Gestational Diabetes Screening case studies by diabetesasia.org

SCREENING AND DIAGNOSIS

Objectives • At the end of this session you will be able to:

GOI GESTATIONAL DIABETES GUIDELINES 2014

– Define GDM – Identify the risks for development of GDM. – State the prevalence of GDM locally – Explain the reason for identifying and treating GDM – Identify appropriate screening measures – Identify who should be screened – Identify diagnostic criteria

GDM POPULATION BASED STUDY UTTAR PRADESH

Glucose regulation during pregnancy

Definition

• Insulin resistance begins in mid pregnancy and progresses through the third trimester

• Glucose intolerance with onset or first recognition during pregnancy

– A result of maternal adiposity and effects of placental hormones

• Characterized by ß-cell function that is unable to meet the body’s insulin needs

• ß -cells usually make more insulin to compensate for resistance – when they cannot meet the needs hyperglycemia occurs

Buchanan, Wiang, Kjos, Watanabe 2007

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• GDM represents a state of chronic ß-cell Prevalence dysfunction in the face of insulin • The prevalence of GDM is estimated to be 1016.9% in pregnant women depending on the resistance diagnostic criteria used.

• Insulin resistance and insulin levels are different prior to pregnancy in women who develop GDM and those who do not • Changes in insulin sensitivity are similar in both groups during pregnancy • However in GDM women, insulin secretion does not increase adequately

• Prevalence also varies by region and ethnicity.

• Highest prevalence is in South East Asia • Lowest in North America and the Caribbean

• Prevalence higher – in less physically active women.

– In older women – In women with higher BMI – In those with a strong family history of diabetes

WHO, 2013 IDF, 2013

Buchanan, Wiang, Kjos, Watanabe 2007

Risk factors for GDM

Discussion • What are the risk factors for gestational diabetes?

• What risk factors do you see most often in your setting?

High risk

Low risk

• Obesity • Diabetes in 1st degree relative • Previous • history of GDM or glucose intolerance • complicated pregnancy • infant with macrosomia > 3.5 kg • Older age • High risk ethnic group; South Asian, East Asian, Indigenous American or Australian, Hispanic • PCOS

• Age less than 25 years • No previous poor pregnancy outcomes • No diabetes in 1st degree relatives • Normal prepregnancy weight and weight gain during pregnancy • No history of abnormal glucose tolerance

Perkins, Dunn, Jagastia , 2007

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Why diagnose and treat GDM?

Is Hypertension a risk factor?

• Hypertension prior to pregnancy or during 1st trimester – doubled the risk of GDM – independent of maternal weight

• Short term risks for the mother –Development of gestational hypertension, worsening essential hypertension or development of preeclampsia –Operative delivery - related to macrosomia –Polyhydramnios –Premature labour

• Hence all women with hypertension should be screened for GDM • Long term risks for the mother –Development of type 2 diabetes in next ~10 years (30-60% depending on population) –Development of cardiovascular disease CDA, 2013 Metzger, Buchanan, et al. 2007

Hedderson, Ferrara, 2008

Why diagnose and treat GDM? Importance of follow up • Long term follow up studies have shown that most women with GDM will develop diabetes within the first decade after the pregnancy

• Short term risks for the baby –Macrosomia –Neonatal hypoglycemia –Jaundice –Preterm birth –Birth injury –Hypocalcemia/ hypomagnesimia –Respiratory distress syndrome

• Testing after pregnancy is important - more about this later

• Long term risks for the baby –Obesity –Type 2 diabetes

Kim, Newton, Knopp 2002

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Who to screen

Screening

Some guidelines recommend screening all women at the first visit to rule out pre existing type 2 diabetes

- Whom to screen

Most guidelines recommend screening all women for GDM at 24-28 weeks gestation.

- When to screen - How to screen

ADA, 2015 CDA , 2013

When to screen?

When to screen

First trimester

Screening for GDM

• Screening in 1st trimester - to rule out unidentified pre -existing diabetes

• Screening should be done at 24-28 weeks • Diagnosis based on a 75 gm glucose load given in fasting state

• Fasting plasma glucose > 126 mg/dl (7 mmol/L) or • HbA1c >6.5% or • Random >200mg/dl (11.1 mmol/L) or • 2hr value in OGTT >200mg/dl (11.1 mmol/L)

• GDM diagnosed when one or more of the following is present • Fasting 92 - 125 mg/dl • 1 hour post 75 gm load >180 mg/dl • 2 hour post 75 gm load >140mg/dl (DIPSI) (Diabetes in Pregnancy study group in India

• If overt diabetes is detected, it must be treated appropriately.

• If woman tests negative, screening at 32 weeks also may be necessary in presence of high risks World Health Organization, 2013

ADA, 2015

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Center-to-center differences occur in GDM frequency and relative diagnostic importance of fasting, 1-h, and 2-h glucose levels. This may impact strategies used for the diagnosis of GDM

V. Seshiah, V. Balaji, Madhuri S Balaji, A Paneerselvam, Manjula Datta, Diabetes Research In Clinical Practice: 2007. Sept; 77(3): 482-4

Frequency of gestational diabetes mellitus at collaborating centers based on IADPSG consensus panel-recommended criteria: the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) Study.

Sacks DA. etal. Diabetes Care 2012 Mar;35(3):526-8

Diabetes Care 2015, WHO 2013

Diagnostic criteria

Crowther CA. Hiller JE, Moss JR. et al. Effect of treatment of gestational diabetes mellitus. N Engl J Med 2005: Vol. 352. No. 24. 2477-86.

Gayle C. Germain S. Marsh Ms. et al. Comparing pregnancy outcomes for intensive versus routine antenatal treatment of GDM based on a 75 gm OGTT 2 - h blood glucose (>140 mg / dl). Diabetologia. 2010. Vol. 53. Suppl. No. 1, S435.

Paul W. Franks, Helen C. Looker, Sayuko Kobes, Lesite Touger, P. Antonio Tataranni, Robert I. Hanson, and Willliam C. Knowler. Diabetes 2006 55: 460-465.

Jitendra Singh et al. Prevalence of Gestational Diabetes Mellitus (GDM) and its Outcomes in Jammu. JAPI (59): April 2011.

Seshiah V, Balaji V, Arjalakshi C, Madhuri S Balaji, et al. A Single test procedure to diagnose GDM. Acta Diabetologica 46 (1) : 51-54, March 2009

Balaji V, Madhuri Balaji, Anjalakshi C, Cynthia A, Arthi T. Seshiah V. (2011). Diagnosis of gestational diabetes mellitus in Asian-Indian women. India J Endocrinol Metab.

