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  • Management of Diabetes in Pregnancy

    Published by: Malaysia Health Technology Assessment Section (MaHTAS)Medical Development Division, Ministry of Health MalaysiaLevel 4, Block E1, Precinct 1Federal Government Administrative Centre62590, Putrajaya, Malaysia

    CopyrightThe copyright owner of this publication is MaHTAS. Content may be reproduced in any number of copies and in any format or medium provided that a copyright acknowledgement to MaHTAS is included and the content is not changed, not sold, nor used to promote or endorse any product or service, and not used in an inappropriate or misleading context.

    ISBN: 978-967-2173-15-1

    Available on the following websites: http://www.moh.gov.myhttp://www.acadmed.org.myhttp://www.mems.myhttp://www.perinatal-malaysia.orghttp://www.fms-malaysia.org

    Also available as an app for Android and IOS platform: MyMaHTAS

    STATEMENT OF INTENT

    These clinical practice guidelines (CPG) are meant to be guides for clinical practice based on the best available evidence at the time of development. Adherence to these guidelines may not necessarily guarantee the best outcome in every case. Every healthcare provider is responsible for the management of his/her unique patient based on the clinical picture presented by the patient and the management options available locally.

    Every care is taken to ensure that this publication is correct in every detail at the time of publication. However, in the event of errors or omissions, corrections will be published in the web version of this document, which is the definitive version at all times. This version can be found on the websites mentioned above.

  • Management of Diabetes in Pregnancy

    UPDATING THE CPG

    These guidelines were issued in 2017 and will be reviewed in a minimum period of four years (2021) or sooner if new evidence becomes available. When it is due for updating, the Chairman of the CPG or National Advisor of the related specialty will be informed about it. A discussion will be done on the need for a revision including the scope of the revised CPG. A multidisciplinary team will be formed and the latest systematic review methodology used by MaHTAS will be employed.

  • Management of Diabetes in Pregnancy

    TABLE OF CONTENTS

    No. Title Page

    Levels of Evidence and Formulation of Recommendation iKey Recommendations ii Guidelines Development and Objectives vDevelopment Group viiiReview Committee ixExternal Reviewers xAlgorithm A: Screening and Diagnosis of Diabetes xi

    in Pregnancy Algorithm B: Intrapartum Glucose Monitoring for Diabetes xii

    in Pregnancy in Active Labour Algorithm C: Insulin Infusion and Titration xiii

    in Active Labour 1. INTRODUCTION 1 2. SCREENING AND DIAGNOSIS 1 2.1 Overt Diabetes in Pregnancy 2 3. MANAGEMENT OF PREGNANT WOMEN AT RISK OF 4 DEVELOPING GESTATIONAL DIABETES MELLITUS 3.1 Medical Nutrition Therapy 4 3.2 Exercise 6 4. MANAGEMENT OF WOMEN WITH 7 PRE-EXISTING DIABETES 4.1 Preconception Care and Counselling 7 4.2 Contraception 8 4.3 Glycaemic Control 8 4.4 Folic Acid Supplementation 8 5. ANTENATAL MANAGEMENT OF DIABETES IN 10

    PREGNANCY 5.1 Glycaemic Control 10 5.2 Medical Nutrition Therapy 12 5.3 Oral Antidiabetic Agents 13 5.4 Insulin 14 5.5 Pre-eclampsia Prophylaxis 17 5.6 Assessment of Complications of Diabetes 18 5.7 Fetal Surveillance 19 5.8 Timing and Mode of Delivery 20

  • Management of Diabetes in Pregnancy

    6. INTRAPARTUM GLYCAEMIC CONTROL FOR 22 DIABETES IN PREGNANCY 7. POSTPARTUM MANAGEMENT OF DIABETES IN 23 PREGNANCY 7.1 Postpartum Glucose Monitoring 23 7.2 Postpartum Use of Metformin 23

    7.3 Breastfeeding 24 7.4 Postpartum Contraception 24 7.5 Postpartum Lifestyle Intervention 24 8. MANAGEMENT OF NEONATES OF MOTHERS WITH 26 DIABETES

    9. MANAGEMENT OF SPECIAL CONDITIONS IN 27 DIABETES IN PREGNANCY

    9.1 Continuous Subcutaneous Insulin Infusion 27 9.2 Corticosteroids 27 9.3 Fasting 27 10. REFERRAL TO SECONDARY/TERTIARY CARE 28

    11. IMPLEMENTING THE GUIDELINES 29 REFERENCES 31 Appendix 1: Examples of Search Strategy 37 Appendix 2: Clinical Questions 38 Appendix 3: Carbohydrate Content of Common 39 Malaysian Foods Food Groups and Exchange Lists 40 Glycaemic Index List 44 Sample Menu 45 Appendix 4: Medication Table 46 Appendix 5: Preparation of Insulin Infusion 48 List of Abbreviations 49 Acknowledgement 50 Disclosure Statement 50 Source of Funding 50

