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 Table of Contents  
ORIGINAL ARTICLES
Year : 2021  |  Volume : 12  |  Issue : 1  |  Page : 83-98

Guidelines for management of hyperglycemia in pregnancy (HIP) by Society of Obstetricians & Gynaecologists of Pakistan (SOGP)#


1 Department of Obstetrics and Gynecology, Isra University, Karachi-Campus, Pakistan
2 Department of Obstetrics & Gynecology, CMH Lahore Medical College, National University of Medical Sciences, Lahore, Pakistan
3 Department of Obstetrics and Gynecology, Baqai Medical University, Karachi, Pakistan
4 Brown School, Washington University in St. Louis, St. Louis, Missouri, USA
5 Department of Obstetrics & Gynecology, Liaquat University of Medical & Health Sciences, Jamshoro, Pakistan
6 Department of Translational Research, Shifa Tameer-e-Millat University, Islamabad, Pakistan
7 Department of Obstetrics & Gynecology, Jinnah Sind Medical University, Karachi, Pakistan
8 Department of Obstetrics & Gynecology, Bahria University Medical & Dental College, Karachi, Pakistan

Date of Submission22-Sep-2020
Date of Decision13-Oct-2020
Date of Acceptance15-Oct-2020
Date of Web Publication25-Dec-2020

Correspondence Address:
Dr. Shabeen Naz Masood
Department of Obstetrics and Gynecology, ISRA University, Karachi Campus. #This document was endorsed by the Diabetes in Asia Study Group (DASG).
Pakistan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jod.jod_88_20

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  Abstract 

Hyperglycemia in pregnancy (HIP) is an important component of primary prevention of diabetes both globally and in Pakistan. To ensure that the opportunity of primary prevention is not missed it is important to diagnose hyperglycemia early in pregnancy. Universal screening in pregnant women at booking is recommended with its implementation at primary, secondary and tertiary levels of health care settings. These guidelines by Society of Obstetricians and Gynecologists (SOGP) are pragmatic addressing screening methodology, preconception care screening & diagnosis, antenatal care plan, intrapartum and postpartum management & follow up, neonatal care, breastfeeding, contraception, counseling for future pregnancy, lifestyle modification, nutritional recommendations and proper techniques for insulin injection, management of diabetic ketoacidosis (DKA) and recommendations for future research. There are many available guidelines for the screening, diagnosis and management of HIP. The SOGP GDM guidelines recommendations are simple, tailored to the local context especially for the busy health care providers; medical as well as nurse practitioners, for whom it is confusing to choose the recommendations from different available guidelines. These guidelines are meant to standardize clinical practice at all health care levels across the country. In order to ensure its practical utilization, a national GDM registry has been proposed and designed so as to observe its applicability in the clinical practice by health care providers.

Keywords: Antenatal postnatal surveillance management, diabetes, GDM guidelines, hyperglycemia in pregnancy, preconception counseling


How to cite this article:
Masood SN, Baqai S, Naheed F, Masood Y, Sikandar R, Chaudhri R, Yasmin H, Korejo R. Guidelines for management of hyperglycemia in pregnancy (HIP) by Society of Obstetricians & Gynaecologists of Pakistan (SOGP)#. J Diabetol 2021;12:83-98

How to cite this URL:
Masood SN, Baqai S, Naheed F, Masood Y, Sikandar R, Chaudhri R, Yasmin H, Korejo R. Guidelines for management of hyperglycemia in pregnancy (HIP) by Society of Obstetricians & Gynaecologists of Pakistan (SOGP)#. J Diabetol [serial online] 2021 [cited 2021 Jan 28];12:83-98. Available from: https://www.journalofdiabetology.org/text.asp?2021/12/1/83/304360




  Overview Top


The Society of Obstetricians and Gynecologists of Pakistan (SOGP) is the specialist professional body of Obstetrics and Gynecology founded in March 1957, with the mission to provide evidence-based Continuous Medical Education to obstetricians and gynecologists of Pakistan and to improve reproductive health of women and new-borns through education, service provision, advocacy, research, and leadership. Overall SOGP has 3,500 members, with two International, and 21 Regional Chapters throughout Pakistan. SOGP has international affiliation with South Asia Federation of Obstetrics and Gynaecology (SAFOG), Asia and Oceania Federation of Obstetrics and Gynaecology (AOFOG), and The International Federation of Gynecology and Obstetrics (FIGO).

SOGP in view of its mission aims to bring together its members to provide quality reproductive health care to women and realized that in the presence of a number of international guidelines for diabetes in pregnancy, a comprehensive local guideline was needed to overcome contextual barriers. In resource constrained health settings of Pakistan a cost-effective and uniformed guidelines for screening, diagnosis, and management of diabetes in pregnancy was essential. This would help to optimize the uniformity of clinical care pragmatically and would assist in assessing the prevalence of disease.

These guidelines are endorsed by Diabetes In Asia Study Group; an international organization with the aim to promote education and awareness of diabetes, to encourage research in the field of diabetes and related disorders, to promote exchange of opinions and to foster advocacy.

The end users of the guidelines are practitioners like obstetricians, family physicians, internist physicians, endocrinologists, diabetologists, primary healthcare physicians, nurse practitioners, and midwives. These health care providers are confronted with a number of varied gestational diabetes mellitus guidelines which are difficult to choose and follow in their busy clinical practices. The best evidence-based descriptiveness about the appropriate use of insulin will be of particular help to nurse practitioners and midwives. Standard protocols, diagnostic tools, feedback mechanism, follow-up system, and future research recommendations have also been included in the guidelines.

