Our aim is to alleviate human suffering related to diabetes and its complications among those least able to withstand the burden of the disease. From 2002 to March 2017, the World Diabetes Foundation provided USD 130 million in funding to 511 projects in 115 countries. For every dollar spent, the Foundation raises approximately 2 dollars in cash or as in-kind donations from other sources. The total value of the WDF project portfolio reached USD 377 million, excluding WDF’s own advocacy and strategic platforms.

1. SCREENING AND DIAGNOSIS
GOI GESTATIONAL DIABETES
GUIDELINES 2014
GDM POPULATION BASED STUDY
UTTAR PRADESH
Objectives
• At the end of this session you will be
able to:
– 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
Definition
• Glucose intolerance with onset or first
recognition during pregnancy
• Characterized by ß-cell function that is
unable to meet the body’s insulin needs
Buchanan, Wiang, Kjos, Watanabe 2007
Glucose regulation during pregnancy
• Insulin resistance begins in mid pregnancy and
progresses through the third trimester
– A result of maternal adiposity and effects of placental
hormones
• ß -cells usually make more insulin to compensate
for resistance – when they cannot meet the
needs hyperglycemia occurs
1

2. • GDM represents a state of chronic ß-cell
dysfunction in the face of insulin
resistance
• 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
Buchanan, Wiang,Kjos, Watanabe 2007
Prevalence
• The prevalence of GDM is estimated to be 10-
16.9% in pregnant women depending on the
diagnostic criteria used.
• 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
Discussion
• What are the risk factors for gestational
diabetes?
• What risk factors do you see most often
in your setting?
Risk factors for GDM
High 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
Low risk
• 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
21

3. Is Hypertension a risk factor?
• Hypertension prior to pregnancy or during
1st trimester – doubled the risk of GDM –
independent of maternal weight
• Hence all women with hypertension should
be screened for GDM
Hedderson, Ferrara, 2008
Why diagnose and treat GDM?
• 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
• 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
Why diagnose and treat GDM?
• Short term risks for the baby
–Macrosomia
–Neonatal hypoglycemia
–Jaundice
–Preterm birth
–Birth injury
–Hypocalcemia/ hypomagnesimia
–Respiratory distress syndrome
• Long term risks for the baby
–Obesity
–Type 2 diabetes
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
• Testing after pregnancy is important- more
about this later
Kim, Newton,Knopp 2002
3

4. Screening
- Whom to screen
- When to screen
- How to screen
Who to screen
Some guidelines recommend screening all
women at the first visit to rule out pre-
existing type 2 diabetes
Most guidelines recommend screening all
women for GDM at 24-28 weeks gestation.
ADA, 2015
CDA , 2013
When to screen?
First trimester
• Screening in 1st trimester
- to rule out unidentified pre -existing diabetes
• 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)
• If overt diabetes is detected, it must be treated appropriately.
ADA, 2015
When to screen
Screening for GDM
• Screening should be done at 24-28 weeks
• Diagnosis based on a 75 gm glucose load given in fasting
state
• 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 woman tests negative, screening at 32 weeks also may
be necessary in presence of high risksWorld Health Organization, 2013
4

5. Diagnostic criteria
Diabetes Care 2015, WHO 2013
5
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
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
V. Seshiah, V. Balaji, Madhuri S Balaji, A Paneerselvam, Manjula Datta, Diabetes Research In
Clinical Practice: 2007. Sept; 77(3): 482-4
V. Seshiah, V. Balaji, Madhuri S Balaji, A Paneerselvam, Manjula Datta, Diabetes Research In
Clinical Practice: 2007. Sept; 77(3): 482-4
Diabetes Care 2015, WHO 2013
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.
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.
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
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
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.
Jitendra Singh et al. Prevalence of Gestational Diabetes Mellitus (GDM) and its
Outcomes in Jammu. JAPI (59): April 2011.
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
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.
Jitendra Singh et al. Prevalence of Gestational Diabetes Mellitus (GDM) and its
Outcomes in Jammu. JAPI (59): April 2011.
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

