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 Table of Contents  
ORIGINAL ARTICLE - GUIDELINES
Year : 2021  |  Volume : 12  |  Issue : 5  |  Page : 3-42

IDF-MENA region guidelines for management of hyperglycemia in pregnancy


1 Department of Obstetrics and Gynaecology, ISRA University, Karachi Campus, Karachi, Pakistan
2 Private Clinic, Jordanian Society for the Care of Diabetes, Rawalpindi, Pakistan
3 GDM Guidelines Committee, Society of Obstetricians & Gynaecologists of Pakistan (SOGP), Department of Obstetrics & Gynaecology, CMH Lahore Medical College, National University of Medical Sciences, Rawalpindi, Pakistan
4 Imperial College London Diabetes Centre, Sudan Diabetes Association, Abu Dhabi, UAE
5 American Board Diabetes, Endocrinology and Metabolism, King Hamad University Hospital, Royal College of Surgeons, Ireland—MUB, Scientific Committee at Bahrain Diabetes Society, Al Sayh, Bahrain
6 Tripoli University, Diabetic Pregnancy Unit (DPU), Al-Jalaa Maternity Hospital, National Libyan Diabetes Programme Committee (NLDPC), Abu Dhabi, UAE
7 Corniche Hospital, UAE, Emirates Diabetic Society, Sudan Diabetes Association, Abu Dhabi, UAE
8 Seethapathy Clinic & Hospital, Chennai, India, FOGSI, India
9 Faisalabad Medical University, Faisalabad, Pakistan
10 Arabian Gulf University, Manama, Bahrain
11 Division of Neonatology, University of Jordan, Jordan University Hospital, Jordanian Society for the Care of Diabetes, Amman, Jordan
12 Abdalla Khalil Diabetes Center, Sudan Diabetes Association (SUDA), Sudan
13 AGU-Arabian Gulf University, Ministry of Health, Diabetes Society, Bahrain
14 Jordan University Hospital, The University of Jordan, Jordanian Society for the Care of Diabetes, Jordan
15 Dubai Hospital, Dubai, UAE
16 Dubai Hospital, Emirates Diabetes Society, Dubai, UAE
17 Baqai Institute of Diabetology and Endocrinology, IDF Center of Excellence in Diabetes Care, Karachi, Pakistan
18 Sohag University, Egypt
19 Assiut University, South Egypt Association of Diabetes and Endocrinology, Asyut, Egypt
20 Ameer-ud-Din Medical College, PGMI, Lahore, Pakistan
21 Faisalabad Medical University, Allied Hospital Faisalabad, Faisalabad, Pakistan
22 American Boards of Diabetes and Endocrinology, Endocrine Division, Tawam Hospital, SEHA, Al Ain, UAE
23 Dubai Hospital, DHA, UAE, Gulf Medical University, Dubai, UAE
24 Endocrine Department, Dubai Hospital, DHA, Dubai, UAE
25 University Medical and Dental College, Faisalabad, Pakistan
26 Department of Medicine, Punjab Medical College Faisalabad, Faisalabad Medical University/Punjab Medical College, Faisalabad, Pakistan

Date of Submission01-May-2021
Date of Decision03-Jul-2021
Date of Acceptance12-May-2021
Date of Web Publication20-Jul-2021

Correspondence Address:
Prof. Shabeen Naz Masood
Department of Obstetrics and Gynaecology, ISRA University, Karachi-Campus, U-19, Hasan Apartment Extension, Hasan Square, Gulshan-e-Iqbal, Block 13D, Karachi.
Pakistan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jod.jod_58_21

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  Abstract 

Introduction: Hyperglycaemia in pregnancy (HIP) is the most common medical disorder complicating pregnancy. This includes women who have pre-existing Type 1 and Type 2 diabetes mellitus (DM) and those diagnosed to have gestational diabetes mellitus (GDM), with glucose intolerance identified for the first time in pregnancy. In the Middle East and North Africa region, the prevalence of DM in women of reproductive age group is high and it varies widely between different regions due to variation in screening and diagnostic criteria for the identification of GDM. Universal blood glucose screening at first antenatal booking visit helps in identifying women with HIP. Women who are screen negative at first antenatal should subsequently be screened with a fasting oral glucose tolerance test (OGTT) around 24-28 weeks to identify GDM. There is a clear evidence that the identification and management of hyperglycaemia improves pregnancy outcomes. Antenatal care involves more visits as these women are at higher risk of fetal malformations, preterm labour and stillbirth. Timing of delivery is based on glycaemic control, fetal wellbeing, and the presence of co-morbidities. Objective: The objective of this article is to provide guidelines regarding the management of hyperglycemia in pregnancy. Materials and Methods: These recommendations are made after reviewing various existing guidelines including American College of Obstetricians and Gynecologists, Royal College of Obstetricians and Gynecologists, and American College of Sports Medicine. A literature search was done using PubMed, Cochrane Database, Google Scholar, EMBASE, various systematic reviews, and original articles. Search was done using key words “Hyperglycemia in pregnancy,” “gestational diabetes mellitus,” and “diabetes in pregnancy.” Conclusion: Hyperglycemia in pregnancy can be managed effectively if appropriate measures are taken and potential consequences can be avoided.

Keywords: Gestational diabetes, guidelines, hyperglycemia in pregnancy, insulin techniques, insulin storage, Ramadan fasting with hyperglycemia in pregnancy, screening and diagnosis of GDM, universal blood glucose screening


How to cite this article:
Masood SN, Shegem N, Baqai S, Suliman M, Alromaihi D, Sultan M, Salih BT, Ram U, Ahmad Z, Aljufairi Z, Badran EF, Saeed OA, Alsaweer A, Basha A, Saquib S, Alani K, Ghafoor E, Mohamed OA, Eltoony LF, Fazal A, Mohsin M, Afandi BO, Hassanein M, Alawadhi F, Khan S, Bilal A. IDF-MENA region guidelines for management of hyperglycemia in pregnancy. J Diabetol 2021;12, Suppl S1:3-42

How to cite this URL:
Masood SN, Shegem N, Baqai S, Suliman M, Alromaihi D, Sultan M, Salih BT, Ram U, Ahmad Z, Aljufairi Z, Badran EF, Saeed OA, Alsaweer A, Basha A, Saquib S, Alani K, Ghafoor E, Mohamed OA, Eltoony LF, Fazal A, Mohsin M, Afandi BO, Hassanein M, Alawadhi F, Khan S, Bilal A. IDF-MENA region guidelines for management of hyperglycemia in pregnancy. J Diabetol [serial online] 2021 [cited 2021 Jul 30];12, Suppl S1:3-42. Available from: https://www.journalofdiabetology.org/text.asp?2021/12/5/3/321823




  Overview Top


The International Diabetes Federation (IDF) is an organization with about 230 national associations for diabetes and it is spread across 170 countries globally. Its mission is to promote diabetes care, prevention, and cure worldwide. The IDF estimates that globally 463 million people of the world population between the ages of 20 and 79 years are living with diabetes.

The IDF’s national diabetes associations are divided into seven regions. The IDF-MENA region currently represents 29 diabetes organizations in 21 countries and territories. It covers a wide area in North Africa and West Asia, extending from Pakistan in the east to Morocco in the west.

Among all the IDF regions, the MENA region has the highest age-adjusted diabetes prevalence of 12.2%. The prevalence of HIP is very high in the IDF-MENA region: It is 17.9% in women who are 20–29 years of age; 15.8% live births, that is one in every six births, are affected by GDM. About 76 million women of reproductive age are suffering from some form of hyperglycemia; 22 million women are coping with diabetes; and 54 million women are living with prediabetes with the likelihood of developing GDM if they become pregnant. There is a wide variation of 1%–28% in the reported prevalence of HIP. This may be because of nonuniform screening and diagnostic criteria to detect HIP.

To address the diversity and nonuniformity of screening, diagnosis, and management in HIP, Chair IDF-MENA Region, Prof. Jamal Belkhadir assigned the task of development of the IDF-MENA HIP guidelines under the Chairpersonship of Prof. Shabeen Naz Masood.

A guideline committee was formed in August 2020, which comprised members from different countries of the MENA region. These members are from the disciplines of Obstetrics and Gynecology, Endocrinology, Neonatology, Internal Medicine, and Diabetes Education with a strong intellectual, clinical, and research background and possessing expertise and interest in diabetes during pregnancy. Different subsections to the author’s HIP guidelines were distributed among 26 participating members. There were about 25 virtual meetings every weekend, and each lasted 2–3 h with active participation of the members. The first meeting started in September 2020 and after seven months the guidelines were completed and ready for publication.

Each member of the guideline team was assigned to author one or multiple subsections of the HIP guidelines. The sections were then reviewed by all members in these multiple weekly virtual meetings, and a consensus of expert opinion was achieved. Editing and internal review was done by a group of six members. Finally, the Chair of the guideline committee with the in-depth research and intellectual input cooperation of team members has been able to produce pragmatic, evidence, and practice-based guidelines on HIP for the MENA region. This was very successfully completed in a short period of about six months.

Keeping in view the rapidly evolving medical evidence, the guidelines are proposed to be updated after two years.

There was no funding available, and this work was completed on a purely voluntary basis.


  Executive Summary Top


HIP is the most common medical disorder in women worldwide.[1] Diabetes has become the fastest growing global public health challenge. GDM parallels and reflects the global rising epidemic trends of T2DM, with 223 million women aged 20–70 living with T2DM.[1],[2] Among the seven IDF regions, MENA region has the highest (12.2%) age-adjusted prevalence of diabetes where one in nine live births are to women affected by HIP.[1] More than 50% of the women in MENA region are likely to become pregnant with either diabetes status undiagnosed or improperly screened.[1],[3],[4] Arab countries have the highest prevalence of T2DM (3.9%–18.3%) and GDM (5.1%–37.7%) in the world.[1],[3],[4] The wide variation in the prevalence of diabetes among MENA region countries is probably because of different screening strategies and diagnostic criteria, confusion and disagreement over uniform screening strategies and diagnostic criteria, among health-care providers (HCPs), and lack of agreed screening and diagnostic methodology globally.[2],[5],[6]

HIP is known to be associated with a higher maternal and perinatal morbidity.[1],[2],[5],[6],[7],[8] Despite the known association with adverse maternal and perinatal outcomes, to date there has been confusion, disagreement, and lack of consensus among international health organizations on the screening and diagnostic criteria for HIP.[2],[5],[6] Given the known relationship between HIP and poor pregnancy outcomes and the role of in utero genetic imprinting in increasing the risk of future development of T2DM, obesity, and cardiovascular disorders in mothers and in the offspring of mothers with HIP, as well as in increasing maternal vulnerability to future diabetes and cardiometabolic disorders, there needs to be a greater focus on the prevention, early identification (screening, diagnosis), and management of HIP to improve pregnancy outcomes and to reduce the future burden of noncommunicable diseases. Pregnancy offers a unique opportunity not to be missed, for the primary prevention of the adverse consequences of hyperglycemia.

An online survey about the knowledge and practices of GDM among HCPs was recently carried out in MENA region, and this revealed a wide variation in the screening and diagnostic practices for HIP (approved for print in J Diabetol). This stimulated the idea for the MENA region HIP guidelines. A multidisciplinary guideline group of international experts developed pragmatic, consensus, and evidence-based key recommendations while taking the local context into account, to address the screening and diagnosis, management, and care of women with HIP regardless of the resource setting. The overall objective of the MENA region HIP guidelines is to equip all HCPs to manage women with HIP, improve clinical practice, and prevent progression to T2DM by continued postpartum BG monitoring and follow-up.[2]

Preconception care is recommended for all women with preexisting diabetes, to optimize glycemic control, improve general health advice to reduce weight, assess for complications, review medications, and add folic acid supplementation. Effective contraception is advised until an HbA1c of <6% is achieved.

The MENA region guideline recommends early universal screening for HIP in all pregnant women at booking by using a one-step 2-h 75 g OGTT. Diagnostic criteria given by the WHO (2013) and IADPSG (2010) are used for the diagnosis of GDM.

Sequential BG screening in the second and third trimesters is done if the initial screening is negative. The idea is not to miss an opportunity to identify women with HIP.

Antenatal management begins with the counseling and education of pregnant women with HIP along with their families. The focus is on optimizing BG control initially by lifestyle modification, including exercise and medical nutrition therapy (MNT). Metformin alone or with insulin is added if the glycemic targets are not achieved.

Self-monitoring of capillary glucose (SMBG) is encouraged. Glycemic targets are to be explained to the pregnant woman. Frequent antenatal follow-ups for review of glycemic control and obstetric care are recommended.

HbA1c testing is recommended at booking, to determine the level of risk for the pregnancy, and again in the second and third trimesters for women who are non-adherent with SMBG, testing insufficiently, or if confirmation is needed to see that targets are being achieved.

The guideline recommends all HCPs to have a high index of clinical suspicion so as to recognize diabetic complications such as hypoglycemia, severe hyperglycemia, and ketoacidosis (DKA) early and to manage with the multidisciplinary team.

The timing of delivery depends on glycemic control, associated complications, and fetal condition. The optimal time of delivery for women with GDM that is well controlled on MNT is between 39 and 40 weeks of gestation whereas with well-controlled, uncomplicated pre-gestational Type 1 and Type 2 diabetes mellitus, the optimal time of delivery is between 37 and 38 weeks of gestation. The delivery should be planned earlier (preferably at 37 completed weeks of gestation) in poorly controlled diabetes or with complications. Pregnancy with diabetes should not go beyond 40 weeks of gestation. BG is monitored closely in labor. Maternal BG levels are maintained between 72 mg/dL and 126 mg/dL (4.0–7.0 mmol/L) to reduce neonatal hypoglycemia.