    TABLE OF CONTENTS

    No. Title Page

  • Management of Diabetes in Pregnancy

    i

    LEVELS OF EVIDENCE

    SOURCE: US / CANADIAN PREVENTIVE SERVICES TASK FORCE 2001

    FORMULATION OF RECOMMENDATION

    In line with new development in CPG methodology, the CPG Unit of MaHTAS is in the process of adapting Grading Recommendations, Assessment, Development and Evaluation (GRADE) in its work process. The quality of each retrieved evidence and its effect size are carefully assessed/reviewed by the CPG Development Group. In formulating the recommendations, overall balances of the following aspects are considered in determining the strength of the recommendations:- overall quality of evidence balance of benefits versus harms values and preferences resource implications equity, feasibility and acceptability

    Level

    I

    II-1

    II-2

    II-3

    III

    Study design

    Evidence from at least one properly randomised controlled trial

    Evidence obtained from well-designed controlled trials without randomisation

    Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one centre orgroup

    Evidence from multiple time series with or without intervention. Dramatic results in uncontrolled experiments (such as the results of the introduction of penicillin treatment in the 1940s) could also be regarded as this type of evidence

    Opinions of respected authorities based on clinical experience; descriptive studies and case reports; or reports of expert committees

  • Management of Diabetes in Pregnancy

    KEY RECOMMENDATIONS

    The following recommendations were highlighted by the guidelines Development Group as the key clinical recommendations that should be prioritised for implementation.

    Screening

    Screening for gestational diabetes mellitus based on risk factors using 75 gram oral glucose tolerance test (OGTT) should be done at booking. If the test is negative, it should be repeated at 24-28 weeks of

    gestation. For women at the age of 25 or more with no other risk factors, OGTT

    should be done at 24-28 weeks of gestation. Overt diabetes in pregnancy should be managed as pre-existing

    diabetes.

    Preconception Care

    Preconception care of women with pre-existing diabetes which involve a multidisciplinary team should be fully implemented in all healthcare facilities.

    Antenatal Management of Diabetes in Pregnancy

    Self-monitoring of blood glucose (SMBG) should be done in diabetes in pregnancy. The blood glucose targets should be as the following: fasting or preprandial: 5.3 mmol/L 1-hour postprandial: 7.8 mmol/L 2-hour postprandial: 6.7 mmol/L

    The frequency of SMBG in diabetes in pregnancy should be individualised based on mode of treatment and glycaemic control.

    Pregnant women with pre-existing diabetes on multiple daily insulin (MDI) injection regimen should perform SMBG at least three times daily. It can be done at fasting, preprandial, postprandial or bedtime.

    Women with gestational diabetes mellitus (GDM) on MDI injection regimen should perform SMBG two to three times daily, for two to three days a week.

    Pregnant women with type 2 diabetes mellitus or GDM on diet and exercise therapy, oral antidiabetic agents (OAD), single-dose intermediate-acting or long-acting insulin should perform fasting and postprandial SMBG at least once daily until blood glucose targets are reached.

    Pregnant women who are on insulin or OAD should maintain their capillary blood glucose level >4.0 mmol/L.

    ii

  • Management of Diabetes in Pregnancy

    iii

    Pregnant women with diabetes should be given individualised medical nutrition therapy which includes carbohydrate-controlled meal plan and monitoring of gestational weight gain.

    In gestational diabetes mellitus, metformin should be offered when blood glucose targets are not met using changes in diet and exercise within 1-2 weeks. It should be prescribed after consultation with specialists.

    Metformin should be continued in women who are already on the treatment before pregnancy.

    Insulin therapy can be initiated at outpatient setting in pregnant women with diabetes.

    The preferred choice of insulin regime in diabetes in pregnancy is multiple daily injections.

    Insulin analogues should be continued during pregnancy in women with pre-existing diabetes who are already on the treatment and have established good blood glucose control before pregnancy.

    Rapid-acting insulin analogue may be considered as an option, particularly in patients with frequent hypoglycaemia or postprandial hyperglycaemia using human insulin during pregnancy.

    Pregnant women with pre-existing diabetes should be offered ultrasound scan at: 11-14 weeks of gestation for dating and major structural

    malformation 18-20 weeks of gestation for detailed structural anatomy scan (by

    a trained specialist or ultrasonographer) In women with pre-existing diabetes and gestational diabetes

    mellitus, serial growth scan should be performed every four weeks from 28 to 36 weeks of gestation.

    In women with pre-existing diabetes or gestational diabetes mellitus who develop maternal or fetal co