6. How to screen
Key considerations for screening in low resource
countries
• Low cost
• No requirement for elaborate preparation
• High sensitivity and specificity
• Short turn-around time
• Be administered by health workers with minimal training
• Need little maintenance, calibration, or refrigeration
Agarwal et al, 2007
Venous or capillary
The venous plasma is the gold standard
Where laboratory facilities or technicians are not
available, capillary glucose estimations may be done
using a hand held glucose meter.
The glucose meter must be standardized with a lab and
calibrated against the lab on a regular basis.
Which of these women has GDM?
All have had 75g glucose load at about 25 weeks
–Rupinder, overweight, 35 years old,
• fasting 90 mg/dl (5.0 mmol/L),
• 1 hr 170mg/d (9.4 mmol/L),
• 2hr 135mg/dl (7.5 mmol/L)
–Joanne, 3rd pregnancy, history of big babies,
–fasting 130 mg/dl (7.2mmol/L),
–1 hr 190mg/dl (10.5mmol/L)
–2 hr 220mg/dl (12.2mmol/L)
–Maria, 1st pregnancy, 25 years old, obese,
–fasting 90mg/dl (5mmol/L),
–1 hr 168mg/dl (9.3mmol/L)
–2 hr 160 mg/dl (8.8mmol/L)
Giving the diagnosis
Will my baby be ok? – 1st question often asked
Is this temporary? – 2nd question
Questions provide an opportunity for teaching
• Must answer truthfully
• Must convey importance of management during
pregnancy for healthy outcome but also for
future health of baby and mother
ØRisk of type 2 diabetes
ØRisk of obesity
6

7. 7

8. Post Partum Screening
-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.
Post Partum follow up of Pregnant Women with GDM:
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.
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..
Subsequently, ANM to perform 75 g GTT at 6 weeks postpartum to
evaluate glycemic status of woman.
Cut offs for normal blood glucose values are:
l. Fasting plasma glucose: = 126 mg/dl
lI. 75 g OGTT 2 hour plasma glucose
III. Normal: < 140 mg/dl
IV. IGT: 140-199mg/dl
V. Type II Diabetes: = 200 mg/dl
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.
Type II Diabetes mellitus in later life. They should be counselled for
healthy lifestyle and behaviour, particularly role of diet & exercise.
IX.GDM should be a part of NCD (Non communicable Disease)
programme.
8
Pregnant Woman with GDM
2 hr PPPG ³120 mg/dl
MNT for 2 weeks
2 hr PPPG < 120 mg/dl
Start Human Insulin premix 30:70
vSubcutaneous Injection, 30 mlns before
breakfast, once a day
vDose of Insulin calculated by blood glucose level
Continue MNT, repeat 2 hr
PPPG after 2 week, still
30 weeks and thereafter,
120 mg/dl³ < 120 mg/dlBlood glucose
Between 120 -160
Between 160-200
More than 200
Dose of Insulin
4 units
6 units
8 units
FBG & 2 hour PPPG every 3rd day
FBG <95mg/dl & 2 hrs PPPG
<120 mg/dl
Continue same dose of
Insulin + MNT
Increase dose of Insulin
by 2 U + MNT
FBG <95mg/dl & 2 hrs PPPG
<120 mg/dl
FBG <95mg/dl & 2 hrs PPPG
<120 mg/dl
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
>
Increase pre breakfast
Insulin by 4 U
Increase dose of Insulin
by 2 U + MNT
Continue same dose of
Insulin +
Repeat FBG & 2 hr PPPG every 3rd day
Adjust dose of Insulin accordingly till FBG <95mg/dl, 2 hr PPPG <120 mg/dl
v
v
Continue same dose of Insulin + MNT
Repeat FBG & 2 hr PPPG 2 weekly before 30weeks & weekly after 30 weeks
v
v
* Only Injection human premix Insulin 30/70 to be used * Insulin syringe - 40 IU syringe * Subcutaneous Injection only
Insulin Therapy

