SOGC CLINICAL PRACTICE GUIDELINE

It is SOGC policy to review the content 5 years after publication, at which time the document may be re-affirmed or revised to reflect
emergent new evidence and changes in practice.

No. 393, December 2019 (replaces No. 334, July 2016)

Guideline No. 393-Diabetes in Pregnancy

This Clinical Practice Guideline has been prepared by the The disclosure statements have been received from all authors
Maternal Fetal Medicine committee, reviewed by the Family and no conflicts of interest were declared.
Physicians Advisory, Aboriginal Health Initiative and Clinical
Key Words: Diabetes, pregnancy, stillbirth
Practice − Obstetrics guideline committees and the Canadian
Diabetes Association, endorsed by the Canadian Diabetes Corresponding author: Dr. Howard Berger
Association and approved by the Board of the Society of
Obstetricians and Gynaecologists of Canada.

Howard Berger, MD, Toronto, ON

CHANGES IN PRACTICE
1. Universal screening for gestational diabetes is recommended.
al, QC
Robert Gagnon, MD, Montre
2. Serial ultrasounds to assess fetal growth velocity and
Mathew Sermer, MD, Toronto, ON amniotic fluid volume provides objective endpoints to assess
the effectiveness of glycemic control in pregnancy with
diabetes.
3. When betamethasone is administered for lung maturation,
Maternal Fetal Medicine Committee (2019): James Andrews,
close maternal glycemic surveillance is recommended.
MD, Surrey, BC; Hayley Bos, MD, Victoria, BC (co-chair); Sheryl
Screening for gestational diabetes should be postponed for at
Choo, London, ON; Elisabeth Codsi, MD, Montreal, QC; Venu
least 7 days after the administration of betamethasone.
Jain, Edmonton, AB; Lisa Kuechler, RN, Victoria, BC; Noor
4. Pregnant women with either gestational or pre-gestational
Ladhani, MD, Toronto, ON; Heather Martin, RM, Edmonton, AB;
diabetes should be offered induction between 38 to 40 weeks
N. Lynne McLeod, MD, Halifax, NS; William Mundle, MD, Windsor,
gestation depending on their glycemic control and other
ON (co-chair); Kirsten Niles, Toronto, ON; Christy Pylypjuk, MD,
comorbidity factors.
Winnipeg, MB; Jennifer Walsh, MD, Calgary, AB

Special Contributor: Venu Jain, MD, Edmonton, AB

KEY MESSAGES
1. Multidisciplinary management to achieve optimal glycemic
control improves perinatal outcome.
2. There is an increased risk of stillbirth in women with diabetes
in pregnancy, particularly near term.
J Obstet Gynaecol Can 2019;41(12):1814−1825 3. Optimizing glycemic control in pregnancies complicated with
diabetes reduces the risk of preeclampsia, shoulder dystocia,
https://doi.org/10.1016/j.jogc.2019.03.008
and a large for gestational age fetus.
© 2019 The Society of Obstetricians and Gynaecologists of Canada/La 4. The occurrence of gestational diabetes increases the risk of
Société des obstétriciens et gynécologues du Canada. Published by developing type 2 diabetes in the future.
Elsevier Inc. All rights reserved.

This document reflects emerging clinical and scientific advances on the date issued and is subject to change. The information should not be
construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate amendments to these
opinions. They should be well documented if modified at the local level. None of these contents may be reproduced in any form without prior
written permission of the publisher.
All people have the right and responsibility to make informed decisions about their care in partnership with their health care providers. In order to
facilitate informed choice, patients should be provided with information and support that is evidence-based, culturally appropriate and tailored to
their needs.
This guideline was written using language that places women at the centre of care. That said, the SOGC is committed to respecting the rights of
all people—including transgender, gender non-binary, and intersex people—for whom the guideline may apply. We encourage healthcare
providers to engage in respectful conversation with patients regarding their gender identity as a critical part of providing safe and appropriate
care. The values, beliefs and individual needs of each patient and their family should be sought and the final decision about the care and
treatment options chosen by the patient should be respected.

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 Guideline No. 393-Diabetes in Pregnancy

Abstract

Objectives: This guideline reviews the evidence relating to the 1.3. If the value of the GCT is ≥11.1 mmol/L, gestational diabetes
diagnosis and obstetrical management of diabetes in pregnancy. mellitus is diagnosed