Guidelines are intended to assist in the provision of optimal clinical care and to make informed decisions with full responsibility and not to override or supersede clinical judgments.

Society of Obstetrics & Gynecologists of Pakistan (SOGP)

Department of Obstetrics and Gynaecology, Jinnah Postgraduate Medical Center, Karachi, Pakistan

Telephone: +92-99205040

Fax: +92-99205040

Email: [email protected]

Website: http://www.sogp.org


  Executive Summary Top


International Diabetes Federation (IDF) estimates that 463 million people of world’s population aged 20–79 years (9.3%) are coping and living with diabetes.[1]

Among all IDF Regions, Middle East and North Africa (MENA) Region has the highest age-adjusted diabetes prevalence of 12.2%. In the MENA Region, Pakistan ranks second in number (19.9%) after Sudan (22.1%), whereas in the Southeast Asian (SEA) Region 8.8% of adult population is living with diabetes. In India, Bangladesh, and Sri Lanka, people in the age group of 20–79 years make up 98.9% of the total adult population with diabetes in this Region.[1]

Gestational diabetes mellitus (GDM) is reflected by the global epidemic of Type 2 diabetes mellitus (T2DM) with an estimated 223 million women aged 20–79 years living with diabetes.[1]

Globally, of 76 million women of reproductive age, about 22 million women are with diabetes and 54 million had impaired glucose tolerance (IGT) or prediabetes with potential to develop GDM if they become pregnant.[2]

Of the seven IDF Regions, prevalence of hyperglycemia in pregnancy is highest in IDF-MENA and SEA Regions in women aged 20–49 years. The age-adjusted prevalence is 17.9% and 26.6%.[2] IDF in 2019 estimates that 20.4 million (15.8%) live births are affected by hyperglycemia in pregnancy; that is, 1 in 6 births are affected by GDM.[1]

The prevalence of GDM in different studies is 1–28% of all pregnancies. These vide variations are because of nonuniformity of universally agreed definition, screening, and diagnostic criteria for GDM.[3],[4]

Although GDM is a short-term disorder and resolves after the birth, it leaves its legacy in the form of future development of T2DM, 3–6 years after the index pregnancy. This exposes the women to high risk of all complications related to T2DM and 1.9-fold odds of developing cardiovascular disease.[5]

Uncontrolled hyperglycemia not only results in early pregnancy losses, it also exposes neonate to the risk of congenital abnormalities, metabolic disorders like hypoglycemia, hypocalcaemia, and hypomagnesaemia immediately after birth. Infants born out of a diabetic pregnancy may develop insulin resistance and IGT as early as 10–14 years of age,[6] and lifetime risk of development of T2DM, hypertension, obesity, cardiovascular disease, and metabolic syndrome in the future.[7]

To prevent future complications of diabetes in women and in children in early adulthood, screening diagnosis and appropriate management of hyperglycemia in pregnancy can reduce the risk and future burden of the disease. Adequate glycemic control during pregnancy has shown to improve insulin resistance, particularly in female offsprings, which they may develop as early as 5–10 years of age and prevent them from future development of T2DM.[8]

The overall objective of this guideline was to provide healthcare professionals a pragmatic approach for clinical management of women with preexisting diabetes or with previous history of GDM. It addresses prepregnancy counseling to women and their families so that they may have optimal health conditions before planning a pregnancy. This guideline incorporates evidence- and practice-based recommendations about prevention, blood glucose (BG) screening and diagnosis, management of diabetes in pregnancy, neonatal care, and breastfeeding. In addition, it also emphasizes postpartum follow-up for BG screening and contraception. It also includes implications and recommendations for future research.

GDM guideline recommendations are made after reviewing different guidelines, researches, reviews, updates, consensus, and meta-analysis from EMBASE, MEDLINE, PsycINFO, Cochrane Database of Systematic Reviews (CDSR), Google Scholar, and MedlinePlus by using MESH terms. The literature was reviewed over the period of 2008 to 2020. Search strategy was systematic and transparent to avoid biases, devised as Population Intervention Comparison Outcomes (PICO). Only published evidence-based guidelines were included in the study, anecdotal and experimental studies were excluded, and robust evidence was selected with the group consensus. The information gathered from the above-mentioned literature search was used by the committee for the development process and formation of recommendations according to scientific evidence and local cultural practices to assist in making informed clinical decisions and modify practices to improve the standard of care for women with diabetes. All the recommendations are evidence-based and supported by the references.


  Areas of Disagreement Top


The areas of disagreement were fundamentally about the timings of screening, its methodology and diagnostic criteria. IDF-MENA and SEA Regions are known to have a high prevalence of T2DM in the younger age group, increasing prevalence of metabolic syndrome, central obesity, and ethnicity being the highest risk factors. Therefore, the link between scientific evidence and clinical recommendations were reinforced, and the consensuses were agreed for universal, single-step OGTT at first antenatal booking visit.

After an in-depth review of NICE, FIGO, WHO, and IADPSG guidelines, the committee developed consensus for diagnostic and control values of BG, its feasibility, application, and implementation in the local context.

In view of poor postpartum follow-up by women, the difference of opinion among the core group was on appropriate timings of postnatal BG screening and diagnosis, (within 24–48h or 6 weeks after birth). This was resolved by discussion and evidence from literature, published studies, and guidelines.

