CDC - Antepartum Surveillance - South Dakota Gestational Diabetes Care Guidelines - Publications

South Dakota
Gestational Diabetes Care Guidelines

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.

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.

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

2-hour 75 gram GCT
Any single abnormal value is diagnostic	Serum/Plasma Glucose Values for Diagnosis of Pre-Diabetes (mg/dl)	Serum/Plasma Values for Diagnosis of Type 2 Diabetes (mg/dl)
Fasting	100-125	> or equal to 126
1-hour		> or equal to 200
2-hour	140-199	> or equal to 200

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

Casual or fasting serum/plasma glucose
Any single abnormal value is diagnostic	Serum/Plasma Glucose Values for Diagnosis of Pre-diabetes	Serum/Plasma Glucose Values for Diagnosis of Type 2 Diabetes (mg/dl)
Fasting	100-125	> or equal to 126
Casual		> or equal to 200

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.