July 2011, Vol. 15, Issue 3, pp. 187-190

Diabetes Care 2015, WHO 2013

Diabetes Care 2015, WHO 2013

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Venous or capillary

How to screen Key considerations for screening in low resource countries

The venous plasma is the gold standard

• Low cost • No requirement for elaborate preparation • • • •

Where laboratory facilities or technicians are not available, capillary glucose estimations may be done using a hand held glucose meter.

High sensitivity and specificity Short turn-around time Be administered by health workers with minimal training Need little maintenance, calibration, or refrigeration

The glucose meter must be standardized with a lab and calibrated against the lab on a regular basis.

Agarwal et al, 2007

Giving the diagnosis

Which of these women has GDM? All have had 75g glucose load at about 25 weeks

Will my baby be ok? – 1st question often asked

–Rupinder, overweight, 35 years old,

Is this temporary? – 2nd question

• fasting 90 mg/dl (5.0 mmol/L), • 1 hr 170mg/d (9.4 mmol/L), • 2hr 135mg/dl (7.5 mmol/L)

Questions provide an opportunity for teaching

–Joanne, 3rd pregnancy, history of big babies,

• Must answer truthfully

–fasting 130 mg/dl (7.2 mmol/L), –1 hr 190mg/dl (10.5 mmol/L) –2 hr 220mg/dl (12.2 mmol/L)

• Must convey importance of management during pregnancy for healthy outcome but also for future health of baby and mother

–Maria, 1st pregnancy, 25 years old, obese, –fasting 90mg/dl (5 mmol/L), –1 hr 168mg/dl (9.3mmol/L) –2 hr 160 mg/dl (8.8mmol/L)

Ø Risk of type 2 diabetes Ø Risk of obesity

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Insulin Therapy Pregnant Woman with GDM

MNT for 2 weeks

2 hr PPPG ³ 120 mg/dl

2 hr PPPG < 120 mg/dl

Start Human Insulin premix 30:70 v Subcutaneous Injection, 30 mlns before breakfast, once a day v Dose of Insulin calculated by blood glucose level Blood glucose Between 120 -160 Between 160-200 More than 200

Continue MNT, repeat 2 hr PPPG after 2 week, still 30 weeks and thereafter,

Dose of Insulin 4 units 6 units 8 units

< 120 mg/dl

120 mg/dl ³

FBG & 2 hour PPPG every 3rd day

FBG <95mg/dl & 2 hrs PPPG <120 mg/dl

FBG <95mg/dl & 2 hrs PPPG <120 mg/dl

FBG <95mg/dl & 2 hrs PPPG <120 mg/dl

Continue same dose of Insulin + MNT

Increase dose of Insulin by 2 U + MNT

Give Inj. Insulin 2 doses pre breakfast - by 4 U

Repeat FBG & 2 hr PPPG every 3rd day till dose of Insulin adjusted

FBG <95mg/dl 2 hrs PPPG <120 mg/dl

FBG <95mg/dl 2 hrs PPPG >120 mg/dl

FBG >95mg/dl 2 hrs PPPG >120 mg/dl

Continue same dose of Insulin +

Increase dose of Insulin by 2 U + MNT

Increase pre breakfast Insulin by 4 U

v Repeat FBG & 2 hr PPPG every 3rd day v Adjust dose of Insulin accordingly till FBG <95mg/dl, 2 hr PPPG <120 mg/dl Continue same dose of Insulin + MNT v v Repeat FBG & 2 hr PPPG 2 weekly before 30weeks & weekly after 30 weeks * Only Injection human premix Insulin 30/70 to be used

* Insulin syringe - 40 IU syringe

* Subcutaneous Injection only

Post Partum Screening

Cut offs for normal blood glucose values are: l. Fasting plasma glucose: = 126 mg/dl

-Post Partum Screening for Diabetes after 6 weeks of delivery to be done in Immunization clinic or MCH clinic, both the facility link through training of staff,this is mandatory for GDM,Post Prandial Blood sugar is to be done and diagnosed Type II Diabetes if blood sugar >=200 mg/dl and treated for Type II diabetes in NCD clinic.

lI. 75 g OGTT 2 hour plasma glucose III. Normal: < 140 mg/dl IV. IGT: 140-199mg/dl

Post Partum follow up of Pregnant Women with GDM:

V. Type II Diabetes: = 200 mg/dl

Immediate postpartum care women with GDM is not different from women without GDM but these women are at high risk to develop Type 2 Diabetes mellitus in future.

VI. Test normal: Woman is counselled about lifestyle modifications, weight monitoring & exercise.VII. Test positive: Woman advised to consult a physician/NCD Clinic.VIII. PW with GDM and theiroffsprings are at increased risk of developing.

Maternal glucose levels usually return to normal after delivery.Nevertheless, a FPG & 2 hr PPPG is performed on the 3rd day of delivery at the place of delivery. For this reason, GDM cases are not discharged after 48 hours unlike other normal PNC cases..

Type II Diabetes mellitus in later life. They should be counselled for healthy lifestyle and behaviour, particularly role of diet & exercise.

Subsequently, ANM to perform 75 g GTT at 6 weeks postpartum to evaluate glycemic status of woman.

IX.GDM should be a part of NCD (Non communicable Disease) programme.

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Gestational Diabetes Uttar Pradesh

Gestational Diabetes Prevalence and Outcome Study in Uttar Pradesh

18 Districts to be covered under NHM District Hospital and CHC to be target Any hospital where more>200 Deliveries in a month

Why Screening All Pregnant Women

Maternal health Clinic HCPs to be trained

Population based Study

3000 Doctors and 6000 Nurse/Paramedical staff to be covered in next 3 years in two full day Certified Training.

57,000 Pregnant Women covered through Single OGTT Test.

Syllabus as IDF and NHM GOI Guidelines

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Materials and Methods A prospective study from September, 2012 to October, 2014 was done at 198 healthcare facilities in antenatal mothers and 24,656 mothers were screened in their 24th to 28th weeks of pregnancy by impaired oral glucose were notea.

During the total study period of September, 2012 to September, 2014 > 55,000 women were supposed to be registered for pregnancy on 198 health centres in and around Kanpur, Uttar Pradesh, India

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Jain, et al: Role of management of blood sugar in improving outcomes in GDM cases Table 2 : Fetal outcomes in gestational diabetes mellitus versus nongestational diabetes mellitus and its relationship with history of previous birth complications.