To address the screening diagnosis and management of GDM, these guidelines recommend the following:

  • Prepregnancy clinic includes the importance of screening and counseling of women and their family members regarding control of BG before planning a pregnancy. Review and adjustment of dosage and types of medications being taken for preexisting diabetes which includes oral hypoglycemic drugs and insulin. Antihypertensives like ACE inhibitors and ARBs to be replaced with safer antihypertensives. Statins and fibrates are to be stopped. Advice for folic acid 5 mg 3 months prior to planning pregnancy were incorporated.


  • Blood glucose screening: In view of rising trends of central obesity, increasing prevalence of metabolic syndrome, high prevalence of young age onset of T2DM and Asian ethnicity, this guideline recommends Universal BG screening of pregnant women using one-step OGTT at first antenatal booking visit.[9],[10],[11]


  • In screen negative women, subsequent screening in later trimesters of pregnancy as per guidelines should be continued.


  • Diagnostic criteria for GDM: The diagnostic criteria for GDM are based on WHO 2013 and IADPSG 2010 criteria using venous serum/plasma glucose.


  • Management of GDM: It includes nonpharmacological management, lifestyle, and diet.


  • Pharmacological management: Insulin and or Metformin when NPT alone fails to control BG.


  • Antenatal and intrapartum management: The protocol for antenatal management has been summarized according to the gestational age, which includes glycemic and clinical management.


  • Neonatal management: It includes a protocol for BG estimation by heel prick, metabolic screening, and breastfeeding.


  • Postpartum follow-up: BG screening at 6 weeks after birth then every year.


  • Contraception: Recommendations are provided according to women’s wishes and safety of medications.


  • Future research recommendations: These have also been proposed for a better understanding of the disease process and its outcomes to seek wider collaboration between IDF Regional partners.


  • In view of rapidly evolving scientific evidence, the guidelines are proposed to be updated after 2 years.

    Strengths and limitations

  • This additional Executive Summary is provided as a tool to support the implementation of GDM guidelines in practice.


  • The guidelines are practical and can be implemented nationwide as was tested by a pilot study at two public sector hospitals which verified that it is easier to use and follow-up in clinical practice.


  • Monitoring and or auditing to assess guideline implementation or adherence to recommendations will be evaluated by the results from National GDM Registry.


  • Early identification of the pregnant women with diabetes is known to improve pregnancy outcomes. The limitations of early and universal BG screening by OGTT at booking visit may increase the laboratory workload and can be a little uncomfortable for the women.



  •   Introduction Top


    Gestational diabetes mellitus (GDM) is defined as any degree of glucose intolerance with onset or first recognition during pregnancy whether or not the condition persists after pregnancy.[12]

    However, there is a possibility that unrecognized glucose intolerance may have antedated or begun concomitantly with the pregnancy. Hence, if the pregnant woman on screening meets the criteria for diabetes mellitus (DM), then she is considered as having preexisting DM or Pre-Gestational DM.

    According to the latest National Survey,[11] almost 25% of the population is suffering from Type 2 diabetes mellitus (T2DM) and 76.2% and 62.1% are overweight and obese, respectively. Obesity, higher body mass index (BMI), and insulin resistance are added risk factors for undiagnosed diabetes in early pregnancy.[13] Where metabolic testing outside the pregnancy is not commonly performed, this increases the need for early screening during pregnancy to identify and treat dysglycemia before the period of rapid fetal organogenesis from 0 to 8 weeks to avert congenital fetal anomalies.

    Recent improvements in maternal health indicators show that maternal mortality has decreased from 276 to 186 deaths per 100,000 live births. Reproductive healthcare coverage in Pakistan is improving; nearly 9 in 10 women of reproductive age receive antenatal care from a skilled provider.[14] However, among noncommunicable diseases (NCDs), diabetes in pregnancy is a medical disorder that needs serious attention for implementation of guidelines at national levels so that the screening, diagnosis, and control of diabetes is instituted. This will help to reduce maternal morbidity and perinatal mortality and transmission of disease in future generations.

    Recent national health data shows that more births are delivered in health facilities, from 48% in 2012–2013 to 66% in 2017–2018, yet 1 in 3 births are delivered at home. In view of higher maternal and perinatal morbidity and mortality associated with diabetes in pregnancy, institutional delivery should be encouraged.[15]

    Asian ethnicity falls under high risk of hyperglycemia during pregnancy with previously undiagnosed diabetes.[16],[17],[18]

    The detection rate in 90% of all cases of GDM is poor because of low level of literacy, awareness, and inappropriate data keeping.[19],[20],[21],[22],[23],[24],[25]

    Universal screening of all pregnant women is recommended in early pregnancy, and selective risk-based screening has poor sensitivity for the detection of GDM in our population.[19]


      Recommendation 1: BG Screening Top


    1.1: Screening methodology

    At first antenatal visit, all pregnant women are advised a 75 g 2h oral glucose tolerance test (OGTT), irrespective of risk factors.[19] OGTT and blood glucose screening should be done following 8h of fasting and 2h after 75 g glucose load, dissolved in 250 cc of water which women are advised to drink over a period of 3–5 min to avoid nausea and vomiting. For diagnostic values of OGTT, see [Table 1]. For diagnostic values of preexisting diabetes, see [Table 2].[12]
    Table 1: GDM, diagnostic values of blood glucose for OGTT

    Click here to view
    Table 2: Preexisting diabetes mellitus, diagnostic values of blood glucose for OGTT

    Click here to view


    Women who have normal glucose values on initial OGTT, a second OGTT is recommended during 24th to 28th weeks and again in third trimester if she is screen negative in first two trimesters, especially if she belongs to high-risk group* (see Recommendation 1.3).