Vaginal delivery is encouraged. Elective cesarean section is recommended if the estimated fetal weight is >4kg or for obstetric reasons. Neonates of mothers with HIP are at risk of hypoglycemia. BG checks soon after birth and early feeding are recommended.

The postpartum risk of hypoglycemia in the mother is high if the insulin requirement falls with the delivery of the placenta. Insulin is adjusted/titrated immediately after delivery. Maternal BG is monitored frequently to achieve optimum glycemic control. All women should be encouraged to breastfeed, since this may reduce obesity in the offspring. Metformin and insulin are safe while breastfeeding.

Every pregnancy in a woman with diabetes needs to be planned. Effective long-acting reversible contraception is recommended.

Postpartum, the woman is advised to continue the lifestyle modification and regular follow-up in order to reduce the development of subsequent T2DM. Screening should be conducted at six weeks postpartum by a 2-h 75 g OGTT using the WHO nonpregnant criteria; lifelong screening for T2DM/prediabetes by fasting BG every one to three years is recommended.

Women with HIP are to be counseled to report in the preconception clinic when planning pregnancy subsequently to optimize pregnancy outcomes.

The MENA region has a predominant Muslim population. Women with HIP who are even well controlled on MNT/Metformin are recommended against fasting. If they decide to fast, then they require close glycemic monitoring and they need to be educated regarding frequent SMBG and when to break the fast.

A guideline-developing methodology is given along with the strengths and limitations of the evidence-based consensus document.

Future research recommendations have been made to better understand HIP in women of MENA region and to find the impact/change in clinical practice by the implementation of MENA region guidelines in member countries.


  Strengths and Limitations Top


Strengths

  1. This is the first comprehensive, evidence-based, locally tailored guideline from MENA region where the burden of disease estimated by the IDF is the highest in the world; authored by a multidisciplinary group of HCPs with expertise in managing diabetes in pregnancy.


  2. It suggests a uniform strategy for screening and diagnosis of HIP that will enable MENA region to determine the prevalence of HIP and compare the burden of disease among different countries of the region. Previous sporadic studies have given a wide variation in the prevalence of HIP (1%–28%) due to the use of different screening strategies and varied diagnostic criteria.


  3. The format is clear, user-friendly, and it offers clear recommendations for clinical practice. The writing group recommends that this guideline be translated and adapted into local health-care policies and health-care pathways, considering all relevant local and cultural factors.


  4. The guideline is practical and comprehensive; it addresses all aspects of care for pregnant women with hyperglycemia, both GDM and preexisting T1DM and T2DM. It not only covers preconception management, antenatal management (glycemic and obstetric), intrapartum care, postpartum management, neonatal care, and breastfeeding, but it also addresses contraception, care of women with fetal loss, and management of the complications of diabetes.


  5. In addition, the document includes clear instructions for insulin administration, technique, and storage guidelines.


  6. It explicitly explains MNT, including calorie requirement, common food types of MENA region with their glycemic index (GI), and the concept of food plate.


  7. It gives clear recommendations for exercise, including types and duration.


  8. It emphasizes preconception management, postpartum BG monitoring, and the need for continued BG follow-up so as to reduce the future burden of T2DM.


Limitations

  1. The guideline does not address routine pregnancy care. It primarily addresses the specific issues pertaining to GDM, preexisting diabetes, and pregnancy.


  2. The relationship between the social determinants of diabetes and diabetes management in pregnancy is beyond the scope of the guideline and has not been evaluated in the already lengthy clinical guideline.


  3. The unique needs of women of different cultures and strata of society have not been catered for. The MENA region countries range from the high-income group to the low-income group, and each has not been addressed separately.


  4. The relationship between clinical care for women with preexisting diabetes and local health-care systems of different countries has not been evaluated. The writing group acknowledges that in different systems, there are different care providers, different levels of care, processes, and funding models.


  5. Women-centered care and culturally safe care, in a particular country and other geographical nuances, have not been addressed. We recommend that all HCPs should provide women-centered and culturally safe care for women with HIP.


  6. The recommendations of the guideline, though evidence based, have not been pilot tested. Future research will determine the impact on clinical practice and women’s health in the region.


  7. The recommendation of early universal screening by a 2-h 75 g OGTT at booking visit may increase the local laboratory workload along with requiring women to come fasting for the test. Perhaps the benefits outweigh the discomfort.


  8. The guideline did not aim at meeting the National Health/Medical Council standard for guidelines.


  9. Rating the quality of evidence or strength of each recommendation was out of scope.


  10. Not all 22 member countries of MENA region were involved in guideline development.



  Introduction Top


HIP is a major public health issue. It is a global concern and is the most common metabolic abnormality encountered in pregnancy.[1],[2],[9],[10] According to the IDF, globally 20.4 million women of reproductive age (16%) are affected by HIP, of whom 83.6% have GDM; 7.9% have preexisting diabetes; and 8.5% have diabetes first detected during pregnancy.[1] According to the IDF estimates, MENA region has the highest age-adjusted prevalence of diabetes (12.2%), which is likely to double by the year 2045.[1]

Due to similarities in genetics and pathogenesis, the prevalence of GDM correlates and parallels with T2DM.[2],[4] In MENA region, the prevalence of T2DM varies from 3.9% (Yemen) to 18.3% (Saudi Arabia) and the prevalence of GDM varies from 5.1% (Yemen) to 37.7% (United Arab Emirates).[2],[11] The vast variation among MENA countries is because of dissimilar screening strategies, nonuniform diagnostic criteria for GDM, and economic differences among the countries.[2],[5],[6],[8] This makes accurate assessment and comparison of burden of HIP among the countries very challenging.[5] The aim of the guidelines proposed here is to create a standardized pragmatic approach for the screening, diagnosis, and management of HIP that is effective, simple, and accessible to all HCPs. This will eventually assist in improving clinical practice and preventing long-term health complications in the region.

The MENA region has a high prevalence of overweight (65.5%) and obesity (33.9%) among women ≥20 years, thereby increasing the burden of T2DM and GDM in the population.[9],[11],[12] With increasing obesity, practice of consanguineous marriages, sedentary lifestyle, poor dietary habits, and lack of access to primary health-care facilities in low- and middle-income countries, the likelihood of women presenting with undiagnosed DM in pregnancy is high. Nearly 45% of women of childbearing age with T2DM remain undiagnosed.[9],[11] Undiagnosed, uncontrolled, or inadequately treated HIP poses an increased risk to the mother, developing fetus, and newborn.[7] It not only increases short-term maternal, fetal, and newborn morbidity and mortality, but it also increases long-term health risks in both mother and baby. Specific complications threatening a diabetic pregnancy include miscarriage, preeclampsia, preterm labor, infections, worsening of diabetic retinopathy, and nephropathy. Fetal and newborn complications include stillbirth, congenital malformations, macrosomia, birth injury, respiratory distress, hypoglycemia, hypocalcemia, and hypomagnesemia.[7],[13],[14]

Exposure to hyperglycemia in utero affects fetal programming and predisposes the offspring to develop insulin resistance and impaired glucose tolerance as early as 10–14 years of age, with an increased lifetime risk of developing T2DM, obesity, hypertension, and cardiovascular and renal disease.[9],[12] Timely identification (screening and diagnosis) and intervention to control HIP will not only reduce short- and long-term maternal and neonatal morbidity and mortality, but it will also improve quality of life and prove to be cost-effective.[9],[10]

GDM has emerged as a marker for future T2DM, obesity, and cardiovascular problems.[9],[12],[15] Women who had prior GDM are at a 7.4-fold increased risk of developing T2DM within three to six years after an index pregnancy compared with women with a normoglycemic pregnancy.[9],[10],[12] Hence, it is important for women with GDM to monitor their BG levels postdelivery to reduce the risk of T2DM.[9],[10],[16]

Despite being aware of adverse consequences, to date there is lack of consensus among international health organizations on the screening and diagnostic criteria for HIP. Other areas of controversy include selective versus universal screening, timing of testing, choice of a one-step or two-step approach, and postnatal screening method, timing, and criteria.[2],[16],[17] An HCP who embarks on the care of pregnant women with diabetes is confronted with various guidelines offering conflicting and confusing recommendations.[16],[17]

Pregnancy offers a unique opportunity for the prevention of adverse consequences of hyperglycemia by patient education for lifestyle modification, continued BG monitoring practices, and follow-up postdelivery.[12] Early screening (through a uniform strategy), with strict glycemic control during pregnancy and postdelivery BG surveillance are effective intervention strategies to reduce the future burden of T2DM and obesity. This will improve the health of women not only in the MENA region but globally as well.[2],[9],[10],[15]

This document serves as an evidence-based consensus recommendation obtained from a multidisciplinary group of experts from the MENA region, for guiding HCPs to manage HIP optimally, following the latest available scientific evidence, keeping in view the unique challenges faced in the region.


  1: Screening and Diagnosis Top


Universal screening for HIP is recommended for all pregnant women at the first antenatal booking visit.[9] The recommended test is the one-step 75 g 2-h OGTT using IADPSG criteria.[16]

1.1: When to test

  • BG screening for HIP should be done at the first antenatal visit (preferably in the first trimester).[9]


  • For women with normal glucose values on initial screening, a sequential screening is recommended at the 24th to 28th weeks of gestation.[16]


  • A third-trimester BG testing should be done if the first two trimesters screening was missed, especially for women belonging to a high-risk group who develop clinical features suggestive of HIP [Table 1].[2],[15],[18],[19]
  • Table 1: Risk factors of hyperglycemia in pregnancy[8],[16],[17],[18]

    Click here to view


    1.2: Target population

    Universal screening of all pregnant women is recommended, irrespective of risk factors.[11],[12]

    1.3: BG screening options

  • The recommended gold standard test is a one-step 75 g 2-h OGTT using IADPSG criteria.[16]


  • Alternative options.


  • If the pregnant woman cannot come in fasting state, then the non-fasting 75 g 2-h OGTT by Diabetes in Pregnancy Study Group of India (DIPSI) method may be used.[20]


  • If the pregnant woman cannot tolerate the glucose load or in case glucose is not available, fasting blood glucose (FBG, defined as no caloric intake for at least 8 h) can be done at the first antenatal visit or later in pregnancy.[16]


  • HbA1c is not recommended as a BG screening test for GDM.[21]


  • 1.4: Screening methodology

  • Fasting OGTT: A venous blood sample was taken after 8 h of fasting. Overall, 75 g glucose was dissolved in 250 mL of water and the woman was to asked drink it over 3–5 min.[22] A venous blood sample was taken at 1 h and 2 h after a 75 g glucose load.


  • GDM is diagnosed if any one value out of the three is above the reference range (IADPSG and WHO criteria [Table 2]).[12],[16]
    Table 2: The IADPSG criteria for diagnosis of GDM

    Click here to view


  • During OGTT, if women have an FBG of 126 mg/dL (7 mmol/L), the OGTT test is withheld, as this indicates preexisting diabetes.[22]


  • Preexisting DM is diagnosed when one or more BG values are above cutoff values based on WHO[12] and ADA[23] criteria:

  • FBG: ≥126 mg/dL (≥7 mmol/L)


  • Random blood glucose (RBG): ≥200 mg/dL (≥11.1 mmol/L


  • Two-hour BG: ≥200 mg/dL after 75 g fasting OGTT


  • HbA1C: ≥6.5%[21]




  • DIPSI Method: (Non-fasting OGTT): 75 g of glucose was dissolved in 250 mL of water. The woman was asked to drink it over 3–5 min, irrespective of the time of the last meal.[9],[21],[23],[24]



  • BG level of >140 mg/dL (7.8 mmol/L) is taken as the cutoff for the diagnosis of GDM.[25],[26]



  • If laboratory facilities are not available, a handheld plasma-calibrated glucometer may be used to evaluate BG.

  • FBG after 8 h of fast with or without an HbA1c may be used for women who cannot tolerate oral glucose load.[27] If the FBG level is between 92 and 125 mg/dL (5.1–6.9 mmol/L), women may be considered as having GDM.[16]


  • HbA1c test

    HbA1c test is performed during the first trimester to identify women with preexisting diabetes[8] and to assess the risk to pregnancy.[28]

  • HbA1c value ≥6.5% is diagnostic of preexisting diabetes.[28]

  • ◦ It is not recommended for the screening and diagnosis of GDM. It is not a reliable test during the second or third trimesters since physiological changes in pregnancy and anemia may lower HbA1C values.[21]





  •   2: Preconception Management Top


    Background

    All women with T1DM, T2DM, and past history of GDM must be counseled to plan pregnancies and attend prepregnancy care. Maternal assessment and interventions to optimize health prior to conception improve pregnancy outcomes.[2],[9],[29]

    2.1: Preconception management for women with high risk for HIP

    • 2.1.1: Offer women who are at a high risk for HIP (see Section 1 on screening for HIP) 2-h 75 g OGTT to identify undiagnosed preexisting diabetes (use the nonpregnant WHO diagnostic criteria, 2019).[2]


    • 2.1.2: Give advice regarding physical activity and weight reduction to women with BMI >25kg/m² prior to pregnancy. Referral to a registered dietician may be helpful.[29]


    2.2: Preconception care for women with preexisting diabetes

    • 2.2.1: Educate and counsel women about the importance of euglycemia at conception and throughout pregnancy.[2],[8]


    • 2.2.2: Advise women to avoid unplanned pregnancies and use effective contraception (see Section 14) until good glycemic control is achieved. Ensure HbA1c to be <6–6.5% two months before conception and throughout pregnancy, to minimize the risk of congenital malformations.[2],[8]


    • 2.2.3: Emphasize the importance of regular antenatal care and need for frequent antenatal visits.


    • 2.2.4: Advocate healthy eating.


