Guidelines for Management of Hyperglycemia in Pregnancy (HIP) by Society of Obstetricians & Gynaecologists of Pakistan (SOGP)

• Definition:

  • GDM is defined as any degree of glucose intolerance with onset or first recognition during pregnancy, regardless of whether it persists post-pregnancy.
  • Women meeting diagnostic criteria for diabetes mellitus (DM) during pregnancy are considered to have preexisting DM or Pre-Gestational DM.

• Current Statistics 📊:

  • 25% of the population in Pakistan suffers from Type 2 diabetes mellitus (T2DM).
  • 76.2% and 62.1% are overweight and obese, respectively, contributing to higher risks of GDM.

• Risk Factors ⚠️:

  • Obesity, higher BMI, and insulin resistance.
  • Lack of metabolic testing outside pregnancy emphasizes the need for early screening to prevent fetal anomalies during organogenesis (0–8 weeks).

Screening and Diagnosis of GDM 🔍

Recommendation 1: Blood Glucose (BG) Screening

1. Screening Methodology:

   • Perform a 75 g 2-hour OGTT at the first antenatal visit, regardless of risk factors.
   • Procedure:
     • Fast for 8 hours.
     • Dissolve 75 g glucose in 250 cc of water and drink over 3–5 minutes.
     • Measure BG levels fasting and 2 hours post-load.

2. Diagnostic Values for GDM 📋:

   • Fasting: ≥92 mg/dL (5.1 mmol/L).
   • 1-hour post-load: ≥180 mg/dL (10 mmol/L).
   • 2-hour post-load: ≥153 mg/dL (8.5 mmol/L).
   • Meeting any one value confirms GDM.

3. High-Risk Groups for GDM:

   • Family history of diabetes.
   • Previous GDM or macrosomia.
   • Maternal obesity or sedentary lifestyle.
   • Polycystic ovarian disease (PCOD).
   • Ethnicity (e.g., Asians).
   • Advanced maternal age (>35 years).
   • History of polyhydramnios, fetal anomalies, or recurrent pregnancy losses.

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Management of GDM 🩺

Recommendation 2: Education and Counseling

1. Self-Monitoring of Blood Glucose (SMBG):

   • Regular monitoring:
     • Fasting glucose.
     • 1–2 hours post-meals.
   • Customize frequency based on glycemic control.

2. Continuous Glucose Monitoring System (CGMS):

   • Measures glucose every 5 minutes.
   • Useful for identifying glucose variability but expensive in resource-limited settings.

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Recommendation 3: Treatment Options

Non-Pharmacological Treatment (NPT):

1. Lifestyle Modifications:
   • Exercise:
     • Moderate activity for 30 minutes/day.
     • Brisk walking or seated exercises post-meals.
   • Diet:
     • Minimum 175 g carbohydrates and 28 g fiber/day.
     • Replace high-GI foods with low-GI options (e.g., lentils, milk, carrots).
     • Avoid artificial sweeteners.

Pharmacological Treatment (PT):

1. Oral Hypoglycemic Drugs (OHD):
   • Metformin is safe and effective.
   • Avoid Sulphonylureas unless clinically justified.
2. Insulin 💉:
   • Gold standard for GDM management.
   • Types:
     • Basal Insulin: NPH, Detemir.
     • Bolus Insulin: Aspart, Lispro.

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Control Targets During Pregnancy 🎯

Parameter	Recommended Level
Fasting BG	<95 mg/dL (<5.3 mmol/L)
1-hour Postprandial	<140 mg/dL (<7.8 mmol/L)
2-hour Postprandial	<120 mg/dL (<6.7 mmol/L)

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PREGNANY CARE

📅 Booking Appointment: Up to 12 Weeks

• 📝 Education and Counseling:
  • 📌 Educate women and family about glycemic control, glucometer use, and frequent SMBG.
  • 📌 Discuss the impact of diabetes on pregnancy, breastfeeding, and neonatal care.
  • ⚠️ Highlight risks of non-compliance.
  • 💡 Evaluate joint diabetes and antenatal clinics.
  • 👁️ Perform retinal and renal evaluation for preexisting diabetes (if not done in the last 3 months).
• 💊 Review Medication:
  • Replace contraindicated medications (e.g., ACE inhibitors, ARBs, statins) with safer options.
  • 🥗 Start folic acid (5 mg daily for 3 months) and low-dose aspirin (75–150 mg daily) by 12 weeks or as per recommendation.
• 🍎 Lifestyle and Diet:
  • 🌟 Emphasize appropriate blood glucose control.
• 🧪 Investigations at Booking Visit:
  • Monitoring HbA1c:

    • Measure HbA1c at the booking appointment to assess the level of risk during pregnancy.

  • Investigations at Booking Visit:

    • Complete blood profile.
    • Blood grouping and Rh factor.
    • Urine analysis.
    • Hepatitis B and C screening.
    • Thyroid profile (TSH, FT3, FT4, TPO antibodies).
    • Ultrasound for:
      • Confirmation of pregnancy.
      • Dating.
      • Assessment of fetal viability.
      • Checking for single or multiple pregnancies.
      • Measuring nuchal thickness to rule out anencephaly.
  