    Women who do not tolerate 75 g glucose load may be tested with 8h fasting BG or glycosylated hemoglobin (HbA1c).[25]

    Women who were subjected to fasting BG only in their first trimester, and were normoglycemic, they should also undergo an OGTT at 24–28 weeks gestation (see Recommendation 1.2).[25]

    1.2: Diagnostic values for blood glucose

    If fasting BG is more than ≥126 mg/dl (≥7 mmol/L) or HbA1c ≥6.5% women will be diagnosed as preexisting DM, and if fasting BG is between 92 and 125 mg/dL (5.1–6.9 mmol/L) women will be considered as GDM.

    1.3: HbA1c test

    HbA1c test should be performed during the first trimester of pregnancy to identify and prevent poor pregnancy outcome. Higher value, ≥6.5%, is diagnostic of pre-gestational DM that may be associated with higher risk of fetal anomalies in women with preexisting diabetes.[26],[27],[28],[29]

    However, HbA1c testing is not recommended for screening and diagnosis of GDM.

    1.4: Serum fructosamine test

    Serum fructosamine is a marker of glycemic control and reflects blood glucose levels of past 2–3 weeks. Its laboratory measurement is quick, cost-effective, and simple. However, its use for the predictions of GDM and neonatal outcomes is controversial.[30],[31],[32],[33],[34]

    Measurement of plasma serum fructosamine may help simplify the first step for detecting GDM. It has a poor sensitivity and low predictive value to detect abnormal glucose tolerance test with no definite cut-off values for different trimesters of pregnancy.[35] It may be a poor tool to monitor the control of BG during pregnancy as fructosamine levels can be influenced by relative hypoproteinemia seen in pregnancy.[35]

    1.5:*High-risk group for GDM[36]

  • Family history of diabetes


  • History of GDM in previous pregnancy


  • Maternal obesity


  • Macrosomia in current or previous pregnancies


  • Ethnicity, e.g., Asians.


  • 1.6: Additionally high-risk group has also been identified as[37],[38],[39],[40]

  • Age >35


  • High parity


  • Polyhydramnios


  • Fetal anomaly


  • Recurrent pregnancy losses


  • Bad obstetric history


  • Multi-fetal pregnancy


  • Polycystic ovarian disease (PCOD)


  • Unexplained still birth/intrauterine fetal death (IUFD)


  • Physical inactivity/sedentary lifestyle


  • Persistent hypertension more than 135/80 mmHg



  •   Recommendation 2: Management of GDM Top


    2.1: Education and counseling of women

    2.1.1: Self-monitoring of blood glucose (SMBG)

    Counsel the woman and her family about the appropriate use and storage of glucometer and its sticks. SMBG should be done to achieve good glycemic control and the frequency may be tailored and customized.

    The recommendations for the usual frequency of SMBG are as under:



    1. Fasting capillary glucose (following 8h overnight fasting) and three postprandial capillary glucose values (i.e., 1–2h after each major meal).[41]


    2. Once the target BG levels are achieved, SMBG may be done less frequently, at least 2 readings daily rotating around different meals/fasting on different days of the week.


    3. Monitoring BG before going to bed around 11 pm should be done in women experiencing nighttime symptoms suggestive of hypoglycemia.


    4. The aim of SMBG was to achieve adequate control of BG without inducing hypoglycemia.


    2.1.2: Continuous glucose monitoring system (CGMS)

    CGMS is safe and effective tool to evaluate ambulatory maternal glucose profile continuously and helps to prevent glucose variability through all trimesters. It measures glucose levels in real time by sensing glucose present in interstitial fluid and transmits the results via a connected device to a small receiving device and provides a new glucose levels every 5 min; 288 times/day. The CGMS does not replace SMBG, as frequent calibration of system with SMBG is needed, and the prohibitive cost of transmitter and sensors in resource constrained settings is the prime limiting factor for its use in community and public healthcare settings. It is a good technology for the management of blood glucose, but every new technology comes with a higher cost in the beginning, it may become affordable in the years to come.

    2.2:*Control levels of blood glucose during pregnancy

    Following the diagnosis of diabetes in pregnancy, control values of BG are same, irrespective of preexisting diabetes or GDM, see [Table 3].[19],[36],[37],[38],[39],[40],[42],[43],[44],[45]
    Table 3: The recommended control values for FBG and 1h or 2h PPG[36],[37],[38],[39]

    Click here to view


    *However, the control values of BG are different from diagnostic values.[46] See Recommendation 1.2.


      Recommendation 3: Treatment Top


    3.1: Non-pharmacological treatment (NPT)

    Lifestyle modification comprises of diet and exercise.

    Medical nutritional therapy (MNT) should be advised soon after diagnosis of GDM.

    3.1.1: Lifestyle modification

    3.1.1.1: Exercise/physical activity

    Women with GDM should be encouraged to be as active as possible throughout the day.

    The recommendations are as under:



    1. Moderate exercise of 30 min/day 1h after light meals/snacks.[19],[36],[37],[38],[39],[42],[43],[47],[48] This may be split into 15 min duration twice a day.


    2. Brisk walking can be continued till term at a pace that is comfortable except in women with obstetrical or medical complications.


    3. If brisk walking is not possible, then arm exercises in sitting posture for at least 5–10 min post meal is recommended.


    3.1.1.2: Diet



    1. Consult dietician if available in healthcare settings since dietary advice and adjustments are required throughout pregnancy to maintain glycemic goals.


