accordingly till FBG <95mg/dl, 2 hr PPPG <120 mg/dl
Post Partum Screening Cut offs for normal blood glucose values are:
Subsequently, ANM to perform 75 g GTT at 6 weeks postpartum to IX.GDM should be a part of NCD (Non communicable Disease)
evaluate glycemic status of woman. programme.
8
9
Gestational Diabetes Uttar Pradesh
Gestational Diabetes
18 Districts to be covered under NHM Prevalence and Outcome
District Hospital and CHC to be target
Study in Uttar Pradesh
Any hospital where more>200 Deliveries in a month
Maternal health Clinic HCPs to be trained Why Screening All Pregnant Women
3000 Doctors and 6000 Nurse/Paramedical staff to Population based Study
be covered in next 3 years in two full day Certified
Training. 57,000 Pregnant Women covered through Single
Syllabus as IDF and NHM GOI Guidelines OGTT Test.
10
Materials and Methods
11
12
13
Jain, et al: Role of management of blood sugar in improving outcomes in GDM cases
Stillbirth 247 (3.3) 916 (12) < 0.0001 102(1.2) 212 (2.6) <0.0001
Neonatal death 128 (1.6) 156 (2) < 0.09 56 (0.7) 62 (0.8) <0.5
Perinatal death 375 (4.9) 1072 (14) < 0.0001 158 (1.9) 274 (3.4) <0.0001
14
CONCLUSION
Maternal and fetal outcomes in GDM cases are poor. Perinatal and material outcomes in GDM cases are
also significantly related to control of blood sugar levels. Therefore, blood sugar levels appear to be an
important possible indicator of maternal and perinatal morbidity and mortality in Indian GDM cases.
However, there is a need to unify diagnostic criteria in practices throughout the Indian subcontinent for a
better validation of results from this study as well as other GDM studies conducted in
15
Objectives
Make changes in their behaviour that support their any clear advantage, interventions that
self-management efforts
incorporate behavioural and affective
components are more effective.
Barlow, Wright, Sheasby, Turner, Hainsworth, 2002
Roter, Hall, Merisca, Nordstrom, Cretin,Svarstad, 1998
16
Why is self-management important? What do people need to understand?
People want to be healthy and have healthy babies.
Their own personal goals, values and feelings
Gestational diabetes needs to be self-managed.
Person is responsible for their day-to-day care. Diabetes care and treatment (advantages/
24-hours-a-day management is necessary. disadvantages)
Active, informed self-management leads to better long-term
outcomes.
Behaviour change and problem-solving strategies
Who is the decision-maker the woman, the
Funnell, Brown, Childs, Haas,Hosey, Jensen, et al.,2007
husband, the mother-in-law?
Norris, Lau, Smith, 2002
Gary, Genkinger, Guallar, Peyrot, Brancati, 2003
Duncan, Birkmeyer, Coughlin, Ouijan, Sherr, Boren, 2009 How to assume day-to-day responsibility
17
So what should we do? Reframe our attitudes and behaviours
Self-
Patient centered Ask questions
Ask the person
Management Learn with the person
Education Partnership approach Identify problems
Address concerns
18
Learning
Communication Skills
19
Communicating feelings or attitudes
Watch your body language!
Vocal 38%
Visual 55%
Mehrabian, 1999
Introduce your subject and state a purpose Use the active voice
Paint a picture, make it visual The person should be the subject of the
Keep it organised message
Move from simple to complex You may require medication to achieve target
blood glucose levels
Repetition is important three times
Vs
Summarise
Some women may require medication to
Evaluate
Belton, Simpson, 2010 achieve target blood glucose levels
20
Communication Develop listening skills
The words
the speaker
says
21
Assessment There is a difference
Goals
Establish trust Health professionals and women with GDM
may have different opinions on what is
Determine priorities important
Assess current health status, knowledge and self-
Ask the woman what is important to her.
care practices
Determine family role or other support
Identify available resources
Suhonen, Nenonen, Laukka, Valimaki, 2005
Identify barriers to learning and self-management Timmins, 2005
22
Planning Planning
Implementation Implementation
Simple words
Begin with the learners wishes
Open-ended questions
Most important topics first and last
Positive feedback
Simple to complex
23
Evaluation Evaluation
evaluate - Specific
- Centered on the person
Not an afterthought! - Timed
Individual evaluation
1. Identify the problem
Open-ended questions
Ask the person with diabetes to explain information to 5. Evaluate the results
you teach-back
24
What is the problem? How do you feel?
