Clinical Practice Guidelines

Canadian Diabetes Association
Clinical Practice Guidelines
Pregnancy
Chapter 36
David Thompson, Howard Berger,
Denice Feig, Robert Gagnon, Tina Kader,
Erin Keely, Sharon Kozak, Edmond Ryan,
Mathew Sermer, Christina Vinokuroff
In collaboration with
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

Copyright 2013 Canadian Diabetes Association
Diabetes in Pregnancy: 2 Categories
Pregestational diabetes Gestational diabetes
Pregnancy in
pre-existing diabetes Diabetes diagnosed in
pregnancy
Type 1 diabetes
Type 2 diabetes

Diabetes in Pregnancy: Consider Phases
1. Preconception counseling 1. Screening
2. Glycemic control during 2. Glycemic control during

pregnancy pregnancy
3. Management in labour 3. Management in labour
4. Postpartum considerations 4. Postpartum considerations


pregnancy pregnancy

Dysglycemia in Pregnancy can Result in
Adverse Pregnancy Outcome
Elevated glucose levels can have adverse effects
on the fetus
1st trimester fetal malformations
2nd and 3rd trimester: risk of macrosomia and
metabolic complications

Risk of Fetal Anomaly Relative to
Periconceptional A1C
Glycemic control pre-conception = essential
Guerin A et al. Diabetes Care 2007;30:1-6.

Need a Preconception Checklist for 2013
Women with Pre-existing Diabetes
1. Attain a preconception A1C of 7.0% (if safe)
2. Assess for and manage any complications
3. Switch to insulin if on oral agents
4. Folic Acid 5 mg/d: 3 months pre-conception to 12
weeks post-conception
5. Discontinue potential embryopathic meds:
Ace-inhibitors/ARB (prior to or upon detection of pregnancy)
Statin therapy

Preconception Counseling for
Pregestational Diabetes
Advise reproductive age women with diabetes about
reliable birth control
NOTE: Metformin in PCOS may improve fertility need to
warn about possible pregnancy
Metformin safe for ovulation induction in PCOS
Achieving a healthy weight is essential obesity
associated with adverse pregnancy outcomes

Screen for Complications:
Pre-pregnancy and Intrapartum
Screening for:
1. Retinopathy: Need ophthalmological evaluation
2. Nephropathy: Assess creatinine + urine
microalbumin / creatinine ratio (ACR)
Women with microalbuminuria or overt nephropathy are at
risk for hypertension and preeclampsia

Recommendations 1-2: Preconception Care
1. All women of reproductive age with type 1 or type 2
diabetes should receive advice on reliable birth control,
the importance of glycemic control prior to pregnancy,
impact of BMI on pregnancy outcomes, need for folic
acid and the need to stop potentially embyropathic
drugs prior to pregnancy [Grade D, Level 4].
2. Women with type 2 diabetes and irregular

menses/PCOS who are started on metformin or a
2013
thiazolidinedione should be advised that fertility may
improve and be warned about possible pregnancy [Grade D,
Consensus].

Recommendation 3: Preconception Care
3. Before attempting to become pregnant, women

with type 1 or type 2 diabetes should:
a) Receive preconception counseling that
includes optimal diabetes management and
nutrition, preferably in consultation with an
interdisciplinary pregnancy team to optimize
maternal and neonatal outcomes [Grade C, Level 3]

(continued)
b) Strive to attain a preconception A1C of 7.0% (or
A1C as close to normal as can safely be achieved)
to decrease the risk of:
Spontaneous abortion [Grade C, Level 3]
Congenital anomalies [Grade C, Level 3]
Pre-eclampsia [Grade C, Level 3]
Progression of retinopathy in pregnancy [Grade A, level
1 for type 1 diabetes (23); Grade D, Consensus for type 2 diabetes]

(continued)
c) Supplement their diet with multivitamins containing 5
mg of folic acid at least 3 months pre-conception
and continuing until at least 12 weeks post-
conception [Grade D, Level 4]. Supplementation should
continue with a multivitamin containing 0.4-1.0 mg
of folic acid from 12 weeks postconception
through to 6 weeks postpartum or as long as
breastfeeding continues [Grade D, Consensus].

