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    Feb.09.2021

    Diabetes in Pregnancy (Obstetrics Inpatient)

    Clinical Description

    • Care of the hospitalized perinatal patient with diabetes [pregestational (type 1 or type 2) or gestational (type A1GDM or type A2GDM)] requiring glycemic monitoring and management.

    Key Information

    • Optimizing glycemic control is essential to reduce the risk of adverse outcomes. Maternal adverse outcomes include DKA (diabetic ketoacidosis), acute kidney injury, preeclampsia and fetal loss. Fetal adverse outcomes include intrauterine fetal demise, macrosomia or intrauterine growth restriction and delivery complications, such as shoulder dystocia and birth injury.
    • Due to the increased risk of preeclampsia development, a daily low-dose aspirin regimen may be initiated earlier in pregnancy and continued until delivery.
    • Women do not require delivery before 39 weeks of gestation when blood glucose is well-controlled, appropriate fetal growth with reassuring fetal wellbeing is present and no other comorbidities exist.
    • For hypoglycemia treatment, standards recommend providing a "fast-acting" carbohydrate and to retest within 15 minutes to ensure blood glucose level has stabilized per organizational protocol.
    • “Tight” blood glucose control is recommended in pregnancy, if it can be achieved without excessive hypoglycemia.
    • Women with pregestational diabetes who are breastfeeding will need to make sure that diet contains adequate calories, carbohydrates and protein to avoid maternal blood glucose fluctuations.

    Clinical Goals

    By transition of care

    A. The patient will achieve the following goals:

    • Blood Glucose Level Within Targeted Range

    B. Patient, family or significant other will teach back or demonstrate education topics and points:
    • Education: Overview
    • Education: Self Management
    • Education: When to Seek Medical Attention

    Correlate Health Status

    • Correlate health status to:

      • history, comorbidity
      • age, developmental level
      • sex, gender identity
      • baseline assessment data
      • physiologic status
      • pregnancy status (e.g., complications, weeks of gestation, uterine activity, fetal wellbeing)
      • response to medication and interventions
      • psychosocial status, social determinants of health
      • barriers to accessing care and services
      • health literacy
      • cultural and spiritual preferences
      • safety risks
      • family interaction
      • plan for transition of care

    Diabetes in Pregnancy

    Hypoglycemia Symptoms

    • confusion
    • diaphoresis
    • drowsiness
    • excessive hunger
    • headache
    • judgment impaired
    • inability to concentrate
    • irritability
    • level of consciousness change
    • mood change
    • pallor
    • paresthesia
    • shakiness
    • speech slurred
    • tachycardia
    • tremors
    • vision change

    Hyperglycemia Symptoms

    • abdominal pain
    • blurred vision
    • fatigue
    • generalized weakness
    • headache
    • nausea and vomiting
    • polydipsia
    • polyuria

    Laboratory Values

    • blood glucose increased or decreased from targeted level

    Problem Intervention

    Monitor and Manage Glycemia

    • Establish target blood glucose level.
    • Document blood glucose levels and monitor trend; advocate for adjustment if not within targeted range.
    • Provide pharmacologic therapy to maintain blood glucose levels within targeted range.
    • Check blood glucose level if there is a change in mental or cognitive status.
    • Recognize, treat and document hypoglycemia event and potential cause.
    • Avoid hypoglycemic episodes by advocating for insulin dose adjustment when there is a change in condition, such as illness severity, decreased oral intake, missed or refused meals and snacks, as well as with medication change that may include steroid taper.
    • Anticipate regularly scheduled antenatal fetal surveillance testing that may include nonstress testing, biophysical profiles or modified biophysical profiles.