What are your greatest concerns/fears/ Do you feel ________ about _______?
worries?
What makes this so hard for you?
Why is that happening?
How does this need to change for you to feel Can you/do you want to/will you?
better about it?
What might work?
What will you gain/give-up?
What has/hasnt worked?
What can you do?
What do you need to do to get started?
What do you want to do?
What one step can you take this week?
On a scale of 1-10, how important is this?
25
SMART behavioural goals How did it work?
26
Activity Activity
Imagine you have just been told you have
gestational diabetes
What do you feel is supportive behaviour from
Think of three things you would need to
change to manage your diabetes close family, friends, or the health professional?
What is not supportive?
Then ask yourself
Summary References (1 of 2)
Anderson, R.M., Funnell, M.M., Arnold, M.S). Using the empowerment approach to help patients change behavior. In Anderson, B. J., Rubin,
R.R., eds. Practical Psychology for Diabetes Clinicians, 2nd edition . Alexandria: American Diabetes Association; 2002.
Be selective Anderson, R.M., Funnell, M.M. The Art of Empowerment: Stories and Strategies for Diabetes Educators . 2nd ed. Alexandria: American
Diabetes Association; 2005.
Bastable, S. Nurse as Educator. 3rd ed. Sudbury, MA: Jones & Bartlett Publishers; 2008.
Be specific Barlow J, Wright C, Sheasby J, Turner A, Hainsworth J. Self -management approaches for people with chronic conditions: a review. Patient
Educ Couns 2002 (48) : 177- 87.
Belton AB, Simpson N. The How To of Patient Education. 2nd Ed . Streetsville, ON: RJ & Associates; 2010.
Brown SA. Interventions to promote diabetes self -management: State of the science. Diabetes Educ, 25(Suppl ) 1999: 5261.
Prioritise Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. 2008 Clinical Practice Guidelines for the Preven tion and
Management of Diabetes in Canada. Can J Diab. 32,(suppl 1); 2008 :S82 -83.
Duncan, I., Birkmeyer, C., Coughlin, S., Qijuan, (E)L., Sherr, D., & Boren, S. Assessing the value of diabetes education. The Diabetes Educator
2009; 35: 752-760.
Categorise Fisher EB, Brownson CA, OToole ML, Shetty G et al. Ecological Approaches to Self -Management: The Case of Diabetes, Am J Public Health
2005; 95:15231535.
Funnell MM, Anderson RM. Patient empowerment: A look back, a look ahead. Diabetes Educ, 2003; 29: 454-64.
Funnell MM, Anderson RM, Arnold MS, Barr PA, Donnelly MB, Johnson PD, Taylor -Moon D, White NH. (1991). Empowerment: An idea whos e
Repeat time has come in diabetes patient education. Diabetes Educ 1991; 17: 37-41.
Funnell MM, Anderson RM. Empowerment and self -management education. Clinical Diabetes 2004 ; 22:123-127.
Funnell, M.M., Brown, T.L., Childs, B.P., Haas, L.B., Hosey, G.M., Jensen, B., Maryniuk, M., Peyrot, M., Piette, J.D., Reader, D., Siminerio,
L.M., Weinger, K. and Weiss M.A. National Standards for Diabetes Self -management Education. Diabetes Care 2007; 30:1630-1637.
Reinforce
27
References (2 of 2)
Gary, T.L., Genkinger, J.M., Guallar, E., Peyrot, M. & Brancati, F.L. Meta -analysis of randomized educational and behavioral interventions in
type 2 diabetes. The Diabetes Educator 2003;29:488 -501.
Harvey, J.N., Lawson, V. L. The importance of health belief models in determining self -care behaviour in diabetes, Diabetic Medicine
2009;26:513.
International Diabetes Federation. Standards for Diabetes Education, 4th ed. Brussels: IDF; 2009.
International Diabetes Federation. Diabetes Atlas, 3rd ed. Brussels: IDF; 2009.
Knowles, M. The Adult Learner: a neglected species. Houston, Gulf Publishing Co; 1984.
Mehrabian, A. In P. Bender. Secrets of Power Presentations. Webcom : Toronto The Achievement Group ;1999.