Outcomes: The outcomes evaluated were short and long-term 2. The “alternative 1-step diagnostic” approach of the Canadian
maternal outcomes including pre-eclampsia, Caesarean section, Diabetes Association 2013 guidelines is acceptable. In this strategy
future diabetes and other cardiovascular complications; and fetal pregnant women should be offered testing between 24-28 weeks
outcomes including congenital anomalies, stillbirth, macrosomia, using a standardized 2-hour 75-g oral glucose tolerance test with
birth trauma, hypoglycemia and long-term effects. fasting plasma glucose (FPG), 1-hour plasma glucose (PG),
2-hour PG (III-B).
Evidence: Published literature was retrieved through searches of Gestational diabetes mellitus is diagnosed if 1 value is met or
PubMed and The Cochrane Library using appropriate controlled
vocabulary (MeSH terms “diabetes” and “pregnancy”). Where exceeded:
appropriate, results were restricted to systematic reviews, i. FPG ≥5.1 mmol/L
randomized control trials/controlled clinical trials, and observational ii. 1-h PG ≥10.0 mmol/L
studies. There were no date limits but results were limited to English iii. 2-h PG ≥8.5 mmol/L
or French language materials.
It is recognized that the use of different diagnostic thresholds for
Values: The quality of evidence was rated using the criteria described the “preferred” and “alternate” strategies could cause confusion in
in the Report of the Canadian Task Force on Preventive Health certain settings. Despite this the committee has identified the
Care. importance of remaining aligned with the current CDA 2013 guide-
lines as being a priority. It is thus recommended that each care
Summary Statements:
centre strategically align with one of the two strategies and imple-
1. The adverse outcomes associated with diabetes in pregnancy are ment protocols to ensure consistent and uniform reporting of test
substantially associated with hyperglycemia as well as the co-exist- results.
ing metabolic environment. Women with pre-existing diabetes 3. If there is a high risk of gestational diabetes mellitus based on mul-
should receive preconception care to optimize blood sugar control tiple risk factors, screening or testing should be offered during the
and other co-morbidities. Outcomes for the fetus/neonate and the first half of the pregnancy and repeated at 24-28 weeks gestation if
mother in both pre-gestational diabetes mellitus and gestational dia- initially normal. If for any reason it was missed or if there is a clinical
betes mellitus pregnancies are improved by multidisciplinary man- suspicion of later onset gestational diabetes, a screening or diag-
agement whose goal is achieving optimal blood sugar control and nostic test should be performed (II-2B).
appropriate fetal surveillance (II-2). 4. Women with pre-existing or gestational diabetes mellitus should be
2. Retrospective studies indicate that women with pre-gestational dia- provided with care by a multidisciplinary team aimed at attaining
betes mellitus have an increased risk of stillbirth before 40 weeks of and then maintaining euglycemia (II-2B).
gestation when compared with the general obstetrical population. 5. For patients with pre-gestational diabetes mellitus or gestational
Similarly, large recent cohort and simulation studies of women with diabetes mellitus, starting at 28 weeks as a baseline, with subse-
gestational diabetes mellitus pregnancies also indicate a higher risk quent serial assessment of fetal growth every 3-4 weeks is sug-
of stillbirth between 36-39 weeks gestation (II-2). gested to assess the effect of maternal glycemic control on fetal
3. Women with gestational diabetes mellitus have a higher risk of pre- growth rate and amniotic fluid volume (II-2B).
eclampsia, shoulder dystocia, Caesarean section and large for ges- 6. Initiation of weekly assessment of fetal well-being at 36 weeks is
tational age infants (II-2). recommended in pre-gestational diabetes mellitus and in gesta-
4. Treatment of women with gestational diabetes mellitus and optimi- tional diabetes mellitus. It is also reasonable to consider weekly
zation of glycemic control reduces the risk of pre-eclampsia, shoul- fetal assessment for women with diet controlled gestational diabe-
der dystocia, and large for gestational age infants (I). tes mellitus beginning at 36 weeks. Acceptable methods of assess-
5. The occurrence of gestational diabetes mellitus increases the risk of ment of fetal well-being near term can include the non-stress test,
developing type 2 diabetes in the future for the mother (II-2). non-stress test + amniotic fluid index, biophysical profile or a com-
bination of the above (III-A).
Recommendations: 7. If co-morbid factors are present such as obesity, evidence of sub-
optimal glycemic control, large for gestational age (>90%), previ-
1. The “preferred screening and diagnostic 2-step” approach for ges- ous stillbirth, hypertension or small for gestational age (<10%) are
tational diabetes mellitus of the Canadian Diabetes Association present, earlier onset and/or more frequent fetal health surveillance
2013 guidelines is endorsed. All pregnant women should be is recommended. In specific cases where fetal growth restriction is
offered screening between 24-28 weeks using a standardized non- suspected, the addition of umbilical artery and fetal middle cerebral
fasting 50-g glucose challenge screening test (GCT) with plasma artery Doppler assessment may be helpful (II-2A).
glucose (PG) measured 1 hour later (III-B). 8. Pregnant women with gestational diabetes mellitus or with pre-ges-
tational diabetes mellitus should be offered induction between 38-
1.1. If the value is <7.8 mmol/L, no further testing is required. 40 weeks of gestation depending on their glycemic control and
other co-morbidity factors (II2-B).
1.2. If the value of the GCT is 7.8−11.0, a 2-hour 75-g oral glucose
9. Antenatal corticosteroid therapy should be administered to women
tolerance test with fasting PG (FPG), 1-hour PG, 2-hour PG
with insulin-treated gestational diabetes mellitus and pregesta-
should be performed.
tional diabetic women at the same dosage, according to the same
Gestational diabetes mellitus is diagnosed if 1 value is met or indications, and in the same gestational age range as that recom-
exceeded: mended for non-diabetic women (Skoll A, et al. No. 364-Antenatal
i. FPG ≥5.3 mmol/L Corticosteroid Therapy for Improving Neonatal Outcomes. J Obstet
ii. 1-h PG ≥10.6 mmol/L Gynaecol Can 2018;40:1219-39). When administered to women
iii. 2-h PG ≥9.0 mmol/L with preexisting or poorly controlled diabetes, close maternal

