1. KPSC DIABETES IN PREGNANCY
PATHWAY
Working Regional Guidelines

2. IMMEDIATE IMPACT FOR RIVERSIDE
• Centers will be INDIVIDUALLY graded
regarding COMPLIANCE of the pathway.
• INDIVIDUAL MEDICAL CENTER PERFORMANCE
and possibly some effect on BONUSES which
will be determined by measuring the
completion of TWO performance indicators
MEASURED AS OF THIS JULY 1st 2012

3. MEDICAL CENTER PERFORMANCE INDICATORS
TIED TO ACCOUNTABILITY/MONETARY
INCENTIVE MEASURED AS OF JULY 1, 2012
COMPLETION OF TWO INDICATORS:
1.IN
2.OUT
Anticipate other indicators will be evaluated in
future

4. IN: HbA1c
• IN: All OB patients get a Hemoglobin A1c with
INTAKE prenatal labs
-they will be measuring the percentage of
patients getting their HbA1c test on the FIRST
prenatal visit (a measurement of our center's
compliance with the Clinical Pathway)

5. OUT: FBS
2. OUT: All Patients with GDM COMPLETE a FBS test at the 6-
week post partum appointment:
A. Resolve GDM Diagnosis
B. Patient to be coded with HISTORY OF GDM
C. Patient will get a FBS test or a 2 hour GTT
-if normal: patient to be flagged for annual HbA1c test,
-if abnormal, refer patient to Primary care for diabetes
diagnosis confirmation and medical management.
As you know, A Fasting Blood Sugar (may also be called FPG,
fasting plasma glucose of 126 mg/dL or above is abnormal
and needs to be confirmed. The patient must be fasting of
everything except water for at least 8 hours prior to test)

6. KPSC DIABETES IN PREGNANCY
CLINICAL PATHWAY
COMPLETE PROGRAM
REGIONAL GUIDELINES

7. Program Goals
• Improve and maintain member’s self care skills
and provide treatment to avoid higher level of
care
• Avoid Macrosomia, shoulder dystocia
• Avoid other pregnancy complications such as
Cesarean delivery, NICU admission
• Intensive management to maximize proactive
preventative therapy and medication monitoring
• Minimize the risk of maternal complications
including worsening retinopathy, nephropathy,
or hypertension in Pre-gestational Diabetes
(PGDM)

8. DIABETES SCREENING & EDUCATION
FOR ALL OBSTETRIC PATIENTS
 HgA1c with prenatal labs
 Risk assessment for GDM @ 1st visit
 HIGH RISK FOR GDM/NOT DM- Receive GCT/GTT ASAP
 LOW RISK FOR GDM- GCT/GTT @ 24-28 weeks
 Nutrition, Balanced Diet, Exercise Information
 Healthy Beginnings Newsletter AND/OR Prenatal Classes
 Proper weight gain during pregnancy
 Healthy Beginnings Newsletter AND/OR Prenatal Classes
 Risk Stratification of Diabetic Patients to Low,
Medium, or High
 Based on history or documented laboratory criteria

9. DIABETES SCREENING AND
EDUCATION FOR ALL OBSTETRIC
PATIENTS
OB INTAKE/FIRST PRENATAL VISIT:
-ALL patients screened with hemoglobin A1c
with initial prenatal labs (first compliance measure)
-ALL patients are assessed for risk for GDM at
the first prenatal visit

10. DIABETES SCREENING STRATEGY

11. FIRST PRENATAL VISIT GDM RISK
ASSESSMENT FOR DIABETES
SCREENING
HIGH RISK of GDM: (ANY OF THESE)
-Personal history of GDM
-BMI ≥ 40
-Prior infant ≥ 4000 g (8 lbs 13 oz)
-Prior shoulder dystocia
-HgA1c 6.0 – 6.4 %