Norris, S.L., Lau, J., Smith, S.J., Schmid , C.H., Engelgau, M.M. Self -management education for adults with type 2 diabetes: A meta -analysis on
the effect on glycemic control. Diabetes Care 2002;25:1159 - 71.
Piette, J.D., Glasgow, R.E. Education and self -monitoring of blood glucose. In Gerstein HC, Haynes RB, eds. Evidence -based diabetes ca re.
Hamilton: B.C. Decker, Inc. 2001.
Piette, J.D., Weinberger, M., McPhee, S.J. The effect of automated calls with telephone nurse follow -up on patient-centered outcomes of
diabetes care: a randomized, controlled trial. Medical Care 2000;38:218 -30.
Roter, D.L., Hall, J.A., Merisca, R., Nordstrom, B., Cretin, D., Svarstad , B. Effectiveness of interventions to improve patient compliance: A meta -
analysis. Medical Care 1998;36:1138- 61.
Simmons, David. Personal barriers to diabetes care: Is it me, them or us? Diabetes Spectrum 2001:10 -12.
Skinner, T.C., Cradock, S., Arundel, F., Graham, W. Four theories and a philosophy: self -management education for individuals ne wly
diagnosed with type 2 diabetes. Diabetes Spectrum 2003;16:75 -80.
Suhonen, R., Nenonen, H., Laukka, A., Valimaki , M. Patients informational needs and information received in hospital. J Clin Nursing 2005;
14(10):1167-76.
Timmins, F. Contemporary issue in coronary care nursing. New York: Routledge ; 2005.
Von Kroff , M., Gruman, J., Schaefer, J., et al. Collaborative management of chronic illness. Ann Intern Med 1997;127(12):1097 -102.
28
Objectives
29
Assessing from Clinical Information Body Mass Index (BMI)
Laboratory tests to determine clinical status Use pre pregnancy weight for calculations
OGTT, fasting glucose, HbA1c level
Weight and height measurements to calculate BMI:
SMBG
Urine ketones and proteins
BMI = weight in kg/(height in m)2
lipid profile (cholesterol HDL, LDL)
Haemoglobin, creatinine, thyroid function Standard BMI normograms:
Blood pressure
Asian ADA norms
Underweight <18.5 kg/m2
Anthropometric Data
Normal BMI 18.0-22.9 kg/m2 18.5-24.9 kg/m2
Height , Weight and BMI
Overweight 23.0-24.9 kg/m2 25.0-29.9 kg/m2
Current medications and nutrition supplements Obesity >25 kg/m2 > 30 kg/m2
30
Issues with Dietary Recalls
Activity
Think of things to check for Based on memory
Macro-nutrients
Nutrition Therapy In Gestational Diabetes
protein
carbohydrates
Part 1 Assessment
Part 2 Recommendations
fats
Part 3 Education
Micro-nutrients
vitamins
minerals
31
Dietary Recommendations for GDM
Macronutrient composition
Fluids Proteins
32
Protein Recommendations Carbohydrates
Activity
Amount and source of carbohydrates is
considered when planning meals
Recommended source of carbohydrates is
Name some of the common mainly from
- whole grains: wheat, rice, pasta, bread, rice,
carbohydrates and staple foods wheat, barley, oats, maize and corn
- legumes, beans, pulses (bengal gram, black gram,
in your region. rajma)
- fruit and vegetables
- milk
33
Carbohydrate (CHO) content of common foods Benefits of Fibre
Food Amount Serving CHO (g)
Bread, whole wheat 28 g 1 slice 11
A high-fibre diet is healthy
Rice (cooked) 75 g 0.3 cup 13
Pasta 125 mL 0.5 cup 16 Mixture of soluble and insoluble fibre
Chappati 44 g 1 small 19 - slows absorption of glucose
Corn meal 45 mL 3 tbsps 16
- reduces absorption of dietary fats
Potato 84 g 1 small 15
Couscous, cooked 125 mL 0.5 cup 17 - retains water to soften stool
Lentils 250 mL 1 cup 15 - may reduce the risk of colon cancer
Banana 101 g 1 small 20 - may reduce the risk of heart disease
34
Glycaemic Response of Glucose Factors Affecting the Glycaemic Index
and Lentils
l
e
Type of sugar
v
e
l - glucose, fructose, galactose
e
s
o
c
u
Nature of starch
l
g - amylose, amylopectin
d
o
o
l
B Starch-nutrient interactions
Glucose Lentils - resistant starch