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glycemic surveillance is recommended (III-B). Following the first and pregnancy. Can J Diabetes 2013;37 Suppl 1:S168−83)
dose of betamethasone, the following insulin adjustments are rec- (II-2A).
ommended as per CDA guidelines (Diabetes Canada Clinical
11.1 Normal
Practice Guidelines Expert C, et al. Diabetes and Pregnancy. Can
J Diabetes 2018;42 Suppl 1:S255-S82): i. Fasting plasma glucose (FPG) <6.1 mmol/L
ii. 2h <7.8 mmol/L

Day 1: Increase the night insulin dose by 25%
iii. HbA1C <6.0%

Days 2 and 3: Increase all insulin doses by 40%

Day 4: Increase all insulin doses by 20% 11.2 Pre-diabetic

Day 5: Increase all insulin doses by 10% to 20% i. FPG 6.1-6.9 mmol/L or

Days 6 and 7: Gradually taper insulin doses to pre-betametha- ii. 2h plasma glucose (PG) 7.8-11.0 mmol/L or
sone doses iii. HbA1C 6.0-6.4%

10. If not previously done, in women with threatened preterm labour 11.3 Type 2 Diabetes mellitus
requiring betamethasone, a screening and diagnostic test for i. FPG ≥ 7.0 mmol/L
gestational diabetes mellitus should be performed either ii. Random PG or 2h PG ≥11.1 mmol/L
before or at least 7 days after the administration of betamethasone iii. HbA1C ≥6.5%
(III-B).
11. Women with GDM should be offered testing with a 75-g oral glu- 12. Breastfeeding is strongly recommended after delivery for all
cose tolerance test between 6 weeks and 6 months postpartum women with pre-gestational diabetes mellitus or gestational diabe-
to detect prediabetes and diabetes (Thompson D, et al. Diabetes tes mellitus (II-2A).

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 Guideline No. 393-Diabetes in Pregnancy

INTRODUCTION diagnosis and management of GDM.3,4 The primary goal

of this management is to attain and then maintain euglyce-
large population-based study in Ontario demon-
A strated that between 1996-2010 the incidence of
both gestational diabetes mellitus (GDM) and pre-gesta-
mia. This is best done by a multidisciplinary team with
attention to diet and exercise, and glucose monitoring, and,
as appropriate, medical management with insulin and/or
tional diabetes mellitus (PGDM) which includes both type oral hypoglycemic agents.
1 and type 2 DM, has doubled from 2.7% to 5.6% for
GDM and from 0.7 to 1.5% for PGDM.1 When compared The purpose of these guidelines is to review the diagnostic
with nondiabetic pregnant women, the risk of both con- criteria and issues related to the obstetrical management of
genital anomalies, odds ratio (OR) of 1.86 (95% confidence GDM and PGDM. Specific recommendations regarding
interval [CI] 1.49−2.33) and perinatal mortality, OR 2.33 glycemic control are beyond the scope of this document
(95% CI 1.59-3.43) remained higher in PGDM pregnant but can be found in the 2013 CDA Clinical Practice Guide-
women.1 Similarly, in a Swedish population-based cohort lines http://guidelines.diabetes.ca/browse/chapter36. The
of over 1.2 M pregnancies with singleton gestations, quality of evidence was rated using the criteria described in
women with GDM had a higher risk of adverse maternal the Report of the Canadian Task Force on Preventive
outcomes with adjusted OR of 1.81 (95% CI 1.64-2.00); Health Care (Table 1).
for shoulder dystocia of 2.74 (95% CI 2.04-3.68); and for
Caesarean section, 1.46 (95% CI 1.38-1.54).2 In addition, IMPACT OF DIABETES MELLITUS ON PERINATAL
with GDM, a higher risk of adverse neonatal outcomes MORTALITY
including large-for-gestational age, OR 3.43 (95% CI 3.21-
3.67), Erb’s palsy, OR 2.56 (95% CI 1.96-3.32), prematu- Table 2 summarizes the relative risk or OR for stillbirth in
rity, OR 1.71 (95% CI 1.58-1.86), and major malforma- different populations studied in pregnancies with GDM
tions, OR 1.19 (95% CI 1.02-1.39) has been reported.2 It compared with non-GDM pregnancies. A wide range of
is of interest that no statistically significant improvement in absolute stillbirth rates (per 1000 pregnancies) have been
maternal and neonatal outcome was seen over time in reported from as low as 0.32 up to 4.2 per 1000 pregnancies
either study with the exception of a decline in the rate of depending on the population studied and the gestational age
congenital anomalies by 23%.1,2 cut-off used to define stillbirth (Table 2). Some studies5
have confirmed that GDM may be diagnosed before 24
While the benefits of specialized management of pregnan- weeks gestation approximately 22%−27% of the time.
cies complicated by PGDM is well known, we now have Almost one-third of these patients (or 8% of the total diag-
data from randomized controlled trials (RCTs) that docu- nosed with GDM) will have type 2 diabetes when tested
ment a reduction in certain perinatal morbidities after postpartum.6 This is particularly true in the presence of the
following risk factors: maternal age > 35 years, obesity
(BMI >30), ethnicity (Aboriginal, African, Asian, Hispanic,
ABBREVIATIONS
South Asian), family history of diabetes, polycystic ovary
ACOG American College of Obstetricians and
Gynecologists syndrome, acanthosis nigricans, corticosteroid use, previous
CDA Canadian Diabetes Association
pregnancy complicated with GDM, or previous macrosomic
infant.7 Hutcheon et al.8 have suggested that only stillbirths
FPG fasting plasma glucose
above 28 weeks gestation should be included to determine
GCT glucose challenge screening test
the risk of stillbirth associated with GDM. Including women
GDM gestational diabetes mellitus
with an earlier diagnosis may not represent the risk associ-
HAPO Hyperglycemia and Adverse Pregnancy Outcome
ated with GDM but rather a mix of GDM and other causes
study
of stillbirths leading to the introduction of a bias by includ-
IADPSG International Association of Diabetes and Pregnancy
Study Groups ing a period of follow-up during which, by design, death or
NND number needed to deliver
the study outcome cannot occur. Since GDM is usually diag-
nosed after 24-28 weeks gestation, it would be more appro-
OGTT oral glucose tolerance test
priate to include only late stillbirth occurring after 28 weeks.
PG plasma glucose
Table 2 illustrates this phenomenon. When defining stillbirth
PGDM pre-gestational diabetes mellitus
occurring at >20 weeks, the risk of stillbirth attributable
RCT randomized controlled trial
to GDM is reduced or insignificant.8−11 This is because
RPG random plasma glucose more than 30% of stillbirths occur at 20-23 weeks before
SMBG self-monitored blood glucose GDM is usually diagnosed.12 When including only stillbirths

