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Volume 17 Wi nter 1999

(iii) rates of intervention(iv) birth weight distribution(v) fetal and neonatal markers of glucose

control (ie. fetal/neonatal asymmetric

somatomegaly)

The following guidelines were developed by amultidisciplinary task force of obstetricians, nutritionists, andendocrinologists as part of the perinatal unit at St. Joseph'sHealth Centre in London and endorsed by the Department ofObstetrics andCynecology, University of Western Ontario.They are based on the guidelines published by the CanadianDiabetes Association (CDA) in 1998.1

Classification1. Pregestational Diabetes Mellitus (OM)i) Pregestational OM -Types I and II Diabetes

Mellitusii) "Missed Type II" Gestational Diabetes Mellitus

2. Gestational Diabetes Mellitusi) "True" Gestational Diabetes Mellitus

ii) Unrecognized Type II Diabetes Mellitus

General Objective1. Consistent and comprehensive obstetrical and

medica! management of pregnant women withOM in a multidisciplinary outpatient clinic andinpatient environment.

I PRECONCEPTION MANACEMENTPreconception CounsellingEducation:.risk of congenital anomalies and methods to

prevent malformations.risk of fetal/neonatal complications.risk of maternal diabetes related and obstetric

related complications.importance of strict metabolic control

Preconception Assessment.General medical assessment -glucose control,

hypertension, vascular disease, presence ofneovascularization

.Retinopathy- ophthalmologic examination

.Nephropathy -urinalysis, serum creatinine, 24hour urine for creatinine clearance/protein/microalbumin

.IHO (ischemic heart disease)-(> 35, OM > 15 years)-EKG

Specific Objectives1. Congenital anomaly rate similar to the general

population2. Perinatal mortality similar to the general

population3. Maintain normal rates of intervention (ie. as,

episiotomy rates, admission to NICU)4. Normal distribution qf birth weights5. Ongoing critical evaluation of:

(i) congenital anomaly rate(ii) perinatal morbidity and mortality rate

Diet.Modification as required to achieve strict

glycemic and metabolic control.Folate supplementation -1 mg/day to begin>

6 weeks preconceptually2

Insulin.Split multi dose regimen -insulin 3 or 4 x/day

to achieve strict glycemic control.Regular, lente formulations* Type 110M on oral hypoglycemics to be switched

to insulin

GlycemiaGoal -"euglycemia".fasting 4 -6 mmol/L' ::.ac glucose 4 -6 mmol/L.1 hour pc glucose < 7.8 mmol/L (or rise of <

2 mmol/l).HgbA,c within the normal range (normal rangevaries between laboratories) .

Antenatal Care

Diagnostic evaluation for DM embryopathy

.HgbA1c

.Triple Screen

.Anatomic survey -16-20 weeks

.Fetal echocardiography -18-20 weeks

Maternal Surveillance.DB/Endocrinology visits every 4 weeks until 30

weeks, then weekly (may be modified formedical or obstetrical reasons)

.Hospital admission -poor glucose control,obstetrical indications

.Patients with underlying nephropathy -24 hoururine, serum creatinine every trimester

.Retinopathy -opthamologic examination everytrimester.Urine culture every trimester '

Diet.7500 KJ Diabetic Diet

Monitoring.Self blood glucose monitoring (glucometer).Blood glucose ac meals, and qhs plus pc meals

daily.Glycosylated.Hgb (HgbA1c), repeat every 2

months

II ANTENATAL MANACEMENT

First Visit.Risk Assessment -obstetrical/medical history.Diagnostic evaluation for DM vasculopathy

(unless completed within 6 months).Retinopathy -ophthalmologic consultation.Nephropathy -urinalysis, serum creatinine, 24

hour urine for creatinine clearance/total proteinexcretion/ microalbumin

.Ischemic heart disease-(> 35, DM > 15 years) -EKG

Education: importance of glucose control inreducing malformation rate and reducing the risk ofmaternal/fetal morbidity and mortality

Hospital Admission: aim for outpatientmanagement [it is recognized that some patientsmay require admission for poor glucose control,new insulin starts (type II DM, newly diagnoseddiabetes, clients switching from oral agents toinsulin or gestational DMrequiring insulj.n