(continued)
d) Discontinue medications that are potentially
embryopathic, including any from the following
classes:
ACE inhibitors and ARBs prior to conception
2013 or upon detection of pregnancy [Grade C, Level 3]
Statins [Grade D, Level 4]

4. Women with type 2 diabetes who are planning a

pregnancy should switch from non-insulin
antihyperglycemic agents to insulin for glycemic
control [Grade D, Consensus].
Women with pregestational diabetes who also
have PCOS may continue metformin for
ovulation induction [Grade D, Consensus].

Recommendations 5 and 6: Preconception
and Complications
5. Women should undergo an ophthalmological
evaluation by an eye care specialist [Grade A, Level 1, for
type 1; Grade D, Level 4 for type 2].
6. Women should be screened for chronic kidney

disease prior to pregnancy [Grade D level 4 for type 1 diabetes
Grade D, consensus for type 2 diabetes]. Women with
microalbuminuria or overt nephropathy are at

increased risk for the development of HTN and
preeclampsia [Grade A level 1]; and should be followed
closely for these conditions [Grade D, Consensus]


pregnancy pregnancy

Need Optimal Glycemic Control in
Pregnancy for Pre-existing Diabetes
Individualized insulin therapy with close monitoring
Bolus insulin: May use aspart or lispro instead of regular
insulin
Basal insulin: May use detemir or glargine as alternative to
NPH
Encourage patients to SMBG pre- and postprandially
Target glucose values
Fasting PG <5.3 mmol/L
1h postprandial PG <7.8 mmol/L


pregnancy pregnancy

2013
Glucose Management During Labour and
Delivery
Maternal blood glucose levels should be kept
between 4.0 -7.0 mmol/L neonatal
hypoglycemia
Women should receive adequate glucose during
labour in order to meet the high energy requirements
IV Dextrose + IV insulin protocols may be helpful

Postpartum care for pre-existing diabetes
1. Adjust insulin at risk of hypoglycemia
2. Encourage women to breastfeed
3. Metformin and glyburide may be used during breast-

feeding no long term data but appears safe
4. Screen for postpartum thyroiditis in T1DM

check TSH at 6-8 weeks postpartum

Recommendation 7: Management in
Pregnancy for Pregestational Diabetes
7. Pregnant women with type 1 or type 2 diabetes
should:
a) Receive an individualized insulin regimen and
glycemic targets typically using intensive insulin
therapy [Grade A, Level 1B for type 1; Grade A, Level 1 for type 2]
b) Strive for target glucose values [Grade D consensus]:
Fasting PG below 5.3 mmol/L
1h postprandial below 7.8 mmol/L
2h postprandial below 6.7 mmol/L

Recommendation 7: Management in Pregnancy
for Pre-gestational Diabetes (continued)
c) Be prepared to raise these targets if need be
because of the increased risk of severe
2013
hypoglycemia during pregnancy [Grade D, Consensus]
d) Perform SMBG, both pre- and postprandially

to achieve glycemic targets and improve
pregnancy outcomes [Grade C, Level 3]

Recommendations 8-9: Management in
Pregnancy for Pre-gestational Diabetes
8. Women with pregestational diabetes may use
2013 aspart or lispro in pregnancy instead of regular
insulin to improve glycemic control and reduce
hypoglycemia [Grade C level 2 for aspart , Grade C, Level 3 for lispro].
9. Detemir [Grade C, Level 2] or glargine [Grade C, Level 3 ] may

be used in women with pregestational diabetes as
2013
an alternative to NPH.

Recommendation 10 and 11: Intrapartum
Glucose Management
10. Women should be closely monitored during labour
2013
and delivery and maternal blood glucose levels
should be kept between 4.0 and 7.0 mmol/L in
order to minimize the risk of neonatal hypoglycemia
[Grade D, Consensus]
11. Women should receive adequate glucose during

2013 labour in order to meet the high energy requirements

Recommendations 12 and 13: Postpartum
Glucose Management
12. Women with pregestational diabetes should be
2013 carefully monitored postpartum as they have a
high risk of hypoglycemia [Grade D, Consensus].
13. Metformin and glyburide may be used during

2013 breast-feeding [Grade C, Level 3 for metformin; Grade D, Level 4 for
glyburide].