Outcomes in neonate

Stillbirth Neonatal death Perinatal death

GDM present (n=7641) N (%)

Previous fetal loss present N (%)

p-value

GDM absent (n=8000) N (%)

247 (3.3) 128 (1.6) 375 (4.9)

916 (12) 156 (2) 1072 (14)

< 0.0001 < 0.09 < 0.0001

102(1.2) 56 (0.7) 158 (1.9)

Previous fetal loss p-value present N (%)

212 (2.6) 62 (0.8) 274 (3.4)

<0.0001 <0.5 <0.0001

GDM: Gestational diabetes mellitus

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CONCLUSION Maternal and fetal outcomes in GDM cases are poor. Perinatal and material outcomes in GDM cases are also significantly related to control of blood sugar levels. Therefore, blood sugar levels appear to be an important possible indicator of maternal and perinatal morbidity and mortality in Indian GDM cases.

However, there is a need to unify diagnostic criteria in practices throughout the Indian subcontinent for a better validation of results from this study as well as other GDM studies conducted in

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Objectives After completing this module the participant will be able to § Discuss the value of education in helping women have healthy pregnancies § Implement all components of the teaching process, that is assessment, planning, implementation and evaluation § Discuss ways to make communication more effective § Define what is meant by a patient centered approach to care. § Discuss the impact of gestational diabetes and psychological needs of women and their families

SELF-MANAGEMENT EDUCATION

Diabetes Self-Management Education

Evidence for diabetes education

Purpose

Traditional knowledge-based diabetes education is essential but not sufficient for sustained behaviour change.

To prepare those affected by GDM to § Make informed decisions § Cope with the demands of a pregnancy complicated by GDM § Make changes in their behaviour that support their self-management efforts

(Piette, Weinberger, McPhee, 2000)

While no single strategy or programme shows any clear advantage, interventions that incorporate behavioural and affective components are more effective.

Barlow, Wright, Sheasby, Turner, Hainsworth, 2002 Roter, Hall, Merisca, Nordstrom, Cretin,Svarstad, 1998

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Why is self-management important?

What do people need to understand?

People want to be healthy and have healthy babies.

Their own personal goals, values and feelings

Gestational diabetes needs to be self-managed.

Diabetes care and treatment (advantages/ disadvantages)

Person is responsible for their day-to-day care.

24-hours-a-day management is necessary.

Active, informed self-management leads to better long-term outcomes.

Behaviour change and problem-solving strategies Who is the decision-maker – the woman, the husband, the mother-in-law?

Funnell, Brown, Childs, Haas,Hosey, Jensen, et al.,2007 Norris, Lau, Smith, 2002 Gary, Genkinger, Guallar, Peyrot, Brancati, 2003 Duncan, Birkmeyer, Coughlin, Ouijan, Sherr, Boren, 2009

How to assume day-to-day responsibility

A change in philosophy

Self-management abilities

The ability to self-manage is enhanced by § Considering the individual’s need(s) § Teaching skills to optimise outcomes § Facilitating behaviour change § Providing emotional support

Didactive

Collaborative

Von Kroff, Gruman, Schaefer, 1997 Fisher, Brownson, O’Toole, Shetty, et al., 2005

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Teacher knows all, makes decisions Teacher and patient learn and work together

Reframe our attitudes and behaviours

So what should we do?

Medical Model

Tell the person Cover the basics Judge compliance Teach to the person

SelfManagement Education

Patient centered Ask the person Learn with the person Partnership approach

Educate for informed, self-directed decisions and problem-solving Ask questions Identify problems Address concerns

Teaching does not necessarily result in learning

Teaching

Deliberate interventions that involve sharing information and experiences to meet intended learner outcomes.

When was the last time someone taught you?

Did you learn anything?

Bastable, 2008

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Learning

Active, ongoing process that results in changes in insight, behaviour, perception or motivation

Who is the Learner and Who is the Teacher?

Change may be positive or negative

Communication Skills

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Communicating feelings or attitudes § Verbal § Vocal § Visual

Watch your body language!

Avoid looking like a school teacher!

7% 38% 55% Mehrabian, 1999

"What you do speaks so loudly that I cannot hear what you say."

Ralph Waldo Emerson

Tips for plain speaking

Tips for plain speaking

Introduce your subject and state a purpose

Use the active voice

Paint a picture, make it visual

The person should be the subject of the message

Keep it organised

You may require medication to achieve target blood glucose levels

Move from simple to complex Repetition is important – three times

Vs

Summarise

Some women may require medication to achieve target blood glucose levels

Evaluate Belton, Simpson, 2010

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Develop listening skills

Communication

You can’t talk when you listen

Open-ended question

§ At what time do you take your medication at home? Listen – don’t plan your response Give the person your full attention Paraphrase and ask if you heard correctly

Closed question

§ So, you are saying…. § It sounds like….. § You are wondering if.... § I hear you saying….

§ Do you take your medication on time at home?

The teaching process

Reflective listening

The words the speaker says What the speaker means

Assessment

The words the listener hears

Planning

How the listener interprets the words

Implementation Evaluation

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Assessment

There is a difference

Goals Health professionals and women with GDM may have different opinions on what is important

§ Establish trust § Determine priorities § Assess current health status, knowledge and selfcare practices

Ask the woman what is important to her.

§ Determine family role or other support § Identify available resources Suhonen, Nenonen, Laukka, Valimaki, 2005 Timmins, 2005

§ Identify barriers to learning and self-management

Assessment

Giving the diagnosis Will my baby be ok? – 1st question often asked Is this temporary? – 2nd question

Considerations

Questions provide an opportunity for teaching

§ Should be non-threatening and non-judgemental

Ø Must answer truthfully

§ Consider the cultural and health beliefs of the person

Ø Must convey importance of management during pregnancy for healthy outcome but also for future health of baby and mother

§ Consider physical environment

Ø Risk of type 2 Ø Risk of obesity

§ Building rapport takes time

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Planning

Planning

Develop together

Objectives for each topic

§ What do you want to know? § What must you know?

Reviewed and updated regularly

Offer choices

§ Measurable

§ Individual § Classes

§ Timely

Write learning objectives together

§ Mutually agreed

Objectives should be

§ Specific

Implementation

Implementation Communication is the key

Determine priorities

§ Simple words § Open-ended questions

§ Begin with the learner’s wishes § Most important topics first and last

§ Encouragement

Conducive environment

§ Positive feedback

Simple to complex

§ Positive, caring attitude § Active listening

Be specific

§ Repetition

Repeat! Repeat! Repeat!

