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Gestational Diabetes Insulin Management Intrapartum

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1. Flowchart: Intrapartum management for gestational diabetes mellitus requiring Insulin and/or Metformin

Flowchart: Intrapartum management for gestational diabetes mellitus requiring Insulin and/or Metformin Document Number: F15.33--2-V1-R20 Department of Health Queensland Clinical Guidelines State of Queensland (Queensland Health) 2015 http://creativecommons.org/licenses/by-nc-nd/3.0/au/deed.en Queensland Clinical Guidelines, Guidelines@health.qld.gov.au Intrapartum management for GDM requiring Insulin and/or Metformin Metformin • Cease when labour established Insulin • Cease when labour (...) established • If morning IOL (and labour not established) o Eat breakfast and give usual rapid acting Insulin o Omit morning long or intermediate acting Insulin • If afternoon IOL (and labour not established) o Give usual mealtime and bedtime Insulin GDM Insulin or Metformin Mode of birth? Day before procedure • Cease Metformin 24 hours prior to procedure • Give usual Insulin the night before procedure Day of morning procedure • Fast from 2400 hours • Omit morning Insulin Monitor BGL 2/24 > 7.0 : greater

2015 Queensland Health

2. Gestational Diabetes Insulin Management Intrapartum

Gestational Diabetes Insulin Management Intrapartum Gestational Diabetes Insulin Management Intrapartum Toggle navigation Brain Head & Neck Chest Endocrine Abdomen Musculoskeletal Skin Infectious Disease Hematology & Oncology Cohorts Diagnostics Emergency Findings Procedures Prevention & Management Pharmacy Resuscitation Trauma Emergency Procedures Ultrasound Cardiovascular Emergencies Lung Emergencies Infectious Disease Pediatrics Neurologic Emergencies Skin Exposure Miscellaneous Abuse Cancer (...) Administration 4 Gestational Diabetes Insulin Management Intrapartum Gestational Diabetes Insulin Management Intrapartum Aka: Gestational Diabetes Insulin Management Intrapartum , Insulin Management in Labor II. Indication in Labor Diet controlled rarely warrants intrapartum management III. Preparation Patient Use only 50% of long acting (e.g. / or / ) on the day of delivery Dilute 25 units Regular in 250 cc Coadminister maintenance fluids at 125 cc/hour IV. Monitoring Intrapartum Fingerstick every 1 to 2

2018 FP Notebook

3. GlucoStabilizer™ software-guided insulin dosing improves intrapartum glycemic management in women with diabetes. (PubMed)

] for the GlucoStabilizer software program vs 131.9±10.1 mg/dL [7.3±0.56 mmol/L] for standard insulin treatment group; P=not significant). There were no significant differences in baseline maternal characteristics between the groups or neonatal outcomes.This study is the first to demonstrate that the use of software-guided intravenous insulin dosing in obstetrics can improve intrapartum glycemic management without increasing hypoglycemia in women with both pregestational and gestational diabetes mellitus (...) GlucoStabilizer™ software-guided insulin dosing improves intrapartum glycemic management in women with diabetes. During labor, maintenance of maternal euglycemia is critical to decrease the risk of neonatal hypoglycemia and associated morbidities. When continuous intravenous insulin infusion is needed, standardized insulin dosing charts have been used for titration of insulin to maintain glucose in target range. The GlucoStabilizer software program (Indiana University Health Inc, Indianapolis

2018 American Journal of Obstetrics and Gynecology

4. What is known about options and approaches to intrapartum management of women with gestational diabetes mellitus (GDM)?

breakfast dose. 6 KTA Evidence Summary: Intrapartum Management of Patients with Gestational Diabetes Mellitus (GDM) Page 4 of 19 May 2010 Fetal Surveillance Guidelines ? SOGC - Fetal Health Surveillance: Antepartum and Intrapartum Consensus Guideline: -Insulin-requiring GDM is listed among the obstetrical history and current pregnancy conditions associated with increased perinatal morbidity/mortality where antenatal fetal surveillance may be beneficial. In addition, GDM is listed among the antenatal (...) in labour. In addition, there was no difference in neonatal outcomes between the 2 study groups. 39 B In a 2010 observational study, 86% of maternal intrapartum CBG values fell within target range (3.3-7.2 mmol/L) without need for insulin use. Intrapartum maternal glucose levels were related with third-trimester glycated hemoglobin and higher in those with no endocrinologic follow- up. 40 KTA Evidence Summary: Intrapartum Management of Patients with Gestational Diabetes Mellitus (GDM) Page 10 of 19 May