    • 2.2.5: Set SMBG frequency, charting, and SMBG targets. Pre-meal <5.5 mmol/L (<99 mg/dL) and post-meal <7.8 mmol/L (140 mg/dL) are preferred.[2],[8],[9]


    • 2.2.6: Warn women about hypoglycemia risks, recognition, and management.[8] Inform women about nausea and vomiting in pregnancy and its effect on BG control.[8]


    • 2.2.7: Optimize medications: Discontinue OHD except Metformin. Switch to insulin and/or Metformin.[2],[8]


    2.3: Review medications

    • 2.3.1: Provide folic acid (5 mg/day) at least two months prior to a planned pregnancy until 12 weeks of gestation to reduce the risk of fetal neural tube defects.[2],[8],[9],[29]


    • 2.3.2: Discontinue medications, for example, angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), and thiazide diuretics and switch to safer antihypertensive drugs, for example, Labetalol, Nifedipine, Hydralazine, and Methyldopa.[8],[29]


    • 2.3.3: Stop statins and fibrates as soon as the pregnancy is confirmed.[8],[29]


    2.4: Screen for comorbidities and chronic diabetes complications

    • 2.4.1: Screen for hypertension, thyroid disease (test thyroid-stimulating hormone [TSH] and thyroid peroxidase [TPO]) autoantibodies for T1DM.


    • 2.4.2: Assess for medical complications related to diabetes, for example, ischemic heart disease, renal insufficiency, retinopathy, and neuropathy. Get professional medical consultation to assess the woman’s ability to cope with pregnancy.[8],[30],[31],[32],[33]


    • 2.4.3: Offer a dilated retinal assessment (unless it was performed in the past six months). Consider laser photocoagulation if required to stabilize retinal status before pregnancy.[8],[34],[35]


    • 2.4.4: Advise women with retinopathy to avoid rapid optimization of BC control until treatment has been completed.[8],[31]


    • 2.4.5: Offer a renal assessment, if serum creatinine is abnormal (≥120 µmol/L), or urinary albumin/creatinine ratio is high (>30 mg/mmol) referral to a nephrologist should be considered before conception.[8],[34],[36]



      3: Antenatal Management Top


    Medical management for pregnant women with diabetes:

    Good glycemic control is the key for improving pregnancy outcomes. In addition to routine pregnancy care, the following are the additional recommendations:

    3.1: Educate and counsel the pregnant woman

    • 3.1.1: Explain the key role of glycemic control in reducing maternal, fetal, and neonatal complications.


    • 3.1.2: Counsel women about glycemic targets in pregnancy.[2]


    • 3.1.3: Emphasize the role of diet and exercise in achieving glycemic control (see Section on exercise).[37],[38]


    • 3.1.4: Educate pregnant women on insulin (T1DM), how to avoid hypoglycemia and DKA.[29],[39]


    • 3.1.5: Individualize a food plan based on personal and cultural eating habits throughout pregnancy to optimize glycemic control[35] (see Section 7.1).


    • 3.1.6: Commence aspirin 100–150 mg daily with the evening meal from the 12th week of gestation onward and stop at 36 weeks.[29],[40]


    • 3.1.7: Commence calcium supplementation from the 12th week of gestation.


    • 3.1.8: Check blood pressure (BP) and urinalysis at each visit to identify preeclampsia early.


    • 3.1.9: Continue folic acid 5 mg daily up to the end of the first trimester.[8]


    • 3.1.10: Screen for complications: Offer heart, renal, and retinal assessment in those pregnant women with preexisting diabetes, if it has not been undertaken in the preceding six months.[8],[29],[30]


    3.2: Glycemic control

    3.2.1: Set glycemic targets

  • Fasting and preprandial 72–95 mg/dL (4–5.3 mmol/L)


  • 1 h after meal <140 mg/dL (7.8 mmol/L)


  • 2 h after meal <120 mg/dL (6.7 mmol/L)[8],[9],[29]


  • HbA1c level of <6%[8]


  • 3.2.2: BG monitoring

  • Recommend BG monitoring by SMBG by four to seven daily measurements[8],[9] depending on the glycemic control. Once the glycemic control is achieved, reduce the frequency of SMBGs by two to three days.


  • Review SMBG and/or continuous glucose monitoring (CGM) at each antenatal visit.


  • HbA1c at booking may be repeated once in each trimester.[8]


  • Test for ketonemia to exclude DKA if the pregnant woman on insulin presents with hyperglycemia, hyperemesis or is unwell.[8],[29]


  • 3.2.3: BG control strategy

  • Begin treatment with lifestyle modification and diet.


  • Add pharmacological drugs, Metformin and insulin, if BG targets are not achieved within one to two weeks.


  • Review medication and stop drugs that are harmful to the fetus (refer to preconception counseling).


  • 3.3: Antenatal organization of care for women with HIP

    3.3.1: Booking antenatal visit (up to 12 weeks)

  • Fasting and preprandial 72–95 mg/dL (4–5.3 mmol/L)


  • Review past obstetric history.


  • Review history of diabetes, including type of diabetes, duration, treatment, history of DKA, episodes of hypoglycemia, and associated obstetrics and medical disorders.


  • Ask for complete blood count (CBC), blood grouping and Rh factor, urine analysis, renal function test, thyroid profile, and screening for viral hepatitis.


  • Do an ultrasound scan (USG) to confirm fetal viability, gestational age, and multi-fetal gestation at seven to nine weeks.[8]


  • Arrange an early anomaly USG and measure nuchal thickness at 12 weeks of gestation.


  • Recommend one to two weekly antenatal visits.[41]


  • 3.3.2: At each antenatal visit

  • Monitor maternal weight gain.


  • Do regular assessment for fetal growth and well-being.


  • Serial fetal growth scans every two to four weeks from 28 weeks of gestation.


  • Conduct weekly CTG from 34 weeks of gestation.


  • 3.3.3: 18–23 weeks antenatal visit

  • Recommend a detailed anomaly USG at 18–24 weeks for detection of fetal structural anomalies.[30]


  • 3.3.4: 22–26 weeks antenatal visit

  • Do a fetal echocardiogram at 24–26 weeks in women with preexisting diabetes with high HbA1c at booking visit, or GDM with an abnormal four-chamber view on anomaly scan.[2],[42],[43]


  • Offer USG monitoring of fetal growth and amniotic fluid volume at 28 weeks.[8]


  • 3.3.5: 32–34 weeks antenatal visit

  • Offer USG monitoring of fetal growth and amniotic fluid volume assessment.[8]


  • 3.3.6: 34–36 weeks antenatal visit

  • Assess USG fetal growth, abdominal circumference, and amniotic fluid volume.[2],[8]


  • Offer umbilical artery doppler velocimetry if there is evidence of fetal growth restrictions.[2]


  • Provide information, discuss, and advise about the timing and mode of delivery to the woman and her family.


  • Create and document a plan of delivery.


  • Carry out CTG if the woman reports reduced fetal movements.[44]


  • 3.3.7: 37–40 weeks antenatal visit

  • Individualize timing and mode of delivery (see Section 4.1).


  • In women with uncomplicated GDM on diet control or Metformin, await spontaneous labor and offer induction of labor at 39–40 weeks.


  • Consider delivery at 37–38 weeks for a woman with metabolic or obstetric complications.[2],[8]


  • Aim for vaginal birth unless there are obstetric or medical contraindications or suspected fetal weight >4000 g.[9]



  •   4: Intrapartum Management Top


    Plan and discuss for the time and mode of birth during the third trimester.[45] Women with diabetes are at an increased risk of stillbirth in late pregnancy, with the risk increasing exponentially after 40 weeks of gestation.[46] No diabetic pregnancy should go beyond 40 weeks.

    Maintain good glycemic control during labor, since maternal hyperglycemia increases the risk of fetal acidemia and neonatal hypoglycemia.[47]

    4.1: Timing of delivery

    • 4.1.1: The optimal timing of delivery in pregnancies that are complicated by hyperglycemia depends on glycemic control, as well as associated metabolic and obstetric complications.[47]


    • 4.1.2: Deliver women with well-controlled and uncomplicated pregnancies, at 37–39 weeks.


    • 4.1.3: In case of associated complications, deliver women at around 37 weeks gestation.[5]


    4.2: Mode of delivery

    • 4.2.1: Aim for vaginal birth and recommend cesarean section for obstetric reasons only.[47]


    • 4.2.2: Consider elective cesarean section if the estimated fetal weight is greater than 4kg to reduce maternal and perinatal morbidity and mortality.[48],[49]


    • 4.2.3: Offer induction of labor for obstetric reasons.


    • 4.2.4: Diabetes by itself is not a contraindication to vaginal birth after cesarean section.[8]


    • 4.2.5: Use partogram/labor care guide to monitor labor.


    • 4.2.6: Anticipate shoulder dystocia at birth, especially if the progress of labor is slow or if instrumental delivery is required or senior and skilled staff are to be present in the labor ward.


    4.3: Glycemic management during labor

    • 4.3.1: Avoid maternal hyperglycemia to optimize pregnancy outcomes. Maternal hyperglycemia during labor increases the risk of neonatal hypoglycemia and adverse neonatal outcomes. Intrapartum glucose levels >10.0 mmol/L (180 mg/dL) have been associated with neonatal hypoglycemia and an increased risk of maternal DKA in T1DM.[47]


    • 4.3.2: Recommended intrapartum target BG is between 72 mg/dL and 126 mg/dL (4–7 mmol/L).[50]


    • 4.3.3: Intrapartum glucose monitoring:

    • Consider four-hourly BG monitoring in women with HIP on MNT.[16],[17],[51]


    • Women on insulin should have BG monitoring every 1–2 h.[2]


    • Monitoring frequency can be decreased in women with glucose values that are consistently within the target range.[52]


    4.4: Glycemic control during labor and delivery[2],[53]

  • The usual dose of intermediate-acting or long-acting insulin is given at bedtime.


  • On the morning of induction, the morning dose of insulin is withheld.


  • Omit the morning dose of insulin for elective cesarean section and schedule as the first case on the operative list.[53],[54]


  • Two simultaneous intravenous (IV) infusions are used:

  • (A) insulin infusion (50 units of regular insulin in 50 mL normal saline at 1.0 unit/h to maintain BG between 4 mmol/L and 7 mmol/L [72–126 mg/dL]) given through a syringe pump; the insulin infusion rates are titrated according to the BG level, and they are checked hourly using a bedside glucometer.


  • (B) 5% dextrose 1000 mL with 12 units of regular insulin to cater to metabolic needs at a fixed rate of 125 mL/h.[2],[8],[53] If BG is >7 mmol/L (126 mg/dL), the infusion is changed from 5% dextrose to normal saline.


  • Keep IV-line infusion separate from the infusion that is given for induction/augmentation of labor.[8]




    • 4.5: Consider continuous electronic fetal heart rate monitoring[47],[55]



      5: Preterm Labor Top


    5.1: Management of preterm labor in women with HIP

    Preterm birth is associated with significant perinatal morbidity and mortality.[56] The rate of prematurity doubles in women with HIP.[57],[58] This could be either due to spontaneous preterm birth or induced due to complications of HIP.

    • 5.2: Administer a single course of corticosteroids to women at risk of preterm delivery between 24+0 and 35+6 weeks of gestation to accelerate fetal lung maturation.[45]

    • Monitor BG values and adjust the insulin doses accordingly (see recommendation 9.6).


    • Repeat course: If steroids were given before 28 weeks, a repeat single dose course can be considered.[45]


    • Avoid multiple courses of antenatal steroids, as they may cause fetal growth restriction and affect neurological development.[59],[60]


    • Medications: Both Betamethasone and Dexamethasone are effective.[61],[62]


    • Dosage and route of administration:

    • Betamethasone is given as two intramuscular doses, 12 mg each and 24 h apart.[61],[62]


    • Dexamethasone is given as four intramuscular doses, 6 mg each and 12 h apart.[61],[62]


    5.3: Tocolytics

    Tocolysis enables pregnancy prolongation for at least a short term and, thus, provides time for further in utero maturation and interventions that may improve neonatal outcome.[45]

  • Indications:

  • Women with suspected preterm labor with an uncomplicated pregnancy


  • For in utero transfer of the mother to tertiary care


  • For the full course of corticosteroids




  • Contraindication:

  • Established labor (4cm dilatation with regular contraction)


  • Maternal hemorrhage, preeclampsia, and intra-amniotic infection


  • Severe intrauterine growth restriction


  • Maternal contraindication to tocolytic drugs




  • Duration: 48 h after administration of the first corticosteroid dose.
  • Drugs of choice: Summarized in [Table 3].


  • Table 3: Options for tocolytic drugs, its contraindication, side effects, and doses

    Click here to view


    5.4: Magnesium sulfate for neuroprotection[45],[63]

  • The dose of magnesium sulfate as tocolytics is higher than that for neuroprotection.


  • Women in established preterm labor or planned for preterm delivery should receive magnesium sulfate for fetal neuroprotection 24 h prior to birth. The usual loading dose is 4 gm IV over a median 25 min. The median maintenance dose is 1 g/h IV for 7.4 h.[64]


  • If delivery is no longer imminent, magnesium sulfate should be discontinued.


  • Do not delay delivery to administer antenatal magnesium sulphate for fetal neuroprotection if there are maternal and/or fetal indications for emergency delivery. (For dose of magnesium sulfate, see [Table 3].)


  • Monitor clinical signs of magnesium toxicity every 2–4 h.
  • Decreased deep tendon (patellar) reflexes


  • Respiratory rate <12/min


  • Urine output < 30 mL/h




  • If a woman has or develops oliguria or other signs of renal failure:

  • Monitor more frequently for magnesium toxicity.