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Table 1. Key to evidence statements and grading of recommendations, using the ranking of the Canadian Task Force on
Preventive Health Care
Quality of Evidence Assessment* Classification of Recommendationsy
I: Evidence obtained from at least one properly randomized A. There is good evidence to recommend the clinical preventive
controlled trial action
II-1: Evidence from well-designed controlled trials without B. There is fair evidence to recommend the clinical preventive action
randomization C. The existing evidence is conflicting and does not allow to make a
II-2: Evidence from well-designed cohort (prospective or recommendation for or against use of the clinical preventive
retrospective) or case-control studies, preferably from more than action; however, other factors may influence decision-making
one centre or research group D. There is fair evidence to recommend against the clinical
II-3: Evidence obtained from comparisons between times or places preventive action
with or without the intervention. Dramatic results in uncontrolled E. There is good evidence to recommend against the clinical
experiments (such as the results of treatment with penicillin in the preventive action
1940s) could also be included in the category L. There is insufficient evidence (in quantity or quality) to make a
III: Opinions of respected authorities, based on clinical experience, recommendation; however, other factors may influence decision-
descriptive studies, or reports of expert committees making
*
The quality of evidence reported in these guidelines has been adapted from The Evaluation of Evidence criteria described in the Canadian Task Force on Preventive
Health Care.
y
Recommendations included in these guidelines have been adapted from the Classification of recommendations criteria described in The Canadian Task Force on
Preventive Health Care.
Taken from: Woolf SH, Battista RN, Angerson GM, Logan AG, Eel W. Canadian Task Force on Preventive Health Care. New grades for recommendations from the
Canadian Task Force on Preventive Health Care. CMAJ 2003;169:207e8.

Table 2. Risk of stillbirth; GDM versus no GDM

Absolute stillbirth
Gestational rate in GDM (per 1000 Relative risk or
Author age cut-off Population (n) pregnancies) odds ratio (95% CI) Policy management
Hutcheon et al. 8
≥20 weeks 2 001 749 4.2 0.88 (0.79-0.99) Not available
Peticca et al. 11
≥20 weeks 120 604 2.0 0.31 (0.11-0.67) Induction rate: 38% vs 24%
Karmon et al.9 ≥20 weeks 184 256 4.0 0.5 (0.4-0.7) Routine induction at 40 weeks
Ohana et al. 10
≥20 weeks 228 293 0.32 0.7 (0.5-0.8) Not available
Fadl et al.2 >28 weeks 1 260 297 4.0 1.18 (0.87-1.60) Not available
Hutcheon et al.8 >28 weeks 1 988 320 3.5 1.25 (1.11-1.41) Not available
Rosenstein et al.13 ≥36 weeks 4 190 953 1.71 1.34 (1.2-1.5) At >39 weeks risk higher if
expectant management
GDM: gestational diabetes mellitus.

