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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 careA. The patient will achieve the following goals:
Blood Glucose Level Within Targeted Range
- 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]
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- 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]
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- 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]
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Disclaimer
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.