9. 9

10. Gestational Diabetes 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
Maternal health Clinic HCPs to be trained
3000 Doctors and 6000 Nurse/Paramedical staff to
be covered in next 3 years in two full day Certified
Training.
Syllabus as IDF and NHM GOI Guidelines
Gestational Diabetes
Prevalence and Outcome
Study in Uttar Pradesh
Why Screening All Pregnant Women
Population based Study
57,000 Pregnant Women covered through Single
OGTT Test.
10

11. 11
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 werenotea.
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

12. 12

13. 13

14. 14
Jain,etal:RoleofmanagementofbloodsugarinimprovingoutcomesinGDMcases
Table2:Fetaloutcomesingestationaldiabetesmellitusversusnongestationaldiabetes
mellitusanditsrelationshipwithhistoryofpreviousbirthcomplications.
Outcomes in
neonate
GDM present
(n=7641)
N (%)
Previous fetal loss
present
N (%)
p-value GDM absent
(n=8000)
N (%)
Previous fetal loss
present
N (%)
p-value
Stillbirth
Neonatal death
Perinatal death
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)
212 (2.6)
62 (0.8)
274 (3.4)
<0.0001
<0.5
<0.0001
GDM: Gestational diabetes mellitus

15. 15
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
bettervalidationofresultsfromthisstudyaswellasotherGDMstudiesconductedin

16. SELF-MANAGEMENT EDUCATION
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
Diabetes Self-Management Education
Purpose
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
Evidence for diabetes education
Traditional knowledge-based diabetes
education is essential but not sufficient for
sustained behaviour change.
While no single strategy or programme shows
any clear advantage, interventions that
incorporate behavioural and affective
components are more effective.
(Piette, Weinberger, McPhee, 2000)
Barlow, Wright,Sheasby, Turner,Hainsworth,2002
Roter, Hall,Merisca, Nordstrom, Cretin,Svarstad,1998
16

17. Why is self-management important?
People want to be healthy and have healthy babies.
Gestational diabetes needs to be self-managed.
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.
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
What do people need to understand?
Their own personal goals, values and feelings
Diabetes care and treatment (advantages/
disadvantages)
Behaviour change and problem-solving strategies
Who is the decision-maker – the woman, the
husband, the mother-in-law?
How to assume day-to-day responsibility
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
Von Kroff, Gruman, Schaefer,1997
Fisher,Brownson, O’Toole,Shetty, et al.,2005
A change in philosophy
Didactive
Collaborative
Teacher and patient learn and
work together
Teacher knows all, makes
decisions
17

18. So what should we do?
Medical
Model
Self-
Management
Education
Tell the person
Cover the basics
Judge compliance
Teach to the person
Patient centered
Ask the person
Learn with the person
Partnership approach
Reframe our attitudes and behaviours
Educate for informed, self-directed decisions
and problem-solving
Ask questions
Identify problems
Address concerns
Teaching
Deliberate interventions that involve sharing
information and experiences to meet intended
learner outcomes.
Bastable,2008
Teaching does not necessarily result in
learning
When was the last time someone
taught you?
Did you learn anything?
18

19. Learning
Active, ongoing process that results in
changes in insight, behaviour, perception or
motivation
Change may be positive or negative
Who is the Learner
and
Who is the Teacher?
Communication Skills
19

20. Communicating feelings or attitudes
§Verbal 7%
§Vocal 38%
§Visual 55%
Mehrabian,1999
"What you do speaks so loudly that I cannot hear
what you say."
Ralph Waldo Emerson
Watch your body language!
Avoid looking like a school teacher!
Tips for plain speaking
Introduce your subject and state a purpose
Paint a picture, make it visual
Keep it organised
Move from simple to complex
Repetition is important – three times
Summarise
Evaluate
Belton, Simpson,2010
Tips for plain speaking
Use the active voice
The person should be the subject of the
message
You may require medication to achieve target
blood glucose levels
Vs
Some women may require medication to
achieve target blood glucose levels
20