Belton, Simpson, 2010

Belton, Simpson, 2010

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Evaluation

Evaluation

Integral part of programme management

Clear description

Through all phases

§ Objectives that are - Measurable

Plans should include how and when to evaluate

- Specific - Centered on the person

Not an afterthought!

- Timed

Evaluation

5 steps to self directed goal setting for behaviour change

Individual evaluation

1. Identify the problem

§ Have objectives been met?

2. Explore feelings

§ Open-ended questions § How are skills used?

3. Set goals

§ “Do you understand?” is not a valid question

4. Make a plan

§ Ask the person with diabetes to explain information to you – “teach-back”

5. Evaluate the results

Belton, Simpson, 2010

Funnell, Anderson,2004

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What is the problem?

How do you feel?

What do you find the easiest thing to manage in your diabetes?

What are your thoughts and feelings about?

What is the most difficult/worst thing about caring for your diabetes?

How will you feel if this doesnâ&#x20AC;&#x2122;t change?

Do you feel ________ about _______?

What are your greatest concerns/fears/ worries?

What makes this so hard for you?

Why is that happening?

Funnell, Anderson,2004

Funnell, Anderson,2004

What do you want?

What will you do?

How does this need to change for you to feel better about it?

Can you/do you want to/will you?

What might work?

What will you gain/give-up?

What has/hasnâ&#x20AC;&#x2122;t worked?

What can you do?

What do you need to do to get started?

What do you want to do?

What one step can you take this week?

On a scale of 1-10, how important is this?

Funnell, Anderson,2004

Funnell, Anderson,2004

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SMART behavioural goals

How did it work?

Eat three meals

What did you learn?

§ I will eat three meals every day starting tomorrow.

What barriers did you encounter?

I will walk more

What support did you have?

§ I will walk for 10 minutes at my lunch hour for four days next week

What did you learn about yourself?

What would you do the same or differently next time?

Funnell, Anderson,2004

Funnell, Anderson,2004

How to respond?

Patient-Centered education Interventions are more effective when § Tailored to individual preferences § Tailored to the person’s social/cultural environment

Avoid judgments

§ Actively engage the person in goal-setting § Incorporate coping skills

Avoid minimising negative experiences

§ Provide follow-up support

Celebrate with - not for Repeat process

Piette, Weinberger, McPhee, 2000

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Activity

Activity Imagine you have just been told you have gestational diabetes

§ What do you feel is supportive behaviour from close family, friends, or the health professional?

Think of three things you would need to change to manage your diabetes

§ What is not supportive?

Then ask yourself

§ If you had gestational diabetes, what would you expect from the people listed above?

§ What would be easiest for you? § What would be hardest?

Summary

References (1 of 2) Anderson, R.M., Funnell, M.M., Arnold, M.S). Using the empowerment approach to help patients change behavior. In Anderson, B. R.R., eds. Practical Psychology for Diabetes Clinicians, 2nd edition . Alexandria: American Diabetes Association; 2002.

Be selective

J., Rubin,

Anderson, R.M., Funnell, M.M. The Art of Empowerment: Stories and Strategies for Diabetes Educators . 2nd ed. Alexandria: American Diabetes Association; 2005.

Bastable, S. Nurse as Educator. 3rd ed. Sudbury, MA: Jones & Bartlett Publishers; 2008.

Be specific

Barlow J, Wright C, Sheasby J, Turner A, Hainsworth J. Self -management approaches for people with chronic conditions: a review. Patient Educ Couns 2002 (48) : 17787.

Belton AB, Simpson N. The How To of Patient Education. 2nd Ed . Streetsville, ON: RJ & Associates; 2010.

Brown SA. Interventions to promote diabetes self -management: State of the science. Diabetes Educ, 25(Suppl ) 1999: 52–61.

Prioritise

Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. 2008 Clinical Practice Guidelines for the Preven tion and Management of Diabetes in Canada. Can J Diab. 32,(suppl 1); 2008 :S82 -83.

Duncan, I., Birkmeyer, C., Coughlin, S., Qijuan, (E)L., Sherr, D., & Boren, S. Assessing the value of diabetes education. The Diabetes Educator 2009; 35: 752-760.

Categorise

Fisher EB, Brownson CA, O’Toole ML, Shetty G et al. Ecological Approaches to Self -Management: The Case of Diabetes, Am J Public Health 2005; 95:1523–1535.

Funnell MM, Anderson RM. Patient empowerment: A look back, a look ahead. Diabetes Educ, 2003; 29: 454-64.

Funnell MM, Anderson RM, Arnold MS, Barr PA, Donnelly MB, Johnson PD, Taylor -Moon D, White NH. (1991). Empowerment: An idea whos e time has come in diabetes patient education. Diabetes Educ 1991; 17: 37-41.

Repeat

Funnell MM, Anderson RM. Empowerment and self -management education. Clinical Diabetes 2004 ; 22:123-127.

Funnell, M.M., Brown, T.L., Childs, B.P., Haas, L.B., Hosey, G.M., Jensen, B., Maryniuk, M., Peyrot, M., Piette, J.D., Reader, D., Siminerio, L.M., Weinger, K. and Weiss M.A. National Standards for Diabetes Self -management Education. Diabetes Care 2007; 30:1630-1637.

Reinforce

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References (2 of 2) Gary, T.L., Genkinger, J.M., Guallar, E., Peyrot, M. & Brancati, F.L. Meta -analysis of randomized educational and behavioral interventions in type 2 diabetes. The Diabetes Educator 2003;29:488 -501.

Harvey, J.N., Lawson, V. L. The importance of health belief models in determining self -care behaviour in diabetes, Diabetic Medicine 2009;26:5â&#x20AC;&#x201C;13.

International Diabetes Federation. Standards for Diabetes Education, 4th ed. Brussels: IDF; 2009.

International Diabetes Federation. Diabetes Atlas, 3rd ed. Brussels: IDF; 2009.

Knowles, M. The Adult Learner: a neglected species. Houston, Gulf Publishing Co; 1984.

Mehrabian, A. In P. Bender. Secrets of Power Presentations. Webcom : Toronto The Achievement Group ;1999.

