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In the United States, rates of both pre-existing and gestational diabetes have increased over the last decade. In the most recent report by the CDC, the prevalence of pre-existing diabetes and gestational diabetes were 0.9% and 6% in 2016, respectively. In New York City, rates were similar with a prevalence of 5.9% for gestational diabetes in the same year. Pre-existing diabetes increases adverse perinatal outcomes, including birth defects, stillbirth, and growth abnormalities. Gestational diabetes may increase the risk of shoulder dystocia, macrosomia, and pre-eclampsia.

The Maternal Fetal Medicine specialists at Carnegie Imaging work hand-in-hand with obstetricians, midwives, and their patients to manage diabetes in pregnancy. Successful management of gestational diabetes improves perinatal outcomes and results in a safer pregnancy for both mother and baby.

Gestational Diabetes Support Program

The Gestational Diabetes Support Program is a comprehensive co-management program that includes consultation with a certified diabetic educator and licensed nutritionist, a consultation with a Maternal Fetal Medicine specialist, weekly review of blood sugars, medication management (if required), and fetal surveillance. Each patient’s management strategy is individualized to her specific medical needs and with input from our MFM specialists, diabetic educator, and our referring obstetricians and midwives.

Diabetes Education and Nutrition Counseling

After a patient is referred to the Gestational Diabetes Support Program, an initial consultation is performed by our certified diabetic educator (CDE) and nutritionist, Christina McGeough. Christina received formalized training in health and nutrition at NYU. She subsequently completed a Master’s Degree in Public Health at Hunter College. Christina has an extensive background in diabetic education, oral medication therapy, and insulin management. During this consultation, the patient is also provided with a glucometer and instructed on its use.

Nutrition counseling is personalized based on individual dietary preferences, pre-pregnancy weight, and underlying medical problems. In addition, glucose log sheets and additional educational resources for diabetes are provided for the patient. Women are advised to submit glucose logs weekly by fax (212-722-7185) or by email (gdm@mfmnyc.com), and logs are reviewed by Christina and an MFM on a weekly basis. Some women, particularly if requiring medication, may require more frequent review.

Maternal Fetal Medicine Consultation

At the MFM consultation visit, the MFM will conduct a thorough review of the patient’s medical history, recent ultrasound findings, and estimated fetal weight, and, if available, most recent blood glucose values. The MFM will review the pathophysiology of gestational diabetes, risks to pregnancy, safety, and use of various anti-glycemic medications and fetal monitoring recommendations.

Pharmacologic management is typically recommended when over 20% of glucose values are elevated despite dietary changes, with emphasis on control of fasting blood glucose. Options for pharmacologic management include insulin therapy (typically first-line), metformin, and glyburide. For pre-gestational diabetic patients who are well controlled on metformin or glyburide, these medications may be continued during pregnancy. When insulin is prescribed, administration instructions are provided by in-house nursing staff or by the CDE.

Communication with Referring Providers

Communication with referring obstetricians and midwives is of utmost importance to the MFMs at Carnegie Imaging. We feel that this multidisciplinary approach to diabetic management provides the most optimal outcome to the patient. Carnegie MFMs are in constant dialog with referring providers about the progress of patients who are referred to us for co-management. As such, regular reports are provided to referring providers detailing any changes to diabetic management, in addition to ultrasound reports and any additional consultations. We are also accessible via email (gdm@mfmnyc.com) and by contacting our office directly by phone.

Fetal Surveillance and Delivery Timing

Our recommended fetal surveillance protocol for diabetes in pregnancy includes serial growth ultrasounds and biophysical profiles (BPP), the timing/frequency of which depends on whether the patient has pregestational, diet-controlled (A1GDM) or medication-controlled (A2GDM) diabetes and on associated comorbidities. Our general management guidelines are summarized below.

Pregestational Diabetes

• Baby aspirin 81 mg daily initiated at 12 weeks gestation
• Baseline workup for pre-eclampsia (24-hour urine protein collection and serum labs) and A1c
• Fetal echocardiogram at 20 to 22 weeks
• Serial growth ultrasound every 4 weeks
• Weekly BPP after 32 weeks
• Additional consultations if needed (e.g. Ophthalmology, Nephrology)
• Delivery timing individualized based on glucose control and fetal growth

A1GDM*

• Serial growth ultrasound every 4 weeks
• Weekly BPP after 36 weeks
• Delivery timing between 40 and 41 weeks

A2GDM*

• Serial growth ultrasound every 4 weeks
• Weekly BPP after 32 weeks
• Delivery timing between 39 and 40 weeks

*Fetal echocardiography is also recommended to women with gestational diabetes who are diagnosed prior to 24 weeks, as this may represent pre-gestational diabetes

Carnegie Imaging for Women blogs are intended for educational purposes only and do not replace certified professional care. Medical conditions vary and change frequently. Please ask your doctor any questions you may have regarding your condition to receive a proper diagnosis or risk analysis. Thank you!