    Associated Documentation

    • Fetal Wellbeing Promotion
    • Glycemic Management

    Education

    CPG-Specific Education Topics

    Overview

    • description

    • signs/symptoms

    Self Management

    • activity

    • blood glucose monitoring

    • medical nutrition therapy

    • medication management

    • provider follow-up

    • safety

    When to Seek Medical Attention

    • unresolved/worsening symptoms

    General Education Topics

    General Education

    • admission, transition of care

    • orientation to care setting, routine

    • advance care planning

    • diagnostic tests/procedures

    • diet modification

    • opioid medication management

    • oral health

    • medication management

    • pain assessment process

    • safe medication disposal

    • tobacco use, smoke exposure

    • treatment plan

    Safety Education

    • call light use

    • equipment/home supplies

    • fall prevention

    • harm prevention

    • infection prevention

    • MDRO (multidrug-resistant organism) care

    • personal health information

    • resources for support

    References

    • American College of Obstetricians and Gynecologists Committee on Practice Bulletins. Gestational diabetes mellitus practice bulletin 180. Obstetrics and Gynecology. 2017;(180), e17. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • American Diabetes Association. American Diabetes Association Standards of Medical Care in Diabetes--2021. Diabetes Care. 2021, January;44(1), S1-S232. Source[Clinical Practice Guidelines]
    • American Diabetes Association. American Diabetes Association Standards of Medical Care in Diabetes--2021. Diabetes Care. 2021, January;44(1), S1-S232. Source[Clinical Practice Guidelines]
    • Anastasiou, E.; Farmakidis, G.; Gerede, A.; Goulis, D. G.; Koukkou, E.; Kourtis, A.; Mamopoulos, A.; Papadimitriou, K.; Papadopoulos, V.; Stefos, T. Clinical practice guidelines on diabetes mellitus and pregnancy: ΙI. Gestational diabetes mellitus.. Hormnones. 2020;19, 601-607. Source[Clinical Practice Guidelines]
    • Anastasiou, E.; Farmakidis, G.; Gerede, A.; Goulis, D. G.; Koukkou, E.; Kourtis, A.; Mamopoulos, A.; Papdimitriou, K; Papdopoulos, V.; Stefos, T. Clinical practice guidelines on diabetes mellitus and pregnancy: Ι. Pre-existing type 1 and type 2 diabetes mellitus. Hormones. 2020;19, 593-600. Source[Clinical Practice Guidelines]
    • Berger, H.; Gagnon, R.; Sermer, M. Guideline no. 393-Diabetes in Pregnancy. Journal of Obstetrics and Gynaecology Canada. 2019;41(12), 1814-1825. doi:10.1016/j.jogc.2019.03.008 Source[Quality Measures,Clinical Practice Guidelines]
    • Bradley, P. K.; Duprey, M.; Castorino, K. Identifying key intervention opportunities during a pregnancy complicated by diabetes: A review of acute complications of diabetes during pregnancy. Current Diabetes Reports. 2016;16(2), 17. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Caughey, A. B.; Kaimal, A. J.; Gabbe, S. G.; Committee on Practice Bulletins-Obstetrics. ACOG Practice Bulletin Number 201: Pregestational diabetes mellitus. Obstetrics & Gynecology. 2018;132(6), e228-e248. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Farrar, D.; Simmonds, M.; Bryant, M.; Sheldon, T. A.; Tuffnell, D.; Golder, S. P.; Lawlor, D. Treatments for gestational diabetes: A systematic review and meta-analysis. BMJ Open. 2017;7, e015557. doi:10.1136/bmjopen-2016-015557 [Metasynthesis,Meta-analysis,Systematic Review]
    • Farrar, D.; Tuffnell, D. J.; West, J.; West, H. M. Continuous subcutaneous insulin infusion versus multiple daily injections of insulin for pregnant women with diabetes. Cochrane Database of Systematic Reviews. 2016;(6) doi:10.1002/14651858.CD005542.pub3 [Metasynthesis,Meta-analysis,Systematic Review]
    • Feghali, M. N.; Scifres, C. M. Novel therapies for diabetes mellitus in pregnancy. British Medical Journal. 2018;362, k2034. doi:10.1136/bmj.k2034 Source[Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Feig, D. S.; Berger, H.; Donovan, L.; Godbout, A.; Kader, T.; Keely, E.; Sanghera, R. Diabetes and pregnancy. Canadian Journal of Diabetes. 2018;42, S255-S282. doi:10.1016/j.jcjd.2017.10.038 [Quality Measures,Clinical Practice Guidelines]