Norris, S.L., Lau, J., Smith, S.J., Schmid , C.H., Engelgau, M.M. Self -management education for adults with type 2 diabetes: A meta -analysis on the effect on glycemic control. Diabetes Care 2002;25:1159 71.

Piette, J.D., Glasgow, R.E. Education and self -monitoring of blood glucose. In Gerstein HC, Haynes RB, eds. Evidence -based diabetes ca re.

Hamilton: B.C. Decker, Inc. 2001.

Piette, J.D., Weinberger, M., McPhee, S.J. The effect of automated calls with telephone nurse follow -up on patient-centered outcomes of diabetes care: a randomized, controlled trial. Medical Care 2000;38:218 30.

Roter, D.L., Hall, J.A., Merisca, R., Nordstrom, B., Cretin, D., Svarstad , B. Effectiveness of interventions to improve patient compliance: A meta analysis. Medical Care 1998;36:113861.

Simmons, David. Personal barriers to diabetes care: Is it me, them or us? Diabetes Spectrum 2001:10 -12.

Skinner, T.C., Cradock, S., Arundel, F., Graham, W. Four theories and a philosophy: self diagnosed with type 2 diabetes. Diabetes Spectrum 2003;16:75 -80.

-management education for individuals ne wly

Suhonen, R., Nenonen, H., Laukka, A., Valimaki , M. Patientsâ&#x20AC;&#x2122; informational needs and information received in hospital. J Clin Nursing 2005; 14(10):1167-76.

Timmins, F. Contemporary issue in coronary care nursing. New York:

Routledge ; 2005.

Von Kroff , M., Gruman, J., Schaefer, J., et al. Collaborative management of chronic illness. Ann Intern Med 1997;127(12):1097 -102.

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Objectives • Discuss factors that should be considered when doing a nutritional assessment

Nutrition Therapy In Gestational Diabetes Part 1 – Assessment Part 2 – Recommendations Part 3 – Education

• Discuss appropriate balance of meals/snacks through the day • Discuss appropriate weight gain based on preconception weight • Discuss the value of a late night snack to prevent early morning ketosis • Evaluate the importance of folic acid supplementation before and during pregnancy • Discuss the value of multivitamin supplementation during pregnancy

Goals for MNT in GDM

Assessing from an Interview • • • • • • •

•Optimal nutrition and weight gain for fetus and mother •Maternal euglycemia •Reduce the risk of diabetes related complications for the mother and child •Minimize the maternal and infant morbidity and mortality rates •Integrate diet, activity and pharmalogic therapy

• • •

•Introducing healthy habits that can prevent or delay onset of type 2 DM

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Age Obstetric history Weight History Significant medical history (co-morbidities) Food preferences and eating habits Food Allergies Individual psychological, social and physical status Lifestyle, culture, and socio-economic status Oral health Readiness to change

Assessing from Clinical Information

Body Mass Index (BMI) Use pre pregnancy weight for calculations

Laboratory tests to determine clinical status § OGTT, fasting glucose, HbA1c level

Weight and height measurements to calculate BMI: BMI = weight in kg/(height in m)2

§ SMBG § Urine ketones and proteins § lipid profile (cholesterol — HDL, LDL) § Haemoglobin, creatinine, thyroid function

Standard BMI normograms:

§ Blood pressure

Asian

<18.5 kg/m2

Underweight

Anthropometric Data § Height , Weight and BMI

Current medications and nutrition supplements

ADA norms

Normal BMI

18.0-22.9 kg/m2

18.5-24.9 kg/m2

Overweight

23.0-24.9 kg/m2

25.0-29.9 kg/m2

Obesity

>25 kg/m2

> 30 kg/m2

Nutrition Assessment

Weight Gain Chart •Plot weight on a prenatal weight gain grid to obtain an accurate assessment of total pregnancy weight gain and rate of weight gain.

Nutrition history § usual food intake recorded through interview

•Determine if weight gain is above, at or below the recommended range.

Dietary recall

•If weight gain has already exceeded the recommended range, slow weight gain in order to prevent further excess gain.

§ food and drink consumed in previous 24 hours (24-hour recall)

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Issues with Dietary Recalls

Activity – Think of things to check for when doing a dietary history.

•Based on memory •Based on willingness to disclose the truth to a healthcare provider •Nutrient intake and long-term habits are not represented •Accurate estimations of food quantities/ingredients are difficult

Composition of Food and Drinks Macro-nutrients § protein

Nutrition Therapy In Gestational Diabetes

§ carbohydrates

Part 1 – Assessment Part 2 – Recommendations Part 3 – Education

§ fats Micro-nutrients § vitamins § minerals

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Dietary Recommendations for GDM Macronutrient composition Nutrient Carbohydrates

% of daily calorie intake 45-65%

Fats

20-35%

Protein

10-35%

Dietary fibre 28g/day Institute Of Medicine 2002

Proteins

Fluids

•Essential for all body functions

• Provide amino acids •40-60% of body weight is water

• Help to build muscle mass

•Important to drink adequate amounts

• Animal sources

of fluid

• Plant sources •Restrictions may be required in case

• 1 g of protein gives 4 kcal energy

of pedal edema

32

Protein Recommendations

Carbohydrates

•1.1 g protein per kg bodyweight per day •10-35% of total energy per day

• Provide main source of energy for the body (45-65%) – individualized

•Animal protein often high in fat, especially saturated.

• Nutrient that most influences blood glucose levels

•Attention must be paid to meeting the protein requirements of women who are vegetarians or vegans

• Source of simple sugars – glucose, fructose • 1 g of carbohydrate provides 4 kcal

Carbohydrates And Meal Planning

Activity •Amount and source of carbohydrates is considered when planning meals •Recommended source of carbohydrates is mainly from

Name some of the common carbohydrates and staple foods in your region.

- whole grains: wheat, rice, pasta, bread, rice, wheat, barley, oats, maize and corn - legumes, beans, pulses (bengal gram, black gram, rajma) - fruit and vegetables - milk

33

Carbohydrate (CHO) content of common foods Benefits of Fibre Food

Amount

Serving

CHO (g)

Bread, whole wheat

28 g

1 slice

11

Rice (cooked)

75 g

0.3 cup

13

125 mL

0.5 cup

16

Chappati

44 g

1 small

19

Corn meal

45 mL

3 tbsps

16

84 g

1 small

15

Couscous, cooked

125 mL

0.5 cup

17

Lentils

250 mL

1 cup

15

Banana

101 g

1 small

20

Pasta

Potato

A high-fibre diet is healthy Mixture of soluble and insoluble fibre - slows absorption of glucose - reduces absorption of dietary fats - retains water to soften stool - may reduce the risk of colon cancer - may reduce the risk of heart disease

Fibre Recommendations

Glycaemic Index (GI)

Recommended amounts of total fibre : 28 g per day Sources of insoluble fibre include: wheat bran, whole grains, seeds, fruits and vegetables Sources of soluble fibre: legumes (beans), oat bran, barley, apples, citrus fruits

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Ranks carbohydrate-rich foods according to the increase in blood glucose levels they cause in comparison with a standard food (white bread/glucose).

