SCREENING AND DIAGNOSIS Objectives

At the end of this session you will be

able to:
GOI GESTATIONAL DIABETES Define GDM
GUIDELINES 2014 Identify the risks for development of GDM.
State the prevalence of GDM locally
Explain the reason for identifying and treating
GDM POPULATION BASED STUDY GDM
UTTAR PRADESH Identify appropriate screening measures
Identify who should be screened
Identify diagnostic criteria

Definition Glucose regulation during pregnancy

Glucose intolerance with onset or first
recognition during pregnancy
Characterized by -cell function that is
unable to meet the bodys insulin needs
Insulin resistance begins in mid pregnancy and
progresses through the third trimester
A result of maternal adiposity and effects of placental
hormones

-cells usually make more insulin to compensate

for resistance when they cannot meet the
Buchanan, Wiang, Kjos, Watanabe 2007 needs hyperglycemia occurs

1
 GDM represents a state of chronic -cell Prevalence
dysfunction in the face of insulin The prevalence of GDM is estimated to be 10-
resistance 16.9% in pregnant women depending on the
diagnostic criteria used.
Insulin resistance and insulin levels are different
prior to pregnancy in women who develop GDM Prevalence also varies by region and ethnicity.
and those who do not Highest prevalence is in South East Asia
Lowest in North America and the Caribbean
Changes in insulin sensitivity are similar in both
groups during pregnancy Prevalence higher
in less physically active women.
However in GDM women, insulin secretion does In older women
In women with higher BMI
not increase adequately In those with a strong family history of diabetes

WHO, 2013
Buchanan, Wiang, Kjos, Watanabe 2007 IDF, 2013

Risk factors for GDM

Discussion High risk Low risk
Obesity Age less than 25 years
Diabetes in 1st degree relative
No previous poor
Previous pregnancy outcomes
What are the risk factors for gestational history of GDM or glucose
intolerance No diabetes in 1st degree
relatives
diabetes? complicated pregnancy
infant with macrosomia > Normal prepregnancy
3.5 kg weight and weight gain
Older age during pregnancy
High risk ethnic group; South No history of abnormal
What risk factors do you see most often Asian, East Asian, Indigenous glucose tolerance
American or Australian,
in your setting? Hispanic
PCOS
Perkins, Dunn, Jagastia , 2007

1
2
Is Hypertension a risk factor?
Hypertension prior to pregnancy or during
1st trimester doubled the risk of GDM
independent of maternal weight
Hence all women with hypertension should
be screened for GDM
Hedderson, Ferrara, 2008
Why diagnose and treat GDM? Importance of follow up
Short term risks for the baby
Macrosomia
Neonatal hypoglycemia
Jaundice
Preterm birth
Birth injury
Hypocalcemia/ hypomagnesimia
Respiratory distress syndrome
Long term risks for the baby
Obesity
Type 2 diabetes
Why diagnose and treat GDM?
Short term risks for the mother
Development of gestational hypertension, worsening essential
hypertension or development of preeclampsia
Operative delivery - related to macrosomia
Polyhydramnios
Premature labour
Long term risks for the mother
Development of type 2 diabetes in next ~10 years (30-60%
depending on population)
Development of cardiovascular disease
CDA, 2013
Metzger, Buchanan, et al. 2007
Long term follow up studies have shown
that most women with GDM will develop
diabetes within the first decade after the
pregnancy
Testing after pregnancy is important - more
about this later
Kim, Newton, Knopp 2002
3
 Who to screen
Screening
Some guidelines recommend screening all
women at the first visit to rule out pre -
- Whom to screen existing type 2 diabetes

Most guidelines recommend screening all

- When to screen women for GDM at 24-28 weeks gestation.

