Diabetes Asia (4)

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Monitoring During Pregnancy
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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

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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
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Targets

• Fasting lt95 mg/dl ( lt 5.3 mmol/l)
• 1 hour PP lt 140 mg/dl ( lt 7.8 mmol/L)
• 2 hour PP lt 120 mg/dl ( lt 6.7 mmol/L)

Metzger, Buchanan et al 2007 Seshiah Balaji,
2006 ADA 2015
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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

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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

Lalor et al 2008
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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)

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Other parameters

• Blood pressure every visit
• Values above 140/90 mm Hg are of concern
• If gt 140/90 re measure same day If gt 150/100
  initiate therapy
• If BP gt 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

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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

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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

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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
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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

Julie DL 2007, NICE 2008
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2.
1.
3.
4.
5.
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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

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Growth - IUGR

• IUGR seen in
• Women with vasculopathy
• Preeclampsia
• Diabetes with too strict glycaemic control
• SGA babies(lt 10th centile for GA) have an
  increased risk of perinatal morbidity and
  mortality

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Doppler

• Doppler studies are not useful for LGA fetuses
• Doppler studies are useful in IUGR

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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

Coustan 2009, NICE 2008
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References

• American Diabetes Association. Standards of
  Medical Care 2015. Diabetes Care 201538(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, 32835-847.
• Bode, B.W. (2007). Incorporating postprandial and
  fasting plasma glucose into clinical management
  strategies.  Insulin, 217-29.
• 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. 201337(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, 33991-1011.
• Metzger, BE, Buchanan TA, Coustan DR, et al.
  Summary and recommendations of the Fifth
  International workshop-Conference on Gestational
  Diabetes Mellitus. Diabetes Care. 200730(Supple
  2)S251-260.
• National Collaborating Centre for Womens and
  Childrens Health. Diabetes in pregnancy. Revised
  reprint July 200. LondonRCOG 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.

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• Reece CA 2004
• Roberts AB, Stubbs SM, Mooney R, et al. Fetal
  activity in pregnancies complicated by maternal
  diabetes mellitus. Br J Obstet Gynaecol.
  198087845849.
• Seshiah V, Balaji V, et al. Gestational Diabetes
  Mellitus Guidelines. J Assoc Physic of India.
  200654622-28.
• 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. 2000900137150.
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