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Referral and warning signs
When to refer
Refer ALL women with pre-existing DM or diagnosed GDM to specialist care for management (medication initiation, fetal surveillance). Advise delivery in hospital.
Red flags
- Poorly controlled BGLs
- Development of pre-eclampsia
- Signs of fetal macrosomia/IUGR
- Reduced fetal movements
- Ketoacidosis
Signs and symptoms
- Often asymptomatic (GDM).
- May have symptoms of hyperglycaemia (thirst, polyuria).
- Symptoms related to complications (macrosomia, polyhydramnios).
Risk factors
- GDM: BMI >35, Age >40, Previous GDM, Family history DM, Previous macrosomic baby (>4kg) / stillbirth, PCOS, Ethnicity.
- Pre-existing: Type 1 or Type 2 DM before pregnancy.
Diagnosis
Clinical assessment
Screening based on risk factors. Symptoms unreliable.
Investigations
- Screening (24-28 weeks, or earlier if high risk): Random/Fasting Blood Sugar. Oral Glucose Tolerance Test (OGTT - 75g) - Diagnostic standard.
- Diagnostic Criteria (WHO 2013/UCG context): Fasting >= 5.1 mmol/L OR 1-hr post >= 10.0 mmol/L OR 2-hr post >= 8.5 mmol/L. (Check local exact thresholds).
- Glycosuria indicates need for testing.
- HbA1c (pre-pregnancy control).
Diagnostic criteria
Meeting glucose thresholds on OGTT or significantly elevated fasting/random glucose.
Management
Non-pharmacological management
- Dietary Modification (Medical Nutrition Therapy).
- Physical Activity.
- Blood Glucose Monitoring (SMBG - fasting & postprandial).
- Weight management.
- Smoking cessation.
Pharmacological treatment
- Goal: Optimal glycaemic control (Targets: Pre-prandial <5.3, 1hr post <7.8, 2hr post <6.4 mmol/L - UCG).
- If diet/exercise insufficient: Metformin (start 500mg OD, max 2g/day). Insulin (if Metformin contraindicated/insufficient, or Type 1 DM - specialist Rx). Glibenclamide generally avoided.
- Pre-existing DM: Optimize preconception. Adjust regimen during pregnancy. Insulin standard for Type 1.
Monitoring
Frequent SMBG. Regular ANC. Fetal growth ultrasound. Monitor for maternal complications (hypertension). Postpartum glucose testing.
Complications
- Maternal: Pre-eclampsia, C-section, Obstructed labour, Future Type 2 DM.
- Fetal/Neonatal: Macrosomia, Birth trauma, Neonatal hypoglycaemia, RDS, Jaundice, Polycythaemia, Congenital abnormalities (pre-existing DM), Stillbirth.
Prevention
- Healthy lifestyle pre-conception.
- Screening high-risk women.
- Good glycaemic control.
Patient education
- Explanation of GDM/diabetes.
- Importance of diet/exercise.
- SMBG technique.
- Medication use.
- Recognizing hypo/hyperglycaemia.
- Fetal movement monitoring.
- Follow-up/postpartum screening.
Uganda-specific notes
Screening often risk-based/glycosuria due to limited OGTT. Metformin common 1st line drug. Insulin access/management limited. Macrosomia significant issue.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 16, Section 16.2.5
- Uganda Clinical Guidelines (UCG) 2023
Chapter 8, Section 8.1.3 (General Diabetes Mgt)
- Uganda Clinical Guidelines (UCG) 2023
Chapter 19, Section 19.1.3 (Nutrition)