2010 OHRI Knowledge to Action

5. Intrapartum Glucose and Insulin Compared to Glucose Alone in Diabetic Women

Intrapartum Glucose and Insulin Compared to Glucose Alone in Diabetic Women Intrapartum Glucose and Insulin Compared to Glucose Alone in Diabetic Women - Full Text View - ClinicalTrials.gov Hide glossary Glossary Study record managers: refer to the if submitting registration or results information. Search for terms x × Study Record Detail Saved Studies Save this study Warning You have reached the maximum number of saved studies (100). Please remove one or more studies before adding more (...) . Intrapartum Glucose and Insulin Compared to Glucose Alone in Diabetic Women The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. of clinical studies and talk to your health care provider before participating. Read our for details. ClinicalTrials.gov Identifier: NCT03273881 Recruitment Status : Recruiting First Posted : September 6, 2017 Last Update Posted : December

2017 Clinical Trials

6. Intrapartum Glucose Management Among Women With Gestational Diabetes Mellitus

manage intrapartum maternal glucose levels among Type I and and Type II DM, there is a paucity of data guiding practitioners in the intrapartum management of blood glucose levels for women with GDM, particularly those treated with insulin antepartum. The goal of this project is to compare two protocols of intrapartum glucose management in women with GDM and investigate the impact on neonatal blood glucose levels. Condition or disease Intervention/treatment Phase Gestational Diabetes Mellitus Other (...) Intrapartum Glucose Management Among Women With Gestational Diabetes Mellitus Intrapartum Glucose Management Among Women With Gestational Diabetes Mellitus - Full Text View - ClinicalTrials.gov Hide glossary Glossary Study record managers: refer to the if submitting registration or results information. Search for terms x × Study Record Detail Saved Studies Save this study Warning You have reached the maximum number of saved studies (100). Please remove one or more studies before adding more

2015 Clinical Trials

7. Intrapartum fetal surveillance

Fetal Growth Restriction; GDM Gestational Diabetes; IOL Induction of labour; MoM Multiples of Median; PaPP-A Pregnancy associated plasma protein-A; PROM Premature Rupture of Membranes; PTL Preterm labour; PV Per Vaginal; T Temperature; = greater than or equal to; Greater than; 4.8 Abnormal: urgent birth · pH 5.0 No Queensland Clinical Guidelines: Intrapartum Fetal Surveillance Guideline No: MN15.15-V4-R20 Confirmatory CTG Normal? Yes Normal CTG · Baseline FHR 110-160 bpm · Baseline variability 6-25 (...) or more of the following antenatal or intrapartum indications are present in labour, CEFM is recommended 2 because of the synergistic effect on the woman: · 41 to 41 + 6 weeks gestation · Gestational hypertension · Gestational Diabetes Mellitus (GDM) without complicating factors · Obesity (BMI 30–40 kg/m 2 ) · Maternal age greater than or equal to 40 and less than 42 years · Maternal pyrexia (temperature 37.8 o C or 37.9 o C) · Prior to epidural block to establish baseline features 2 3 Fetal heart

2019 Queensland Health

8. Gestational Diabetes Insulin Management Intrapartum

Gestational Diabetes Insulin Management Intrapartum Gestational Diabetes Insulin Management Intrapartum Toggle navigation Brain Head & Neck Chest Endocrine Abdomen Musculoskeletal Skin Infectious Disease Hematology & Oncology Cohorts Diagnostics Emergency Findings Procedures Prevention & Management Pharmacy Resuscitation Trauma Emergency Procedures Ultrasound Cardiovascular Emergencies Lung Emergencies Infectious Disease Pediatrics Neurologic Emergencies Skin Exposure Miscellaneous Abuse Cancer (...) Administration 4 Gestational Diabetes Insulin Management Intrapartum Gestational Diabetes Insulin Management Intrapartum Aka: Gestational Diabetes Insulin Management Intrapartum , Insulin Management in Labor II. Indication in Labor Diet controlled rarely warrants intrapartum management III. Preparation Patient Use only 50% of long acting (e.g. / or / ) on the day of delivery Dilute 25 units Regular in 250 cc Coadminister maintenance fluids at 125 cc/hour IV. Monitoring Intrapartum Fingerstick every 1 to 2