21. Communication
Open-ended question
§At what time do you take your medication at home?
Closed question
§Do you take your medication on time at home?
Develop listening skills
You can’t talk when you listen
Listen – don’t plan your response
Give the person your full attention
Paraphrase and ask if you heard correctly
§So, you are saying….
§It sounds like…..
§You are wondering if....
§I hear you saying….
Reflective listening
The words
the speaker
says
What the
speaker
means
How the
listener
interprets
the words
The words
the listener
hears
The teaching process
Assessment
Planning
Implementation
Evaluation
21

22. Assessment
Goals
§Establish trust
§Determine priorities
§Assess current health status, knowledge and self-
care practices
§Determine family role or other support
§Identify available resources
§Identify barriers to learning and self-management
There is a difference
Health professionals and women with GDM
may have different opinions on what is
important
Ask the woman what is important to her.
Suhonen,Nenonen,Laukka,Valimaki,2005
Timmins,2005
Giving the diagnosis
Will my baby be ok? – 1st question often asked
Is this temporary? – 2nd question
Questions provide an opportunity for teaching
ØMust answer truthfully
ØMust convey importance of management during
pregnancy for healthy outcome but also for future
health of baby and mother
ØRisk of type 2
ØRisk of obesity
Assessment
Considerations
§Should be non-threatening and non-judgemental
§Consider the cultural and health beliefs of the
person
§Consider physical environment
§Building rapport takes time
22

23. Planning
Develop together
§What do you want to know?
§What must you know?
Offer choices
§Individual
§Classes
Write learning objectives together
Planning
Objectives for each topic
Reviewed and updated regularly
Objectives should be
§Measurable
§Timely
§Specific
§Mutually agreed
Implementation
Communication is the key
§Simple words
§Open-ended questions
§Encouragement
§Positive feedback
§Positive, caring attitude
§Active listening
§Repetition
Belton, Simpson,2010
Implementation
Determine priorities
§Begin with the learner’s wishes
§Most important topics first and last
Conducive environment
Simple to complex
Be specific
Repeat! Repeat! Repeat!
Belton, Simpson,2010
23

24. Evaluation
Integral part of programme management
Through all phases
Plans should include how and when to
evaluate
Not an afterthought!
Evaluation
Clear description
§Objectives that are
- Measurable
- Specific
- Centered on the person
- Timed
Evaluation
Individual evaluation
§Have objectives been met?
§Open-ended questions
§How are skills used?
§“Do you understand?” is not a valid question
§Ask the person with diabetes to explain information to
you – “teach-back”
Belton, Simpson,2010
5 steps to self directed goal
setting for behaviour change
1. Identify the problem
2. Explore feelings
3. Set goals
4. Make a plan
5. Evaluate the results
Funnell, Anderson,2004
24

25. What is the problem?
What do you find the easiest thing to manage
in your diabetes?
What is the most difficult/worst thing about
caring for your diabetes?
What are your greatest concerns/fears/
worries?
What makes this so hard for you?
Why is that happening?
Funnell, Anderson,2004
How do you feel?
What are your thoughts and feelings about?
How will you feel if this doesn’t change?
Do you feel ________ about _______?
Funnell, Anderson,2004
What do you want?
How does this need to change for you to feel
better about it?
What will you gain/give-up?
What can you do?
What do you want to do?
On a scale of 1-10, how important is this?
Funnell, Anderson,2004
What will you do?
Can you/do you want to/will you?
What might work?
What has/hasn’t worked?
What do you need to do to get started?
What one step can you take this week?
Funnell, Anderson,2004
25