Presence of other food components Lentils/dhal Some rice (long White Rice
grain)
- fat and protein
- dietary fibre Yogurt Pasta Processed
breakfast cereal
Milk Bananas Glucose
Most Fruits and Grapes Mashed and
vegetables baked potatoes
35
Low GI - Advantages Fats
Fats
Fat Recommendations
Common sources of different fats
Polyunsaturated safflower oil, sunflower oil,
Low in polyunsaturated fats (up to 10% of corn oil
total daily energy) Monounsaturated olive oil, canola oil, rape
seed oil, groundnut oil, mustard oil, sesame oil
High in monounsaturated fats (>10%) Saturated red meats, butter, cheese,
margarine, ghee (clarified butter), whole milk,
Low in saturated fats (<10%) cream, lard
Trans or hydrogenated fat should be Trans fats baked products, biscuits, cakes
avoided
36
Vitamins
Daily multivitamin supplement should be added Substance present in bones, teeth, soft
as they are often not met by diet alone. tissue, muscle, blood and nerve cells
Help maintain physiological processes,
Multivitamin content varies depending on the strengthen skeletal structures, preserve heart
product used. and brain function and muscle and nerve
systems
Women at higher risk for dietary deficiencies Act as a catalyst to essential enzymatic
include multiple gestation, heavy smokers, reactions
adolescents, complete vegetarians, substance Low levels of minerals puts stress on
abusers, and women with lactase deficiency. essential life functions
37
Minerals And Trace Elements Sodium Recommendations
38
Food Labels
Sweeteners
Nutrition information
Food labels
Activity
Nutrition Facts
Per 1 cup (250g)
Amount % Daily Value
Calories 100 Practice reading a food label
Fat 0g 0%
Saturated 0 g
+ Trans 0 g
Cholesterol 0 mg
0%
Calculate the following:
Sodium 3 mg
Carbohydrate 26 g
0%
8%
Serving size
Fibre 1 g 4%
Food labels may look
Number of calories in one serving
Sugars 23 g
different in different countries,
Protein 2 g
Number of carbohydrates in one serving
Vitamin A 20 % Vitamin C 170 % but the same information is
Calcium 2% Iron 2% usually available
Amount of fat in one serving
39
Summary of Dietary Recommendations
Carbohydrates: 45-65%
Nutrition Therapy in Gestational Diabetes
Dietary fibre: 28 g / day
Part 1 Assessment
Fats: 20-35% Part 2 Recommendations
Part 3 Education
Protein: 10-35% (1.1 g/kg/day)
Sodium: 1500 - 2300 mg/day
Meal Planning
Approach To Meal Planning
Before deciding on the content of meal plans,
consider:
A uniform approach to meal planning does
not work for everyone Food preferences and eating habits
Previous experience, knowledge and skills
A flexible plan or a variety of approaches is Current clinical, psychological and dietary status
necessary to address different needs Appropriate clinical and nutrition goals
Lifestyle factors
40
What to teach and when? Nutrition Education: Tools
Basic
Basic information about nutrition
Awareness of the basics of healthy
Nutrient requirements
eating/balance of good health
Healthy eating guidelines
Making healthy food choices Food Pyramid
Self-management training and use
of educational tools
The plate model
Canadas Food Guide Sex Girls and Boys Females Males Females Males Females Males
Vegetables
and fruits
4 5 6 7 8 7-8 8-10 7 7
Grain
Products 3 4 6 6 7 6-7 8 6 7
Milk and
Alternatives 2 2 3-4 3-4 34 2 2 3 3
Meat and
Alternatives
1 1 1-2 2 3 2 3 2 3
The chart above shows how many Food Guide Servings you need
from each of the four food groups every day.
Having the amount and tyoe of food recommended and following the
tips in Canadas Food Guide will help:
Meet your needs for vitamins, minerals and other nutrients.
Reduce your risk of obesity, type 2 diabetes, heart disease,
certain types of cancer and osteoporosis.
Contribute to your overall health and vitality.