    • Gougen, J.; Gilbert, J. Hyperglycemic emergencies in adults. Canadian Journal of Diabetes. 2018;42, S109-S114. doi:10.1016/j.jcjd.2017.10.013 [Quality Measures,Clinical Practice Guidelines]
    • Han, S.; Middleton, P.; Shepherd, E.; Van Ryswyk, E.; Crowther, C. A. Different types of dietary advice for women with gestational diabetes mellitus. Cochrane Database of Systematic Reviews. 2017;(2) doi:10.1002/14651858.CD009275.pub3 [Metasynthesis,Meta-analysis,Systematic Review]
    • Handelsman, Y.; Bloomgarden, Z. T.; Grunberger, G.; Umpierrez, G.; Zimmerman, R. S.; Bailey, T. S.; Blonde, L.; Bray, G. A.; Cohen, A. J.; Dagogo-Jack, S.; Davidson, J. A.; Einhorn, D.; Ganda, O. P.; Garber, A. J.; Garvey, W. T.; Henry, R. R.; Hirsch, I. B.; Horton, E. S.; Hurley, D. L.; Jellinger, P. S.; Jovanovič, L.; Lebovitz, H. E.; LeRoith, D.; Levy, P.; McGill, J. B.; Mechanick, J. I.; Mestman, J. H.; Moghissi, E. S.; Orzeck, E. A.; Pessah-Pollack, R.; Rosenblit, P. D.; Vinik, A.; Wyne, K.; Zangeneh, F. American association of clinical endocrinologists and american college of endocrinology - clinical practice guidelines for developing a diabetes mellitus comprehensive care plan - 2015. Endocrine Practice. 2015;21(s1), 31778. doi:10.4158/EP15672.GL [Quality Measures,Clinical Practice Guidelines]
    • HAPO Study Cooperative Research Group. Hyperglycemia and adverse pregnancy outcomes. New England Journal of Medicine. 2008;2008(358), 1991. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • HAPO Study Cooperative Research Group. The hyperglycemia and adverse pregnancy outcome (HAPO) study [Landmark study]. International Journal of Gynecology & Obstetrics. 2002;78(1), 69. doi:https://doi.org/10.1016/S0020-7292(02)00092-9 [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Healthcare Improvement Scotland. (2010, Updated 2017). 116-Management of diabetes a national clinical guideline. Source[Quality Measures,Clinical Practice Guidelines]
    • Jones, L. V.; Ray, A.; Moy, F. M.; Buckley, B. S. Techniques of monitoring blood glucose during pregnancy for women with pre-existing diabetes. Cochrane Database of Systematic Reviews. 2019;(5) doi:10.1002/14651858.CD009613.pub4 [Metasynthesis,Meta-analysis,Systematic Review]
    • Lawrence, R. A.; Lawrence, R. M. (2016). Breastfeeding: A guide for the medical profession. Philadelphia: Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Malcolm, J.; Halperin, I.; Miller, D. B.; Moore, S.; Nerenberg, K A.; Woo, V.; Yu, C. H. In-hospital management of diabetes. Canadian Journal of Diabetes. 2018;42, S115-S123. doi:10.1016/j.jcjd.2017.10.014 [Quality Measures,Clinical Practice Guidelines]
    • Mattson, S.; Smith, J. (2016). Core curriculum for maternal-newborn nursing. St. Louis: Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Middleton, P.; Crowther, C. A.; Simmonds, L. Different intensities of glycaemic control for pregnant women with pre-existing diabetes. Cochrane Database of Systematic Reviews. 2016;(5) doi:10.1002/14651858.CD008540.pub4 [Metasynthesis,Meta-analysis,Systematic Review]
    • Napoli, A. Insulin therapy and diabetic pregnancy. American Journal of Therapeutics. 2020;27(1), e91-e105. doi:10.1097/MJT.0000000000001095 [Review Articles]
    • National Institute for Health and Care Excellence. (February 2015 [updated 2020]). Diabetes in pregnancy: management from preconception to the postnatal period. Source[Clinical Practice Guidelines]
    • O'Neill, S. M.; Kenny, L. C.; Khashan, A. S.; West, H. M.; Smyth, R. M. D.; Kearney, P. M. Different insulin types and regimens for pregnant women with pre-existing diabetes. Cochrane Database of Systematic Reviews. 2017;(2) doi:10.1002/14651858.CD011880.pub2 [Metasynthesis,Meta-analysis,Systematic Review]
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    Clinical Practice Guidelines represent a consistent/standardized approach to the care of patients with specific diagnoses. Care should always be individualized by adding patient specific information to the Plan of Care.

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