Gestational Diabetes Pregnancy Pathway

Routine Screening

  • All pregnant women not known to have GDM should have an OGTT at 24 -28 weeks gestation. Earlier testing of those at increased risk of GDM is advised.
  • The previous Australasian Diabetes in Pregnancy Society (ADIPS) guidelines for the diagnosis of Gestational Diabetes Mellitus (GDM) on 75gm Oral Glucose Tolerance Test (OGTT) was a venous plasma glucose level of: Fasting ≥5.5 mmol/L and /or 2 hour ≥8.0 mmol/L
  • New ADIPS diagnostic criteria- if one or more of the following levels are elevated: fasting ≥5.1mmol/L, 1hr≥10.0mmol/L, 2hr≥8.5mmol/L
  • Both criteria are currently in use by various pathology groups as not all pathology groups have transferred to using the new criteria


Moderate Risk factors for GDM

  •  A woman is considered moderate risk if she has either one of the risk factors below:

Ethnicity: Asian, Indian subcontinent, Aboriginal, Torres Strait Islander, Pacific Islander, Maori, Middle Eastern, non‐white African

OR

BMI 25 – 35 kg/m2

  • Those in “moderate risk” group should have early screening with either a random or a fasting glucose test in early pregnancy followed by a pregnancy OGTT if clinically indicated.
  • Women considered as “moderate risk” but with normal early pregnancy glucose testing should have a repeat OGTT at the usual time of 24‐28 weeks gestation. However a OGTT should be performed at any earlier time during pregnancy, if clinically indicated.

 


High Risk for GDM

  • A woman is considered high risk if she has both of the above “moderate risk” factors related to BMI and ethnicity or any of the following risk factors:

Previous GDM, Previously elevated blood glucose level, Maternal age ≥40 years, Family history DM (1st degree relative with diabetes or a sister with GDM), BMI > 35 kg/m2, Previous macrosomia (baby with birth weight > 4500 g or > 90th centile), Polycystic ovarian syndrome, Medications: corticosteroids, antipsychotics.

  • Women at “high risk” of GDM (one high risk factor or two moderate risk factors) should undergo a 75 g OGTT, at the first opportunity after conception.
  • Women considered as “high risk” but with normal early pregnancy glucose testing should have a repeat OGTT at the usual time of 24‐28 weeks’ gestation.
  • However a OGTT should be performed at any earlier time during pregnancy, if clinically indicated.


Referral to GDM Clinic

  • All women with GDM should be referred to GDM clinic ASAP- GDM Clinic referral form 
  • Routinely fortnightly reviews – may be increased or decreased as required


Self Blood Glucose Levels

  • Are recommended QID (fasting and 2 hours post meals)
  • Target range- fasting BGL <5.0mmol/L, 2 hour post meal <6.7mmol/L
  • If they have two or more elevated BGL readings in a week women should make contact with DM Educators
  • Insulin therapy should be considered if BGL’s exceed target on two occasions in in one week


Frequency of Antenatal Visits

  • If not receiving insulin then routine antenatal care is assumed. The following is the suggested regime: 4/52 until 28 weeks, then 3/52 until 34 weeks, then 2 weekly until 38 weeks, then weekly until term.
  • Once insulin is administered the following is the suggested regime : as above, then weekly from 34/40 gestation


Hospital Visits

 ALL WOMEN should visit Hospital at :

  • Booking In Clinic (around 12 weeks). Appointments can be made by calling 9784 2600 , GP referral required Referral Form- Antenatal Clinic
  • Either 34 OR 36 weeks. The 34/36 week hospital appointment is made during the Booking In clinic visit. The patient can also book ph 9784 2600.
  • From 36/40 all women should have a plan of management discussed and documented from 36/40 regarding timing of birth and management of medication in labour
  • Advanced Pregnancy Clinic. All uncomplicated post-date pregnancies are booked for induction of labour between 41 weeks 3 days and 42 weeks. Appointments for the Advanced Pregnancy Clinic (weekly) can be made by calling 9784 2600.


Tests and Results

  • GP SMCAs (Shared Maternity Care Affiliates) are responsible for following up results of tests ordered in general practice.
  • SMCAs should record test results in the VMR AND SEND COPIES to Frankston Hospital Antenatal Clinic- Outpatient Area 1- Building D
  • Significantly ABNORMAL results should be discussed with Obstetric Registrar or Consultant.

 

First Trimester

Visit 1 - Confirmation of pregnancy

Supplements

  • Folic acid
  • High risk dose 5mg daily (includes PHx GDM, High BMI, DM, PHx of Neural Tube Defect)
  • 1 month preconception and for 1st Trimester
  • Iodine- 150mcg daily

Dietary Advice

Dietary Advice 2014 includes list of foods to avoid

Lifestyle Advice

Lifestyle Advice 2014

Refer to Booking In Clinic

Referral Form- Antenatal Clinic

Discuss Screening


Visit 2 - Around 10 weeks

Aim to diagnose GDM EARLY at 10-12 weeks if high risk (high BMI or PH GDM)

  • If abnormal refer to GDM Clinic
  • If normal repeat 24-28 weeks

General History & Examination

  • Medical, reproductive, obstetric, family/genetic, medications, alcohol and drug, nutritional, psychosocial and demographic
  • Physical Exam (Medical Clearance): BP, CVS ( Heart murmurs), BMI (BMI ≥35-40 follow High BMI pathway , BMI ≤18 or ≥40 high risk not for Shared Care)

Establish Estimated Due Date (EDD)