41
Food pyramid India Balance of good health - UK eat well plate
Bread, cereals
Fruits and
and potatoes
vegetables
Diabetes India, 2005 (Reproduced with kind permission of the Food Standards Agency)
42
Practical Advice/ 1 Practical Advice/ 2
Make healthy food choices At least five servings of fruit and vegetables per day
- Choose colourful fruits and vegetables
Avoid fatty foods - Choose whole fruits over juices
Use low-fat cooking methods Replace high calorie beverages with water
Substitute high fat foods with low fat options; Eat small frequent meals that are well spaced
e.g use low fat milk
Do not skip meals
Minimize consumption of sugar and salt
Calories should be restricted especially if overweight
Use fresh foods instead of preserved or
Eat free foods as desired, include in between major
canned foods meals
Kalergis, M., De Grandpre, E., Andersons, C. (2005). The Role of Glycemic Index in the Prevention and
Eat low GI snacks instead of high GI snacks
Management of Diabetes: A Review and Discussion. Can J of Diab, 29(1), 27-38.
Misra A, Chowbey P, Makkar PM, Vikram NK, Wasir JS, Chadha D, et al. Consensus Statement for
(remember to choose lower fat snacks) Diagnosis of Obesity, Abdominal Obesity and the Metabolic Syndrome for Asian Indians and
Recommendations for Physical Activity, Medical and Surgical Management. JAPI 2009;57.
43
Objectives
Gestational Diabetes
Discuss the value of regular activity
Recognize the limitations regarding exercise especially
during the third trimester
Background
Types of Exercise
Physical activity can prevent or delay type 2 DM in Aerobic Exercise:
individuals at risk
Aerobic means using oxygen for energy.
Studies show that pre-pregnancy exercise helps to
prevent GDM during pregnancy.
use large muscles (legs, shoulders, chest, and arms)
can be performed continuously
More intensity equals more benefits.
burns calories and is critical to losing fat and keeping it off.
Any activity has more benefit than no physical activity in
prevention of GDM.
Resistance Training
helps in increasing the number of Insulin receptors
Improves sensitivity of insulin receptors in skeletal muscle
maintains muscle while losing fat.
Oken et al, 2006, Zhang et al, 2006, Dempsey JC et al 2004
44
Benefits of Exercise in GDM Where to start
Exercise causes significant decrease in:
Activity should be discussed with a medical
practitioner
insulin requirement
30 minutes a day total is recommended
Appropriate exercise
Jovanovic-Peterson et al 1989; Brankston et al, 2004.
Low-impact aerobics, swimming, yoga, light weights
ACOG Committee on Obstetric Practice, 2002. ACOG Committee on Obstetric Practice, 2002.
45
Caution Education before exercise
Increased risk of soft tissue injury avoid exercising when insulin is peaking
know how to recognize and treat hypoglycemia
carry fast acting glucose
Need to monitor
46
References
Artal R, OToole M. Guidelines of the American College of Obstetricians and
Gynecologists for exercise during pregnancy and the postpartum period. Br J
Sports Med. 2003 February;37(1):612. doi: 10.1136/bjsm.37.1.6
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.
47
Objectives
After completing this Module the participant
will be able to
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
48
Targets HbA1C during pregnancy?
Fasting: <95 mg/dl ( < 5.3 mmol/l) May be valuable in determining those who had
undiagnosed diabetes prior to pregnancy
1 hour PP : < 140 mg/dl ( < 7.8 mmol/L)
May give indication of overall control during
2 hour PP : < 120 mg/dl ( < 6.7 mmol/L)
pregnancy BUT
Not valuable for day-to-day management during
pregnancy
May give falsely low results
Metzger, Buchanan et al 2007
Other factors such as anemia make it unreliable
Seshiah Balaji, 2006
ADA 2015
May give indication of overall control during Reduction of activity associated with chronic fetal distress
49
FETAL MOVEMENT
Fetal movement counting Inexpensive, involving the mother, easy to
use
The rationale - decreased fetal movements may signal
decreased oxygenation which often precedes fetal Foetal movements related to maternal
demise
glucose levels
Reduction of activity associated with chronic fetal distress
Among inactive fetuses, approximately 50% are either
Patients taught generally from late third
stillborn, tolerate labor poorly or require resuscitation at trimester - after 35 weeks at routine ANC
birth
Reduced activity needs to be evaluated by
NST (non stress test)
Lalor et al 2008
50