- How to screen ADA, 2015

CDA , 2013

When to screen? When to screen

First trimester Screening for GDM
Screening in 1st trimester
Screening should be done at 24-28 weeks
- to rule out unidentified pre -existing diabetes
Diagnosis based on a 75 gm glucose load given in fasting
Fasting plasma glucose > 126 mg/dl (7 mmol/L) state
or
HbA1c >6.5% GDM diagnosed when one or more of the following is
present
or
Random >200mg/dl (11.1 mmol/L) Fasting 92 - 125 mg/dl
or 1 hour post 75 gm load >180 mg/dl
2hr value in OGTT >200mg/dl (11.1 mmol/L) 2 hour post 75 gm load >140mg/dl (DIPSI)
(Diabetes in Pregnancy study group in India
If overt diabetes is detected, it must be treated appropriately.
If woman tests negative, screening at 32 weeks also may
be necessary in presence of high risks
World Health Organization, 2013
ADA, 2015

4
 Center-to-center differences occur in GDM frequency
and relative diagnostic importance of fasting, 1-h, and
2-h glucose levels. This may impact strategies used for
V. Seshiah, V. Balaji, Madhuri S Balaji, A Paneerselvam, Manjula Datta, Diabetes Research In
the diagnosis of GDM
Frequency of gestational diabetes mellitus at collaborating centers based on IADPSG
Clinical Practice: 2007. Sept; 77(3): 482-4 consensus panel-recommended criteria: the Hyperglycemia and Adverse Pregnancy
Outcome (HAPO) Study.
Sacks DA. etal. Diabetes Care 2012 Mar;35(3):526-8

Diabetes Care 2015, WHO 2013

Diagnostic criteria

Crowther CA. Hiller JE, Moss JR. et al. Effect of treatment of gestational diabetes
mellitus. N Engl J Med 2005: Vol. 352. No. 24. 2477-86.

Gayle C. Germain S. Marsh Ms. et al. Comparing pregnancy outcomes for intensive
versus routine antenatal treatment of GDM based on a 75 gm OGTT 2 - h blood
glucose (>140 mg / dl). Diabetologia. 2010. Vol. 53. Suppl. No. 1, S435.
Paul W. Franks, Helen C. Looker, Sayuko Kobes, Lesite Touger, P. Antonio Tataranni, Robert I. Hanson, and
Willliam C. Knowler. Diabetes 2006 55: 460-465. Jitendra Singh et al. Prevalence of Gestational Diabetes Mellitus (GDM) and its
Seshiah V, Balaji V, Arjalakshi C, Madhuri S Balaji, et al. A Single test procedure to diagnose GDM. Outcomes in Jammu. JAPI (59): April 2011.
Acta Diabetologica 46 (1) : 51-54, March 2009
Balaji V, Madhuri Balaji, Anjalakshi C, Cynthia A, Arthi T. Seshiah V. (2011). Diagnosis
Diabetes Care 2015, WHO 2013 of gestational diabetes mellitus in Asian-Indian women. India J Endocrinol Metab.
July 2011, Vol. 15, Issue 3, pp. 187-190

Diabetes Care 2015, WHO 2013

5
How to screen Venous or capillary
Key considerations for screening in low resource
countries The venous plasma is the gold standard
Low cost
No requirement for elaborate preparation
High sensitivity and specificity Where laboratory facilities or technicians are not
Short turn-around time available, capillary glucose estimations may be done
Be administered by health workers with minimal training
using a hand held glucose meter.
Need little maintenance, calibration, or refrigeration

The glucose meter must be standardized with a lab and

Agarwal et al, 2007 calibrated against the lab on a regular basis.

Which of these women has GDM? Giving the diagnosis

All have had 75g glucose load at about 25 weeks Will my baby be ok? 1st question often asked
Rupinder, overweight, 35 years old,
fasting 90 mg/dl (5.0 mmol/L), Is this temporary? 2nd question
1 hr 170mg/d (9.4 mmol/L),
2hr 135mg/dl (7.5 mmol/L) Questions provide an opportunity for teaching
Joanne, 3rd pregnancy, history of big babies, Must answer truthfully
fasting 130 mg/dl (7.2 mmol/L),
1 hr 190mg/dl (10.5 mmol/L) Must convey importance of management during
2 hr 220mg/dl (12.2 mmol/L)
pregnancy for healthy outcome but also for
Maria, 1st pregnancy, 25 years old, obese,
future health of baby and mother
fasting 90mg/dl (5 mmol/L),
1 hr 168mg/dl (9.3mmol/L)
Risk of type 2 diabetes
2 hr 160 mg/dl (8.8mmol/L)
Risk of obesity