2015 FP Notebook

9. Gestational Diabetes Management

Gestational Diabetes Management Gestational Diabetes Management Toggle navigation Brain Head & Neck Chest Endocrine Abdomen Musculoskeletal Skin Infectious Disease Hematology & Oncology Cohorts Diagnostics Emergency Findings Procedures Prevention & Management Pharmacy Resuscitation Trauma Emergency Procedures Ultrasound Cardiovascular Emergencies Lung Emergencies Infectious Disease Pediatrics Neurologic Emergencies Skin Exposure Miscellaneous Abuse Cancer Administration 4 Gestational Diabetes (...) Management Gestational Diabetes Management Aka: Gestational Diabetes Management II. Indications: Gestational Diabetes Abnormal Preexisting III. Monitoring: Blood Glucose Frequency of therapy 4 times daily Diet control s 4 times on 2 days per week Increase monitoring if 2 values/week abnormal Target Levels Before Breakfast or early morning (2-6 am): 60 to 95 mg/dl Before Lunch,Dinner: 60 to 115 mg/dl One hour post prandial goal: under 140 mg/dl Two hour post prandial goal: under 120 mg/dl Check s in early

2018 FP Notebook

10. Diabetes in pregnancy: management from preconception to the postnatal period

Intrapartum care 29 1.5 Neonatal care 30 1.6 Postnatal care 32 2 Research recommendations 37 2.1 Preconception care for women with diabetes: insulin pump therapy and continuous glucose monitoring 37 2.2 T esting for gestational diabetes 37 2.3 Barriers to achieving blood glucose targets before and during pregnancy 38 2.4 Risk of fetal death for women with diabetes 38 2.5 Postnatal treatment for women diagnosed with gestational diabetes 39 Finding more information and resources 40 Diabetes in pregnancy (...) at diagnosis. [new [new Diabetes in pregnancy: management from preconception to the postnatal period (NG3) © NICE 2019. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and- conditions#notice-of-rights). Page 20 of 552015] 2015] 1.2.20 Offer metformin [2] to women with gestational diabetes if blood glucose targets are not met using changes in diet and exercise within 1–2 weeks. [new 2015] [new 2015] 1.2.21 Offer insulin instead of metformin to women with gestational diabetes

2015 National Institute for Health and Clinical Excellence - Clinical Guidelines

11. Guideline Supplement: Gestational diabetes mellitus

be downloaded in Portable Document Format (PDF) from www.health.qld.gov.au/qcg 4.1 Guideline resources The following guideline components are provided on the website as separate resources: • Flowchart: Screening and diagnosis of GDM • Flowchart: Intrapartum management for GDM requiring Insulin and/or Metformin • Flowchart: Postpartum management for all women with GDM • Flowchart: Antenatal schedule of care • Education resource: Gestational diabetes mellitus • Knowledge assessment: Gestational diabetes (...) Guideline Supplement: Gestational diabetes mellitus Maternity and Neonatal C linical G uideline Department of Health Supplement: Gestational diabetes mellitus Queensland Clinical Guideline Supplement: Gestational diabetes mellitus Refer to online version, destroy printed copies after use Page 2 of 12 Table of Contents 1 Introduction 3 1.1 Funding 3 1.2 Conflict of interest 3 1.3 Guideline review 3 2 Methodology 4 2.1 Topic identification 4 2.2 Scope 4 2.3 Clinical questions 4 2.4 Exclusions 4

2015 Queensland Health

12. Gestational diabetes mellitus

• Maternal age = 40 years • Family history DM (1 st degree relative or sister with GDM) • Previous macrosomia (birth weight > 4500 g or > 90 th percentile • Previous perinatal loss • Polycystic Ovarian Syndrome • Medications (corticosteroids, antipsychotics) • Multiple pregnancy Queensland Clinical Guideline: Gestational diabetes mellitus Refer to online version, destroy printed copies after use Page 4 of 38 Flowchart: Intrapartum management for GDM requiring Insulin and/or Metformin Metformin • Cease (...) -administration of Insulin therapy 26 5 Birthing 27 5.1 Pharmacotherapy as birth approaches 28 5.2 Intrapartum monitoring 28 5.3 Intrapartum BGL management 29 5.3.1 Insulin infusion 29 6 Postpartum care 30 6.1 Newborn care 30 6.2 Breastfeeding 31 6.3 Discharge planning 31 References 32 Appendix A: Antenatal schedule of care 36 Appendix B: Physical activity 37 Acknowledgements 38 Queensland Clinical Guideline: Gestational diabetes mellitus Refer to online version, destroy printed copies after use Page 8 of 38

