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Gestational Diabetes Care Guidelines

• Antepartum Surveillance
• Intrapartum / Delivery Management
• Postpartum Follow-Up

Antepartum Surveillance

• Initiate daily fetal movement determinations (kick counts) at 28 weeks in all patients with GDM.

• Antepartum surveillance includes a twice weekly nonstress test (NST) or a weekly Biophysical Profile or Contraction Stress Test.

  • If euglycemic with diet only, then initiation of antepartum testing may be delayed until 40 weeks.
• If insulin is not required, but euglycemia has not been documented, then initiate antepartum testing at 36 weeks.
• If insulin therapy is required, then initiate antenatal testing at 32-34 weeks.

Intrapartum/Delivery Management

• All patients should have a clinical or ultrasound estimate fetal weight (EFW) within 2 weeks of estimated delivery date. Decisions regarding route of delivery need to involve appropriate counseling regarding risks and consequences of shoulder dystocia as well as risks associated with cesarean delivery.
  • If EFW > 4500 grams, then delivery by cesarean section without a trial labor is reasonable.
  • If EFW 4000-4500 grams, then clinical pelvimetry, obstetrical history, and fetal growth pattern should be used to counsel the patient regarding trial of labor.
  • If EFW < 4000 grams, then the patients should be managed according to standard obstetric practice.
• Monitor fingerstick blood glucose (FSBG) every 1 to 2 hours in labor with the goal of maintaining whole blood glucose levels between 70 and 100 mg/dl.

• If labor is anticipated to exceed 6 hours duration, then maintenance intravenous fluids containing 5% dextrose should be initiated. Bolus fluids should not contain glucose.

• Initiate an insulin drip during labor if FSBGs are > 120. If they are between 100 and 120 mg/dl, then the decision to initiate an insulin drip will depend on the expected time interval to delivery; the longer the interval the more beneficial the use of an insulin drip.

• This is one of many insulin drip regimens. Mix 25 units of regular human insulin in 250cc of normal saline (concentration 1 unit/10 cc Normal Saline). Initiate infusion at 10 cc/hour (1 unit insulin/hour). Adjust rate hourly based on hourly FSBG results. If patient has been requiring large doses of insulin to achieve euglycemia antenatally, a higher initial infusion rate may be appropriate. Consultation is recommended if the primary obstetrical provider is not prepared to manage an intrapartum insulin drip.

• Each institution should have a consistent protocol for intrapartum glucose monitoring and insulin use.

Postpartum Follow-up

• Discontinue insulin therapy after delivery.

• Obtain a casual (random) blood glucose on postpartum day 1-3; if it is normal (<200 mg/dl), then blood glucose monitoring is not required during the postpartum period.

• Obtain a 2-hour 75 g OGTT 6 to 8 weeks postpartum if:
  • Patient required insulin during pregnancy
  • Patient diagnosed with GDM prior to 24 weeks gestation
  • Patient had a value >200 mg/dl on the 1-hour 50 g GCT
  • Patient had a fasting result of >95mg/dl on the 3-hour 100 g OGTT

• Alternatively, these patients can be tested with a casual or fasting serum/plasma glucose; however, the result will not be as sensitive.

• Refer patients diagnosed with Pre-diabetes, Type 2 DM, or Impaired Fasting Glucose to a primary care provider.

• Fasting blood glucose should be obtained annually on all patients with history of GDM. Communicating this to patients and primary care providers is important.

• All patients with GDM should be strongly encouraged to have a consultation with a diabetes educator and Diabetes Education following discharge regarding the long-term implication of a history of GDM.

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