Factors Affecting the Glycaemic Index

Glycaemic Response of Glucose and Lentils

Type of sugar

l e v e l e s o c u l g d o o l B

- glucose, fructose, galactose

Nature of starch - amylose, amylopectin

Starch-nutrient interactions Glucose

- resistant starch

Lentils

Cooking/food processing

Reprinted with permission from CDA, 2004

Factors Affecting The Glycaemic Index

Glycaemic Index of Foods

Processing/form of the food

Low glycaemic Intermediate High glycaemic index foods glycaemic index index

- gelatinization - particle size - cellular structure

Presence of other food components - fat and protein - dietary fibre

Kalergis, De Grandpre, Andersons, 2005

Oats

Multigrain bread

White Bread

Lentils/dhal

Some rice (long grain)

White Rice

Yogurt

Pasta

Processed breakfast cereal

Milk

Bananas

Glucose

Most Fruits and vegetables

Grapes

Mashed and baked potatoes CDA , 2006

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Low GI - Advantages

Fats

Promotes healthy eating

• The most concentrated source of energy

Increases fibre intake

• Foods may contain fat naturally or have it added during cooking

Helps control - appetite - blood glucose levels - blood lipid levels

• 1 g fat provides 9 kcal

Fats

Fat Recommendations • Common sources of different fats • Polyunsaturated – safflower oil, sunflower oil, corn oil • Monounsaturated – olive oil, canola oil, rape seed oil, groundnut oil, mustard oil, sesame oil

• Low in polyunsaturated fats (up to 10% of total daily energy) • High in monounsaturated fats (>10%)

• Saturated – red meats, butter, cheese, margarine, ghee (clarified butter), whole milk, cream, lard • Trans fats – baked products, biscuits, cakes

• Low in saturated fats (<10%) • Trans or hydrogenated fat should be avoided

36

Vitamins • Organic substances present in very small amounts in food

Activity

• Essential to good health

Identify major sources of fats in foods in your region.

• A balanced meal automatically provides all necessary vitamins • Either fat-soluble or water-soluble • In some countries foods are “fortified” with vitamins and minerals

Vitamin Recommendations

Minerals

Daily multivitamin supplement should be added as they are often not met by diet alone.

•Substance present in bones, teeth, soft tissue, muscle, blood and nerve cells

Multivitamin content varies depending on the product used.

•Help maintain physiological processes, strengthen skeletal structures, preserve heart and brain function and muscle and nerve systems •Act as a catalyst to essential enzymatic reactions

Women at higher risk for dietary deficiencies include multiple gestation, heavy smokers, adolescents, complete vegetarians, substance abusers, and women with lactase deficiency.

•Low levels of minerals puts stress on essential life functions

37

Minerals And Trace Elements

Sodium Recommendations •Most people consume too much salt •Sodium restriction may be advised in case of uncontrolled hypertension and edema

• A balanced diet supplies minerals and trace elements • Supplements are important as requirements are higher during pregnancy

•Targets for daily sodium intake

§ Calcium supplementation § Iron supplementation § Folic acid supplementation 0.4mg (should be started three months prior to conception)

Age

Adequate Intake (mg/day)

Upper limit (mg/day)

14-50 51-70 over 70

1500 1300 1200

2300 2300 2300

Health Canada, 2005

Lowering Salt Intake

Substance Use The following substances should be avoided completely once the woman plans a pregnancy

• Sodium content is often high in restaurant foods • Encourage meal plans with • more fresh foods – fruits and vegetable • less processed, fast, convenience or canned foods • herbs and spices used when cooking instead of salt.

§ Tobacco in any form § Alcohol § Drugs (street, illegal)

• Teach people to read food labels.

• Choose salt free, reduced or low in sodium foods

38

Food Labels Sweeteners Sweeteners that increase blood glucose § Sugar, honey § Polydextrose & Sugar alcohols – maltitol, sorbitol, Xylitol

•Nutrition facts •Serving size (if available)

Sweeteners that do not increase blood glucose § Acesulfame potassium § Aspartame *Must be avoided during § Cyclamate* pregnancy § Saccharin* § Sucralose To check with Health care team

•Nutrient content •Ingredients

prior to starting use of sweeteners

•Nutrition information

Activity

Food labels Nutrition Facts Per 1 cup (250g) Amount

% Daily Value

Practice reading a food label

Calories 100 Fat 0g Saturated 0 g + Trans 0 g Cholesterol 0 mg

0% 0%

Calculate the following:

Sodium 3 mg

0%

Carbohydrate 26 g

8%

§ Serving size § Number of calories in one serving § Number of carbohydrates in one serving § Amount of fat in one serving

4%

Fibre 1 g Sugars 23 g Protein 2 g Vitamin A Calcium

20 % 2%

Vitamin C Iron

170 % 2%

Food labels may look different in different countries, but the same information is usually available

39

Summary of Dietary Recommendations •Carbohydrates: 45-65%

Nutrition Therapy in Gestational Diabetes

•Dietary fibre: 28 g / day Part 1 – Assessment Part 2 – Recommendations Part 3 – Education

•Fats: 20-35% •Protein: 10-35% (1.1 g/kg/day) •Sodium: 1500 - 2300 mg/day

Meal Planning

Approach To Meal Planning Before deciding on the content of meal plans, consider:

A uniform approach to meal planning does not work for everyone

• • • • •

A flexible plan or a variety of approaches is necessary to address different needs

40

Food preferences and eating habits Previous experience, knowledge and skills Current clinical, psychological and dietary status Appropriate clinical and nutrition goals Lifestyle factors

Nutrition Education: Tools

What to teach and when?