6
7
 Insulin Therapy
Pregnant Woman with GDM
MNT for 2 weeks

2 hr PPPG
120 mg/dl 2 hr PPPG < 120 mg/dl

Start Human Insulin premix 30:70 Continue MNT, repeat 2 hr

v Subcutaneous Injection, 30 mlns before PPPG after 2 week, still
breakfast, once a day 30 weeks and thereafter,
v Dose of Insulin calculated by blood glucose level

Blood glucose Dose of Insulin 120 mg/dl

< 120 mg/dl
Between 120 -160 4 units
Between 160-200 6 units
More than 200 8 units

FBG & 2 hour PPPG every 3rd day

FBG <95mg/dl & 2 hrs PPPG FBG <95mg/dl & 2 hrs PPPG FBG <95mg/dl & 2 hrs PPPG
<120 mg/dl <120 mg/dl <120 mg/dl

Continue same dose of Increase dose of Insulin Give Inj. Insulin 2 doses
Insulin + MNT by 2 U + MNT pre breakfast - by 4 U

Repeat FBG & 2 hr PPPG every 3rd day till dose of Insulin adjusted

FBG <95mg/dl FBG <95mg/dl FBG >95mg/dl

2 hrs PPPG <120 mg/dl 2 hrs PPPG >120 mg/dl 2 hrs PPPG >120 mg/dl

Continue same dose of Increase dose of Insulin Increase pre breakfast

Insulin + by 2 U + MNT Insulin by 4 U

v
Repeat FBG & 2 hr PPPG every 3rd day
v
Adjust dose of Insulin accordingly till FBG <95mg/dl, 2 hr PPPG <120 mg/dl

Continue same dose of Insulin + MNT

v
v
Repeat FBG & 2 hr PPPG 2 weekly before 30weeks & weekly after 30 weeks
* Only Injection human premix Insulin 30/70 to be used * Insulin syringe - 40 IU syringe * Subcutaneous Injection only

Post Partum Screening Cut offs for normal blood glucose values are:

l. Fasting plasma glucose: = 126 mg/dl

-Post Partum Screening for Diabetes after 6 weeks of delivery to be
done in Immunization clinic or MCH clinic, both the facility link lI. 75 g OGTT 2 hour plasma glucose
through training of staff,this is mandatory for GDM,Post Prandial
Blood sugar is to be done and diagnosed Type II Diabetes if blood III. Normal: < 140 mg/dl
sugar >=200 mg/dl and treated for Type II diabetes in NCD clinic.
IV. IGT: 140-199mg/dl
Post Partum follow up of Pregnant Women with GDM:
V. Type II Diabetes: = 200 mg/dl
Immediate postpartum care women with GDM is not different from
women without GDM but these women are at high risk to develop VI. Test normal: Woman is counselled about lifestyle modifications,
Type 2 Diabetes mellitus in future. weight monitoring & exercise.VII. Test positive: Woman advised to
consult a physician/NCD Clinic.VIII. PW with GDM and theiroffsprings
Maternal glucose levels usually return to normal after are at increased risk of developing.
delivery.Nevertheless, a FPG & 2 hr PPPG is performed on the 3rd
day of delivery at the place of delivery. For this reason, GDM cases Type II Diabetes mellitus in later life. They should be counselled for
are not discharged after 48 hours unlike other normal PNC cases.. healthy lifestyle and behaviour, particularly role of diet & exercise.

Subsequently, ANM to perform 75 g GTT at 6 weeks postpartum to IX.GDM should be a part of NCD (Non communicable Disease)
evaluate glycemic status of woman. programme.

8
9
Gestational Diabetes Uttar Pradesh
Gestational Diabetes
18 Districts to be covered under NHM Prevalence and Outcome
District Hospital and CHC to be target
Study in Uttar Pradesh
Any hospital where more>200 Deliveries in a month
Maternal health Clinic HCPs to be trained Why Screening All Pregnant Women
3000 Doctors and 6000 Nurse/Paramedical staff to Population based Study
be covered in next 3 years in two full day Certified
Training. 57,000 Pregnant Women covered through Single
Syllabus as IDF and NHM GOI Guidelines OGTT Test.