    2. Women should be advised to avoid dietary items/foods containing simple sugars and honey, and awareness should be given to read food labels and calorie count.


    3. Manage calorie intake, 25–35 kcal/kg according to the body weight. In obese women with GDM, a minimum of 1500–1800 kcal/day is recommended. Calorie restriction less than 1500 kcal/day for women with GDM is not safe.[49]


    4. A minimum of 175 g of carbohydrate (CHO) and 28 g of fiber per day should be included in the diet.


    5. Take complex CHO, 3 meals +3 snacks (including 1 snack at bed time).[50],[51]


    6. Women should be guided to replace high glycemic index (GI) foods with low GI ones. This will help to reduce the risk of macrosomia by lowering BG peaks after meals.[52],[53] (For GI of common food items, see [Table 4].)


    7. Artificial sweeteners are not recommended during pregnancy. Although in some studies, Aspartame is reported to be a safer artificial sweetener if taken in moderation whereas saccharine is reported to cross placental barrier.[54],[55]


    8. Women on insulin should have sweets or sugar candies readily available with them if they experience hypoglycemia.


    9. The aim was to achieve normoglycemia, providing adequate maternal weight gain and adequate fetal growth, and to prevent starvation ketosis.
    Table 4: Glycemic index of common food items[137]

    Click here to view


    3.2: Pharmacological treatment (PT)

    Oral hypoglycemic drug (OHD)/insulin should be started if target BGs are not achieved within 1 week of MNT and exercise.

    3.2.1: Oral hypoglycemic drugs (OHDs)

    3.2.1.1: Metformin is safely recommended during pregnancy.[56],[57] The doses of metformin may vary from 250 mg per day to 2550 mg per day depending upon individual’s BG control.

    Insulin must be supplemented if metformin monotherapy is unable to achieve control within a week.

    3.2.1.2: Sulphonylureas are not recommended during pregnancy according to clinical evidence.[58],[59],[60] Although some studies, recommend Glibenclamide in pregnancy with diabetes.[61],[62]

    3.2.1.3: Other OHD to be avoided.

    3.2.2: Insulin

  • Insulin is gold standard of treatment for women with diabetes in pregnancy.[63]


  • When NPT and OHD fail to control BG values (see Recommendation 2.2), either insulin only should be started or may be combined with metformin.[64],[65]


  • Insulin may be started as a first-line treatment in women with associated obstetrical complications, e.g., pre-eclampsia, polyhydramnios, macrosomia or when FBS ≥126 mg/dL (≥7.0 mmol/L) and for RBS ≥200 mg/dL (≥11.1 mmol/L).


  • 3.2.2.1: Insulin types

    The type of insulin and treatment regimens should be individualized.

    Basal insulin: Recombinant human intermediate acting (NPH) or detemir.

    3.2.2.2: Bolus insulin



    1. Recombinant human short-acting (regular) insulin.


    2. Insulin analogues, e.g., Aspart and Lispro.[63],[66],[67],[68],[69]


    For women with nausea and vomiting, short-acting insulin analogues, e.g., Aspart and Lispro, can be taken after the successful meal as this has a tendency to reduce hypoglycemic episodes and improve postprandial BG levels.[70]

    3.2.2.3: The premixed insulin regimens put the woman at risk of fluctuating glycemic control during pregnancy and should be avoided. Women well controlled on this regimen may continue the same.

    3.2.2.4: Use of Glulisine, Degludec, is not recommended until more safety data are available.[71]

    3.3: Calculation of insulin dosage

    [Table 5] shows an arbitrary guide to start insulin dosage according to body weight and period of gestation:[63]
    Table 5: Arbitrary guide to start insulin dosage according to body weight and period of gestation

    Click here to view


  • As an example, for a woman with 60 kg of body weight at term, the requirements of insulin will be 1 unit × weight in kg = 60 units.


  • Split these 60 units, into morning dose of insulin two-thirds (2/3 × 60 = 40) and evening dose of one-third (1/3 × 60 = 20).


  • Further split morning dose (40 units) into one-third of regular insulin (1/3 × 40 = 13 approx.) and two-thirds of NPH (2/3 × 40 = 26 approx.).


  • Split remaining one-third (20 units) of evening dose into half regular (1/2 × 20=10 units) and half NPH Insulin (1/2 × 20=10 units). See [Figure 1], insulin dosage chart.


  • The optimal glycemic goals after insulin therapy should be achieved as per Recommendation 2.2.


  • See Appendix 1. Appropriate techniques for use of insulin.
  • Figure 1: Insulin dosage chart

    Click here to view


    3.4: Titration of insulin dosage



    1. Titrate the dose of insulin after 48–72h, if BG control values are not achieved.


    2. If FBS is persistently high, the dosage of basal insulin (NPH) may be increased.


    3. Similarly, if any post-prandial BG level is high, then increase the dosage of Bolus insulin either regular/lispro/aspart before meal.


    4. For every 10 mg change in BG control values as given in (Recommendation 2.2), titrate the dose of insulin by 1 unit.


    5. If hypoglycemia occurs, i.e. <63 mg/dL (<3.5 mmol/L), reduce insulin dosage and increase fetal surveillance.


    3.4.1: Insulin titration after steroid administration

    If administration of corticosteroid is required for obstetrics indications in women on insulin therapy[72]:



    1. Following first dose of prophylactic administration of corticosteroids, the dosage of insulin adjustments is required to increase by 20–40% of their pre-corticosteroids insulin dosage according to SMBG.