  • Reduce the dose of magnesium sulfate.




  • Antidote for magnesium sulfate toxicity: Administer an IV infusion of calcium gluconate 1 g (10 mL of 10% solution) slowly over 10 min.




  •   6: Postpartum Management Top


    The postpartum period is crucial, in terms of addressing the immediate perinatal problems, and for the early preventive health of both mother and child, who are at risk for future obesity, metabolic syndrome, diabetes, hypertension, and cardiovascular disorders.[9]

    6.1: Women with preexisting diabetes

    • 6.1.1: Encourage breastfeeding immediately after delivery and support it for the sake of maternal and child benefits.[65]


    • 6.1.2: Inform women who are breastfeeding about the potential increased risk of hypoglycemia, especially during nighttime.[65]


    • 6.1.3: Provide women with a postdelivery plan to reduce prepregnancy insulin pump dosage settings or readjust antihyperglycemic drugs and record this in the birth plan document.[65]


    • 6.1.4: Screen women with T1DM for thyroid hormone abnormalities during pregnancy and at approximately one to three months postpartum.[66],[67] These mothers have a higher risk for autoimmune thyroid disease and postpartum thyroid dysfunction.[68]


    • 6.1.5: Provide appropriate hygiene, antibiotics, and proper glycemic control,[2] in order to detect early signs of infection for the breast, genitourinary tract, and surgical site infections.[9]


    • 6.1.6: Advise women about effective contraception.[65]


    • 6.1.7: Advice women about preconception management prior to a subsequent pregnancy.[2]


    6.2: Gestational diabetes mellitus

    • 6.2.1: Encourage women to breastfeed since breastfeeding protects against the occurrence of infant and maternal complications.[65]


    • 6.2.2: Counsel women about the diagnosis of GDM and regarding the high rate of recurrence for GDM.[69],[70]


    • 6.2.3: Inform women with previous GDM as well as their families about their increased risk for the development of T2DM[71] and advise lifelong screening.[19]


    • 6.2.4: Offer lifestyle advice as weight control, diet, and exercise and/or Metformin to prevent or delay progression to T2DM,[2],[19],[72],[73],[74],[75] which is about 50%–70% in the next 5–10 years if mothers are not compliant.[2],[71]


    • 6.2.5: Encourage obstetricians to establish connections with family physicians, internists, pediatricians, and HCPs to support postpartum follow-up for those mothers and connect it to the regular follow-up and vaccination program of the child to ensure continued engagement of the mothers with their children.[9]


    • 6.2.6: Screen women with a recent history of GDM with 75 g OGTT after 4–12 weeks postpartum by using the WHO criteria,[76],[77] followed by six months postpartum[63] if possible, then one year later, followed by every one to three years.[19],[78],[79],[80],[81] Offer FBG or HbA1c if OGTT is not possible.[2]


    • 6.2.7: Screen all components of the metabolic syndrome, because it is more prevalent in these women.[82],[83]


    • 6.1.8: Advise women about using proper contraceptive methods.[9]


    • 6.1.9: Counseled women are to attend preconception management clinics before planning for their next pregnancy.[2]


    • 6.1.10: Psychosocial assessment and support for self-care should be included[2] to enable women and their families to carry out diabetes care tasks.[84]


    6.3: Adjustment of pharmacological treatment:

    6.3.1: Women with preexisting diabetes

    • 6.3.1.1: Continue BG monitoring in women who were on Metformin or on low-dose insulin (<0.5 units/kg/day) by FBG and 2-h postprandial for the next 48–72 h; then adjust the frequency of SMBG monitoring according to glycemic status.[65]


    • 6.3.1.2: In women with preexisting T1DM with an insulin requirement of >1 unit/kg/day, the insulin dose may be reduced to 50% postpartum; however, in the case of those on 0.5–1 unit, the dose needs to be individualized according to the SMBG levels.[65]


    • 6.3.1.3: Resume and or continue medications (Metformin/insulin) in women with preexisting T2DM after birth according to the SMBG values.[65]


    • 6.3.1.4: Advise women with preexisting diabetes to see their primary care physician postnatally for further management of diabetes.[65]


    6.3.2: Women with GDM

    Women with GDM usually go back to normoglycemia. Stop or modify pharmacological treatment.[2] Postpartum target FBG should be <5.5 mmol/L (<99 mg/dL), the same as in nonpregnant women.[2],[8],[9],[73]

    • 6.3.2.1: SBGM may be stopped after birth in women on non-pharmacotherapy.[73]


    • 6.3.2.2: Readjust the medications for women on pharmacotherapy.[73]


    • 6.3.2.3: Stop pharmacological therapy (Metformin and insulin) immediately after birth (vaginal or cesarean section).[73]


  • Continue SBGM monitoring four times per day for 24 h (preprandial and before bed).[73]


  • Stop monitoring 24 h after birth if all preprandial SMBGs are between 4.0 mmol/L and 7.0 mmol/L (72–126 mg/dL).[71]


  • BG monitoring may continue every four to six hourly till oral food is allowed and thereafter 2 h postprandially according to blood glucose levels during the immediate postoperative period in the case of cesarean section.[2]


  • Stop IV fluids early if diet is tolerated.[73]


  • Seek medical review if diet is not tolerated or SBGM <4.0 mmol/L (72 mg/dL); however, consider 4% dextrose/0.18% Sodium Chloride or Hartmann’s/dextrose IL IV, 12 hourly.[78]


  • Seek medical review and continue SBGM if persistent preprandial BG is >7.0 mmol/L (126 mg/dL).[78]


  • Prescribe a lower dose of insulin (if required) than during pregnancy.[78]



  •   7: Management of Hyperglycemia in Pregnancy Top


    • a. Non-pharmacological treatment (NPT)


    • b. Pharmacological management (PT)


    a. Non-pharmacological management

    This consists of MNT, exercise, and physical activity.

    7.1: Medical nutrition therapy

    Introduction

    It is a customized dietary plan for diabetes and HIP for optimum glycemic control and long-term fetal and maternal well-being.[36]

    Goals

    Recommended gestational weight gain and caloric requirements [See [Table 4]]:
    Table 4: Recommendations for calorie intake and weight gain during pregnancy according to BMI[31],[51]

    Click here to view


  • Women with HIP should consume adequate calories and gain weight as recommended.


  • Weight gain in the first trimester should be 0.5–2kg.


  • No increase in caloric intake is recommended during the first trimester.


  • An additional 340 kcal/day is recommended during the second trimester.


  • An additional 452 kcal/day is recommended during the third trimester.


  • In women with polycystic ovarian disease (PCOS), weight monitoring should be fortnightly as these women are likely to gain excessive weight.[34]


  • 7.1.1: Glycemic index

  • Select the foods that have a lower GI to avoid postprandial glucose spikes.[85]

  • Low GI (55 or less) Choose most often


  • Medium GI (56–69) Choose more often


  • High GI (70 or more) Choose less often




  • 7.1.2: Macronutrient and micronutrient requirement

    Take into consideration multiple factors such as BMI, glycemic control, personal and sociocultural preferences, patterns of eating, and financial constraints while planning meals/snacks [Table 5].
    Table 5: Daily Requirement Index (DRI) for pregnant women[29],[32]

    Click here to view


    7.1.3: Carbohydrates

  • The minimum requirement of carbohydrates is approximately 175 g/day. Overall, 35%–45% of total calories should come from carbohydrates.


  • Spread carbohydrate-containing foods throughout the day.


  • Balance protein with carbohydrates, as a pure protein meal may cause hypoglycemia in people taking insulin.[86]


  • Avoid severe caloric restriction in pregnancy, especially in TIDM, as it may promote ketosis, which is associated with adverse effects on the fetal brain and nervous system.[87]


  • 7.1.4: Oils and fats

    Overall, 25%–35% calories per day should come from fats. Do not exceed >40% of total calories.

  • The following proportion of fats should be used in a meal:

  • Animal sources:[88] (Saturated fat) should be <7% (butter, clarified butter, egg yolk, meat, and fats)


  • Plant sources:[89] (Unsaturated fat)


    • - 90% should be monounsaturated fat (Olive oil, Canola oil)


    • - 10% should be polyunsaturated fats (Sunflower oil, Corn oil, Soya oil)




  • Prefer cooking oils with a high smoke point instead of a low smoke point to decrease trans-fat formation and advanced glycosylation end products (AGEs) [See [Table 6]].
    Table 6: Recommendation for type and sources of oils and fats[83],[84],[85],[195],[196]

    Click here to view




  • Additional saturated fat should not be consumed (such as clarified butter, butter, cream), because daily intake of eggs, dairy, and meat fulfills the recommended amount of saturated fat (<7%) per day [Table 6].



  • 7.1.5: Protein

  • Daily requirement index (DRI) in pregnancy is a minimum 71 g of proteins daily. At least 20% of the calories should come from proteins.


  • Chicken, fish, egg white, low/no fat dairy, beans, lentils, and nuts are healthy sources of protein and should be evenly distributed in the meal plan.[29]


  • Protein supplements do not improve pregnancy outcomes.[90]


  • 7.1.6: Fiber

  • Encourage fiber in the diet to control glycemic spikes.


  • 7.1.7: Fluid requirements

  • The minimum fluid requirement is 2.3L/day (10 cups of beverages to maintain adequate hydration).[91]


  • Increase fluid intake while staying active and in a hot environment.


  • Alcohol, sugar-sweetened, sugar-free fizzy drinks, and coffee should be avoided.[92],[93]


  • 7.1.8: Daily meal planning

    1. Distribute the meal in three main courses and three snacks given at a fixed time of the day.


    2. Space meals/snacks at 2- to 3-h intervals, breakfast before 8 am and dinner before 8 pm.


    3. Advise a bedtime snack to avoid nocturnal hypoglycemia. Bedtime snack and breakfast should not be more than 10 h apart.


    4. Avoid skipping meals/snacks. In case a meal is skipped, monitor blood sugar and judiciously compensate it with appropriate food.


    5. Monitor blood sugar to avoid hypoglycemia for any unscheduled exercise or physical activity.


    6. Plan daily meals and snacks. For convenience, food is categorized into seven groups. Group 7 consists of food items to be avoided (indicated in bold formatting). Food groups along with the number and serving size are given next [Table 7].


    7. Tobacco and smoking are prohibited during pregnancy.
    Table 7: Food groups for daily meal planning

    Click here to view


    7.1.9: Smart plate (to plan a given meal)

    Learn to make a smart plate for a given meal.

  • Principles to make a customized food plate according to dietary habits, job, daily workout, and lifestyle.
  • Size of plate: 9 inches [See [Figure 1]].


  • Proportion of nutrients to be filled in plate:


    • a) Half plate: Non-starchy vegetables.


    • b) One quarter plate: Proteins, e.g., lean meat or skinless poultry or fish and food or egg white or peanut butter or soya beans and products.


    • c) One quarter plate: Grains, vegetables (starchy), beans, and lentils.


    • d) In addition to contents in the plate, the following can be used for healthy meal planning:

      • - Outside plate contents: dairy (<1% fat) and fruits.






    Figure 1: Smart plate

    Click here to view



      8: Exercise and Physical Activity Top


    Pregnancy provides a unique opportunity to motivate women for exercise. It facilitates glucose entry into the muscles,[94] improves glycemic control, and reduces excessive weight gain during pregnancy and in the postpartum period.[95] Women should be evaluated for obstetric and medical complications before advising them to indulge in exercise.

    8.1: Recommendations for exercise in HIP

    Advise women to:

    • 8.1.1: Tailor exercise according to physical endurance and increase the intensity of exercise gradually if there are no obstetric or medical contraindications (See recommendation 8.2).


    • 8.1.2: Advise women to stop exercise and immediately contact their HCP if there are obstetric/medical complications:[96]


  • Vaginal bleeding


  • Abdominal pain with or without nausea


  • Regular painful contractions


  • Premature rupture of membranes/new-onset dyspnea


  • Dizziness, syncope


  • Headache


  • Chest pain


  • Muscle weakness affecting balance


  • Calf pain or swelling


    • 8.1.3: Exercise should be done for 30–60 min[97] daily (at least three to five days/week) with correct posture.


    • 8.1.4: Exercise time should be split preferably into 10- to 15-min intervals.


    • 8.1.5: Exercise preferably post-meal; if not tolerated, shift to pre-meal.


    • 8.1.6: The intensity of physical activity must be gauged, and it must not exceed the recommended limit (See recommendation 8.1.7).


    • 8.1.7: Exercises during pregnancy can be done using the following tools:


  • Talk test[98]: As long as a woman can talk during exercise, she is not overexerting herself.


  • The age-predicted maximum maternal heart rate[99] should not exceed 140 bpm.


  • Moderate-intensity exercise should not exceed a 12–14 score on Borg scale.[100]


    • 8.1.8: Exercise to be done in a smoke-free, well-ventilated, temperature-controlled environment.


    • 8.1.9: Wear air-filled joggers, cotton socks.


    • 8.1.10: Modify physical exercises if there are medical and obstetric contraindications/complications according to physicians’ recommendations.


    • 8.1.11: Possibility of hypoglycemia with unscheduled exercise should be taken into consideration.


    • 8.1.14: Resume strenuous exercise three months after cesarean section.[101]


    • 8.1.15: Advise a safer form of physical exercises in pregnancy, such as aerobics, brisk walking, stationary cycling, swimming (diving is contraindicated), modified Yoga, pelvic exercises (Kegel’s exercises), strength training (under supervision), and jogging (only in previously active women).[102]


    • 8.1.16: Advise against strenuous exercise and/or sports with a risk of fall.


    • 8.1.17: Continue exercise through the postpartum period and thereafter.