26. SMART behavioural goals
Eat three meals
§I will eat three meals every day starting tomorrow.
I will walk more
§I will walk for 10 minutes at my lunch hour for four days
next week
Funnell, Anderson,2004
How did it work?
What did you learn?
What barriers did you encounter?
What support did you have?
What did you learn about yourself?
What would you do the same or differently next
time?
Funnell, Anderson,2004
How to respond?
Avoid judgments
Avoid minimising negative experiences
Celebrate with - not for
Repeat process
Patient-Centered education
Interventions are more effective when
§Tailored to individual preferences
§Tailored to the person’s social/cultural environment
§Actively engage the person in goal-setting
§Incorporate coping skills
§Provide follow-up support
Piette, Weinberger,McPhee,2000
26

27. Activity
Imagine you have just been told you have
gestational diabetes
Think of three things you would need to
change to manage your diabetes
Then ask yourself
§What would be easiest for you?
§What would be hardest?
Activity
§What do you feel is supportive behaviour from
close family, friends, or the health professional?
§What is not supportive?
§If you had gestational diabetes, what would you
expect from the people listed above?
Summary
Be selective
Be specific
Prioritise
Categorise
Repeat
Reinforce
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. J., Rubin,
R.R., eds. Practical Psychology for Diabetes Clinicians, 2nd edition . Alexandria: American Diabetes Association; 2002.
Anderson, R.M., Funnell, M.M. The Art of Empowerment: Stories and Strategies for Diabetes Educators . 2nd ed. Alexandria: American
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Bastable, S. Nurse as Educator. 3rd ed. Sudbury, MA: Jones & Bartlett Publishers; 2008.
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) : 177-87.
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.
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.
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.
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.
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28. 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;26:5–13.
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;36:1138-61.
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 -management education for individuals ne wly
diagnosed with type 2 diabetes. Diabetes Spectrum 2003;16:75 -80.
Suhonen, R., Nenonen, H., Laukka, A., Valimaki, M. Patients’ 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.
28

29. Nutrition Therapy In Gestational Diabetes
Part 1 – Assessment
Part 2 – Recommendations
Part 3 – Education
Objectives
• Discuss factors that should be considered when doing a nutritional
assessment
• 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
•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
Assessing from an Interview
• 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
29

30. Assessing from Clinical Information
Laboratory tests to determine clinical status
§OGTT, fastingglucose, HbA1c level
§SMBG
§Urine ketones and proteins
§lipid profile (cholesterol — HDL, LDL)
§Haemoglobin, creatinine, thyroid function
§Blood pressure
Anthropometric Data
§Height , Weight and BMI
Current medications and nutrition supplements
Use pre pregnancy weight for calculations
Weight and height measurements to calculate BMI:
BMI = weight in kg/(height in m)2
Standard BMI normograms:
Body Mass Index (BMI)
Asian ADA norms
Underweight <18.5 kg/m2
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
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.
•Determine if weight gain is
above, at or below the
recommended range.
•If weight gain has already
exceeded the recommended
range, slow weight gain in order
to prevent further excess gain.
Nutrition Assessment
Nutrition history
§usual food intake recorded through interview
Dietary recall
§food and drink consumed in previous 24
hours (24-hour recall)
30

31. 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
Issues with Dietary Recalls
Nutrition Therapy In Gestational Diabetes
Part 1 – Assessment
Part 2 – Recommendations
Part 3 – Education
Composition of Food and Drinks
Macro-nutrients
§protein
§carbohydrates
§fats
Micro-nutrients
§vitamins
§minerals
31

32. Dietary Recommendations for GDM
Macronutrient composition
Nutrient % of daily calorie
intake
Carbohydrates 45-65%
Fats 20-35%
Protein 10-35%
Dietary fibre 28g/day
Institute Of Medicine 2002
Fluids
•Essential for all body functions
•40-60% of body weight is water
•Important to drink adequate amounts
of fluid
•Restrictions may be required in case
of pedal edema
Proteins
• Provide amino acids
• Help to build muscle mass
• Animal sources
• Plant sources
• 1 g of protein gives 4 kcal energy
32