    2. This increase in dosage is required from day 1 of steroid administration up to day 5.


    3. Thereafter taper the dose of insulin by 6–7th day to presteroid administration dosage.



      Recommendation 4: Preconception Care Top


    4.1: Risk factor identification before planning pregnancy

    Women, planning pregnancy who visit health care for some other reasons, should undergo risk factor identification and a BG screening by OGTT (12h fasting and 2h after 75 g glucose load) to screen for abnormalities of glucose homeostasis prior to conception. (See diagnostic values in Recommendation 7.5.2.)

    4.2: Prepregnancy care for women with preexisting diabetes

    All women with previous history of diabetes who plan pregnancy must be counseled to attend prepregnancy clinics.[73]

    For control levels of BG in preconception period, see [Table 6].[36]
    Table 6: Control levels of BG in preconception period

    Click here to view


    4.2.1: Review and adjustment of medications

    4.2.1.1: OHDs

    Discontinue medications which are teratogenic/not safe at the time of conception, e.g. oral hypoglycemic drugs other than Metformin and Glybenclimide.

    4.2.1.2: Insulin

    Switch from noninsulin agents to insulin. However, metformin can be continued.

    4.2.1.3: Antihypertensive drugs

    Stop statins and replace ARBs, ACE inhibitors by Labetalol, Methyl DOPA, or Nifidipine.

    4.2.1.4: Folic acid

    Supplement folic acid 5 mg starting 3 months prior to conception and continue for 3 months after conception.[74]

    4.2.2: Manage comorbidities

    Women with preexisting T1DM or T2DM should get baseline screening for retinopathy and nephropathy. Appropriate treatment and stabilization of any complications prior to conception are prudent.

    4.2.3: Target blood glucose values during preconception period

    Educate and ensure SMBG.[41] Targets for fasting and post prandial glucose should be optimized. Counsel to achieve good glycemic control with an HbA1C closer to 6–6.5%, if these values can be safely attained without putting the woman at risk of hypoglycemia.


      Recommendation 5: Antenatal Care (ANC) Top


    Education and counseling at booking
    Table 8: Diagnostic criteria for ketoacidosis[91]

    Click here to view



      Recommendation 6: Intra-partum Management Top


    6.1: Timing and mode of delivery

    6.1.1: Timing of delivery

    Women with well-controlled diabetes without obstetric complications may go for spontaneous labor up to 38–39 weeks of gestation.

    In women with uncontrolled diabetes earlier intervention may be required after 37 completed weeks.

    6.1.2: Mode of delivery

    Vaginal delivery should be the aim in women with well-controlled diabetes.

    C-Sec is indicated if there is fetal macrosomia, bad obstetric history (BOH), pre-eclamptic toxaemia (PET) or any other obstetric indications/complications.

    6.2: Glycemic management during labor

    6.2.1: Intra-partum blood glucose monitoring

    If the woman is on MNT, BG monitoring is recommended 6 to 8 hourly. If she is on pharmacotherapy for glycemic control, she needs more frequent BG monitoring (every 1 to 2 hourly).

    6.2.2: Intra-partum target blood glucose level

    Goal of intra-partum capillary BG should be between 72 and 126 mg/dL (4–7 mmol/L).[19],[36],[37],[39],[43],[44],[75],[78]

    In women on insulin or in whom the BG is not maintained between 72 and 126 mg/dL (4–7 mmol/L), 12 units of insulin in 1000 cc of 5% dextrose water may be added. This should be separate from the infusion which may be given for induction/augmentation of labor.[36]

    6.3: Management of diabetic ketoacidosis

    Diabetic ketoacidosis (DKA) is a critical condition commonly seen in pregnant women with T1DM but may be present in T2DM and GDM. This condition requires immediate intensive care admission. If woman is hyperglycemic or feels unwell ketone testing in the blood is advised for an accurate and timely assessment of ketosis. See Appendix 2 for the management of DKA in pregnancy with diabetes.

    6.4: Management of preterm labor

    HIP increases the risk of spontaneous and iatrogenic preterm labor.[136] A three-pronged approach to manage threatened/established preterm labor in women with GDM is recommended:



    1. Tocolysis and in utero transfer to tertiary care with neonatal care facilities.


    2. Antenatal corticosteroids (ACS) as given in Recommendation 5.4.2.


    3. Give magnesium sulphate for neuro-protection.


    4. Give Tocolytics,[79] for 48h after the first dose of antenatal corticosteroids.


    5. Start calcium channel blocker Nifedipine,[80] 10 mg oral/sublingual.


    6. Repeat every 15–20 min if uterine contractions persist.


    7. The maximum total dose of calcium channel blockers is 40 mg during the first hour of treatment followed by 20 mg orally every 8h for 2–3 days.


    8. Indomethacin[79] can be used in gestation 24 weeks to 30 weeks but is contraindicated after 32 weeks of gestation because of risk of premature closure of the ductus arteriosus in the infant.


    9. Atosiban (oxytocin receptor antagonist) can be used as second-line tocolytic but is expensive and not available in Pakistan.[36],[79]


    10. Caution must be used if combining magnesium sulfate with β-adrenergic receptor agonists or calcium channel blockers because of possible maternal complications.


    11. Injection magnesium sulphate[81] should be given to women below 34 weeks of gestation to reduce the incidence of cerebral palsy.



      Recommendation 7: Postpartum Management Top


    7.1: Re-adjustment of pharmacological treatment (PT)

    Women on pharmacotherapy require re-adjustment of their medication.