Glycemia ;:.Goal -"euglycemia".Fasting -4-6 mmol/L

ac glucose 4-6 mmol/L.1 hour pc glucose < 7.8 mmol/L (or rise of < 2

mmol/L).HgbA1c within the normal range (normal range

varies between laboratories)

Monitoring.Self blood glucose monitoring (glucometer).Blood glucose acmeals, and qhs plus pc meals

daily.Glycosolated Hgb (HgbA1c) every 8 weeks

Fetal Surveillance.Fetal movement counts -after 28-30 weeks.Growth assessment -Ultrasound 28-30 weeks

and every 4 weeks thereafter (may beindividualized)

Antepartum Fetal Testinga) good control, no macrosomia, no vascular

disease -weekly Non Stress Test (NST) after 34weeks, amniotic fluid volume measurementevery 2 weeks [Biophysical Profile Score (BPPj]NST 2x/week after 37 weeks

b) poor control, macrosomia, vascular disease-weekly NST after 28-30 weeks, amniotic fluidvolume measurement weekly (BPP), NST2x/week after 37 weeks

IV postpartum Management.continue IV fluid until drinking well and

switch to diabetic diet.stop insulin infusion following delivery of

placenta.glucometer every 4 hours initially.Endocrinology will order sic insulin on an

individual basis postpartum

BirthTiming of birth should be individualized based onthree factors (all charts reviewed at 36 weeks)1. Glycemic control2. Maternal complications (pre-existing or

developing vascular disease or hypertension,obstetrical factors)

3. Fetal wellbeing (antenatal testing, macrosomia)

Principlesi) Patients with good glycemic control in the

absence of maternal complications and fetalmacrosomia or growth restriction are allowedto achieve spontaneous labour. In theabsence of spontaneous labour, gestation willnot go beyond 40 weeks.

ii) Delivery of patients in poor metabolic control,or with evidence of deterioration of maternalcondition, or with fetal growth restriction isindividualized based on clinical circumstances.

iii) Patients with a sudden drop in insulinrequirements (>30% in 24-48 hours) mayrequire increased surveillance or considerationfor delivery c'

Specific Objectives1. To achieve perinatal morbidity and mortality

rates similar to the general population.2. To maintain normal rates of intervention (ie.

as, episiotomy rates, admission to NICU).3. To achieve normal distribution of birth weights.4.

To adopt diagnostic criteria and managementprotocols consistent with other centres in NorthAmerica to allow comparative evaluation ofoutcome measures and development of clinicalstudies.III INTRAPARTUM MANACEMENT

Patients On Insulin (this will include womenwith Type 10M, Type 110M and COM on insulin)

2.3.

Universal Screening.Recommend screening of all pregnant women

between 24 -28 wks gestation.50 gm oral glucose challenge [GCT]

(independent of diet, last meal, time of day)-normal < 7.8 mmol\L-if > 7.8, proceed to 2 hour 75 gm oralglucose tolerance test (OGTT) (CDARecommendations, 1998)

* if glucose greater than 10.3 OGn not required.

Initiate gestational diabetes treatment.

Individualized Screening forUndiagnosed Type II DM.Recommend screening in patients at risk for

undiagnosed Type 110M in the first trimester,

e.g.,-previous gestational diabetic requiring insulin-previous macrosomic infant (> 4500 gm)-previous unexplained stillbirth

4.

Nutrition -clear fluids within the calorie countof her normal diabetic dietIV:D5W/NS or D5W/0.45NS at 100 cdhrInsulin drip (50 units Humulin regular insulinin 500 cc NS)

a) run at 1 u/hourb) use following sliding scale to change the

insulin during labour:Blood Glucose < 3mM- stop insulinBlood Glucose 3-4 mM- reduce the insulinby 0.5 u/hour (5cdhour)Blood Glucose 4-6mM- maintain theinsulin infusion at the same rateBlood Glucose> 6 mM- increase theinsulin infusion by 0.5 u(5cdhour)

Monitoring.Venous glucose inttia.l1y and every 4 hours

until delivery.glucometer every 1 hour until delivery

(patient may do her own while feeling wellenough during the early part of labour).