    8.2: Contraindications to exercise during pregnancy[102]

    8.2.1: Absolute contraindications

  • Hemodynamically significant heart disease


  • Restrictive lung disease


  • Cervical incompetence


  • Antepartum hemorrhage


  • Placenta previa


  • Threatened preterm labor


  • Ruptured membranes


  • Preeclampsia


  • Severe anemia


  • 8.2.2: Relative contraindications

  • Multiple gestation unevaluated maternal cardiac arrhythmias


  • Chronic bronchitis


  • Poorly controlled T1DM at risk of ketosis


  • Morbid obesity


  • Extreme underweight (BMI less than 12)


  • Fetal growth restriction


  • Orthopedic limitations


  • Poorly controlled seizure disorders


  • Poorly controlled hyperthyroidism


  • Heavy smokers


  • 8.3: Exercise in special situations

    • 8.3.1: Women on bed rest should be advised the following exercises:

    • Lie in the left lateral position (advise the women not to exercise while lying supine or in the right lateral position) [Figure 2]A and B.


    • Perform full flexion at the ankle joint and toes and hold for 10s followed by a full extension of the ankle and toes and hold for 10s [Figure 3]A and B. Alternate this movement 10 times/h while awake.


    • Do alternate flexion and extension of both legs at the knee and hip joints 10 times/h while awake [Figure 4]A.


    • A combination of movements of the arms and legs will help in glycemic control and prevent deep venous thrombosis.




    Figure 2: Lie on left lateral position. (A) Dorsiflex feet for 10s, (B) plantarflex feet for 10 s

    Click here to view
    Figure 3: (A) Plantarflexion of feet, (B) dorsiflexion of feet

    Click here to view
    Figure 4: Alternate flexion and extension movement at hip joint and knee joints and movements of arms at shoulder joints

    Click here to view
    Figure 5: Alternate flexion and extension movement at hip joint and knee joints and movements of arms at shoulder joints

    Click here to view



      9: Pharmacological Management of Hyperglycemia in Pregnancy (HIP) Top


    9.1: Self-monitoring of blood glucose (SMBG)

    The following advice should be given to pregnant women with diabetes:

  • The recommended frequency of capillary glucose levels (using SMBG) is four times a day, including fasting, and 1 or 2 h after each meal.


  • Monitor BG at bedtime or during the night, especially if hypoglycemia is experienced (especially T1DM).


  • The frequency of testing may be reduced if glucose levels are well controlled with diet and lifestyle in GDM and T2DM.


  • 9.1.1: Target glucose levels

    Advise pregnant women with T1DM, T2DM, or GDM that the recommended targets of capillary glucose levels (using SMBG) are as follows:

  • Fasting: <95 mg/dL (5.3 mmol/L)And either


  • 1 h postprandial: <140 mg/dL (7.8 mmol/L)Or


  • 2 h postprandial: <120 mg/dL (6.7 mmol/L)


  • 9.2: Pharmacological management of gestational diabetes mellitus (GDM)

    GDM is characterized by an increased risk of macrosomia and birth complications as well as an increased risk of maternal T2DM after pregnancy.[29],[111] Treatment of GDM with the aim of achieving target glucose levels has been demonstrated to improve perinatal outcomes.[29],[105] Glycemic targets for GDM are similar to those for pregestational T1DM or T2DM[29],[53],[112] (See recommendation 9.1.1).

    • 9.2.1: Women with GDM in whom glycemic targets have not been achieved with diet and lifestyle; pharmacological therapy should be added in the form of Metformin and/or insulin.


    • 9.2.2: Use insulin, with or without Metformin, in addition to diet and exercise, as the first-line treatment in women with GDM who have a fasting BG level of >126 mg/dL (7 mmol/L) or a 2-h post-OGTT BG level >200 mg/dL (11.1 mmol/L).


    • 9.2.3: Consider insulin, with or without Metformin, in addition to diet and exercise, in women with GDM who have a fasting plasma glucose level between 108 mg/dL and 125 mg/dL (6–6.9 mmol/L) or if there are complications such as macrosomia or polyhydramnios.


    • 9.2.4: Add insulin if target glucose levels are not achieved within one to two weeks of starting Metformin.


    • 9.2.5: Glibencalmide is inferior to Metformin, and insulin[8],[9],[29],[53],[65],[112],[113] is not indicated in pregnancy. (It is still used in some situations when there is intolerance to Metformin or insulin therapy is refused by the woman.)


    • 9.2.6: Insulin therapy in GDM.
      1. If insulin is indicated, the type and timing of insulin should be guided by the results of SMBG,[8],[29],[112] with the aim of achieving target BG levels while avoiding hypoglycemia [see [Table 8]].


      2. Regular human insulin can provide satisfactory mealtime coverage if injected about 20–30 min before the meal.


      3. The rapid-acting insulin analogues, Lispro and Aspart are safe in pregnancy.[9],[53],[65],[112] The advantages of the rapid-acting analogues over regular human insulin is consumer convenience, as they can be injected immediately before the meal due to their quick absorption and rapid onset of action and their better control of postprandial hyperglycemia. Basal insulin analogues are expensive as compared with regular insulin. Long-acting analogue, Detemir is safer than Glargine.[9],[29],[53],[65],[112]


      4. Another rapid-acting insulin analogue, Glulisine, has also recently been tested in pregnancy and has been found to be safe.[114]


      5. The recently introduced basal insulin analogues, Degludec U-100, Degludec U-200, and Glargine U-300 have not been tested in pregnancy.[65]


      6. If the fasting glucose levels are high, add a bedtime dose of intermediate-acting human NPH insulin or long-acting basal insulin analogues, for example, Detemir.


      7. If postprandial glucose levels are above the target, start short-acting human regular insulin or one of the rapid-acting insulin analogues Lispro or Aspart before a meal.


      8. Consider a full basal-bolus insulin regime with three doses of regular human insulin or rapid-acting analogue before each of the three meals and NPH or Detemir as basal insulin once daily, as indicated by the results of SMBG.


      9. A less desirable alternative is the use of twice-daily mixed insulin, which has the advantage of convenience for patients by reducing the number of injections but with the major disadvantage of losing the flexibility of adjusting insulin doses. The use of premixed insulin should only be considered for pregnant women if alternatives are not available or affordable, they are under follow-up and supervision by an endocrinologist.


      10. Consider starting insulin at a dose of 0.5–1 unit/kg/day depending on initial glucose levels and the period of gestation.


      11. Discontinue insulin and other BG lowering therapies immediately after birth in women with GDM provided that glucose levels remain normal after delivery.
    Table 8: Action profile of commonly used insulins

    Click here to view


    9.2.7: Metformin

    1. Metformin crosses the placenta but there is no evidence for increased congenital anomalies, lower incidence of neonatal hypoglycemia, and less maternal weight gain when compared with insulin.[113],[115],[116]


    2. Start Metformin at a dose of 500 mg once or twice daily after meals and increase gradually to the required maximum dose.


    3. Most patients derive maximum benefit from a total dose of 2000 mg/day but it is licensed up to 3000 mg/day.


    4. Use either the immediate or the slow-release form.


    5. Avoid Metformin in women with a serum creatinine level ≥150 µmol/L.


    9.3: Pharmacological management of type 1 diabetes in pregnancy

    • 9.3.1: During pregnancy, insulin requirements increase, especially from 28 weeks to 32 weeks of gestation.


    • 9.3.2: On average, insulin needs increase from 0.7–0.8 units/kg/day during the first trimester to 0.8–1.0 units/kg/day during the second trimester to 0.9–1.2 units/kg/day during the third trimester.


    • 9.3.3: If women cannot achieve targets without significant hypoglycemia, set less stringent targets, based on individualization of care.


    • 9.3.4: For women with T1DM who use CGM or FGM, aim for the following targets:


    Click here to view


    • 9.3.5: Advise women to seek medical consultation to adjust insulin doses if BG results of SMBG are not according to target values.


    • 9.3.6: Educate women and family members about the prevention, recognition, and treatment of hypoglycemia, before, during, and after pregnancy to help prevent and manage the risks of hypoglycemia.


    • 9.3.7: If insulin requirements decrease immediately after delivery, adjust the insulin requirements according to SMBG.


    • 9.3.8: There is no evidence that any particular insulin regime or insulin type is better than another in the management of diabetes in pregnancy.


    • 9.3.9: Treat pregnant women with T1DM with both basal and meal-time insulin in a multiple dose injection (MDI) regime.


    • 9.3.10: Consider, as an alternative, the use of continuous subcutaneous insulin infusion (CSII), or insulin pump therapy in those who can afford and have the availability of the necessary support and expertise.


    9.4: Pharmacological management of type 2 diabetes in pregnancy

    • 9.4.1: As T2DM may often be associated with obesity, lifestyle and dietary advice should be intensified to avoid excessive weight gain during pregnancy.


    • 9.4.2: Use insulin as the preferred treatment if BG is not controlled on diet and lifestyle alone.


    • 9.4.3: Women on Metformin and/or Glibenclamide preconception may continue on these agents if glycemic control is adequate until pregnancy is achieved.


    • 9.4.4: For women taking oral hypoglycemic drugs other than Metformin or who are on GLP agonist injections, shift them to insulin (and/or Metformin) prior to conception.


    • 9.4.5: For women who decline insulin therapy, cannot afford or cannot safely administer insulin, consider oral therapy with Metformin.


    • 9.4.6: Glycemic control is often easier to achieve in women with T2DM than in those with T1DM.


    • 9.4.7: Consider the use of Metformin together with insulin, as this may help reduce the insulin doses and help prevent excess weight gain.


    9.5: Pregnant women with diabetes receiving steroids

    • 9.5.1: In women suspected of preterm delivery, two doses of betamethasone are often given to aid in the maturation of the fetal lungs.


    • 9.5.2: Adjust insulin doses to prevent severe hyperglycemia and DKA in women with T1DM.


    9.6: Management of women with diabetes on insulin receiving betamethasone for lung maturity

    The following indicate the first dose of betamethasone:


    Click here to view


    • 9.6.1: Elective cesarean section <38 weeks of gestation
    • The woman may require antenatal betamethasone. Betamethasone can lead to hyperglycemia, and the effect can last up to five days. Consider admitting the woman for a minimum of 48 h. Commence seven-point BG monitoring.


    • Give a stat dose of insulin in addition to routine insulin according to the following BG levels:




    Click here to view



      10: Diabetes-related Emergencies during Pregnancy Top


    10.1: Diabetic ketoacidosis

  • DKA in pregnancy is a serious, life-threatening medical emergency, especially for the fetus.


  • Maternal mortality is estimated to be less than 1%, whereas fetal mortality can be as high as 9%–35%.[117]


  • DKA mainly occurs in patients with T1DM, but it may also occur in some patients with T2DM[13] and GDM.


  • Management should be by a multidisciplinary team.


  • 10.1.1: Diagnosis

    The diagnostic criteria for DKA are:[118]

  • Hyperglycemia: BG is usually ≥200 mg/dL (11.1 mmol/L); however it can occur at lower levels in pregnancy (euglycemic DKA)


  • Ketonemia ≥3 mmol/L or ketonuria ≥2+ on standard urine sticks


  • Metabolic acidosis: bicarbonate <15 mmol/L and/or arterial or venous pH <7.30


  • 10.1.2: Precipitating factors

  • Infection


  • Noncompliance with insulin treatment


  • Inappropriate dose of insulin (e.g., pump failure, omission of doses)


  • Drugs that cause hyperglycemia (e.g., corticosteroids)


  • 10.1.3: Fetal effects of diabetic ketoacidosis

  • Both ketoacids and glucose cross the placenta.


  • Fetal heart abnormalities on CTG are expected, but they are usually reversed with the treatment of DKA.


  • 10.1.4: History and physical examination

  • Thirst/polyuria/nocturia


  • Generalized weakness


  • Nausea/vomiting


  • Tachypnea/tachycardia/ketotic breath


  • Kussmaul’s respiration or air hunger


  • Dehydration/hypotension


  • Muscle cramps


  • Abdominal pain


  • Confusion/coma (exclude other causes)


  • Abnormal fetal heart tracing


  • 10.1.5: Investigations

  • CBC


  • Urea and electrolytes (UandEs)


  • BG


  • Blood culture, if infection is suspected


  • Midstream urine


  • Arterial blood gases/venous pH


  • Serum/urine ketone levels


  • Electrocardiogram (ECG)


  • Chest X-ray if indicated (with shielding of abdomen)


  • 10.1.6: Management[118],[119],[120]

  • Management should be by a multidisciplinary team


  • Fluid resuscitation


  • Correction of hyperglycemia


  • Correction of electrolyte abnormalities


  • Treatment of precipitating factors


  • Fetal assessment


  • Fluid replacement[118],[119],[120]

  • Insert two wide bore IV cannulas


  • Commence IV normal saline 0.9%, via a volumetric pump, as follows:


    • - 1L over 30 min


    • - 1L over 1 h


    • - 1L over 2 h


    • - 1L over 4 h


    • - 1L over 6 h




  • Monitor BG levels by using a glucometer hourly. When the blood glucose ≤180 mg/dL (10 mmol/L), the IV fluid should be changed to 5% dextrose.


  • Electrolyte replacement[118],[119],[120]

  • Add potassium chloride to 1L each of IV fluids after the first liter of fluid has been infused according to serum potassium level as follows:




  • Click here to view


  • Insulin infusion[118],[119],[120]

  • A fixed rate of intravenous insulin infusion calculated on 0.1 unit/kg/hour is recommended.


  • The metabolic targets are:


    • - Reduction of blood ketone concentration by at least 0.5 mmol/L/h


    • - In the absence of blood ketone monitoring, the venous bicarbonate should rise by 3 mmol/L/h and capillary BG should fall by 55 mg/dL/h (3 mmol/L/h)


    • - Long-acting basal insulin analogues should be continued subcutaneously as normal.




