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Investigating Global Guidelines and Preferred Practices for Gestational Diabetes
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In this article, Endocrine Today provides a brief overview of some of the key clinical guidelines for gestational diabetes care recommended by the International Diabetes Federation and the International Association of Diabetes in Pregnancy Study Groups and speaks to Patti Duprey, MSN, APRN, CDE, family nurse practitioner and certified diabetes educator, Primary Care at Memorial Hospital, North Conway, NH, about her preferred methods for gestational diabetes care.
During the 2009 International Diabetes Federation (IDF) Conference, new global guidelines for gestational diabetes (GD) were announced. Below are some of the recommendations for GD care that are found in this comprehensive document:
- Advise optimization of glycemic control, defined as preconception target Diabetes Control and Complications Trial–aligned HbA1c <6.5%, or <7.0% if insulin is being used, and approximate self-monitored capillary plasma glucose concentrations of <100 mg/dL (<5.5 mmol/L) fasting and of <145 mg/dL (<8.0 mmol/L) after meals.
- Actively discourage women with HbA1c values greater than 8% from becoming pregnant until glycemic control improves.
- Offer an oral glucose tolerance test (OGTT), at the first prenatal visit, to women who are at high risk of diabetes because of a previous diagnosis of GD. If the results for these patients are normal, offer an OGTT between the 26th and 28th week of gestation (a one-stage definitive procedure is preferred). For women who are not at high risk of GD (unless a selective process based on risk factors is deemed more appropriate), advise them that they will be offered testing for GD between the 26th and 28th week of gestation.
- Offer glucose-lowering medication to women with GD if glucose control targets are not met within 1 to 2 weeks after initiation of lifestyle management. Although insulin remains the preferred treatment for GD, limited evidence supports the consideration of metformin and glibenclamide (glyburide) as treatment options. However, combination therapy has not been specifically studied and the use of oral hypoglycemic agents remains controversial.
The decision to create a universal approach for handling GD sparked considerable debate because the committee based their recommendation on the standards of care price point that would be most affordable worldwide. However, the resources available to health care providers throughout the world vary greatly, especially in the United States, where providers are better equipped to provide care. The IDF recommendations were written prior to the International Association of Diabetes in Pregnancy Study Groups (IADPSG) proposal, which was created based on the results of the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study. IADPSG have since announced their proposed diagnostic criteria. Their suggested changes in screening include:
- Testing for overt diabetes at the initial prenatal visit. Universal early testing in populations with a high prevalence of type 2 diabetes is recommended; others may choose to test only high-risk groups.
- A 75-g OGTT after an overnight fast at 24 to 28 weeks gestation in all women not previously diagnosed with overt diabetes or GD.
Although the two groups have different approaches to diagnosing GD, both agree on a one-step approach.
“Although such considerations are understandable, they do not always fit into my preferred methods of practice because of the resources that I have available and creates debate among US providers who might still adhere to the older guidelines of two-step screening,” said Patti Duprey, MSN, APRN, CDE, family nurse practitioner and certified diabetes educator, Primary Care at Memorial Hospital, North Conway, NH.
To accommodate the different perspectives on the best care options for GD, Duprey explained that her organization had a healthy discussion that addressed each department’s specific concerns.
“The combined Diabetes and Women’s Health Centers at Memorial Hospital wanted to use more stringent target goals, as advocated by Lois Jovanovic from Samsung Research Center in California, rather than the IDF’s recommendations. However, members of the OB/GYN department were concerned about the methods used to achieve this because they felt that administering the 2-hour GD testing would prove difficult for patients who were required to fast for long periods of time,” Duprey said.
After each department had the opportunity to voice their opinions and concerns, it was determined that, because of the continuum of risk associated with a patient’s blood glucose concentration (the higher the concentration, the greater the risk to the mother and fetus), a healthy blood glucose range would be based on a fasting blood glucose concentration less than 90 mg/dL and on a concentration less than 130 mg/dL 1 hour after initiation of an oral glucose tolerance test (IDF treatment targets are fasting blood sugar >100 mg/dL, 1-hour post prandial of <140 mg/dL and 2 hour less than <120 mg/dL).
Although the current guidelines offer general strategies for GD care, Duprey suggests that each provider independently examine the research (see “suggested references” below) and then adapt these strategies to best fit their own practice.
“The established guidelines and protocols are important to consider, but they should also be adjusted to best serve your patients and the organization of your establishment,” said Duprey.
She also stressed the need to recognize that the management of GD requires a team approach.
“The obstetrician, the mid-wife, the endocrinologist, the dietitian and the diabetes educator should work together and keep each other abreast of care decisions that may affect the treatment they are providing (ie, the patient’s blood sugar numbers, if changes are made to a patient’s insulin therapy or if the patient is being counseled for nutrition therapy as well as medical therapy),” she said.
Duprey and her colleagues have constant communication between departments so that the delivering provider is kept up to date about glucose control and the treatment plan. “The women with GDM report weekly glucose levels and we adjust the insulin plan accordingly,” Duprey said. “The two departments also meet quarterly to discuss potential problems and adjust target goals if necessary.”
— Sara W. MorenoSuggested References
- Coustan DR, Lowe LP, Metzger BE, Dyer AR. The Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study: paving the way for new diagnostic criteria for gestational diabetes mellitus. Am J Obstet Gynecol. 2010;202:e1-e6.
- HAPO Study Cooperative Research Group, Metzger BE, Lowe LP, Dyer AR, Trimble ER, Chaovarindr U, Coustan DR, Hadden DR, McCance DR, Hod M, McIntyre HD, Oats JJ, Persson B, Rogers MS, Sacks DA Hyperglycemia and adverse pregnancy outcomes. N Engl J Med. 2008 May 8;358(19):1991-2002.
- International Association of Diabetes and Pregnancy Study Groups Consensus Panel. International Association of Diabetes and Pregnancy Study Groups recommendations on the diagnosis and classification of hyperglycemia in pregnancy. Diabetes Care. 2010; 33: 676-682