Recommendation 14 and 15: Postpartum
Glucose Management
14. Women with type 1 diabetes in pregnancy should
be screened for postpartum thyroiditis with a TSH
test at 6-8 weeks postpartum [Grade D, Consensus].
15. All women should be encouraged to breast-feed,

since this may reduce offspring obesity, especially in
the setting of maternal obesity [Grade C level 3-]

1. Preconception counseling 1. Screening & diagnosis

pregnancy pregnancy

Gestational Diabetes (GDM) Diagnosis
Universal screening for GDM @ 24-28 weeks
Gestational Age (GA)
Screen earlier if risk factors for GDM:
Previous GDM BMI 30 kg/m2
Prediabetes Polycystic ovarian syndrome
High risk population Current fetal macrosomia or
(Aboriginal, Hispanic, South polyhydramnios
Asian, Asian, African)
Age 35 years History of macrosomic infant
Corticosteroid use Acanthosis nigricans

Why Diagnose and Treat GDM?
Macrosomia Caesarian section

Shoulder dystocia and Offspring obesity (?)
nerve injury Offspring diabetes (?)
Neonatal hypoglycemia
Preterm delivery
Hyperbilirubinemia

HAPO: Incidence of Adverse Outcomes
Increases Along Continuum

Copyright
Metzger BE,et2013 Canadian Diabetes
al. Hyperglycemia andAssociation
Adverse Pregnancy Outcomes. NEJM 2008;358(19):1991-2002.
Benefits of Treatment of GDM

Benefits of Treatment of GDM

Horvath K et
Copyright al.2013
BMJCanadian
2010;340:c1935
Diabetes Association
Diagnosis of GDM
Are there clear threshold glucose levels

above which the risk of adverse neonatal
or maternal outcomes increases?

IADPSG
Diabetes Care 2010;22:676-682

HAPO: Incidence of Adverse Outcomes
Increases Along Continuum No Threshold

Metzger BE,et2013
Copyright al. HAPO. NEJM
Canadian 2008;358(19):1991-2002.
Are there clear threshold glucose levels
above which the risk of adverse neonatal
or maternal outcomes increases?
NO

IADPSG Consensus Threshold Values for
Diagnosis of GDM (1 Value is Diagnostic)
Glucose measure Glucose threshold Proportion of HAPO
with a 75 g OGTT (mmol/L) cohort above
threshold (%)
Fasting plasma 5.1 8.3
glucose (FPG)
1-h plasma glucose 10.0 14.0
Based on odds ratio (OR) of 1.75 for primary outcome

OGTT = Oral Glucose Tolerance Test
HAPO = Hyperglycemia and Adverse Pregnancy Outcomes study
IADPSG. Diabetes Care 2010;22:676-682
Odds Ratio (OR) of 1.75 vs. 2.0 for Primary
Outcome in HAPO
Threshold glucose OR 1.75 OR 2.0
levels (mmol/L) after
a 75g OGTT
Fasting plasma 5.1 5.3

glucose

% of cohort that met 16.1% 8.8%
1 threshold above
OGTT = Oral Glucose Tolerance Test

HAPO = Hyperglycemia and Adverse Pregnancy Outcomes study
IADPSG. Diabetes Care 2010;22:676-682
HAPO: Incidence of Adverse Outcomes for
Glucose Categories (OR 1.75 or 2.0 )

Metzger BE,et2013
Copyright al. HAPO. NEJM
Canadian 2008;358(19):1991-2002.
Remains a Controversial Topic

Considerations for the CDA Adopting the
IADPSG Thresholds
How can we select an odds ratio threshold in the
absence of a true threshold in the data?
What is the impact on the patient and workload of
increasing the prevalence of GDM?
Do we have sufficient evidence with respect to
treatment benefit at the various thresholds to make
an informed decision?
In the absence of clear benefit, should the diagnostic
criteria be changed from 2008?

2013 CDA Diagnostic Criteria for GDM 2013
PREFERRED APPROACH (2 steps)

1. 50 gram glucose challenge test
2. 75 gram oral glucose tolerance test
Using thresholds of OR 2.0
ALTERNATIVE APPROACH (1 step)