    10.1.7: Resolution of DKA is identified as

  • PH >7.3 and/or bicarbonate >15 mmoL


  • Blood ketone levels <0.6 mmol/L


  • 10.1.8: Ongoing assessment and monitoring[118]

  • After initial stabilization, the woman should be transferred to the intensive care unit or high dependency unit.


  • The woman should be a part of a multidisciplinary team comprising an endocrinologist, an obstetrician, an intensivist, as well as trained midwives and nurses.


  • UandEs should be performed every 4 h.


  • 10.1.9: Fetal assessment

  • Maternal resuscitation and stabilization measures should take priority before any surgical intervention.


  • Most fetal losses occur before diagnosis and they may be due to maternal dehydration with acidosis, possibly leading to reduced uteroplacental circulation; high potassium may lead to fetal cardiac arrhythmias.[121]


  • 10.1.10: Prevention

  • Prepregnancy and antenatal education of pregnant women


  • The importance of SMBG should be stressed to women and their families


  • Ketone strips should be considered for early detection if the resources allow them.


  • 10.1.11: Uncontrolled hyperglycemia

  • Hyperglycemia is defined as glucose levels above the recommended targets in pregnancy.[29]


  • For pregnant women who present with acute hyperglycemia, it is most important to rule out DKA, especially in T1DM.[29]


  • If DKA is confirmed, follow the DKA protocol (see recommendation 10).


  • 10.1.12: Decide on need for hospital admission

  • If DKA is ruled out, the next step is to decide whether the woman needs admission to hospital.


  • If the woman is clinically unwell, vomiting, or unable to take orally, stabilization in hospital is preferred.


  • 10.1.13: In-hospital treatment[29],[65]

  • For women admitted to hospital, perform clinical assessment to identify the reasons for hyperglycemia and provide the appropriate treatment, for example, urinary tract infection, hyperemesis, etc.


  • Although the underlying cause is being treated, specific treatment for the hyperglycemia should be provided as given next:


  • For women who are already on insulin: Review insulin regime and step up insulin doses aiming for pregnancy glycemic targets (see HIP treatment protocol).


  • For women who are on Metformin or Glibenclamide, consider switching to insulin.


  • Prior to discharge from hospital, identify any gaps in diabetes education and arrange for reeducation; help should be sought from the diabetes educator/dietician.


  • Avoid using the insulin sliding scale, as it results in fluctuating glucose levels.


  • 10.1.14: Outpatient management

  • If the woman is clinically well, she can be managed as an outpatient.


  • Seek help from a diabetes educator.


  • Give glycemic targets and advice on how to step up insulin doses and arrange follow-up.


  • 10.2: Hypoglycemia

  • Hypoglycemia is a life-threatening condition that requires immediate medical attention and can affect any patient with diabetes. It is the most common acute diabetes emergency, and most cases are avoidable.[120],[122]


  • Women with T1DM have an increased risk of hypoglycemia in the first trimester and have an altered counter-regulatory response in pregnancy that may decrease hypoglycemia awareness.[122]


  • Education for women and their family members about the prevention, recognition, and treatment of hypoglycemia is important before, during, and after pregnancy to help to prevent and manage the risks of hypoglycemia.


  • Insulin resistance drops rapidly with delivery of the placenta, leading to a drop in insulin requirement and, hence, it makes the woman prone to hypoglycemia.


  • 10.2.1: Definition of hypoglycemia in pregnancy[123],[124]

    The cutoff level for defining hypoglycemia in pregnancy is a glucose level of <60 mg/dL (3.3 mmol/L).

    10.2.2: Symptoms and signs

  • Adrenaline-induced:

  • Sweating/clammy skin


  • Palpitations/tachycardia


  • Shaking/incoordination


  • Hunger


  • Visual disturbance


  • Tingling around lips


  • Nausea


  • Malaise




  • Cognitive symptoms:

  • Confusion


  • Drowsiness


  • Speech difficulty


  • Atypical behavior




  • Hypoglycemia should be considered in an individual with acute agitation, abnormal behavior, or impaired consciousness. These signs do not usually occur unless BG falls below 45 mg/dL (2.5 mmol/L) but can occur at higher concentrations in patients with T1DM who have poor control.



  • Investigations
  • BG measurement using a glucometer (if not available, treatment should not be delayed)


  • A glucose level of <60 mg/dL (3.3 mmol/L) suggests that the symptoms are caused by hypoglycemia.




  • 10.2.3: Immediate treatment[120]

  • If able to take orally:

  • Oral glucose (15–20 g) given immediately in liquid form:




    • - e.g., four teaspoons of glucose powder in 100 mL water


    OR

  • 150–200 mL of fruit juice (approximately one teacup)

    • - An alternative is three dextrose tablets, or three to four dates with instruction to chew and swallow


  • OR

  • Any available glucose drinks.

    • - Repeat after 5 min if no improvement in symptoms


  • If semiconscious or unconscious:

  • IM/SC Glucagon 1 mg




  • OR

  • Administer IV dextrose 50% (50 mL) or 20% (100 mL) into a large vein over 15 min and flush with sodium chloride 0.9% (10 mL). Repeat once if still unconscious after 15 min. If still failing to respond, start IV 10% dextrose (500 mL) over 2 h.


  • Once conscious, give oral glucose or further carbohydrate intake.


  • 10.2.4: Subsequent management

  • Check finger prick glucose every 30 min until it has arisen to >70 mg/dL (3.9 mmol/L).


  • Oral glucose should be followed by complex carbohydrates, for example, two to three biscuits or a sandwich.


  • If the hypoglycemia was induced by a sulfonylurea or intermediate-acting or long-acting insulin (e.g., human NPH insulin or glargine), the patients should have regular monitoring of finger prick glucose levels every 2 h until stable and then four hourly for 24 h.


  • If there is failure to recover consciousness within 15 min, an IV infusion of dextrose 10% should be started and the BG level should be maintained between 140 mg/dL and 220 mg/dL (7.7–12.2 mmol/L).


  • Continuous fetal monitoring should be applied during the management of hypoglycemia.


  • Consider the possible causes of hypoglycemia, and appropriate action should be taken:


  • Click here to view


  • A major change to the patient’s regular diabetes medications should not be made unless it is absolutely necessary.


  • Remember that in most cases the hypoglycemic episode might have been caused by missing or delaying a meal, and in these cases all that is needed is to correct the hypoglycemia by glucose administration followed by a carbohydrate meal or snack.


  • Remember that patients with T1DM, in particular, are prone to DKA and their insulin should not be omitted.



  •   11: Insulin Injection Techniques and Storage Guidelines Top


    11.1: Injection sites

    The following instructions should be given to women regarding the insulin injection site:

  • Inject insulin into the fat layer just under the skin.


  • Inject insulin on the lateral side of the abdomen and thigh in pregnancy [See [Figure 6]].


  • 11.1.1: Example of Insulin Injection Sites

  • Abdomen:

  • In the abdomen, inject insulin between the bottom of the ribs and the pubic area, 1cm away from the umbilicus. Avoid insulin injection around scars, moles, or skin blemishes [See [Figure 7]].




  • Thighs:

  • Best practice is to avoid insulin injection along dermal scars, moles or deformities and disfigurement [See [Figure 8]].


  • Figure 6: Insulin injection sites

    Click here to view
    Figure 7: Insulin injection sites (abdomen)

    Click here to view
    Figure 8: Insulin injection sites (thighs)

    Click here to view


    11.1.2: Site assessment

  • Examine before each insulin injection and on follow-up for inflammation, bruise, wound, or lipohypertrophy.


  • Change the injection site (e.g., from the abdomen to the thigh) after three months, and the methodical site rotation within the site must be advised for each injection.[118]


  • Increase self-monitoring of BG while switching injection sites, as the rate of absorption may vary the BG levels.


  • 11.1.3: Special conditions

    Exercise, local massage, exposure to heat, a hot bath, or long exposure to the sun may change the rate of insulin absorption. In these situations, insulin gets absorbed more quickly than its normal course so special instructions must be provided.

    11.1.4: Injection site rotation

    The systematic switching of insulin injections from one site to another and within the injection site is important to avoid complications such as lipohypertrophy, which can slow down the absorption of insulin.[3]

  • Take another injection at least 1 inch away from the first injection.


  • The best practice is to rotate the injection site clockwise or anticlockwise within the site [See [Figure 9]].
  • Figure 9: Insulin injection site rotation

    Click here to view


    11.2: Insulin injection during pregnancy

  • First trimester:

  • No change in insulin site or technique is needed, and women need to be reassured.




  • Second trimester:

  • Lateral sides of the abdomen are recommended for the injections because of stretching of the skin over the central abdomen.




  • Third trimester:

  • Skin folds have to be ensured to be properly raised. Very apprehensive patients may use other sites such as the thighs.




  • 11.3: Insulin technique through syringe[125]

  • Wash hands thoroughly with soap and make sure to clean and properly dry them [See [Figure 10]].


  • Always inspect the insulin vial for the correct type of insulin.
  • Visual appearance and expiry date should be checked.


  • If a woman is using a new vial, then make sure to remove its seal first [See [Figure 11]].




  • Roll the clear insulin vial to bring it on room temperature though it does not require mixing [See [Figure 12]].



  • Roll the cloudy insulin vial to mix it homogenously, at least 10 times between the palms.



  • Do not shake insulin, as it will damage its molecules and create bubbles inside the vial, which may be transferred into the syringe and cause pain and reduce the insulin dose as prescribed.



  • Check the syringe, either that it is working properly or not by pulling the plunger out and in a few times to avoid malfunctioning of the syringe [See [Figure 13]].



  • Place the vial at an angle of 45° and insert a needle into it [See [Figure 14]].



  • Always draw clear insulin (short-acting) in the syringe first.



  • Draw cloudy insulin from the vial after drawing the clear insulin.



  • Make sure that no bubbles are formed while drawing insulin from the vial, as it may cause pain while drawing insulin.



  • If any bubbles are formed, they can be removed by tapping the syringe with the forefinger nail.



  • Pinch a generous fold of skin for the insulin injection [See [Figure 15]].



  • Insert a needle at an angle of 90° [See [Figure 16] and [Figure 17]].



  • Before disposing of the syringe, clip it properly and dispose of it in a safe manner [See [Figure 18]].

  • Figure 10: Wash hands

    Click here to view
    Figure 11: Inspect insulin vial

    Click here to view
    Figure 12: Roll the insulin vial

    Click here to view
    Figure 13: Check the syringe

    Click here to view
    Figure 14: Insulin drawing technique

    Click here to view
    Figure 15: Skin fold for insulin injection

    Click here to view
    Figure 16: Insulin injection insertion technique, abdominal area

    Click here to view
    Figure 17: Insulin injection insertion technique, thigh area

    Click here to view
    Figure 18: Disposal of used injection

    Click here to view


    11.4: Insulin technique through insulin pen/pen device

  • Roll the pen at least 10 times between the palms of hands to bring insulin on room temperature or take out of the refrigerator, 10 min prior to injection time [See [Figure 19]].


  • Never shake the pen, as it will damage the insulin molecules and create bubbles inside the cartridge area.


  • Remove packing of the needle first [See [Figure 20]].


  • Mask the needle on the interior side of the pen [See [Figure 21]].


  • Remove the outer cover of the needle and dispose of it [See [Figure 22]].


  • Select prescribed units of insulin by rotating the rotator at the posterior end of the pen [See [Figure 23]].


  • Uncap the inner cover of the needle [See [Figure 24]].


  • Insert the needle at an angle of 90° [See [Figure 25] and [Figure 26]].


  • Always avoid taking an insulin injection over the clothes. It may contaminate the insulin or the needle or may result in injecting microfibers of fabrics too [See [Figure 27]].


  • Before disposing of the pen needle, clip it properly and dispose of it in a safe manner [See [Figure 28]].
  • Figure 19: Roll the insulin pen/pen device

    Click here to view
    Figure 20: Remove needle pack

    Click here to view
    Figure 21: Mask needle

    Click here to view
    Figure 22: Outer cover removal and disposal

    Click here to view
    Figure 23: Selection of prescribed units of insulin via rotator

    Click here to view
    Figure 24: Uncap the inner cover of the needle

    Click here to view
    Figure 25: Insulin injection insertion technique, abdominal area

    Click here to view
    Figure 26: Insulin injection insertion technique via pen, thigh area

    Click here to view
    Figure 27: Avoid taking insulin inject over the cloths

    Click here to view
    Figure 28: Disposal of used pen needle

    Click here to view


    11.5: Mode of insulin storage

    Women should be advised about the storage of insulin based on the following important principles:

  • If a refrigerator is not available, insulin can be stored in a bowl of the cooler containing cold water. There should be no ice. The water must be clean and should be changed daily [See [Figure 29]].


  • Once the insulin vial is opened, it should not be used for more than 28 days, except for insulin detemir, which may be used for up to 42 days.[119]


  • Insulin should be kept in a Matkka (clay pot). Hang the insulin vial tied with threads of different color at the neck of the clay pot for identification [See [Figure 30]].


  • The water should be changed daily. The Matkka should be kept in a shaded cool place.


  • Insulin pens and/or vials should not be immersed in water, as this can contaminate the inside of the pens or compromise sterility.[120]


  • Women can also use a double clay pot cooler, in which one bigger pot contains water and the other smaller pot contains insulin. The water should be changed on a daily basis. These pots should be placed in a shaded cool place [See [Figure 31]].


  • Insulin should be stored in the door or vegetable compartment of the refrigerator between 2°C and 8°C, and it can be stored up to two years [See [Figure 32]].