    7.1.1: Women with GDM

    Insulin sensitivity increases and insulin/OHD requirements go down with the delivery of placenta.

    Women with GDM usually revert back to normoglycemia and PT should be stopped/modified.

    7.1.2: Women with preexisting diabetes

    7.1.2.1: Type 1 diabetes mellitus (T1DM)

    In women with T1DM, particular attention is needed to hypoglycemia because of temporary Honey Moon Phase, lactation, erratic sleep, and disturbed eating schedules.

    Insulin sensitivity increases and insulin requirements and dose of insulin both Basal and Bolus go down by about 50% with the delivery of placenta.[82],[83],[84],[85]

    Women who are on insulin >1 units/kg/day, the dose of insulin may be reduced to 50% after birth while those on 0.5–1 units need individualized clinical decision according to BG levels on SMBG.

    7.1.2.2: Type 2 diabetes mellitus

    Women with preexisting T2DM can resume or continue to take OHD, Metformin/insulin after birth according to BG values on SMBG, see [Table 7].
    Table 7: Diagnostic BG values following 12h fasting and 2h after 75 g glucose load (OGTT: WHO criteria)[91]

    Click here to view


    Women with preexisting diabetes should be advised to see their primary care physician postnatally for further management of diabetes.

    7.2: Frequency of blood glucose monitoring after birth

    Women who were on Metformin or on low-dose insulin (<0.5 units/kg/day) should continue BG monitoring; fasting and 2h post meal for the next 48–72h, thereafter, the frequency of BG monitoring may be adjusted according to glycemic status.

    In case of Caesarean section, in the immediate postoperative period BG monitoring may continue every 4–6 hourly till oral food is allowed and thereafter 2h post prandial according to BG control on SMBG.

    7.3: Postpartum counseling

    7.3.1: Counseling of woman and family

    Counseling of women and their families should be directed towards the importance of:

  • Diet, physical activity, lifestyle modification, addressing weight reduction/obesity to prevent future development of diabetes.[19],[36],[38],[39],[40],[42],[43],[44],[47],[86],[87],[88]


  • In view of the poor 6 weeks postpartum follow-up of the women, advise for BG screening must be emphatically incorporated in the counseling sessions.[89]


  • Women with diabetes in pregnancy should be counseled to undergo postpartum OGTT at 6 weeks, 6–12 weeks, and then yearly.


  • They must be educated about the fact that if they follow the advice, they can be prevented from future development of T2DM.


  • Women and their families should be cautioned that in case of noncompliance, 50–70% of mothers with GDM are at risk of development of T2DM in the next 5–10 years.[90]


  • 7.4: Postpartum blood sugar screening OGTT

    Screen the women for diabetes at 6 weeks postpartum with 75 g 2h OGTT** or fasting blood sugar >126 mg/dL (>7 mmol/L) using World Health Organization (WHO) criteria,[91] to exclude/confirm preexisting undiagnosed T2DM from GDM.

    This 6-week OGTT may be linked to pediatric attendance/child immunization to ensure the compliance of postpartum follow-up. If OGTT is not possible, then offer fasting plasma glucose or HbA1c.

    **For diagnostic BG values following 12h fasting and 2h after 75 g glucose load (OGTT: WHO criteria), see [Table 7].[91]

    7.5: Infections

    Pregnant women with diabetes are at high risk of infections at surgical sites, i.e., Cesarean section, episiotomy, urinary tract infections, breast abscess, and endometritis. This can be avoided if appropriate hygiene, antibiotics and proper glycemic controls are taken care of.

    7.6: Postpartum thyroid dysfunction

    Due to high risk (25%) of postpartum auto-immune thyroid dysfunctions in the first four weeks after delivery, the thyroid hormonal abnormalities should be screened at 1–3 months postpartum.[92],[93]


      Recommendation 8: Neonatal Care Top


    8.1: New-born BG should be checked by heel prick within 30 min of birth, the aim is to keep BG around 36–40 mg/dL (2–2.2 mmol/L).[36]

    8.2: Continue BG monitoring every 4 hourly. If BG of infant is below 18 mg/dL (1 mmol/L), treat hypoglycemia with intravenous dextrose immediately.

    8.3: In symptomatic new borns, complete blood count (CBC), serum bilirubin, serum calcium, and serum magnesium should be done.[36],[39],[43]

    8.4: Keep baby admitted in NICU or under surveillance for at least 24h till they maintain their BG levels more than 46.8 mg/dL (2.6 mmol/L).[36],[39],[40],[75]

    8.5: In mothers with HIP, the risk of congenital heart defect (CHD) in neonates with macrosomia is 2- to 3-fold high.[94] If neonate develops physical signs like difficult breathing along with cyanosis, poor feeding and sleepiness urgent echo cardiography should be advised and pediatric cardiologist should be consulted.[95] Prenatal detection by intrauterine echocardiography in pregnancy with diabetes allows early referral to a tertiary care center.[96],[97],[98]

    8.6: The pregnancies complicated by HIP leads to neonatal hypoglycemia if birth weight is >90th centile, irrespective of treatment with or without insulin.[99] Macrosomia further increases the frequency of cesarean section and increase the risk for NICU admission due to difficult and traumatic vaginal birth because of shoulder dystocia which may cause clavicle fracture and injury to brachial plexus.[100],[101]


      Recommendation 9: Breastfeeding Top


    9.1: Early and exclusive breast feeding (BF) is recommended to avoid neonatal hypoglycemia. This also reduces mother’s and offspring’s risk of obesity and this prevents development of future T2DM.