  

📅 13–24 Weeks

• 🕒 Regular ANC visits every 1–2 weeks.
• 🎯 Optimize glycemic control, adjust/add insulin as needed.

📅 20–22 Weeks

• 💊 Medication Review:
  • Continue adjusting medications for glycemic control.
• 📸 Ultrasound:
  • Ultrasound:
    • Perform a detailed anomaly scan, including:
      • Four-chamber view of the fetal heart.
      • Outflow tracts.
      • Three vessels.
• 💉 Immunization:
  • Administer the first dose of tetanus toxoid.

📅 24–28 Weeks

• 🍬 Oral Glucose Tolerance Test (OGTT):
  • Conduct sequential screening for OGTT if previously screen negative.
• ❤️ 2-D Fetal Echocardiography:
  • Perform if cardiac anomaly is suspected.

📅 28–34 Weeks

• 🏥Routine ANC:
  • Frequent antenatal care (ANC) visits with regular review of glycemic control.
• Immunization:
  • Administer the second dose of tetanus toxoid between 26–28 weeks.
• 💉Steroid Administration:
  • Use prophylactic corticosteroid therapy for obstetric indications at the same dose and gestational age as non-diabetic pregnancies.
  • Adjust insulin post-steroid administration per Recommendation 3.4.1.
• 📊 Monitoring:
  • Weekly assessment of:
    • Fetal growth.
    • Abdominal circumference.
    • Amniotic fluid volume.
• Investigations:
  • Repeat CBC and urine DR.
  • Conduct screening and diagnostic tests for BG (if not previously done) either:
    • Before administering steroids.
    • Or at least 7 days post-steroid administration.
 

📅 34–36 Weeks

1. 📸 Ultrasound:

   • Monitor:
     • 🍼 Fetal growth.
     • 📏 Abdominal circumference.
     • 🌊 Amniotic fluid volume.
     • 📍 Placental localization.

2. 📊 Doppler and Biophysical Profile:

   • Conduct Doppler studies for:
     • ⚠️ Clinical evidence or risk of fetal growth restriction.
     • 💔 Preexisting vasculopathy.

3. 🍬 OGTT:

   • Offer sequential 75 g OGTT screening for previously screen-negative women.

4. 👩‍⚕️ Counseling:

   • Discuss:
     • 🕒 Timing and mode of birth.
     • 💉 Regional analgesia and anesthesia options.
     • 🏥 Neonatal care (e.g., NICU admission, early breastfeeding).
     • 🔄 Postpartum care, including BG screening and contraceptive advice.

📅 37–40 Weeks

1. 🩺 Glycemic Monitoring:

   • Continue to assess glycemic control.

2. 🏥 Mode of Delivery:

   • Offer induction of labor or cesarean section for:
     • ❌ Uncontrolled diabetes.
     • 🛑 Obstetric complications.

3. 🌟 Spontaneous Onset of Labor:

   • For uncomplicated pregnancies:
     • Wait for spontaneous labor onset until 38–39 weeks if:
       • 🔵 Diabetes is well-controlled.
       • 🍼 No fetal compromise exists.
   • Ensure delivery no later than 39 weeks for all pregnant women with diabetes.

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💡 Intrapartum Management

6.1 Timing and Mode of Delivery

• ⏰ Timing of Delivery:
  • 🌟 Well-controlled diabetes: Spontaneous labor up to 38–39 weeks.
  • ⚠️ Uncontrolled diabetes: Consider earlier induction (after 37 weeks).
• 👶 Mode of Delivery:
  • 💪 Vaginal delivery preferred for well-controlled diabetes.
  • 🚨 Cesarean for fetal macrosomia, obstetric complications, or preeclampsia.

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🤱 Postpartum Care

7.3 Postpartum Counseling

• Educate women on:
  • 🌟 Lifestyle modifications and healthy weight management.
  • Importance of follow-up for glycemic control within 6–12 weeks.
  • Risks of future Type 2 Diabetes Mellitus (T2DM) and prevention strategies.

7.4 Postpartum Blood Sugar Screening

• Conduct OGTT at 6 weeks postpartum.
• Follow WHO criteria for diagnosing diabetes or prediabetes.

7.6 Postpartum Thyroid Dysfunction

• 📊 Screen for thyroid dysfunction in the first 4 weeks postpartum.

8. Neonatal Care

• 🩸 Monitor Blood Glucose (every 4 hours) and manage hypoglycemia promptly.
• 🏥 NICU Admission:
  • Neonatal BG persistently low (<2.6 mmol/L).
• ⚠️ Macrosomia Risks:
  • Assess for complications like congenital heart defects or trauma during delivery.

11. Contraception

• Provide counseling on:
  • 💊 Progesterone-only options (safe for lactating mothers).
  • Estrogen-containing pills postpartum (after 42 days).
  • 🛡️ Long-acting IUDs for reliable contraception.
  • ✂️ Tubal ligation or vasectomy for permanent solutions.

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