Supplements

Supplements 2014

Dietary Advice

Dietary Advice 2014 includes list of foods to avoid

Discuss Screening

Standard First Trimester Antenatal Investigations

  • Blood group, Rhesus status Antibody Screen
  • Serum ferritin
  • FBE
  • Hepatitis B surface antigen
  • Hepatitis C Antibodies
  • Rubella Antibodies
  • RPR
  • HIV
  • Serum Vitamin D • MSU- microscopy and culture
  • Pap smear- if required (*cytobrush not to be used)
  • Discuss and/or organise Maternal Serum Screening Test (MSST)
  • Consider ; OGTT
  • Chlamydia, TSH, Varicella Screening

Note: All results to Antenatal Clinic – 13 Hastings Road

Visit 3 - Around 16 weeks

Obstetric Assessment

Confirm Estimated Due Date (EDD)

RH Negative

Ensure MSST has been discussed and result checked

Fetal Morphology Scan discussed/ organised at,

  • 18-20 weeks
  • 20-21 weeks if high BMI to facilitate assessment (refer to High BMI Pregnancy Pathway)

 

Second Trimester

Visit 4- Around 20 weeks

Obstetric Assessment

Fetal Morphology Scan results discussed


Visit 5- Around 24 weeks

Obstetric Assessment

Fetal Morphology Scan results discussed

 

Third Trimester

Visit 6- Around 28 weeks

Obstetric Assessment

Standard Antenatal Investigations at 26-28 weeks

  • HB
  • Serum Ferritin

RH Negative


Visit 7- Around 31 weeks

Obstetric Assessment

 

All women must visit Hospital at either 34 OR 36 weeks to allow time for consultant review, discussion of previous results, a routine antenatal check and for an opportunity to discuss issues and ask questions on preparation for labour and birth, unless a alternate schedule of visits has been determined at obstetric review. This appointment is usually made during the Booking In clinic visit or the patient can phone 9784 2600.

Visit 8- Around 34 weeks

 Obstetric Assessment

RH Negative

RH immunoglobulin given – refer to Anti-D Prophylaxis Pathway in the community-Feb 2014 ///Anti-D Consent, Order and Administration Form

Discussion Points

  • Preparation for labour discussion including timing of birth and VBAC (if appropriate)
  • Breast Feeding Information


Visit 9- Around 36 weeks

 Obstetric Assessment

Standard Antenatal Investigations at 36-37 weeks

  • Hb
  • GBS swab- low vaginal (37 weeks)
  • Routine weight

Discussion Points

  • Preparation for labour discussion including VBAC (if appropriate)
  • Breast feeding Information


Visit 10- Around 38 weeks

Obstetric Assessment

GBS swab result

Book Advanced Pregnancy Clinic Appointment (Ph 9783 8324)

Visit 11- Around 39 weeks

Obstetric Assessment

Confirm 41 weeks appointment for Advanced Pregnancy Clinic booked


Visit 12- Around 40 weeks

Obstetric Assessment

Confirm 41 weeks appointment for Advanced Pregnancy Clinic booked

 

Post Partum

Visit 13- Postpartum 4-6 weeks

POSTNATAL AND FOLLOW UP CARE – GDM – DIET CONTROLLED

Hospital Follow up GDM:

  • Diabetes educator review where they will be advised of subsequent risk of GDM and Type 2 before discharge.
  • Review appointment booked for GDM clinic 8 weeks postpartum

GP follow up re GDM:

  • OGTT 6 weeks post partum
  • 1-2 yearly GTT if not pregnant
  •  Early GTT next pregnancy – at first visit or 12-14 weeks gestation

 Maternal Check

  • Debrief of labour
  • Follow up of any pregnancy complications eg hypertension, gestational diabetes
  • Signs of anaemia
  • Blood pressure
  • Breast and nipple examination
  • Breastfeeding
  • Perineum – check symptoms eg urinary and faecal continence, dyspareunia and signs eg wound/episiotomy check
  • LUCS wound check
  • Uterine fundus, vaginal loss
  • Contraception
  • Post-natal depression
  • Parenting support and services
  • Settling and sleep

Consider:

  • FBE
  • Iron Studies
  • Coagulation Studies
  • TSH
  • Vitamin D
  • MSU
  • Glucose Tolerance Test if gestational diabetes
  • Pap Test (6-8 weeks postpartum only)
  • Appropriate vaccinations: MMR, Varicella, Pertussis (“Boostrix”for parents, consider immunization of grandparents)

       Immunisations 2014

 Baby Check

  • Enquire about parental concerns (including vision and hearing)
  • Follow up tests and complications (including Vitamin D supplementation if mother was vitamin D deficient )
  • Feeding, breast feeding issues
  • SIDS
  • Immunisation
  • Passive smoking
  • Height, weight, head circumference, growth charts
  • Developmental assessment including smiling at 6 weeks
  • General Physical examination including
  • Jaundice
  • Tone
  • CDH/ clicky hips
  • Fontanelles
  • CVS/murmurs
  • Hernias
  • Testes
  • Squint/ red reflex
  • Primitive reflexes

Disclaimer

These guidelines have been developed by the Peninsula Health GP Liaison Unit and the Peninsula Health Women's Services as a general guide to the management of women participating in the Peninsula Health Shared Maternity Care Program. They may not be applicable in every clinical case. They should not replace thorough clinical assessment and judgement.

Care should be taken when printing any information or Clinical Guidelines. Updates to these guidelines will take place as necessary. It is therefore advised that regular visits to this Website will be needed to access the most current information.