2015 Queensland Health

13. Fetal Interventricular Septum Thickness and Maternal Gestational Diabetes Control

diabetes mellitus is associated with increased incidence of macrosomia, operative vaginal delivery, shoulder dystocia, cesarean delivery, metabolic complications in the newborn and long-term risk of developing type II diabetes mellitus (HAPO 2008). Early diagnosis and management of gestational diabetes mellitus, including dietary advice and insulin, improves maternal and fetal outcomes (Crowther 2005, Hartling 2013). Various strategies have been tested prenatally to detect those fetuses that might (...) Fetal Interventricular Septum Thickness and Maternal Gestational Diabetes Control Fetal Interventricular Septum Thickness and Maternal Gestational Diabetes Control - Full Text View - ClinicalTrials.gov Hide glossary Glossary Study record managers: refer to the if submitting registration or results information. Search for terms x × Study Record Detail Saved Studies Save this study Warning You have reached the maximum number of saved studies (100). Please remove one or more studies before adding

2018 Clinical Trials

14. Pregnancy Outcomes and Medical Costs According to Gestational Diabetes Mellitus Diagnostic Criteria

Pregnancy Outcomes and Medical Costs According to Gestational Diabetes Mellitus Diagnostic Criteria Pregnancy Outcomes and Medical Costs According to Gestational Diabetes Mellitus Diagnostic Criteria - Full Text View - ClinicalTrials.gov Hide glossary Glossary Study record managers: refer to the if submitting registration or results information. Search for terms x × Study Record Detail Saved Studies Save this study Warning You have reached the maximum number of saved studies (100). Please (...) remove one or more studies before adding more. Pregnancy Outcomes and Medical Costs According to Gestational Diabetes Mellitus Diagnostic Criteria (POMEC) The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. of clinical studies and talk to your health care provider before participating. Read our for details. ClinicalTrials.gov Identifier: NCT03421262

2017 Clinical Trials

15. Glucose Control During Labour in Gestational Diabetes Mellitus With Insulin Treatment: A Randomized Controlled Trial

Glucose Control During Labour in Gestational Diabetes Mellitus With Insulin Treatment: A Randomized Controlled Trial Glucose Control During Labour in Gestational Diabetes Mellitus With Insulin Treatment: A Randomized Controlled Trial - Full Text View - ClinicalTrials.gov Hide glossary Glossary Study record managers: refer to the if submitting registration or results information. Search for terms x × Study Record Detail Saved Studies Save this study Warning You have reached the maximum number (...) of saved studies (100). Please remove one or more studies before adding more. Glucose Control During Labour in Gestational Diabetes Mellitus With Insulin Treatment: A Randomized Controlled Trial The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Read our for details. ClinicalTrials.gov Identifier: NCT02590016 Recruitment Status : Unknown Verified October 2015

2015 Clinical Trials

16. Third Trimester Fetal Well-Being Studies: Criteria and Managing Results

) ? Hypertensive disorders of pregnancy ? Pre-pregnancy diabetes ? Insulin requiring gestational diabetes ? Preterm premature rupture of membranes ? Chronic (stable) abruption ? Iso-immunization ? Abnormal maternal serum screening (hCG or AFP > 2.0 MOM) in absence of confirmed fetal anomaly ? Motor vehicle accident during pregnancy ? Vaginal bleeding ? Morbid obesity ? Advanced maternal age (e.g., >35 years of age) ? Assisted reproductive technologies Fetal ? Decreased fetal movement ? Intrauterine growth (...) of pregnancy, diabetes, autoimmune disorders) o Perceived decreased fetal movements and/or atypical/abnormal non-stress test (NST) o Clinically suspected Fetal Growth Restriction (FGR), Small for Gestational Age (SGA), or Large for Gestational Age (LGA) o Late maternal age (e.g., >35 years) o Post dates (>41 weeks) PRACTICE POINT Although routine comprehensive third trimester ultrasound examination is not standardly performed for routine low-risk pregnancy care, indications commonly arise for ultrasound