occurring after 28 weeks, many studies to date have shown a 39 weeks with an RR of 1.56 (95% CI 1.2−2.0) but not
trend or a statistically significant increased risk of stillbirth at 40 and 41 weeks gestation. The loss of significance at
attributable to GDM.2,8,13 The specific excess risk of still- 40−41 weeks was either due to the increase in stillbirths in
birth in relation to week of gestation has recently been non-GDM pregnancies15 or due to the relatively low num-
shown in a cohort13 and simulation study derived from this ber of patients after 39 weeks in GDM pregnancies com-
cohort.14 This retrospective analysis of population-based pared to non-GDM pregnancies. In addition, the risk of
data from California, showed that the overall risk of stillbirth expectant management in women with GDM carried a
from 36-42 weeks was higher in women with GDM when higher risk of perinatal mortality than the risk of delivery at
compared with women without GDM (17.1 vs. 12.7/10,000 39 and 40 weeks gestation.13,14 The number of women with
deliveries; relative risk (RR) 1.34 (95% CI 1.2−1.5).14 Still- GDM needed to deliver (NND) at 39 and 40 weeks to pre-
birth rates were also examined at each gestational age, and vent 1 excess death was 1518 and 1311, respectively.13 This
from 36 to 39 weeks, women with GDM had a statistically is comparable to an NND of 1299 at 40 weeks for women
significant elevated RR of stillbirth compared with women without GDM and ≥40 years of age at the time of deliv-
without GDM, ranging from RR, 1.45 (95% CI 1.1−1.9) at ery.15 The retrospective nature of this study and the inability
38 weeks to RR 1.84 (95% CI 1.5−2.3) at 37 weeks.14 This to control for glycemic control and insulin treatment are lim-
increased risk of stillbirth remained statistically significant at itations. A retrospective cohort study from a centre with a

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 Guideline No. 393-Diabetes in Pregnancy

policy of induction by 40 weeks for all pregnant women with The Toronto Tri Hospital study established that adverse out-
diet-controlled GDM suggested that it is protective against comes associated with GDM increase along a continuum of
stillbirth when compared with the general obstetrical popula- increasing glucose thresholds.21 More recently, the Hypergly-
tion, OR 0.5 (95% CI 0.4-0.7).9 The impact of this policy of cemia and Adverse Pregnancy Outcome (HAPO) study22
induction on Caesarean section rates and neonatal morbidity confirmed these findings in a large prospective observational
is controversial. However, a small randomized clinical trial study but were unable to define outcome based thresholds
in mainly non-diabetic women by Nicholson et al.16 demon- for the diagnosis of GDM. Despite this, the International
strated a lower neonatal intensive care unit admission rate, a Association of Diabetes and Pregnancy Study Groups
higher uncomplicated vaginal birth rate and a lower mean (IADPSG) published recommendations for new thresholds
adverse outcome index score (better pregnancy outcomes) for the diagnosis of GDM based on statistical re-analysis of
among women who were actively managed through elective the HAPO data.23 The thresholds for the 2-hour 75-g
labour induction based on a unique management of risk OGTT used were calculated by defining glucose concentra-
scoring system. tions at which the OR of the 4 HAPO primary outcomes
(birthweight >90%; primary Caesarean section rate; neonatal
There is good evidence that PGDM is associated with a 3- hypoglycemia and cord C-peptide levels >90%) reached
5-fold increase in stillbirths when compared with non-dia- 1.75. These thresholds, when applied to the HAPO cohort,
betic pregnant women.17 Further prospective research is led to an average GDM incidence of 17% across all HAPO
needed on the optimization of timing of delivery in both sites. In addition the IADPSG recommended abandoning
GDM and PGDM pregnancies with specific attention to the 1-hour 50-g glucose load in favour of a 1-step testing
stratification by adequacy of glycemic control; the impact strategy. Table 3 provides a summary of the glucose thresh-
on maternal, fetal and neonatal outcomes; as well as eco- olds, screening, and diagnostic strategies used worldwide. In
nomic analysis of different management strategies. North America, either a 2-step or a 1-step approach is felt
to be acceptable since there is no demonstrated difference in
outcome using either strategy.7,24,25
REFERS TO SUMMARY STATEMENTS 1 & 2
The Canadian Diabetes Association (CDA) guidelines in
which the Society of Obstetricians and Gynaecologists of
SCREENING FOR GESTATIONAL DIABETES Canada (SOGC) was represented in an attempt to achieve
MELLITUS (GDM) − APPENDIX A consensus between obstetricians and endocrinologists were
updated in 2013.7 Guiding the decisions of the committee
Despite not meeting many of the criteria for a program of were the realization that: (1) women with one abnormal value
population-based screening,18 screening for GDM has on the OGTT (previously classified as intolerance to glucose
been accepted widely and is almost universally practised of pregnancy or IGT) have similar outcomes to women with
among health care professionals in North America.19,20 two abnormal values and are routinely managed in the same
Methods for screening for GDM include: manner6,26−30; (2) the HAPO trial22 provided data that could
1. Screening with a 1-hour 50-g glucose load (or alterna- be used to help formulate outcome based diagnostic thresh-
tive) olds for GDM and; (3) there is a need to achieve some
2. Risk factor based screening degree of uniformity with regards to screening methodology
3. One step testing with a diagnostic 2-hour 75 gram oral and diagnostic criteria in Canada. The CDA 2013 guidelines
glucose tolerance test (OGTT). This does not in fact recommends a universal screening for GDM for all pregnant
constitute a screening test but rather universal testing women between 24 and 28 weeks gestation followed with a
4. Screening with alternative biochemical tests: Fasting 2-hour 75-g oral glucose tolerance test if the 1-hour plasma
plasma glucose (FPG); HbA1C, random plasma glucose glucose (PG) post 50 g glucose load value is ≥7.8 mmol.7
(RPG) This is referred to as the “preferred 2-step” approach with
diagnostic criteria thresholds corresponding to an OR of 2.0
There have been no RCTs comparing screening for GDM for the four main HAPO outcomes.22 An “alternative 1-
with no screening20 thus the decision to perform screening step” approach with diagnostic criteria thresholds with an
is based on the recent RCTs that have shown certain health OR of 1.7522 for adverse perinatal outcome is also accept-
benefits for treatment of GDM.3,4 As GDM is an asymp- able.7 The 2014 American Diabetes Association guidelines24
tomatic condition, logic dictates that some form of screening endorsed an approach similar to the CDA 2013 although the
would need to be performed in order to diagnose cases that second step differs with the diagnostic test remaining the 100
might benefit from treatment and management of GDM. gram OGTT.24 These guidelines are also more in line with