  • Do not store insulin in the freezer, as insulin loses its efficacy below 2°C.[125]
  • Figure 29: Insulin in a cooler

    Click here to view
    Figure 30: Clay pot for insulin storage (Matkka)

    Click here to view
    Figure 31: Double clay pot technique for insulin storage

    Click here to view
    Figure 32: Insulin storage in a refrigerator

    Click here to view



      12: Clinical Management of Neonates of Mothers with Diabetes Top


    12.1: Background

  • Hypoglycemia in neonates may be asymptomatic or may show clinical signs.


  • All neonates of mothers with diabetes are at risk for the development of hypoglycemia, irrespective of treatment, whether they are on insulin or not and they should be observed closely.[126]


  • Advise women with diabetes to give birth in hospitals where advanced neonatal resuscitation skills are available 24 h a day.[8],[127],[128],[129],[130],[131]


  • These clinical guidelines have been developed because of the observed association between symptomatic neonatal hypoglycemia and neurodevelopmental impairment.[132]


  • Evaluate newborns for major congenital malformations.[133]


  • 12.2: Clinical neonatal management

    12.2.1: Thermoregulation

  • Thoroughly dry the newborn after birth and cover it. Cover the head with a hat at all times.[131]


  • Avoid wet clothing, use a warm blanket to wrap the newborn, and set the ambient temperature to >22°C.[131]


  • 12.2.2: Feeding[8],[134],[135],[136],[137],[138],[139]

  • Initiate skin-to-skin contacts and start breastfeeding as soon as possible after birth, preferably within the first hour.


  • Provide feeding at frequent intervals (every 2–3 h) until the neonate maintains normal pre-feed capillary BG levels that are around 40–45 mg/dL.


  • Neonates should be given supplemental breastmilk substitutes. Feeding may be supplemented to low-birth-weight neonates (<2.5kg) and also to newborns who cannot be fed their mother’s breastmilk as either direct or expressed breast milk.


  • If the hospital has a policy for using donor human milk, it can be considered. If donor milk (Donor human milk: When a mother’s milk is not available, the alternatives are either expressed breast milk or breast milk from a donor mother if acceptable.) is unavailable or culturally unacceptable, then breast milk substitutes may be given.[140]


  • 12.2.3: Rooming-in[8],[140]

  • Newborns should stay with their mothers, unless complications or abnormal clinical signs require intensive or special care admission.[8],[132]


  • 12.2.4: Neonatal assessment

  • Conduct a careful examination and observation looking at morbidities after birth and at 24 h of age (See [Appendix 1]). Observe for symptoms and clinical signs [See [Table 9]].
  • Table 9: Sign in a newborn for hypoglycemia

    Click here to view
    Appendix 1: Examination and observation looking for morbidities

    Click here to view


    12.3: Observe for symptoms of hypoglycemia

  • Observe a newborn for the following signs for hypoglycemia[141],[142] [See [Table 9]].


  • 12.4: Diagnosis of hypoglycemia

  • Hypoglycemia is defined as the measurement of capillary glucose by a glucometer that is less than 45 mg/dL (or 2.5 mmol/L).


  • Intervention is recommended for BG <40 mg/dL (<2.22 mmol/L) in the first 4 h of life and <45 mg/dL (<2.5 mmol/L) at 4–24 h of life.


  • 12.5: Point-of-care testing (POCT)

  • Procedure for capillary BG testing
  • A blood sample obtained from a heel puncture is useful and recommended test in neonates (See [Appendix 2])[143],[144]


  • Allow trained health care personnel, preferably a pediatrician or a trained HCP, to perform a heel prick for BG estimation. The procedure may cause increased pain in the newborn, local trauma, damage to the nerves, blood vessels, and bones, excessive blood loss, and infection.[143],[144]


  • The glucometers use nonenzymatic methods that are less accurate at lowering glucose values than laboratory analysis using the glucose oxidase method (the gold standard).[145]


  • Whole-blood samples have 10% to 18% lower glucose concentrations than plasma, depending on the hematocrit.[145] Therefore, abnormally low glucose values require confirmation by measuring plasma glucose concentration using clinical laboratory methods.[142],[143],[146]


  • The most definite diagnosis of hypoglycemia is by measurement of plasma glucose by established laboratory methods.[135],[138]


  • In view of the nonavailability of laboratory facilities at all places and the time delay in getting results, BG values obtained by glucometers constitute an acceptable alternative. Wherever lab facilities are available, the treating physician can take a decision to send a BG sample to the lab without delaying management.


  • Appendix 2: How to do Heel-Stick Sampling[158],[159]

    Click here to view
    Appendix 3: Important Link to Support Breast feeding (Published By WHO (Global Health Media Project) https://globalhealthmedia.org/videos/

    Click here to view


    12.6: Refer babies to higher care level service or intensive care management[8]

  • Hypoglycemia associated with abnormal clinical signs


  • Respiratory distress


  • Signs of cardiac decompensation from congenital heart disease or cardiomyopathy


  • Signs of neonatal encephalopathy


  • Signs of polycythemia, and they are likely to need partial exchange transfusion


  • The neonate is not able to suck at repeated attempts, and BG is <45 mg/dL


  • Need for tube feeding (unless adequate support is available in the postnatal ward)


  • Jaundice requires intense phototherapy and frequent monitoring of bilirubinemia


  • Neonate with persistent hypoglycemia <45 mg/dL despite increased feeding frequency


  • If BG cannot be maintained and is >40–50 mg/dL despite IV infusion, 10% dextrose infusion (5–8 mg/kg/min) at a rate of 80–100 mL/kg/day is recommended for the neonate.


  • If glucose infusion rate > 8–10 mg/kg/min, the neonate may need central line, medical therapy, and further investigation.


  • Need for intravenous fluids


  • Neonates born before 34 weeks (or between 34 and 36 weeks, if the initial assessment of the neonate and their feeding suggests that this is clinically appropriate).


  • 12.7: When to discharge the newborn[128],[129]

  • They are at least 24 h old and
  • The neonate is maintaining BG levels and is feeding well.


  • BG is maintained above the threshold of BG goals (See [Figure 33] for the management of hypoglycemia in neonates].


  • Figure 33: Summarized pathway for evaluation of management of neonatal hypoglycemia

    Click here to view


    • - Maintain preprandial glucose concentrations through three feed–fast cycles; these should be >50 mg/dL in neonates <48 h of age.


    • - Maintain preprandial glucose concentrations >60 mg/dL in those who are ≥48 h of life.



      13: Breastfeeding Top


    Introduction

    Considering the value of breastfeeding for both mother and newborn, all women should be encouraged and supported to attempt breastfeeding.[79] Breastfeeding is known to offer long-term metabolic benefits to both mother and offspring.[147],[148] Further, it protects from several complications occurring in the infant and mother, including reduction of childhood obesity, T1DM, and T2DM, and it helps with postpartum weight loss.[149],[150],[151],[152]

    Women with preexisting diabetes should be given additional support and encouragement to breastfeed, as they tend to have delayed milk production due to poor glycemic control.[153]

    13.1: Recommendations

    1. Encourage women with a history of HIP to initiate and maintain breastfeeding.[65] Start counseling from the prenatal period onward and motivate women to breastfeed using strategies from guidance on the baby-friendly hospital initiative by the WHO.[140]


    2. Encourage women with preexisting diabetes to breastfeed immediately after delivery and for at least six months postpartum, as it may contribute to the reduction of neonatal hypoglycemia, offspring obesity and prevent the development of diabetes.[63] Exclusive breastfeeding up to six months and the continuation of breastfeeding up to two years with appropriate complementary feeding has shown further benefits and is currently recommended for all women.[154],[155]


    3. Educate and support women and alleviate postoperative discomfort to improve breastfeeding practices.[9],[156]


    4. Consult with a lactation consultant/diabetes educator to support women needing help with positioning, initiation of breastfeeding, or overall support.[140] Counseling should begin from the prenatal period onward.[140] Women need support and encouragement to continue breastfeeding if mastitis occurs.[157] (See Appendices 3 and 4 for links to educational videos to help promote and support breastfeeding.)


    5. Educate women on the option of breast pumps to help achieve personal lactation goals and include a range of options, including manual, battery-operated, electric, and hospital-grade ones.[158]


    6. Explain to women with preexisting diabetes who were treated with insulin to have a meal or snack available before or during feeds to avoid hypoglycemia.[159]


    7. Reduce insulin doses immediately during the postpartum period by approximately 30%–50% to avoid hypoglycemia in breastfeeding women.[156] For women on insulin pump therapy, reduce basal insulin by at least 50% after delivery to avoid hypoglycemia.[160],[161]


    Review the list of medications, insulin, and commonly used oral antidiabetic medications that are not contraindicated in breastfeeding, as their concentration in breastmilk is negligible and does not cause hypoglycemia in the newborn.[51],[156] (See [Appendix 4] for details on the recommendations of use for individual antidiabetic medications.)
    Appendix 4: Links to educational videos to help support women with breast feedingNote: Permission to disseminate the link for education purposes of this guidelines was obtained from Global Health Media®

    Click here to view


    • 8. Advise women to avoid any medicines for the treatment of diabetes complications that were discontinued for safety reasons during the preconception period (See [Appendix 5]).[159]


    • 9. For women with symptoms of COVID-19 or confirmed infection, breastfeeding can continue while the woman is wearing a face mask or a cloth covering the face and maintaining hand hygiene. Breastfeeding women should be vigilant with washing their hands before using a breast pump and should clean bottles and pump parts after every use.[162]


    • 10. Women with diabetes and HIP are considered at high risk to develop severe COVID-19 complications and therefore vaccination can be considered.[163] Up to the date of publication of this guideline, the Center for Disease Control and Prevention (CDC) as well as the International Federation of Gynaecology and Obstetrics (FIGO) indicate that breastfeeding women can choose to get vaccinated.[164] However, vaccines have not been studied in lactating women.[165]
    Appendix 5: Review of safety of antidiabetic medications during lactation

    Click here to view



      14: Contraception Top


    A family planning scheme, including contraception that is either permanent or reversible, should be discussed with all women with diabetes who are of reproductive age. The aim of pregnancy spacing is to ensure that a pregnancy is planned when the mother’s metabolic health is optimum to reduce the risks of spontaneous abortions or congenital malformations.[8],[9],[29]

    The WHO Medical Eligibility (MEC) Criteria for Contraceptives may be considered for the categorization of contraceptive methods into beneficial categories.[166]


      Recommendations Top


    14.1: Providing family planning solutions

    • 14.1.1: Provide family planning solutions during the antenatal visits and document in the antenatal card.


    • 14.2:Explore women’s preferences, beliefs, and wishes and counsel them about optimal contraceptive methods, either temporary or permanent, to ensure compliance.[67],[167]


    14.3: Hormonal contraceptive therapy (HCT)

    • 14.3.1: Recommend combined hormonal contraception (CHC), including combined contraceptive pills, transdermal contraceptive patches, combined vaginal rings, and combined injectable contraception in women <35 years of age without comorbidities such as hypertension, nephropathy, and retinopathy (category 2 of MEC)[2],[166],[167],[168],[169] [See [Table 10]]. In women with these comorbidities, other choices may be preferred (categories 3–4 of MEC).[2],[167],[168],[169]


    • Recommend progestin-only pill (POP) for women with diabetes, especially lactating mothers of any age, regardless of their complication status[2],[167],[168],[169] [See [Table 10]].[166],[168]


    • The failure rate of HCT is quite low in perfect users, that is 0.3%, but the typical user failure rate is 9% [See [Table 11]].[170]
    Table 10: Contraception method and diabetes[159],[162]

    Click here to view
    Table 11: Failure rates of different family planning methods[166]

    Click here to view


    14.4: Long-acting reversible contraception

    • 14.4.1: Long-acting reversible contraceptives (LARC), including Levonorgestrel intrauterine devices (LNGIUS-based systems), progestogen-only injectable contraceptives, and progestogen-only subdermal implants, are relatively safe and can be recommended if resources permit [See [Table 10]].[167]


    • 14.4.2: Non-hormonal Intrauterine Contraceptive Devices (NH-IUCD), for example, Copper-T, multi-load can be offered safely as an inexpensive method, especially during the immediate postpartum period [See [Table 10]].[2],[167],[168],[169],[170]


    • 14.4.3: The failure rate of LARC is low (0.3%–0.6%) and it is a very effective family planning method for women with diabetes [See [Table 11]].[170]


    14.5: Natural and barrier methods of contraception



    14.6: Emergency contraception methods (ECM)

    • 14.6.1: The use of copper intrauterine devices (Cu-IUCD) in women with diabetes is not restricted.[168],[171] Cu-IUCD can be inserted within five days of unprotected intercourse. The efficacy of an emergency Cu-IUCD insertion is very high in preventing pregnancy, reaching up to 99%.[170]


    • 14.6.2: The use of progesterone-only oral contraceptive pills in women with diabetes is not restricted.[2],[166],[167],[168],[169],[170],[172] The availability of emergency progesterone-only oral contraceptive pills is varied in different countries of the region. The dose of Levonorgestrel (LNG) is 1.5 mg, or two doses of 0.75 mg each, 12 h apart within five days after unprotected intercourse.[173]


    14.7: Permanent contraception

    • 14.7.1: Offer pre-procedure counseling to couples to prevent regrets. Factors such as young age, number of children, and religious and cultural beliefs should be taken into consideration before initiating the process.[174]


    • 14.7.2: Provide the choice of tubal ligation/vasectomy, as safe and effective methods for couples wishing for permanent contraception.[2],[167],[168],[169] The failure rate of tubal ligation is around 1 in 200 and –1 in 1000 after vasectomy.[2],[167],[168],[169],[170]



