Maternal and Fetal Outcomes in Women with Diabetes in Pregnancy Treated before and after the Introduction of a Standardized Multidisciplinary Management Protocol
Table 1
The standardized multidisciplinary management protocol details.
Antenatal care
Delivery criteria
Pregestational diabetes
(i) Counseling regarding the risks and complications associated with diabetes in pregnancy (ii) Baseline evaluation of thyroid function, microalbuminuria, electrocardiogram, and baseline evaluation by ophthalmologist, dietitian, cardiologist, and nephrologist (iii) Regular assessment of blood glucose values and hemoglobin A1c (iv) Ketonemia/ketonuria in case of intercurrent infections/conditions (v) Detailed ultrasound anatomical survey at 16-18 weeks and at 20-22 weeks (vi)Fetal echocardiography at 24-26 weeks (vii) Antenatal appointments (with assessment of fetal growth and amniotic fluid volume) are scheduled monthly until 28 weeks and every 3 weeks afterwards (viii) Weekly cardiotocography is planned from 34 weeks of gestation
In women with a good glycemic control
(a) If and AFV is normal, admission at 37+6 weeks and IOL or CD is planned from 39+0 weeks. Delivery must take place within 40+1weeks (b) If and/or AFV is increased, admission at 36+0 weeks for daily monitoring of fetal well-being If there are no concerns about fetal well-being IOL or CD is planned from 37+2 weeks, delivery must take place within 38+4 weeks.
In women with no optimal glycemic control despite increase in the insulin therapy
Admission can be considered to optimize glucose control and for close monitoring of fetal well-being, and delivery is planned within 38+0 weeks. A conservative management is usually undertaken until 34+1 weeks.
Gestational diabetes
(i) Counseling regarding the risks and complications associated with diabetes in pregnancy (ii) Woman is referred to a team of highly experienced diabetologists, and a dietary plan is provided by a nutritionist. Physical activity is encouraged (iii) Antenatal appointments (with fetal growth and amniotic fluid volume) are scheduled monthly, both for obstetrics and diabetologists reevaluation (iv) Cardiac assessment is evaluated in conjunction with the diabetologists to identify women at increased risk of hypertensive disorders (v) Weekly cardiotocography is planned from 36 weeks of gestation (vi) Women are informed on how to monitor glycemia at home which is usually advised from 3 to 10 times per day
In women with a good glycemic control
(a) If EFW is <97th centile and AFV is normal, admission is scheduled at 39+0 weeks and IOL or CD is planned at 39+1 weeks (b) If EFW is ≥97th centile and/or the AFV is increased, admission is scheduled at 38+0 weeks for daily monitoring of fetal well-being If there are no concerns about fetal well-being IOL or CD is planned at 39+1 weeks.
In women with no optimal glycemic control despite insulin therapy
Admission is scheduled from 37+1 weeks for daily monitoring of fetal well-being, and delivery is planned within 38+0 weeks. At earlier gestations, in women with poor glycemic control, hospitalization can be offered to optimize glucose control by improving the dietary compliance and by accurate monitoring of blood glucose levels. A conservative management is usually undertaken until 34+1 weeks.