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Table 3. Universal Screening and Diagnostic criteria for GDM (mmol/L)

ACOG 201325 ACOG 201325 CDA 20137 “alternative
ADA 201424 ADA 201424 approach”, IADPSG
Carpenter and National Diabetes CDA 20137 2010,86 ADIPS 201431,
Coustan Data Group “preferred approach” ADA 201424 WHO 201332
Gestational age at screeninga 24-28 weeks 24-28 weeks 24-28 weeks 24-28 weeks Any time
Steps 2-step 2-step 2-step 1-step 1-step
Step 1 Screening Step 2 if value ≥7.8 Step 2 if value ≥7.8 GDM if ≥11.1
1-h 50 g glucose challenge No diagnostic cut-off No diagnostic cut-off Step 2 if value
for GDM for GDM 7.8-11.0
Step 2
Loading dose 100 g 100 g 75 g 75 g 75 g
Fasting ≥5.3 ≥5.8 ≥5.3b ≥5.1c ≥5.1c
1 hour ≥10.0 ≥10.6 ≥10.6b ≥10.0c ≥10.0c
2 hours ≥8.6 ≥9.2 ≥9.0b ≥8.5c ≥8.5c
3 hours ≥7.8 ≥8.0 Not needed Not needed Not needed
GDM if ≥2 abnormal values ≥2 abnormal values ≥1 abnormal value ≥1 abnormal value ≥1 abnormal value
Prevalence of GDM (%) 4.8 3.2 7.0 16.1 16.1
ACOG: American College of Obstetrics and Gynecology; ADA: American Diabetes Association; ADIPS: Australasian Diabetes in Pregnancy Society; CDA: Canadian
Diabetes Association; IADPSG: International Association of Diabetes in Pregnancy Group; GDM: gestational diabetes mellitus; WHO: World Health Organization.
a
Screening offered at any stage in the pregnancy if multiple risk factors
b
OR of 2.00 for adverse perinatal outcome based on HAPO study
c
OR of 1.75.

the American College of Obstetricians and Gynecologists There are no established criteria for the diagnosis of GDM
(ACOG) 2013 guidelines.25 It is of note that the Australasian based on the 1-hour 50-g post-load value but it is recog-
Diabetes in Pregnancy Society and the World Health Organi- nized that there are results of this test that indicate a very
zation have both adopted the IADPSG criteria in their 2013 high chance of diagnosing GDM on the confirmatory test.
guidelines.31,32 The incidence of GDM will vary between Cheng et al.,34 in a cohort of 14 771 pregnancies with
3.2% and 17.8% depending of the thresholds used and the GDM have shown that there is an increase in Caesarean
composition of the screened population. Table 3 summarizes section, OR 4.18 (95% CI 1.15-15.2), and an increase in
the different screening and diagnostic criteria used for GDM. shoulder dystocia, OR 15.14 (95% CI 1.64-140) in women
who had a screening 1-hour post 50-g glucose load value
above 11.1 mmol/L. When the outcome post 1-hour 50-g
THE 1-HOUR 50-g GLUCOSE CHALLENGE
glucose load is defined by an abnormal oral glucose toler-
SCREENING TEST ance test only, the cutoff values that can reliably diagnose
GDM is probably >12.2 mmol/L.34,35
It is recognized that there is controversy regarding the use of
a 1-hour 50-g non-fasting GCT as a screening test for For these reasons, the joint CDA-SOGC 2013 committee
GDM. Criticism is focused on the following issues: (1) the on diabetes in pregnancy decided that if a value of
inability to identify women with isolated elevated FPG; (2) ≥11.1 mmol/L after a 1-hour 50-g glucose load is
limited reproducibility; (3) incomplete uptake of the diagnos- obtained, a 2-hour 75-g OGTT is unnecessary.
tic test in those that screen positive; (4) delay in diagnosis of
GDM; and (5) Sensitivity of the test is only 76.6%.33 In con- When the a priori risk of diagnosing GDM or overt DM is
trast, this test is widely practised in North America and has high based on clinical, demographic, or historical risk factors
high acceptance in both patients and caregivers. Until data it will be prudent to offer either screening or testing earlier in
emerges that support significant superior outcomes with a gestation. This is mainly to facilitate the diagnosis of unrec-
one-step diagnostic test, the SOGC has decided to recom- ognized type 2 DM that will benefit from earlier interven-
mend the continued use of the 50-g OGTT as the primary tions to ensure adequate glycemic control. In the presence
screening tool in women without high-risk characteristics. of the following risk factors: maternal age >35 years, obesity