2017 Toward Optimized Practice

17. Management of Pregnancy

. Implementation 18 IV. Guideline Work Group 19 V. Algorithm 20 A. Algorithm Key 21 B. Actions at Every Visit 21 C. Interventions by Weeks Gestation 21 D. Standard of Pregnancy Care 23 a. Additional Information on Actions at Every Visit 23 b. Screenings 24 c. Time Sensitive Care 28 d. Summary 28 VA/DoD Clinical Practice Guideline for the Management of Pregnancy March 2018 Page 4 of 147 VI. Routine Pregnancy Care 29 VII. Recommendations 33 A. Care Throughout Pregnancy 36 a. Routine Care During Pregnancy 36 b (...) continues to develop throughout the course of the pregnancy, the gestational age at birth can help predict outcomes ( ).[ ] Table 1 2-4 While pregnancy and birth are normal physiological events, pregnancy is a period of increased risk for a range of conditions. It is also a time of great interaction with the healthcare system, affording an opportunity to optimally manage chronic health conditions and provide preventative care. The healthcare team’s goal is to maintain or improve the mother’s health

2018 VA/DoD Clinical Practice Guidelines

18. Gestational Diabetes Management

Gestational Diabetes Management Gestational Diabetes Management Toggle navigation Brain Head & Neck Chest Endocrine Abdomen Musculoskeletal Skin Infectious Disease Hematology & Oncology Cohorts Diagnostics Emergency Findings Procedures Prevention & Management Pharmacy Resuscitation Trauma Emergency Procedures Ultrasound Cardiovascular Emergencies Lung Emergencies Infectious Disease Pediatrics Neurologic Emergencies Skin Exposure Miscellaneous Abuse Cancer Administration 4 Gestational Diabetes (...) Management Gestational Diabetes Management Aka: Gestational Diabetes Management II. Indications: Gestational Diabetes Abnormal Preexisting III. Monitoring: Blood Glucose Frequency of therapy 4 times daily Diet control s 4 times on 2 days per week Increase monitoring if 2 values/week abnormal Target Levels Before Breakfast or early morning (2-6 am): 60 to 95 mg/dl Before Lunch,Dinner: 60 to 115 mg/dl One hour post prandial goal: under 140 mg/dl Two hour post prandial goal: under 120 mg/dl Check s in early

2015 FP Notebook

19. Intrapartum fetal surveillance

Fetal Growth Restriction; GDM Gestational Diabetes; IOL Induction of labour; MoM Multiples of Median; PaPP-A Pregnancy associated plasma protein-A; PROM Premature Rupture of Membranes; PTL Preterm labour; PV Per Vaginal; T Temperature; = greater than or equal to; Greater than; 4.8 Abnormal: urgent birth · pH 5.0 No Queensland Clinical Guidelines: Intrapartum Fetal Surveillance Guideline No: MN15.15-V4-R20 Confirmatory CTG Normal? Yes Normal CTG · Baseline FHR 110-160 bpm · Baseline variability 6-25 (...) or more of the following antenatal or intrapartum indications are present in labour, CEFM is recommended 2 because of the synergistic effect on the woman: · 41 to 41 + 6 weeks gestation · Gestational hypertension · Gestational Diabetes Mellitus (GDM) without complicating factors · Obesity (BMI 30–40 kg/m 2 ) · Maternal age greater than or equal to 40 and less than 42 years · Maternal pyrexia (temperature 37.8 o C or 37.9 o C) · Prior to epidural block to establish baseline features 2 3 Fetal heart

2010 Clinical Practice Guidelines Portal

20. Acute pain management: scientific evidence (3rd Edition)

Acute pain management: scientific evidence (3rd Edition) ? ? ? ? Acute Pain Management: Scientific Evidence Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine ? ? ? Endorsed by: Faculty?of?Pain?Medicine,?Royal?College?of? Anaesthetists,?United?Kingdom?? Royal?College?of?Anaesthetists,? United?Kingdom?? Australian?Pain?Society? Australasian?Faculty?of?Rehabilitation?Medicine? College?of?Anaesthesiologists,?? Academy?of?Medicine,?Malaysia? College (...) and New Zealand College of Anaesthetists, 630 St Kilda Road, Melbourne, Victoria 3004, Australia. Website: www.anzca.edu.au Email: ceoanzca@anzca.edu.au This document should be cited as: Macintyre PE, Schug SA, Scott DA, Visser EJ, Walker SM; APM:SE Working Group of the Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine (2010), Acute Pain Management: Scientific Evidence (3rd edition), ANZCA & FPM, Melbourne. Copyright information for Tables 11.1 and 11.2 The material

2015 National Health and Medical Research Council

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