33. Protein Recommendations
•1.1 g protein per kg bodyweight per day
•10-35% of total energy per day
•Animal protein often high in fat,
especially saturated.
•Attention must be paid to meeting the
protein requirements of women who are
vegetarians or vegans
Carbohydrates
• Provide main source of energy for
the body (45-65%) – individualized
• Nutrient that most influences blood
glucose levels
• Source of simple sugars – glucose,
fructose
• 1 g of carbohydrate provides 4 kcal
Name some of the common
carbohydrates and staple foods
in your region.
Activity
Carbohydrates And Meal Planning
•Amount and source of carbohydrates is
considered when planning meals
•Recommended source of carbohydrates is
mainly from
- 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

34. Carbohydrate (CHO) content of common foods
Food Amount Serving CHO (g)
Bread, whole wheat 28 g 1 slice 11
Rice (cooked) 75 g 0.3 cup 13
Pasta 125 mL 0.5 cup 16
Chappati 44 g 1 small 19
Corn meal 45 mL 3 tbsps 16
Potato 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
Benefits of Fibre
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
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
Glycaemic Index (GI)
Ranks carbohydrate-rich foods
according to the increase in blood
glucose levels they cause in
comparison with a standard food (white
bread/glucose).
34

35. Glycaemic Response of Glucose
and Lentils
B
lo
o
d
g
lu
c
o
s
e
le
v
e
l
Glucose Lentils
Reprinted with permission from CDA, 2004
Type of sugar
- glucose, fructose, galactose
Nature of starch
- amylose, amylopectin
Starch-nutrient interactions
- resistant starch
Cooking/food processing
Factors Affecting the Glycaemic Index
Processing/form of the food
- gelatinization
- particle size
- cellular structure
Presence of other food components
- fat and protein
- dietary fibre
Factors Affecting The Glycaemic Index
Kalergis, De Grandpre, Andersons, 2005
Glycaemic Index of Foods
Low glycaemic
index foods
Intermediate
glycaemic index
High glycaemic
index
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
35

36. Promotes healthy eating
Increases fibre intake
Helps control
- appetite
- blood glucose levels
- blood lipid levels
Low GI - Advantages Fats
• The most concentrated source of
energy
• Foods may contain fat naturally or
have it added during cooking
• 1 g fat provides 9 kcal
Fat Recommendations
• Low in polyunsaturated fats (up to 10% of
total daily energy)
• High in monounsaturated fats (>10%)
• Low in saturated fats (<10%)
• Trans or hydrogenated fat should be
avoided
Fats
• 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
• Saturated – red meats, butter, cheese,
margarine, ghee (clarified butter), whole milk,
cream, lard
• Trans fats – baked products, biscuits, cakes
36

37. Identify major sources of fats in
foods in your region.
Activity
Vitamins
• Organic substances present in very
small amounts in food
• Essential to good health
• 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
Daily multivitamin supplement should be added
as they are often not met by diet alone.
Multivitamin content varies depending on the
product used.
Women at higher risk for dietary deficiencies
include multiple gestation, heavy smokers,
adolescents, complete vegetarians, substance
abusers, and women with lactasedeficiency.
Minerals
•Substance present in bones, teeth, soft
tissue, muscle, blood and nerve cells
•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
•Low levels of minerals puts stress on
essential life functions
37

38. Minerals And Trace Elements
• A balanced diet supplies minerals and
trace elements
• Supplements are important as
requirements are higher during
pregnancy
§Calcium supplementation
§Iron supplementation
§Folic acid supplementation 0.4mg (should
be started three months prior to conception)
Sodium Recommendations
•Most people consume too much salt
•Sodium restriction may be advised in case of
uncontrolled hypertension and edema
•Targets for daily sodium intake
Age Adequate
Intake
(mg/day)
Upper limit
(mg/day)
14-50 1500 2300
51-70 1300 2300
over 70 1200 2300
Health Canada, 2005
Lowering Salt Intake
• 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.
• Teach people to read food labels.
• Choose salt free, reduced or low in sodium foods
Substance Use
The following substances should be avoided completely once
the woman plans a pregnancy
§Tobacco in any form
§Alcohol
§Drugs (street, illegal)
38