    9.2: Breastfeeding should be initiated immediately after birth and should be provided at intervals of 2–3h.

    9.3: Women with preexisting insulin-treated diabetes should take some snacks while breast feeding and at night time before going to bed.

    9.4: Medications during BF

    9.4.1: Review the drugs that were discontinued for safety reasons in the preconception period. These drugs may also be contraindicated for lactating mothers. See Recommendation 4.2.1.

    9.4.2: In women with preexisting diabetic nephropathy, ACE inhibitors can be restarted but the use of ARBs need to be discussed with the physician and women.

    9.4.3: Insulin, Metformin,[102] can be safely used in lactating women.


      Recommendation 10: Diabetes Mellitus and Fetal Loss Top


    Women who had a pregnancy loss require special attention by the healthcare professionals for their physical and psychological well-being in consultation with a mental health professional as and when needed. They should be screened with standard 75 g 2h OGTT at 6–12 weeks following fetal loss.


      Recommendation 11: Contraception Top


    Counseling should be done on methods of contraception that are effective to limit family size, to achieve optimal physical health, good glycemic control between pregnancies. Following contraceptive choices are recommended:

    11.1: Progesterone-only contraception can be offered to lactating mothers any time after delivery including subdermal implants and Depot medroxyprogesterone acetate (DMPA).[103]

    11.2: Estrogen containing contraceptive pills should be avoided after delivery. After 42 days postpartum, low-dose estrogen and progesterone combined hormonal pills may be given to women irrespective of lactation.

    11.3: Long-acting hormonal contraceptive device like Levonorgestrel (LNGIUS)-based systems are relatively safer, if affordable.

    11.4: Nonhormonal Intrauterine Contraceptive Devices (IUCD), e.g., Copper-T, multi-load are cheaper and can be used safely and placed in the immediate postpartum period.[103]

    11.5: Barrier methods are considered safer.

    11.6: Tubal ligation/vasectomy may be offered as a permanent method of contraception to couples who do not desire further pregnancies.[104]


      Recommendation 12: Counseling of women for future pregnancy Top


    Women with pre-hyperglycemia or past history of GDM should be counseled to attend preconception care clinics before planning for next pregnancy. In women with preexisting diabetes, glycemic control and medications may be reviewed and modified before conception, see Recommendation 4.

    Future research recommendation

    Following are the future research recommendations for care providers, researchers, and policy makers.

  • Due to poor show up of the women in postpartum clinics, it is pragmatic to do an OGTT after 24–72h of delivery when she is still in the hospital. If BG remains elevated, continued follow-up of screened positive women is mandatory after 6 weeks postpartum.


  • Advantages of IADPSG criteria compared with the previous WHO criteria, to screen and to prevent adverse neonatal and maternal outcomes.


  • International Association for Diabetes and Pregnancy Study Group (IADPSG) criteria is expected to increase the number of women identified with GDM and consequently increase the burden on the health system.


  • Intensive BG screening and surveillance during pregnancy results in higher rate of primary Cesarean deliveries.


  • Labelling women with gestational glucose intolerance increases maternal anxiety and adverse health perceptions.


  • False-positive or false-negative BG results increase inconveniences/psychological trauma and outweigh the benefits of diagnostic testing.


  • Is it cost-effective to use IADPSG criteria for screening of hyperglycemia in pregnancy in low middle income countries?


  • Evaluation of the new diagnostic criteria IADPSG in diverse settings and ethnic groups: costs, acceptability.


  • Randomized trials (e.g. country or region specific) comparing different strategies for the detection of GDM.


  • Evaluation of a “single step versus two step procedure” in diagnosing GDM


  • Cost-effectiveness studies with different detection strategies.


  • Long-term risks related to HIP in mother and child and impact of treatment on long-term outcomes in mother and child.


  • Knowledge attitude and practice (KAP) studies to evaluate myths about diabetes in pregnancy:



    • i. Eating too much sugar during pregnancy causes diabetes


    • ii. Once on insulin will always be on insulin


    • iii. Insulin is a drug of addiction


    • iv. Gestational diabetes is baby diabetes and is not worrying.


  • To conduct national surveys to evaluate the level of knowledge about diabetes in pregnancy; in community, nurses, non-nurses and healthcare providers.


  • Existing, Pakistan Diabetes Prevention Program (PDPP) should focus and integrate on diabetes and pregnancy with special reference to screening, management and prevention at national level.
  • [137]

    Acknowledgments

    The authors would like to acknowledge Dr. Viswanathan Mohan, Chairman and Chief Diabetologist, Dr. Mohan’s Diabetes Specialties Centre, President and Director, Madras Diabetes Research Foundation, Chennai, for his guidance, persistent help, unceasing encouragement, and unconditional support for in-depth review of the guidelines.

    Our deepest gratitude to Dr. Akhtar Hussain, Professor of (Chronic Disease – Diabetes), NORD University, Norway and President, Diabetes in Asia Study Group for his kind review and endorsement of the guidelines.

    The authors would also like to express deepest thanks and sincere appreciation to Dr. Jamal Belkhadir, Professor of Internal Medicine at the University of Rabat, President of the Moroccan League for the Fight against Diabetes and Chair IDF-MENA Region, for his review and support.

    We would like to thank all the people whose assistance was a milestone in the completion of these guidelines especially Mr. Syed Imran Shah, for his invaluable assistance. Without his persistent help the preparation of this manuscript would not have materialized.

    Financial support and sponsorship

    Nil.

    Conflicts of interest

    There are no conflicts of interest.



     
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