1. 75 gram oral glucose tolerance test
Using thresholds of OR 1.75

2013 GDM Diagnosis: Two Approaches 2013

2013 GDM Diagnosis: Preferred Approach 2013




2013 GDM Diagnosis: Preferred Approach
2013

2013 GDM Diagnosis: Preferred Approach
2013

2013 GDM diagnosis: Alternative Approach 2013

2013 GDM diagnosis: Alternative Approach 2013

Recommendations 16-17: Diagnosis of GDM
16. All pregnant women should be screened for GDM

at 24-28 weeks of gestation [Grade C, Level 3].
17. If there is a high risk of GDM based on multiple

clinical factors, screening should be offered at any
stage in the pregnancy [Grade D, Consensus]. If the initial
screening is performed before 24 weeks of
gestation and is negative, rescreen between 24-28
weeks of gestation. (see next slide)

Recommendation 17: Risk Factors for GDM
(continued)
Age 35 years Polycystic ovarian
Previous GDM syndrome
Prediabetes Acanthosis nigricans
High risk population Corticosteroid use
Aboriginal, Hispanic, South History of macrosomic
Asian, Asian, African
infant
BMI 30 kg/m2 Current fetal macrosomia
or polyhydramnios

Recommendation 18: Diagnosis of GDM
18. The preferred approach for the screening and
diagnosis of GDM is the following [Grade D, Consensus]:
a) Screening for GDM should be conducted using the 50 g
glucose challenge test (GCT) administered in the non-
2013 fasting state with plasma glucose measured one hour later
[Grade D, Level 4]. A plasma glucose value 7.8 mmol/L at
one hour will be considered a positive screen and will be
an indication to proceed to the 75 gram OGTT [Grade C, Level
2]. A plasma glucose value >11.1 mmol/L can be
considered to be diagnostic of gestational diabetes and
does not require a 75 gram OGTT for confirmation [Grade C,
Level 3].

(continued)
b) If the GCT screen is positive, a 75 gram OGTT
should be performed as the diagnostic test for
GDM using the following criteria: >1 of the
following values:
Fasting >5.3 mmol/L,
2013 1h >10.6 mmol/L,
2h >9.0 mmol/L
[Grade B, Level 1]

19. An alternative approach that may be used to screen
and diagnose GDM is the one-step approach [Grade D,
Consensus]:
a) A 75 gram OGTT should be performed (with no

prior screening 50g GCT) as the diagnostic test for
2013
GDM using the following criteria [Grade D, Consensus]:
1 of the following values:
Fasting > 5.1 mmol/L,
1h > 10.0 mmol/L,
2h > 8.5 mmol/L
[Grade B, Level 1 (4)]

1. Preconception counseling 1. Screening & diagnosis

pregnancy pregnancy

GDM: Glycemic Management During Pregnancy
Perform SMBG, both fasting and postprandially
Glycemic Targets during pregnancy:
Target glucose values
Fasting PG <5.3 mmol/L
Receive nutrition counseling
Moderate carbohydrate restriction: 3 meals + 3 snacks
Targets not met within 2 weeks start insulin
Avoid hypocaloric diet weight loss + ketosis

IOM Guidelines for Gestational Weight Gain
Pre-Pregnancy BMI Recommended range Recommended range
of total weight gain of total weight gain
(Kg) (lb)
BMI <18.5 12.5 18.0 28 40
BMI 18.5 - 24.9 11.5 16.0 25 35
BMI 25.0 - 29.9 7.0 11.5 15 23
BMI > or = 30 5.0 9.0 11 20
Recommended rate of weight gain and total weight gain for singleton
Pregnancies according to pre-pregnancy BMI
Institute of Medicine. Weight gain during pregnancy: reexamining the guidelines. Consensus
Report. May 2009. The National Academies Press. Washington, DC.
What About Insulin Analogues and Oral
Agents Among Patients with GDM?
May use rapid-acting analog insulin for postprandial
glucose control no difference in perinatal outcomes
May use glyburide or metformin for women who

are non-adherent to or who refuse insulin
Likely safe BUT it is OFF-Label no long-term data, need
discussion with patient

2013
GDM: Glycemic Management During Labour

and Delivery
Keep maternal blood glucose l between 4.0 and 7.0
mmol/L reduce risk of neonatal hypoglycemia
Women should receive adequate glucose during


Postpartum GDM Management Checklist
1. Encourage Breastfeeding
2. 75g OGTT between 6 weeks - 6 months

postpartum to detect prediabetes or diabetes
3. Discuss increased long-term risk of diabetes