39. Sweeteners
Sweeteners that increase blood glucose
§Sugar, honey
§Polydextrose & Sugar alcohols– maltitol, sorbitol, Xylitol
Sweeteners that do not increase blood glucose
§Acesulfame potassium
§Aspartame
§Cyclamate*
§Saccharin*
§Sucralose
*Must be avoided during
pregnancy
To check with Health care team
prior to starting use of sweeteners
Food Labels
•Nutrition facts
•Serving size (if available)
•Nutrient content
•Ingredients
•Nutrition information
Food labels
Food labels may look
different in different countries,
but the same information is
usually available
Nutrition Facts
Per 1 cup (250g)
Amount % Daily Value
Calories 100
Fat 0g 0 %
Saturated 0 g
+ Trans 0 g
0 %
Cholesterol 0 mg
Sodium 3 mg 0 %
Carbohydrate 26 g 8 %
Fibre 1 g 4 %
Sugars 23 g
Protein 2 g
Vitamin A 20 % Vitamin C 170 %
Calcium 2 % Iron 2 %
Practice reading a food label
Calculate the following:
§Serving size
§Number of calories in one serving
§Number of carbohydrates in one serving
§Amount of fat in one serving
Activity
39

40. Summary of Dietary Recommendations
•Carbohydrates: 45-65%
•Dietary fibre: 28 g / day
•Fats: 20-35%
•Protein: 10-35% (1.1 g/kg/day)
•Sodium: 1500 - 2300 mg/day
Nutrition Therapy in Gestational Diabetes
Part 1 – Assessment
Part 2 – Recommendations
Part 3 – Education
Approach To Meal Planning
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
Meal Planning
Before deciding on the content of meal plans,
consider:
• Food preferences and eating habits
• Previous experience, knowledge and skills
• Current clinical, psychological and dietary status
• Appropriate clinical and nutrition goals
• Lifestyle factors
40

41. What to teach and when?
Basic
• Basic information about nutrition
• Nutrient requirements
• Healthy eating guidelines
• Making healthy food choices
• Self-management training and use
of educational tools
Nutrition Education: Tools
•Awareness of the basics of healthy
eating/balance of good health
•Food Pyramid
•The plate model
Food Guides
•Australian Food Guide
Healthy eating
•Eating Well with
Canada’s Food Guide
Recommended Number of Food Guide Servingsper Day
Children Teens Adults
Age In Years 2-3 4-8 9-13 14-18 19-50 51+
Sex Girls and Boys 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 3 4 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 andtyoeof 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

42. Food pyramid – India
Diabetes India, 2005
Balance of good health - UK eat well plate
Bread, cereals
and potatoes
Milk and
dairy products
Foods rich in
sugars and fat
Meat, fish and
protein alternatives
Fruits and
vegetables
(Reproduced with kind permission of the Food Standards Agency)
Example of Healthy food plate with
South-Asian foods
Healthy food plate
(Source: Diabetes Education Modules 2011)
These graphics will change
to be the same as the new
ones going in the booklets
Draw on a paper plate either:
The recommended proportions of foods
from your region
The proportions of what you ate last night
Activity
42

43. 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/ 2
•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
Practical Advice/ 3
•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)
References
• 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/hl-
vs/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.
43

44. Exercise in
Gestational Diabetes
Background
• Physical activity can prevent or delay type 2 DM in
individuals at risk
• Studies show that pre-pregnancy exercise helps to
prevent GDM during pregnancy.
• More intensity equals more benefits.
• Any activity has more benefit than no physical activity in
prevention of GDM.
Oken et al, 2006, Zhang et al, 2006, Dempsey JC et al 2004
Objectives
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
Aerobic Exercise:
§Aerobic means “using oxygen for energy”.
• use large muscles (legs, shoulders, chest, and arms)
• can be performed continuously
• burns calories and is critical to losing fat and keeping it off.
§Resistance Training
• helps in increasing the number of Insulin receptors
• Improves sensitivity of insulin receptors in skeletal muscle
• maintains muscle while losing fat.
• Upper arm resistance training shown to lower blood glucose
44