Diagnosis.2 hour 75 gm OGTT (following 3 days of

unrestricted activity and diet [> 150 gm CHO/day i

(CDA Recommendations, 1998)]'.Diagnostic criteria (CDA Criteria, 1998)'

-serum glucose fasting...~ 5.3 mmol\l

1 hr... ~ 10.6 mmol\l2 hr... ~ 8.9 mmol\l

Based on these criteria, patients are classified as (a) Gestational Oiabetes~ 2 or more abnormal

values -

(b) Glucose IntoleranceofPregn~ncy ~ 1. abnormal

value

(c) Unrecognized Type II OM ~e1evated fasting

glucose

-Growth assessment -Serial ultrasoundindivtdualized based on clinical suspicion formacrosomia, or intrauterine growth restriction

-Antepartum fetal testing -institute weeklyNSTor biophysical profile (BPP) after 40weeks, may institute at 37 weeks if poorcontrol, polyhydramnios, or macrosomia

GDM (requiring insulin)-As for pregestational OM (see pathway for

pregestational OM)

(b) Glucose Intolerance of Pregnancy--None, except when indicated for other

obstetrical reasons

(c) Unre('ognized Type 110M-As for pregestational OM -see pathway for

pregestational OM

Birth -For Diet Controlled CDMTiming of birth individualized based on threefactors:

1. Glycemic control2. Maternal complic;ations (pre-existing or

developing hypertension or other obstetricalfactors "

3. Fetal wellbeing (antenatal testing,macrosomia)

In general, patients under good glycemic controland in the absence of maternal complications andfetal macrosomia may achieve spontaneous labouror be induced at 40-41 weeks.

Delivery of patients in poor metabolic control, orwith evidente of preeclampsia, or with suspectedfetal macrosomia, growth restriction orpolyhydramnios is individuatized based on clinicalcircumstances.

Management

(a) Gestational Diabetes Mellitus-Referra1 to dietitian-Consultation to obstetrician-Consultation to ~ndocrinologist

.Dietary ManagementBreakfast 25 gmorning snack 2SgLunch 30 gafternpon snack 25 gDinner 40 gevening snack 25gbedtime snack 30 gTotal Carbohydrate 200 g

.Insulin Therapy1. Institute insulin if elevated fasting blood

g1ucose persistent> 5.42. Consistently elevated pc blood glucoses (1 hr

pc ~ 7.3), despite dietary modifications.

.G1ucosemanitoring(i) diet alone

Glucometer- fasting and pc meals (fasting<5.8, 1 hr pc <7.0 mmol\L)

(il) diet and insulinAs pregestational DM (see pathway forPregestational DM)

(b) Glucose Intolerance of PregnancyReferral tod1etitra~Dret -as GDM -see aboveGluco$e monitorrng\ -none

'-repeat 3 hr OGTT at 34 wks

(c) Unrecognized Type II OM-Treat as pregestati,olJal OM

Intrapartum Management

GDM (diet controlled)1. Nutrition- clear fluids (calorie count of GOM

diet)2. IV 05/0.45 NS atlOOcdhr

3. Monitoring -venous gtucose initially and every4 hrs until delivery-glucometer every 1 hr4.

Insul1n infusion if glucose> 6.5 mmol/L

COM (requiring Insulin)As for Pregestational OM(see Pathway for

Pregestptional OM)

Fetal Surveillance(a) G OM (diet controlled)

-Fetal movement counts -initiate ~t 37 wks

Maternal/Newborn/Paediatrics at the Chatham-KentHealth Alliance -Public General Hospital Campus.Her leadership and vitality will be sorely missed.

Postpartum ManagementGestational DM (diet controlled)

-Education -diet, exercise, weight reduction-Recurrence risk of gestational OM 60-70% .-Risk of Type 110M 40-60°/0 0'

-OGTT in 3 months

Gestational DM (requiring insulin)-stop the insulin infusion as soon as placenta is

del ivered-IV fluid orders then as per OB concerns-diet to be OAT postpartum

-monitoring: a 2 hr PC glucose is ordered onthe 2nd day postpartum

-Education -see above

Does your hospital, health unit, or communityhave a successful project or programme,concerning perinatal health that you would like toshare with your colleagues in SouthwesternOntario? We would love to hear from you!

Submissions should include a brief synopsis of yourprogram (1,000 words or less), including adiscussion of the method, evaluation, and a contactname. The Perinatal Outreach Program reservesthe right to edit all submissions.