Basic • Basic information about nutrition

•Awareness of the basics of healthy eating/balance of good health

• Nutrient requirements • Healthy eating guidelines • Making healthy food choices

•Food Pyramid

• Self-management training and use of educational tools

•The plate model

Food Guides

Healthy eating

•Australian Food Guide

•Eating Well with Canada’s Food Guide

Recommended Number of Food Guide Servings per Day Children Age In Years

2-3

Sex

4-8

Teens 9-13

Girls and Boys

Adults

14-18

19-50

51+

Females

Males

Females

Males

Females

Males

Vegetables and fruits

4

5

6

7

8

7-8

8-10

7

7

Grain Products

3

4

6

6

7

6-7

8

6

7

Milk and Alternatives

2

2

3-4

3-4

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2

2

3

3

Meat and Alternatives

1

1

1-2

2

3

2

3

2

3

The chart above shows how many Food Guide Servings you need from each of the four food groups every day.

Having the amount and tyoe of food recommended and following the tips in Canada’s Food Guide will help: § Meet your needs for vitamins, minerals and other nutrients. § Reduce your risk of obesity, type 2 diabetes, heart disease, certain types of cancer and osteoporosis. § Contribute to your overall health and vitality.

41

Food pyramid â&#x20AC;&#x201C; India

Balance of good health - UK eat well plate Bread, cereals and potatoes

Fruits and vegetables

Meat, fish and protein alternatives

Foods rich in sugars and fat

Milk and dairy products

(Reproduced with kind permission of the Food Standards Agency)

Diabetes India, 2005

These graphics will change to be the same as the new ones going in the booklets

Activity Draw on a paper plate either: The recommended proportions of foods from your region The proportions of what you ate last night

Healthy food plate (Source: Diabetes Education Modules 2011)

Example of Healthy food plate with South-Asian foods

42

Practical Advice/ 2

Practical Advice/ 1 • Make healthy food choices • Avoid fatty foods • Use low-fat cooking methods • Substitute high fat foods with low fat options; e.g use low fat milk • Minimize consumption of sugar and salt • Use fresh foods instead of preserved or canned foods

Practical Advice/ 3

•At least five servings of fruit and vegetables per day - Choose colourful fruits and vegetables - Choose whole fruits over juices

•Replace high calorie beverages with water •Eat small frequent meals that are well spaced •Do not skip meals •Calories should be restricted especially if overweight •Eat free foods as desired, include in between major meals

References

•One low GI food at each meal •Mix high and low GI food = intermediate GI meal •Substitute high GI cereals/breads/rice with low GI cereals/bread/rice •Eat low GI snacks instead of high GI snacks (remember to choose lower fat snacks)

43

•

American Diabetes Association. (2013). Clinical Practice Recommendations. Diabetes Care, 36, (supple 1).

•

Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. (2013). Canadian Diabetes Association 2013. Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada.

Canadian Journal of Diabetes, 37(suppl 1).

•

Canadian Diabetes Association. (2006). Beyond the Basics. Toronto ON: Canadian Diabetes Association

•

Diabetes India. (2005). Diet Charts. Retreived September 13, 2010. http://www.diabetesindia.com/diabetes/diet_chart.htm

•

Franz MJ, Evert AB (Eds.) American Diabetes Association Guide to Nutrition Therapy for Diabetes. 2nd Ed. 1012

•

Health Canada. Food and Nutrition. Sodium. It’s Your Health. Available from: http://www.hc-sc.gc.ca/hlvs/iyh-vsv/food-aliment/sodium-eng.php

•

Health Canada. (2005). Food and Nutrition. The Issue of sodium. (Retrieved September 13, 2010) http://www.hc-sc.gc.ca/fn-an/nutrition/reference/table/ref_elements_tbl-eng.php

•

Institute of Medicine 2002 http://www.iom.edu/Global/News%20Announcements/~/media/C5CD2DD7840544979A549EC47E56A02B.a shx

•

Institute Of Medicine 2009 http://www.ncbi.nlm.nih.gov/books/NBK32799/table/summary.t1/?report=objectonly

•

Kalergis, M., De Grandpre, E., Andersons, C. (2005). The Role of Glycemic Index in the Prevention and Management of Diabetes: A Review and Discussion. Can J of Diab, 29(1), 27-38.

•

Misra A, Chowbey P, Makkar PM, Vikram NK, Wasir JS, Chadha D, et al. Consensus Statement for Diagnosis of Obesity, Abdominal Obesity and the Metabolic Syndrome for Asian Indians and Recommendations for Physical Activity, Medical and Surgical Management. JAPI 2009;57.

Objectives

Exercise in Gestational Diabetes

After completing this Module the participant will be able to § Discuss the value of regular activity § Recognize the limitations regarding exercise especially during the third trimester

Types of Exercise

Background • Physical activity can prevent or delay type 2 DM in individuals at risk

Aerobic Exercise: § Aerobic means “using oxygen for energy”.

• Studies show that pre-pregnancy exercise helps to prevent GDM during pregnancy.

• use large muscles (legs, shoulders, chest, and arms) • can be performed continuously • burns calories and is critical to losing fat and keeping it off.

• More intensity equals more benefits.

• Any activity has more benefit than no physical activity in prevention of GDM.

§ Resistance Training • helps in increasing the number of Insulin receptors • Improves sensitivity of insulin receptors in skeletal muscle • maintains muscle while losing fat.

Oken et al, 2006, Zhang et al, 2006, Dempsey JC et al 2004

• Upper arm resistance training shown to lower blood glucose

44

Where to start

Benefits of Exercise in GDM Exercise causes significant decrease in:

Activity should be discussed with a medical practitioner

§ fasting plasma glucose § 1hour plasma glucose § HbA1c § insulin requirement

§ Start with light to moderate exercise, i.e. 10 minute walk after meals, upper body exercises while seated § 30 minutes a day total is recommended

Appropriate exercise § Low-impact aerobics, swimming, yoga, light weights

Jovanovic-Peterson et al 1989; Brankston et al, 2004.

Medical contraindications for exercise in pregnancy

Relative contraindications for exercise in pregnancy

• Haemodynamically significant heart disease, eg. Modsevere valvular heart disease, cardiomyopathy, cyanotic heart disease • Restrictive lung disease • Preclampsia • Incompetent cervix/ cerclage • Multiple gestation at risk for premature labour • Persistent second or third trimester bleeding • Placenta praevia after 26 weeks gestation • Ruptured membranes

• • • • • • •

Severe anaemia Unevaluated cardiac arrhythmia Chronic bronchitis Poorly controlled type 1 diabetes Extreme morbid obesity (BMI > 40) Extreme Underweight (BMI< 12) Exercise in multiple gestation should be supervised

• • • • • • •

History of extreme sedentary lifestyle Poorly controlled hypertension Orthopedic limitations Poorly controlled seizure disorder Poorly controlled hyperthyroidism Heavy smoker Intrauterine growth restriction in current pregnancy

ACOG Committee on Obstetric Practice, 2002.