12. Possible Smart Phrase: GDM Risk
Assessment. ANY Yes- Early GCT/GTT
GDM RISK ASSESSMENT:
1.Personal history of GDM: No/Yes
2.BMI ≥ 40: No/Yes “.bmi”
3.Prior infant ≥ 4000 g (8 lbs 13 oz): No/Yes
4. Prior shoulder dystocia: No/Yes
5.1st Trimester HgA1c 6-6.4%: No/Yes “.lasta1c” or
“Ordered and Pending”
ASSIGNED GDM SCREENING RISK:
Low- Patient for 24-28 week glucose testing unless
pending HgA1c results score HIGH
HIGH- Patient sent for GCT as soon as possible

13. FIRST PRENATAL VISIT
ALL OB PATIENTS
• Nutrition, Balanced Diet, and Exercise
Information
– Healthy Beginnings Newsletter AND/OR Prenatal
Classes
• Education regarding proper weight gain
during pregnancy
– Healthy Beginnings Newsletter AND/OR Prenatal
Classes

14. Diabetic Patient Risk Stratification:
Documented Criteria
LOW RISK: A1GDM
-Diagnosed as Gestational Diabetes BUT WITH first trimester
HgA1c < 6.5 %
MEDIUM RISK: A2GDM-good controlled
-Well-controlled A2GDM (on Insulin or Glyburide)
HIGH RISK: PGDM, A2GDM-poor control, 1st trimester A1c ≥ 6.5%
-POORLY Controlled A2GDM OR Pre-Gestational Diabetes Mellitus
(PGDM) (diagnosis at time of conception, or poorly controlled
A2GDM, or first trimester HgA1c ≥ 6.5%

15. Risk Group Intervention
*Refer to Diabetes Care Team (includes class, nutritional counseling, dietician, certified Diabetes educator, social worker)
Low Risk
*Issue Glucometer for blood sugar monitoring -FBS, 1 hour post prandial blood sugar after each meal
*Blood sugar review at least every 2 weeks by OB Diabetes Care Team member
*Consider Ultrasound to assess fetal growth between 36-38 weeks or when clinically indicated
A1GDM with
*If good glycemic control and no other complications, consider delivery NO LATER than 41 w 0 d
First Visit
*If other complications such as poor compliance, history of HTN, history of stillbirth; consider delivery before 40 w 0 d
• If EFW ≥ 4500 grams, consider c-section
*At postpartum appointment -resolve GDM diagnosis and code history of GDM diagnosis in problem list
A1c < 6.5 %
*Order FBS or 2 hour GTT between 6-12 weeks postpartum (patient must complete)
Medium Risk * All "Low Risk" Interventions
*Refer to Diabetes Care Team (includes class, nutritional counseling, dietician, certified Diabetes educator, social worker)
Well *Blood sugar review at least every 1-2 weeks with adjustments of medication(s) by care provider
controlled * Non-stress testing twice weekly at 32 -34 weeks, or when medications starts after 32 weeks gestation
A2GDM
Requiring Rx • Consider delivery between 39-0/7 weeks and 40-0/7 weeks gestational age
* All "Low Risk" and "Medium Risk" Interventions
* Refer to Diabetes Care Team (includes class, nutritional counseling, dietician, certified Diabetes educator, social worker) and
Perinatologist for Consultation of management if clinically indicated
* Blood sugar review at least every 1-2 weeks with adjustments of medication(s) by care provider
* Non-stress testing twice weekly at 32 -34 weeks (consider earlier testing if retinopathy, nephropathy, hypertension, poor
High Risk glycemic control, IUGR)
• If poor glucose control or other risk factors, consider amniocentesis for fetal lung maturity and delivery prior to 39 weeks.
Poorly- • If good glycemic control and no other complications, consider delivery at 39 w 0 d. Recommend delivery no later than 40 w
controlled 0 d.
A2GDM, or * Pre-Gestational Diabetes (PGDM):
PGDM, or ***1st Trimester Labs: Serum Creatinine, TSH, ALT, AST, and random urine microalbumin (24 hour urine for total protein if
1st microalbumin > 30)
Trimester A1c ***Eye photo (if not done 6-12 monhs prior to pregnancy); retinal eye exam (with dilation) if moderate or greater diabetic
≥ 6.5 % retinopathy
*** EKG (if age 35 or older, or with vasculopathy, cardiac issues, or hypertension)
***Targeted ultrasound (including careful assessment of fetal cardiac structures) at 18-22 weeks to rule out congenital
anomalies
***Repeat hemoglobin A1c in the third trimester (36 weeks)
***Serial ultrasounds for fetal growth at 28 weeks gestation