ALARM (Advances in Labour and Risk

Management)

References1. Meltzer, Sara, et al. 1998 Clinical practice guidelines for

the management of diabetes in Canada. CMAj 1998; 159(8 Suppl)

2. Society of Obstetricians and Gynecologists of Canada

(SOGC) Policy Statement #19, March 1993.

For further information regarding these Clinical Pathways,please contact:

Robert Gratton, MD, FRCS (C), Department of Obstetricsand Gynaecology, St. joseph's Health Centre, PO Box 5777,London, Ontario N6A 4L6Tel: (519) 646-6106, Fax: (519) 646-6213,E-Mail: rgratton@julian.uwo.ca

The Perinatal Outreach Program extends a fondfarewell to Dr. Don Reid, our Neonatal Co-Director, who accepted a position as Chief ofNurseries, Regina General Hospital, Saskatchewan,in October 1998.

An intensive two day course, including the mostrecent clinical guidelines on high risk conditionsdur1nglabour and delivery. This course includes"hands-on" workshops, group discussions, and apractical exam. Topics include Risk Management,Induction of labour, Management of labour,Assisted Vaginal Birth, Cerebral Palsy and

Asphyxia, Group B Strep, Preterm labour, Severe

Eclampsia/Pre-eclampsia, Analgesia, etc. ThisCanadian course was developed by, and is jointly

taught by family physicians and obstetricians. It isoffered by the Society of Obstetricians and

Gynaecologists of Canada (SOGC) throughout1999 at various times across Canada. The

proposed schedule for courses in Ontario is listedas follows:

Hamilton February 26 -27Toronto May 7 -8Ottawa June 23 -24Thunder Bay October 22 -23Toronto November 20 -21Toronto December 4 -5

Dates are subject to change. Registrations arelimited to 40 participants. The SOGC reserves theright to cancel courses due to insufficient

registration.

We welcome Dr. Jill Boulton, FRCP (C), as the newNeonatal Co-Director of the Perinatal OutreachProgram of Southwestern Ontario. Dr. Boultoncomes to us from Mount Sinai Hospital in Toronto.She will also serve as Medical Director, Nurseries,St. joseph's Health Centre and London HealthSciences Centre, as well as Medical Director of theNeonatal Transport Team.

It is with deep regret that we inform our readers ofthe loss of Mrs. Kathy Walker (Thompson) inOctober 1998. Kathy was the Director of

For further information, please contact:SOGC774 promenade Echo DriveOttawa, ON K1 S 5N8

Tel: (613) 730-4192/1-800-561-2416Fax: (613)730-4314E-mai I: spaquette@sogc.com

workshop with Penny Simkin

When Survivors Give BirthMay 18, 1999 (Evening Session)

Doula Training WorkshopMay 19 -20,1999

For more information, please contact:Nancy DodmanPerinatal Outreach Program of SouthwesternOntarioTel: (519) 646-6100, Ext. 65900

Breastfeeding Education Session "With Dr. }. Newman

For health care professionals working both in thehospital and community setting.

April 7, 19991 :00 -3:00 pmWoodstock General HospitalFinkle Auditorium

Cost: $20.00, Preregistration required.

For more information call:(519) 421-4211, ext. 2249

The First Canadian Conference onShaken Baby Syndrome

A wareness, Prevention, and Response:An Integrated Approach

May 26 -29, 1999, Saskatoon, Saskatchewan

For more information, please contact:Saskatchewan Institute on Prevention of

Handicaps

Tel: (306) 655-2512Fax: (306) 655-2511E-mail: skiph@SK.sympatico.ca

~NDON}-I",.lth Sc!enC"R Cent'"

:; ~Stfte2hsF Health Centre

laxbn

Breastfeeding Challenges: New Ideasfor the New MilleniumPresented by:

The Middlesex-London Breastfeeding Comittee

May 6 -7, 1999Royal Host Hotel (formerly The Westin)London, Ontario

Faculty:C. Robin Walker, MB, ChB, FRCP(C) PediatricsLinda Smith, BSE, FACCE, IbcLcPaula Meier, RN, DNSc, FAAN

Approved for:Mainpro-1, MOCOMP, and IBCLC credits

Contact:Gwen Peterek, Perinatal Outreach Program ofSouthwestern OntarioTel: (519) 646-6100, ext. 65901