ACOG Committee on Obstetric Practice, 2002.

45

Education before exercise

Caution

• Avoid exercise in supine position after 2nd trimester (due

Strenuous exercise could cause

to possibility of supine hypotension)

§ Fetal distress § Uterine contractions § Maternal hypertension § Increased risk of soft tissue injury

• Heart rate should not exceed 140 bpm • Stop activity if contractions are felt • If on insulin • avoid exercising when insulin is peaking • know how to recognize and treat hypoglycemia • carry fast acting glucose

Need to monitor § Blood glucose before and after exercise for women on insulin or sulphonylureas

Harris, White, 2005

Summary

References

•

Any physical activity is better than no physical activity during pregnancy

•

Even lower levels of physical activity have shown benefit in control of blood sugars.

•

Aerobic activity of moderate intensity for 30mins/day on most days of the week has shown benefits in metabolic control.

•

Upper body resistance training in addition to aerobic activity has probable synergistic effects in lowering blood sugars.

Contd....

Brankson gN, Mitchell BF, Ryan EA, Okun NB. Resistance exercise decreases the need for insujlin in overeight women with gestational diabetes mellitus. Am. J. Obstet Gynecol 2004; 190:188-93.

Dempsey JC, Butler CL, Sorenson TK et al. A case-control study of maternal recreational physical activity and risk of gestational diabetes mellitus. Diabetes Res Clin Practi 2004;66 203-215.

Jovanovic-Peterson L, Durak EP, Peterson CM, Randomised trial of diet versus diet plus cardiovascular conditioning on glucose levels in gestational diabetes. Am. J. Obstet Gynecol. 1989; 161: 415-419.

ACOG Committee on Obstetric Practice. ACOG committee opinion. Number 267, January 2002: exercise during pregnancy and the postpartum period. Inj. J. Gynecal Obstet 2002; 77: 79-81.

Dempsy et al 2004, Liu et al 2008,Jovanovic -Peterson et al, 1989, ACOG Committee on Obstetric Practice, 2002

46

References Artal R, Oâ&#x20AC;&#x2122;Toole M. Guidelines of the American College of Obstetricians and Gynecologists for exercise during pregnancy and the postpartum period. Br J Sports Med. 2003 February;37(1):6â&#x20AC;&#x201C;12. doi: 10.1136/bjsm.37.1.6 Harris, GD, White, RD. Diabetes management and exercise in pregnant patients with diabetes. Clinical Diabetes. 2005;23(4):165-168.

Metzger BE, Buchanan TA, Coustan DR, De Leiva A, Hadden DR, Hod M. Summary and recommendations of the fifth international workshop-conference on gestational diabetes mellitus, Diabetes Care. 2007; 30(suppl 2):S251-260.

Oken E, Ning Y, Rifas-Shiman SI, Radesky JS, Rich-Edwards JW, Gillman MW. Association of physical activity and inactivity before and during pregnancy with glucose tolerance. Obstet Gynecol 2006; 208: 2100-7.

Zhang C, Solomon CG, Manson JE, Hu FB. A prospective study of pregravid physical activity and sedentary behaviours in relation to the risk of gestational diabetes mellitus. Arch Intern Med. 2006; 166: 543-8 Contd.....

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Objectives After completing this Module the participant will be able to

Monitoring During Pregnancy

• Discuss the benefit of self monitoring of blood glucose (SMBG) when available • Determine appropriate timing of SMBG depending on availability of strips • Decide on expected target values for fasting and post prandial BG • Discuss methods of fetal monitoring

Daily monitoring provides immediate feedback to the mother and is the ideal.

•Woman must know targets •Must know how to respond to results out of target range When resources are limited •Once weekly monitoring until targets reached nd •When targets reached check once per month until late in the 2 trimester •Then increase to every 1 - 2 weeks

48

Targets

HbA1C during pregnancy?

• Fasting: <95 mg/dl ( < 5.3 mmol/l)

May be valuable in determining those who had undiagnosed diabetes prior to pregnancy

• 1 hour PP : < 140 mg/dl ( < 7.8 mmol/L)

May give indication of overall control during pregnancy BUT

• 2 hour PP : < 120 mg/dl ( < 6.7 mmol/L)

§ Not valuable for day-to-day management during pregnancy § May give falsely low results § Other factors such as anemia make it unreliable

Metzger, Buchanan et al 2007 Seshiah Balaji, 2006 ADA 2015

HbA1C during pregnancy?

Fetal movement counting

May be valuable in determining those who had undiagnosed diabetes prior to pregnancy

The rationale - decreased fetal movements may signal decreased oxygenation which often precedes fetal demise

May give indication of overall control during pregnancy BUT

Reduction of activity associated with chronic fetal distress Among inactive fetuses, approximately 50% are either stillborn, tolerate labor poorly or require resuscitation at birth

§ Not valuable for day-to-day management during pregnancy § May give falsely low results § Other factors such as anemia make it unreliable

1

Lalor et al 2008

49

FETAL MOVEMENT Fetal movement counting

• Inexpensive, involving the mother, easy to use

The rationale - decreased fetal movements may signal decreased oxygenation which often precedes fetal demise

• Foetal movements related to maternal glucose levels

Reduction of activity associated with chronic fetal distress

• Patients taught generally from late third trimester - after 35 weeks at routine ANC

Among inactive fetuses, approximately 50% are either stillborn, tolerate labor poorly or require resuscitation at birth

• Reduced activity needs to be evaluated by NST (non stress test) Lalor et al 2008

Ultrasound fetal measurement

Other parameters Blood pressure – every visit

Early pregnancy scan - 7-8 weeks

Values above 140/90 mm Hg are of concern If > 140/90 re measure same day; If > 150/100 initiate therapy

• Dating and viability

If BP > 140/90 check urine for albuminuria

Estimate Urine albumin / sugar dip stick

• Dating important to offer appropriate timing for antenatal visits/ scans and delivery

Though urine sugar not of value in a known GDM, albumin is important as sometimes predates BP in preeclampsia

• Accurate dating prevents iatrogenic prematurity

50