Diabetes Mellitus
and Pregnancy:
Clinical Guideline
Directorate of Women’s Health
Ministry of Health
Trinidad and Tobago
October 2018
Women’s Health
Message from the Directorate
                

context, is one area that needs further development.



and mother in short as well as long term.


    


new data emerge, criteria for diagnosis and treatment may yet change. This document aims to capture present international
recommendations.
All routine antenatal care management guidelines apply including the Maternal and Child Health Manual (MoH,
2015) and the SOP Obstetric and Midwifery Services (MoH, 2011) unless specically updated in this guideline.
These areas are not repeated in this guideline.
Acknowledgements




of the Corporate Communications Department of the Ministry of Health.

Director, Women’s Health

List of Abbreviations
 
 
CBC Complete Blood Count
 
 
DM Diabetes Mellitus
 
EFW Estimated Fetal Weight
 
GDM Gestational Diabetes Mellitus
 
 
 
 
 
 
MoH Ministry of Health
 
 
 
 
 
 
 
 
 
 
 
Table of Contents
 
 
 
 
 
 
 
 

1.0 Introduction





higher given the high prevalence of obesity and other susceptibility characteristics of our population.
GDM is associated with a higher incidence of maternal morbidity including caesarean deliveries, shoulder dystocia, birth


           

Medical litigation adds to the economic burden faced by the management of the complications that can arise from DM and
pregnancy.
This clinical guideline has been developed as many women are either not screened or improperly screened for diabetes



factors, as is currently the practice.
2.0 Summary of recommendations
The Ministry of Health recommends the following strategies:
2.1 Public health priority:
        
          
measures to increase awareness, access, affordability, and acceptance of preconception counselling,

2.2 Universal testing:          

2.3 Criteria for diagnosis:          
             

2.4 Diagnosis of GDM: Diagnosis should ideally be based on laboratory results of venous serum
or plasma samples that are properly collected, transported, and tested. Though plasma calibrated
             
laboratories, it is acceptable to use such devices for the diagnosis of glucose intolerance in pregnancy
in locations only where laboratory support is either unavailable or at a site remote to the point of care.
2.5 Management of GDM: Management should be in accordance with our available national
resources and infrastructure.
2.6 Lifestyle management:         
tools in the management of GDM. Women with GDM must receive practical nutritional education
and counselling that will empower them to choose the right quantity and quality of food and level of
physical activity. They should be advised repeatedly during pregnancy to continue the same healthy

2.7 Pharmacological management:        

2.8 Postpartum follow-up and linkage to care: Following a pregnancy complicated
             
             
              
           
            
            
mother and child pair.
2.9 Audit and research: There is need for locally based research on the effects of DM
in pregnancy and its short and long term sequelae. The MoH recommends the strengthening of
               
               
teams should be actively involved in audit of their clinical practice.
3
3.0 Preconception care

should be screened for diabetes, offered contraceptive options and if a known diabetic, women should be counselled
as follows:
3.1 
       
neonatal death.
3.2                
pregnancy e.g.
o Lifestyle management including diet, body weight and exercise
 
 
 
 
 
 
o The importance of maternal blood glucose control during labour and birth and early feeding of the baby,

o The possibility of temporary health problems in the baby during the neonatal period, which may require
admission to the neonatal unit
 
 
 

o That more health visits and interactions will be required
 
 
 
3.3 Contraception and planning of pregnancy in patients with DM:
 
 
3.4 Blood sugar control advice:
 
 
o Consider metformin as an adjunct or alternative to insulin
 
3.5 
 
o Use existing imaging methods with mydriasis using tropicamide
o Defer rapid optimisation of blood glucose control until after the retinal assessment
3.6              

4.0 Hyperglycaemia in pregnancy
4.1 Screening and diagnosis:
 
 
 
               

 
screening test followed by a diagnostic test
              

on this topic.
 
                 

Table. OGTT criteria for diagnosis of Diabetes Mellitus (WHO, FIGO, IADPSG)
75 G - OGTT NORMAL GESTATIONAL DIABETES
MELLITUS (GDM)
FBS < 92 mg/dl
(5.1 mmol/l)
92 - 125 mg/dl
(5.1 - 6.9 mmol/l)
1hr post <180 mg/dl
(10 mmol/l)
≥ 10 mmol/l
2hr post <153 mg/dl
(8.5 mmol/l)
153 to 199
(8.5 - 11.0 mmol/l)mg/dl
DIABETES MELLITUS IN
PREGNANCY (DIP)
≥126 mg/d
(7.0 mmol/l)l
≥ 200 mg/dl
(11.1 mmol/l)
4.2 General management plan:
 
others is recognised where available to assist with management and compliance
 
 
6
 
 
 
o Women should be advised to choose where possible carbohydrates from low glycaemic index sources,
lean protein and polyunsaturated fats
 

 
 
 
 
 
                 

                 
the healthcare team
 
               

4.3 
 
 
 
 
 
4.4 
 
  
depending on the patient and the resources available
 
 
            

5.0 Target blood glucose levels
Women should aim to keep:
 
 
 
 
6.0 Antenatal
 

 
                   

  

 
 
 
 
meal and bedtime as directed by their healthcare professional
 

 
 


 

 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
7.0 Intra-partum
 
 
 
 
 
 
 
 
 
 
 
8.0 Post-partum
 
 
 
 
 
 
 
 
 
REFERENCES
       
    

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             
     
               
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 
          
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 
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  
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