      15: Fetal Loss Top


    • 15.1: Women with diabetes, especially those with uncontrolled BG, are at an increased risk of miscarriage, congenital anomalies, and stillbirth (See [Figure 34] for the management of contraception in HIP).[8],[175],[176],[177] Fetal loss is often sudden, unexpected and has a huge psychological impact on both the woman and her family.[134],[178],[179],[180]
    Figure 34: Contraception management in HIP[159],[161],[163]

    Click here to view


    15.2: Management of women with hyperglycemia in pregnancy (HIP) and fetal loss

    • 15.2.1: Confirm the diagnosis of intrauterine fetal death (IUFD) by USG. Communicate the diagnosis with the woman and her partner. Discuss the timing and methods of pregnancy termination.[134],[135],[138]


    • 15.2.2: Methods of pregnancy termination will vary according to gestational age and previous uterine surgery.[134],[135],[138]

    • Vaginal birth is the recommended mode of delivery for most women with late uterine death (after 24 completed weeks).[126],[127],[130]


    • Misoprostol is of equivalent safety, efficacy and with a lower cost as compared with prostaglandin E2.[134],[135],[138]


    • The dose of misoprostol should be adjusted according to gestational age:[181]

    • <13 weeks: 800 ug P/V every 3 h (×2)


    • 13–26 weeks: 200 ug P/V/sublingual/buccal every 4–6 h


    • 27–28 weeks: 100 ug P/V/sublingual/buccal every 4 h


    • >28 weeks: 25 ug P/V every 6 h


    • Use lower doses of misoprostol in previous cesarean section; higher doses should not be used because of the risk of uterine rupture.[182],[183]


    • Use Foley catheter for induction of labor, especially in women with a previous cesarean section.[184]


    • Prostaglandin E2 vaginal pessary can be used for the termination of IUFD >28 weeks’ gestation if a small dose of misoprostol is not available.[51]


    • Offer adequate analgesia during delivery and deliver in a private delivery room with careful monitoring.[134],[135]


    15.2.3: Evaluation of the unexplained IUFD

    Parents can be offered:

  • Postmortem examination or a limited autopsy to explain the cause of IUFD.[134],[135]


  • Limited autopsy includes external examination, birth weight, karyotyping, histology of relevant tissues, skeletal X-rays, and pathological examination of the cord, membranes, and placenta. An MRI can be used as an alternative to postmortem examination.[134],[135]


  • A thorough maternal evaluation, including Antiphospholipid Syndrome screening and a KleihauerBetke test, are advised.[185]


  • 15.2.4: Management after pregnancy termination

    Women with late IUFD:

  • Admit such women in private rooms or gynecological wards.[134],[135]


  • Offer counseling and support to couples and their families.[134],[135]


  • Evaluate the psychological well-being of these women, and the advice of psychiatrists should be sought if any psychological disturbance develops.[2]


  • Offer dopamine agonist cabergoline for lactation suppression but avoid this in women with hypertension or preeclampsia.[134],[135]


  • 15.3: Recommendations for a future pregnancy after fetal loss in pregnant women with hyperglycemia

    Advise the couple to:

  • Delay conception until severe psychological issues have been resolved.[134],[135]


  • Avoid pregnancy before achieving an ideal glycemic control by using an effective contraceptive method.[8],[134],[135],[136],[137],[138]


  • Reduce the risk of congenital anomalies and miscarriages, achieve and maintain HbA1c around 6% (48 mmol/L).[79]


  • Undertake screening with a 75 g 2-h OGTT six to eight weeks postpartum and at 6–12 weeks during their future pregnancies. Women who are planning for a pregnancy are advised to take 5 mg of folic acid two months before conception and to continue it for 12 weeks of pregnancy to prevent neural tube defects.[8],[134],[135],[136],[137],[138]


  • Continue BG monitoring all through the pregnancy and aim at euglycemia.[8],[79]



  •   16: Management of Diabetes in Pregnancy during Ramadan Top


    This section has been adapted with modifications from IDF-DAR Diabetes and Ramadan: Practical guidelines 2021.

    16.1: General principles of care

    Diabetes in pregnancy predisposes women to an increased risk of hyperglycemia and hypoglycemia, which can have adverse effects for both the mother and her fetus.[186],[187] It is because of these risks that women with GDM, even if controlled with diet or metformin, are advised against fasting during Ramadan. Women with a history of T1DM or T2DM in pregnancy are at high risk, and, consequently, advised against fasting.[187]

    Observing the fast during pregnancy is a personal decision and many women wish to fast even though there is a religious exemption attributed to pregnancy and diabetes.

    16.2: Pre-Ramadan assessment for women with preexisting diabetes who insist on fasting against advice

  • Give comprehensive education to women to empower them to care for themselves, leading to better pregnancy outcomes.


  • Encourage women to undergo full medical and obstetric assessments and perform fasting risk evaluations.


  • 16.2.1: Education and blood glucose monitoring of pregnant women with diabetes

    • ◦ Set up an education session prior to Ramadan to ensure maternal and fetal well-being.


    • ◦ Adjust the doses of insulin according to their insulin regimen.


    • ◦ Set up desired BG levels and explain their effect on the mother and fetus. Educate the women about the pharmacodynamics of insulin; review the insulin injection techniques. Make sure that these women know how to cope with hypoglycemia and are aware of when to break their fast.[188]


    • ◦ Reassure pregnant women that the finger-pricking testing for BG levels does not break their fast and regular monitoring is essential for safe fasting.[189]


    • ◦ Educate women on the use of urine ketone strips if they are affordable for them.


    • ◦ The use of CGM or GFM can provide a better assessment of glucose profiles and an opportunity for intervention where resources permit.[190],[191]


    16.2.2: Physical activity

    • ◦ Exercise is a must. Timing and intensity may need alteration, for example, 2 h after the sunset meal. Taraweeh prayer is considered a form of exercise.


    16.2.3: Nutritional care and meal planning

    Give the following professional dietary advice before Ramadan.

  • Do not take high-calorie meals.


  • Avoid fruit juices and sugary drinks.


  • Avoid salty foods and reduce caffeine intake.


  • Eat fiber-rich foods.


  • Drink two to three liters of water a day.


  • Take Suhoor close to the morning call for prayer.


  • 16.2.4: Management of HIP during Ramadan fasting[192],[193]

  • HIP is treated with metformin and insulin.


  • Glibenclamide should be discouraged during Ramadan fasting.


  • 16.2.5: Glycemic targets

  • Pregnant women must achieve the standard BG targets during pregnancy even when fasting in Ramadan.


  • Fasting glucose should be between 70 mg/dL and 95 mg/dL (3.9–5.3 mmol/L).


  • Two-hour postprandial glucose <120 mg/dL (6.7 mmol/L).


  • 16.2.6: Timing of glucose monitoring

  • Conduct regular SMBG during fasting hours as well as 1–2 h after meals.


  • Once before the sunset meal


  • One to two hours after the meal


  • Once during the afternoon


  • Any time the woman feels unwell


  • 16.2.7: Break the fast rules: Advise pregnant women to break their fast whenever

  • BG levels <70 mg/dL (3.9 mmol/L)


  • BG >200 mg/dL (11.1 mmol/L)


  • Feeling unwell


  • Reduction in fetal movements


  • High ketones level if using urine ketone strips


  • 16.2.8: Insulin-treated pregnant women

  • Pregnant women receiving insulin should strictly monitor their BG. The BG should be checked at any time during the day or night when feeling unwell.


  • For insulin dose adjustments, see Recommendation 9.1.1.


  • Insulin modifications for hyperglycemia during Ramadan fasting

    • – Intermediate (Levemir, NPH)


  • Give same am dose at Iftar time


  • Give same pm dose at Suhoor


    • – Long-acting insulins (Glargine)
    • Not approved by the FDA


    • Consider switching to intermediate insulin


    • However, if no alternatives are available, give the dose of Glargine at 8–10 pm.


    • – Short-acting insulins (Regular, Aspart, Lispro)
    • Analogues are preferred


    • Continue insulin and carbohydrate counting


    • If no carbohydrate counting

      • – Iftar: Give same pre-Ramadan lunch dose


      • – Night meal: Give 50% of Iftar dose


      • – Suhoor: Give 75% of Iftar dose






    • Pre-mixed insulins

    • Not preferred in pregnancy, however these are used if no alternatives are available (See 9.2.6)

      • Give prelunch dose at Iftar time


      • Give 50%–70% of that dose at Suhoor




    • – Insulin pump

    • Basal




    • 20%–40% reduction of basal insulin (last 4–6 fasting hours)


    • 10%–30% increase of basal insulin (first 4–6 eating hours)


  • Bolus


    • Same short-acting principles



      17: Future Research Recommendations Top


    1. Comparison of standard one-step 2-h 75 g OGTT and non-fasting 75 g OGTT (DIPSI method) for the diagnosis of HIP to find out what best suits the MENA region.


    2. Application of HbA1c in the screening and monitoring of GDM in MENA region.


    3. Identification of the factors that are responsible for noncompliance for postpartum BG screening and ways to improve postpartum BG screening uptake by the women of MENA region.


    4. Evaluating GDM as a risk factor for future T2DM.


    5. Impact of MENA region guideline recommendations on clinical practice.


    6. Comparison of the prevalence of HIP in MENA region countries using a uniform strategy and diagnostic criteria proposed by the MENA region guideline.


    7. Evaluation of the effectiveness of MNT for effective glycemic control in MENA region.


    8. Impact of mobile health applications on diabetic control during pregnancy in MENA region.


    9. Role of prophylactic Metformin alone or with insulin, in control of BG after antenatal corticosteroids.


    A table on the review of safety of antidiabetic medications during lactation[197],[198],[199],[200],[201],[202],[203],[204],[205],[206],[207],[208] has been provided in Appendix 5.

    Acknowledgments

    Sincere gratitude to Prof. Akhtar Hussain, President IDF Elect and Prof. Jamal Belkhadir, Chair IDF-MENA Region for initiation of idea, guidance and advice to prepare guidelines for Hyperglycaemia in Pregnancy for IDF-MENA Region and placing the trust on chairperson guideline committee, Prof. Shabeen Naz Masood and the collaborative group of authors.

    Special thanks to Dr. Viswanathan Mohan for final review, guidance, coordination and accommodation of the guidelines in the special issue of Diabetes and Pregnancy in Journal of Diabetology (JOD).

    Special acknowledgment and deep gratitude to Dr. Dalal Alromaihi for compiling the document, reference setting, and overall coordination.

    Thanks to Prof. Ahmad Bilal, Dr. Zaheer and Dr. Ayesha for the similarity check, glossary setting of abbreviations, academic and pictorial contribution to diet and lifestyle subsections of the guidelines.

    Dr. Zaheer Ahmad was instrumental in final review and helped corresponding author in responding to queries raised by reviewers.

    Thanks to Dr. Mohamed Bashir for his insightful remarks about the guidelines.

    A special mention of Syed Imran Shah for his invaluable contribution for IT assistance. Special appreciation to Ms. Manal Samir Ahmed, assistant chairman IDF-MENA, for her outstanding technical support in coordination of the virtual meetings and diligence in supporting the group communications.

    We acknowledge all those in leadership positions in their respective countries of IDF-MENA region for their support and nomination of members to the collaborative group of authors for this guideline. Without their assistance, it would not have been possible to gather this valuable group of dedicated experts.

    Prof. Akhtar Hussain, President Elect IDF

    Prof. Jamal Belkhadir, Chair IDF-MENA region

    Dr. Mariam Al-Hajeri, Bahrain

    Prof. Adel El Syed, Egypt

    Dr. Mesbah Kamel, Egypt

    Dr. V. Mohan, India

    Dr. Nadima Shegem, Jordan

    Dr. Mohammad Sandid, Lebanon

    Dr. Suleiman Abusrewil, Libya

    Prof. Abdul Basit, Pakistan

    Prof. Zaman Shaikh, Pakistan

    Prof. Ahmad Abu Al-Halaweh, Palestine

    Dr. Abdulla Al Hamaq, Qatar

    Prof. Mohamed Eltom, Sudan

    Dr. Hana Alghanem, Syria

    Dr. Nizar Albache, Syria

    Dr. Fatheya Alawadi, UAE

    Dr. Zayed Atef, Yemen

    Review Committee:

    1. Prof. Shabeen Naz Masood, Pakistan

    2. Prof. Shehla Baqai, Pakistan

    3. Dr. Uma Ram, India

    4. Dr. Dalal Alromaihi, Bahrain

    5. Dr. Zaheer Ahmad, Pakistan

    6. Dr. Shabnam Saquib, UAE

    Declaration of patient consent

    The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

    Financial support and sponsorship

    Nil.

    Conflicts of interest

    There are no conflicts of interest.



     
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        Figures

      [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19], [Figure 20], [Figure 21], [Figure 22], [Figure 23], [Figure 24], [Figure 25], [Figure 26], [Figure 27], [Figure 28], [Figure 29], [Figure 30], [Figure 31], [Figure 32], [Figure 33], [Figure 34]
     
     
        Tables

      [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Appendix 1], [Appendix 2], [Appendix 3], [Appendix 4], [Appendix 5], [Table 17], [Table 18], [Table 19], [Table 20], [Table 21]



     

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      In this article
    Abstract
    Overview
    Executive Summary
    Strengths and Li...
    Introduction
    1: Screening and...
    2: Preconception...
    3: Antenatal Man...
    4: Intrapartum M...
    5: Preterm Labor
    6: Postpartum Ma...
    7: Management of...
    8: Exercise and ...
    9: Pharmacologic...
    10: Diabetes-rel...
    11: Insulin Inje...
    12: Clinical Man...
    13: Breastfeeding
    14: Contraception
    Recommendations
    15: Fetal Loss
    16: Management o...
    17: Future Resea...
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