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(pre-pregnancy body mass index >30 kg/m2), ethnicity association between excessive fetal weight and certain
(Aboriginal, African, Asian, Hispanic, South Asian), family perinatal complications including shoulder dystocia and
history of diabetes, polycystic ovary syndrome, acanthosis birth trauma,42,43 perinatal mortality,44 and Caesarean
nigricans, corticosteroid use, previous pregnancy compli- delivery.21,45−48 Landon et al.4 have shown that the treat-
cated with GDM, or previous macrosomic infant, either ment of mild gestational diabetes results in a significant
1-hour 50-g glucose challenge screening test or a diagnostic reduction with treatment as compared with usual care in
75-g GTT can be offered in the first half of the pregnancy several pre-specified secondary outcomes, including
and repeated at 24−28 weeks if negative.7 Until there is evi- mean birth weight (3302 vs. 3408 g), neonatal fat mass
dence to support alternate thresholds for the early 50-g (427 vs. 464 g), the frequency of large-for-gestational-age
GCT or 75-g GTT we suggest using the same criteria that is infants (7.1% vs. 14.5%), birth weight greater than 4000 g
used for the standard 24−28 week test. (5.9% vs. 14.3%), shoulder dystocia (1.5% vs. 4.0%), and
Caesarean delivery (26.9% vs. 33.8%). In a secondary
Pregnancy after bariatric surgery is becoming more com- analysis the Maternal Fetal Medicine Network RCT for
mon. GDM diagnostic testing, when applied to women the treatment of mild GDM demonstrated that induction
who have undergone Roux-en-Y gastric bypass, increases of labour between 37 and 40 weeks of gestation in women
the GDM diagnosis without changing pregnancy out- did not increase the rate of Caesarean delivery.49 Treat-
come.36 In addition, a high incidence of 58% of reactive ment of GDM, as compared with usual care, was also
hypoglycemia is encountered during OGTT. Therefore, associated with reduced rates of preeclampsia and gesta-
studies are needed to provide alternative screening and tional hypertension (combined rates for the two condi-
diagnostic criteria for GDM in post bariatric surgery tions, 8.6% vs. 13.6%; P = 0.01).
women. Due to lack of evidence supporting different
thresholds for screening for GDM, it is not possible to Current CDA 2013 guidelines for maternal glycemic control
define alternate thresholds. Until then, it is reasonable to suggest striving for the following targets on self-monitored
order fasting and 1-hour postprandial blood glucose in blood glucose (SMBG): fasting SMBG <5.3 mmol/L;
addition to HbA1C level in these women to rule out abnor- 1-hour postprandial of <7.8 mmol/L or 2 hours postpran-
malities in carbohydrate metabolism. dial <6.7 mmol/L. This often can be achieved by nutritional
counselling and modification of physical activity level. When
unsuccessful after 1−2 weeks of non-medical interventions,
REFERS TO RECOMMENDATIONS 1, 2 & 3 medical therapy should be initiated.7 Optimizing maternal
glycemic control in women with GDM decreases the risk of
pre-eclampsia, decreases the risk of fetal macrosomia, shoul-
ANTEPARTUM MANAGEMENT OF GESTATIONAL der dystocia, and Caesarean section.4
DIABETES MELLITUS
A small-for-gestational-age fetus can also be a complication
The benefits of treating GDM are now generally accepted.3,4 of overtreatment of GDM or a complication of associated
There is also an association between the presence of GDM risk factors.49 An RCT comparing insulin therapy based on
and hypertensive disorders of pregnancy.22,37 The goals of “tight” maternal glycemic control (keeping fasting SMBG
treatment are: (1) optimizing fetal growth and preventing <5.0 mmol/L and 2 hours postprandial at <6.7 mmol/L)
macrosomia, (2) reducing the risk of intrauterine fetal death, alone versus ultrasound-based measurement of fetal abdom-
(3) reducing the risk of pre-eclampsia,38 (4) reducing the inal circumference percentile and more “relaxed” maternal
risks of Caesarean section, and (5) reducing the risk of neo- glycemic control (fasting SMGC <6.6 mmol/L and 2 hours
natal complications including shoulder dystocia, birth postprandial <11.1 mmol/L) has demonstrated that both
trauma and neonatal hypoglycemia. methods resulted in equivalent perinatal outcome.50 The
addition of measuring the abdominal circumference every
3−4 weeks helped guide the decision to treat some pregnant
REFERS TO SUMMARY STATEMENTS 3, 4 & 5
women more aggressively with tighter glycemic control to
prevent macrosomia while using a more “relaxed” control if
Optimizing Fetal Growth and Preventing Macrosomia the abdominal circumference was low to prevent the devel-
Fetal macrosomia may occur without gestational diabetes. opment of a small-for-gestational-age fetus.50−52 If a small-
However, the incidence of macrosomia in pregnancies for-gestational-age fetus is suspected, umbilical artery and
complicated with maternal hyperglycemia is a function of middle cerebral artery Doppler (if available) should be done
maternal glycemic control.22,29,30,37,39−41 There is an as part of the assessment of placental function and fetal well