45. Benefits of Exercise in GDM
Exercise causes significant decrease in:
§fasting plasma glucose
§1hour plasma glucose
§HbA1c
§insulin requirement
Jovanovic-Peterson et al 1989; Brankston et al, 2004.
Where to start
Activity should be discussed with a medical
practitioner
§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
Medical contraindications for exercise in
pregnancy
• Haemodynamically significant heart disease, eg. Mod-
severe 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
ACOG Committee on Obstetric Practice, 2002.
Relative contraindications for exercise in
pregnancy
• 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.
45

46. Caution
Strenuous exercise could cause
§Fetal distress
§Uterine contractions
§Maternal hypertension
§Increased risk of soft tissue injury
Need to monitor
§Blood glucose before and after exercise for women on
insulin or sulphonylureas
Education before exercise
• Avoid exercise in supine position after 2nd trimester (due
to possibility of supine hypotension)
• 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
Harris, White, 2005
Summary
• 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.
Dempsy et al 2004, Liu et al 2008,Jovanovic-Peterson et al, 1989,
ACOG Committee on Obstetric Practice, 2002
References 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.
46

47. References
Artal R, O’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):6–12. 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.....
47

48. Monitoring During
Pregnancy
Objectives
After completing this Module the participant
will be able to
• 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

49. • Fasting: <95 mg/dl ( < 5.3 mmol/l)
• 1 hour PP : < 140 mg/dl ( < 7.8 mmol/L)
• 2 hour PP : < 120 mg/dl ( < 6.7 mmol/L)
Targets
Metzger, Buchanan et al 2007
Seshiah Balaji, 2006
ADA 2015
HbA1C during pregnancy?
May be valuable in determining those who had
undiagnosed diabetes prior to pregnancy
May give indication of overall control during
pregnancy BUT
§Not valuable for day-to-day management during
pregnancy
§May give falsely low results
§Other factors such as anemia make it unreliable
HbA1C during pregnancy?
May be valuable in determining those who had
undiagnosed diabetes prior to pregnancy
May give indication of overall control during
pregnancy BUT
§Not valuable for day-to-day management during
pregnancy
§May give falsely low results
§Other factors such as anemia make it unreliable
Fetal movement counting
The rationale - decreased fetal movements may signal
decreased oxygenation which often precedes fetal
demise
Reduction of activity associated with chronic fetal distress
Among inactive fetuses, approximately 50% are either
stillborn, tolerate labor poorly or require resuscitation at
birth
Lalor et al 2008
1
49

50. Fetal movement counting
The rationale - decreased fetal movements may signal
decreased oxygenation which often precedes fetal
demise
Reduction of activity associated with chronic fetal distress
Among inactive fetuses, approximately 50% are either
stillborn, tolerate labor poorly or require resuscitation at
birth
Lalor et al 2008
FETAL MOVEMENT
• Inexpensive, involving the mother, easy to
use
• Foetal movements related to maternal
glucose levels
• Patients taught generally from late third
trimester - after 35 weeks at routine ANC
• Reduced activity needs to be evaluated by
NST (non stress test)
Other parameters
Blood pressure – every visit
Values above 140/90 mm Hg are of concern
If > 140/90 re measure same day; If > 150/100 initiate
therapy
If BP > 140/90 check urine for albuminuria
Estimate Urine albumin / sugar dip stick
Though urine sugar not of value in a known GDM, albumin is
important as sometimes predates BP in preeclampsia
Ultrasound fetal measurement
Early pregnancy scan - 7-8 weeks
• Dating and viability
• Dating important to offer appropriate timing for
antenatal visits/ scans and delivery
• Accurate dating prevents iatrogenic prematurity
50