Importance of returning to pre-pregnancy weight

Recommendation 20: Management During
Pregnancy (GDM)
20. Women with GDM should:
a. Strive for target glucose values:
Fasting PG below 5.3 mmol/L [Grade B, Level 2]
1h postprandial below 7.8 mmol/L [Grade B, Level 2]
2h postprandial below 6.7 mmol/L [Grade B, Level 2]
b. Perform SMBG, both fasting and postprandially to
achieve glycemic targets and improve pregnancy
outcomes [Grade B, Level 2]
c. Avoid ketosis during pregnancy [Grade C, Level 3]

Pregnancy (GDM)
21. Receive nutrition counseling from a registered
dietitian during pregnancy [Grade C, Level 3] and
postpartum [Grade D, Consensus]. Recommendations for
weight gain during pregnancy should be based on
pregravid BMI [Grade D, Consensus].

Recommendation 22 and 24: Management
During Pregnancy (GDM)
22. If women with GDM do not achieve glycemic targets
within 2 weeks from nutritional therapy alone,
insulin therapy should be initiated [Grade D, Consensus].
23. Insulin therapy in the form of multiple injections

should be used [Grade A, Level 1].
24. Rapid-acting bolus analog insulin may be used

over regular insulin for postprandial glucose control
2013
although perinatal outcomes are similar [Grade B, Level 2].

Pregnancy (GDM)
25. For women who are non-adherent to or who refuse

insulin, glyburide [Grade B, Level 2] or metformin [Grade B,
Level 2] may be used as alternative agents for
glycemic control. Use of oral agents in pregnancy is

off-label and this should be discussed with the
patient [Grade D, Consensus].

Recommendation 26: Intrapartum
Management (GDM)
26. Women should be closely monitored during labour
and delivery and maternal blood glucose levels
2013 should be kept between 4.0 and 7.0 mmol/L in
order to minimize the risk of neonatal hypoglycemia.
27. Women should receive adequate glucose during

2013
[Grade D, Consensus].

Recommendation 28: Postpartum (GDM)
28. Women with GDM should be encouraged to
breastfeed immediately after delivery in order to
2013 avoid neonatal hypoglycemia [Grade D, Level 4] and to
continue for at least three months postpartum in
order to prevent childhood obesity [Grade C, Level 3] and
reduce risk of maternal hyperglycemia [Grade C, Level 3].
29. Women should be screened with a 75g OGTT

between 6 weeks and 6 months postpartum to
detect prediabetes and diabetes [Grade D, Consensus].

CDA Clinical Practice Guidelines
http://guidelines.diabetes.ca for professionals
1-800-BANTING (226-8464)
http://diabetes.ca for patients


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Canadian Diabetes Association

Clinical Practice Guidelines

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

Pregestational diabetes Gestational diabetes

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

Pregestational diabetes Gestational diabetes

1. Preconception counseling 1. Screening

2. Glycemic control during 2. Glycemic control during

3. Management in labour 3. Management in labour

4. Postpartum considerations 4. Postpartum considerations

1. Preconception counseling 1. Screening

2. Glycemic control during 2. Glycemic control during

3. Management in labour 3. Management in labour

4. Postpartum considerations 4. Postpartum considerations

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

Glycemic control pre-conception = essential

Guerin A et al. Diabetes Care 2007;30:1-6.

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

2. Women with type 2 diabetes and irregular

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

3. Before attempting to become pregnant, women

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

4. Women with type 2 diabetes who are planning a

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

6. Women should be screened for chronic kidney

microalbuminuria or overt nephropathy are at

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

1. Preconception counseling 1. Screening

2. Glycemic control during 2. Glycemic control during

3. Management in labour 3. Management in labour

4. Postpartum considerations 4. Postpartum considerations

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

1. Preconception counseling 1. Screening

2. Glycemic control during 2. Glycemic control during

3. Management in labour 3. Management in labour

4. Postpartum considerations 4. Postpartum considerations

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

1. Adjust insulin at risk of hypoglycemia

2. Encourage women to breastfeed

3. Metformin and glyburide may be used during breast-

4. Screen for postpartum thyroiditis in T1DM

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

d) Perform SMBG, both pre- and postprandially

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

9. Detemir [Grade C, Level 2] or glargine [Grade C, Level 3 ] may

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

11. Women should receive adequate glucose during

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

13. Metformin and glyburide may be used during

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

15. All women should be encouraged to breast-feed,

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

1. Preconception counseling 1. Screening & diagnosis

2. Glycemic control during 2. Glycemic control during