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SOGC CLINICAL PRACTICE GUIDELINE

being. In the presence of fetal macrosomia or poor glycemic management. Induction of labour did not increase the risk
control, polyhydramnios may also develop. Therefore, the of Caesarean delivery and improved the likelihood of spon-
measurement of the amniotic fluid volume can be another taneous vaginal delivery. There is only one randomized clin-
tool used to assess maternal glycemic control in the context ical trial comparing elective induction with expectant
of GDM.53 management in GDM pregnancies.65 In a mixed group of
women with uncomplicated insulin-requiring GDM
Reducing the Risk of Intrauterine Fetal Death or PGDM, expectant management of pregnancy after
The most important factor to minimize fetal death is opti- 38 weeks gestation did not reduce or increase the incidence
mizing maternal glycemic control in order to optimize fetal of Caesarean delivery. However, there was an increased prev-
growth. The 2007 SOGC guidelines on antenatal fetal sur- alence of large-for-gestational-age infants (23% vs. 10%) and
veillance54 lists pre-pregnancy diabetes and insulin-requir- shoulder dystocia (3% vs. 0% NS) in the expectant group.
ing GDM as conditions associated with increased perinatal
morbidity/mortality where antenatal fetal surveillance may
be beneficial. In light of more recent evidence that diet- REFERS TO RECOMMENDATIONS 4, 5, 6 & 7
controlled GDM might also be associated with an increase
in perinatal mortality 8,13,14 particularly after 38 weeks ges-
tation, these patients should not be excluded from a proto- TIMING OF DELIVERY
col for antenatal fetal surveillance applicable to high-risk
pregnancies. Landon and Vickers55 previously questioned A recent systematic review demonstrated a reduction in the
if patients with diet-controlled GDM should have any fetal rate of fetal macrosomia with active rather than expectant
health surveillance prior to 40 weeks gestation since the management.66 Due to the significant heterogeneity in the
risk of fetal death is low. In contrast, they advocated twice studies analyzed the authors were limited in their ability to
per week fetal health surveillance starting at 32 weeks for draw conclusions and provide recommendations for man-
all insulin-treated GDM patients. Most published protocols agement. Due to the small number of patients, these stud-
for antenatal fetal surveillance for diet-controlled GDM ies were not powered to address the impact of induction or
include ultrasound for fetal growth every 3-4 weeks start- expectant management on perinatal mortality. In the view
ing at 28 weeks gestation and delivery no later than 40 that the risk of intrauterine fetal death appears to outweigh
weeks gestation.9,50,52,56 The ACOG 2013 guidelines25 the risk of infant death after 39 weeks,13 induction of
states that for women with GDM and poor glycemic con- labour at 39 weeks could be considered in insulin-treated
trol, fetal surveillance may be beneficial. A retrospective GDM patients. Since retrospective studies suggest that a
study of 2134 women with pregnancies complicated by dia- policy of induction by no later than 40 weeks is associated
betes reported that an antepartum fetal surveillance pro- with a decreased rate of stillbirth in women with diet-con-
gram using twice-weekly non-stress test and fluid index trolled GDM when compared with the general obstetrical
assessment in pregnancies complicated by diabetes was population (OR 0.5 (95% CI 0.4-0.7),9 induction by 40
successful in preventing stillbirth.57 The role of the bio- weeks maybe beneficial in this population. It is also reas-
physical profile (BPP) in antenatal surveillance of diabetic suring that a recent study including all randomized clinical
pregnancies has not been studied in a large population, but trials comparing induction of labour at term or post-term
one can logically extrapolate from the known value of the with expectant management for high-and low risk pregnan-
BPP in non diabetic pregnancies58,59 to a diabetic preg- cies showed a reduced risk of fetal death (RR 0.50; 95% CI
nancy surveillance protocol. 0.25−0.99), reduced risk of neonatal intensive care unit
admission (RR 0.86; 95% CI 0.79−0.94) and no increase
The use of pre-delivery weight estimation to detect the in Caesarean section rate with labour induction,67 findings
presence of fetal macrosomia is problematic due to the that have been replicated in other studies.68,69
poor performance of all methods of pre-delivery fetal
weight estimation.60−62 Previous evidence has suggested REFERS TO RECOMMENDATION 8
that in the context of suspected fetal macrosomia there is
no proven benefit of induction of labour compared with
expectant management.63 However, more recently, Boul- SPECIAL CONSIDERATIONS
vain et al.64 demonstrated in a large randomized clinical trial
that induction of labour for suspected large-for-date fetuses Diabetes and the Use of Antenatal Corticosteroids
is associated with a reduced risk of shoulder dystocia The widespread use of corticosteroids in patients at risk
and associated morbidity compared with expectant of preterm delivery, often administered at the same

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 Guideline No. 393-Diabetes in Pregnancy

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Appendix A. Gestational Diabetes Mellitus Screening and Diagnosis

Appendix B. Gestational Diabetes Mellitus Postpartum Testing

1825.e1
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