16. PGDM Retinal Exam Algorithm
1. GDM: No DR(Diabetic Retinopathy)screening
2. PGDM: (Never had screening): Photo during pregnancy –No
dilation*
3. PDGM: (No DR, screen < 1yr): Photo during pregnancy
4. PGDM: (No DR, HgA1c >7.5, screen > 6 mo ago): Photo during
pregnancy –No dilation*
5. PGDM: (Minimal DR with HgA1c 6.5 – 7.5, screened > 6mo ago):
Photo during pregnancy: No dilation*, otherwise photo 1 year
6. PGDM: (Minimal DR with HgA1c 6.5 – 7.5): Photo during
pregnancy –No dilation*
7. PGDM: (Moderate DR): EXAM DURING PREGNANCY WITH
DILATION
*unless moderate or greater DR detected

17. OUT: Post-Partum Appointment
ALL Patients diagnosed with Gestational
Diabetes
 Resolve GDM diagnosis and code with history of
GDM diagnosis on patient problem list
 Fasting Blood Sugar (FBS) or 2 hour GTT is ordered
and completed
 Patient is counseled regarding increased risk of GDM
in future pregnancy
 Discuss options for birth control
 Patients less than 50 years old

18. Post Partum FBS Test by Interventions
OB/GYN
< 126 mg/dL • No interventions from OB/GYN Needed
• Patient with be “flagged” for Annual HbA1c test (results go to Diabetes Case Managers
from Adult Primary Care)
≥ 126 mg/dL • OB/GYN refer patient to adult primary care for diagnosis for Diabetes Mellitus and
management
Annual HbA1c Screening* by Interventions
PCP
≤ 5.6% Continue annual HbA1c screening test
5.7 – 6.4 % • Diabetes Case Managers will contact patient with results
• Patients will be given resources to address exercise, weight loss, nutrition, and diabetes
prevention (either Health Education Classes or Patient handouts)
• Patient screened for reproductive plan: “Are you planning to become pregnant in the next
year?”
o No- assess for birth control and given referral for birth control if appropriate
o YES- referral from preconception counseling (OB/GYN)
≥ 6.4 % • Diabetes Case Mangers will refer patient to adult primary care for diagnosis of
Diabetes Mellitus and management
• Patients will be given resources to address exercise, weight loss, nutrition, and
diabetes prevention (Heath education classes and/or Patient handouts)
• Patient screened for reproductive plan: “Are you planning to become pregnant
in the next year?”
o No- assess for birth control and given referral for birth control if appropriate
o YES- referral from preconception counseling (OB/GYN)
*1. A1c will be specifically labeled for post partum or pregnancy related- using batch order functions or
manual batch orders
2.Patients who miss their annual screening may receive a reminder outreach letter
3.Explore the possibility that results go into a pool

19. Possible Outcome Reports
1. Percentage of patients getting A1c on first prenatal visit (AS
OF JULY 1 2012)
2. Postpartum Appointment Percentage Patients who:
A. Had GDM and COMPLETED FSB or 2 h GTT ordered (AS OF JULY 1
2012)
B. Has PGDM got an A1C ordered
3. For all Mothers with GDM or PGDM, # of neonates ≥4500
grams
4. For all Mothers with GDM/PGDM, the primary C-section rate
5. For all Mothers with GDM/PGDM, the number of NICU
admissions at term (≥37.0 weeks)
6. For all Mothers with PGDM, the percentage of patients who
have a 1st trimester A1c < 6.5% and the percentage of
patients who have a A1c <6.5% in the third trimester (~36
weeks)