10
Materials and Methods
A prospective study from September,
2012 to October, 2014 was done at 198
healthcare facilities in antenatal
mothers and 24,656 mothers were
screened in their 24th to 28th weeks
of pregnancy by impaired oral
glucose were notea.
During the total study period of
September, 2012 to September, 2014 >
55,000 women were supposed to be
registered for pregnancy on 198
health centres in and around Kanpur,
Uttar Pradesh, India
11
12
13
Jain, et al: Role of management of blood sugar in improving outcomes in GDM cases

Table 2 : Fetal outcomes in gestational diabetes mellitus versus nongestational diabetes

mellitus and its relationship with history of previous birth complications.
Outcomes in GDM present Previous fetal loss p-value GDM absent Previous fetal loss p-value
neonate (n=7641) present (n=8000) present
N (%) N (%) N (%) N (%)

Stillbirth 247 (3.3) 916 (12) < 0.0001 102(1.2) 212 (2.6) <0.0001
Neonatal death 128 (1.6) 156 (2) < 0.09 56 (0.7) 62 (0.8) <0.5
Perinatal death 375 (4.9) 1072 (14) < 0.0001 158 (1.9) 274 (3.4) <0.0001

GDM: Gestational diabetes mellitus

14
CONCLUSION
Maternal and fetal outcomes in GDM cases are poor. Perinatal and material outcomes in GDM cases are
also significantly related to control of blood sugar levels. Therefore, blood sugar levels appear to be an
important possible indicator of maternal and perinatal morbidity and mortality in Indian GDM cases.
However, there is a need to unify diagnostic criteria in practices throughout the Indian subcontinent for a
better validation of results from this study as well as other GDM studies conducted in

15
 Objectives

After completing this module the participant

will be able to

Discuss the value of education in helping women have
healthy pregnancies

Implement all components of the teaching process, that
SELF-MANAGEMENT EDUCATION is assessment, planning, implementation and evaluation

Discuss ways to make communication more effective

Define what is meant by a patient centered approach to
care.

Discuss the impact of gestational diabetes and
psychological needs of women and their families

Diabetes Self-Management Education Evidence for diabetes education

Purpose Traditional knowledge-based diabetes

education is essential but not sufficient for
To prepare those affected by GDM to sustained behaviour change.

Make informed decisions (Piette, Weinberger, McPhee, 2000)

Cope with the demands of a pregnancy complicated by

GDM While no single strategy or programme shows

Make changes in their behaviour that support their
self-management efforts
any clear advantage, interventions that
incorporate behavioural and affective
components are more effective.
Barlow, Wright, Sheasby, Turner, Hainsworth, 2002
Roter, Hall, Merisca, Nordstrom, Cretin,Svarstad, 1998

16
Why is self-management important? What do people need to understand?
People want to be healthy and have healthy babies.
Their own personal goals, values and feelings
Gestational diabetes needs to be self-managed.
Person is responsible for their day-to-day care. Diabetes care and treatment (advantages/
24-hours-a-day management is necessary. disadvantages)
Active, informed self-management leads to better long-term
outcomes.
Behaviour change and problem-solving strategies
Who is the decision-maker the woman, the
Funnell, Brown, Childs, Haas,Hosey, Jensen, et al.,2007
husband, the mother-in-law?
Norris, Lau, Smith, 2002
Gary, Genkinger, Guallar, Peyrot, Brancati, 2003
Duncan, Birkmeyer, Coughlin, Ouijan, Sherr, Boren, 2009 How to assume day-to-day responsibility

Self-management abilities A change in philosophy

The ability to self-manage is enhanced by

Considering the individuals need(s) Teacher knows all, makes
Teaching skills to optimise outcomes Didactive decisions
Facilitating behaviour change
Providing emotional support Teacher and patient learn and
Collaborative work together

Von Kroff, Gruman, Schaefer, 1997

Fisher, Brownson, OToole, Shetty, et al., 2005

17
So what should we do? Reframe our attitudes and behaviours

Tell the person

Medical Cover the basics
Judge compliance
Model
Teach to the person Educate for informed, self-directed decisions
and problem-solving

Self-
Patient centered Ask questions
Ask the person
Management Learn with the person
Education Partnership approach Identify problems
Address concerns

Teaching Teaching does not necessarily result in

learning
Deliberate interventions that involve sharing
information and experiences to meet intended
learner outcomes.
When was the last time someone
taught you?

Bastable, 2008 Did you learn anything?

18
Learning

Who is the Learner

Active, ongoing process that results in
and
changes in insight, behaviour, perception or Who is the Teacher?
motivation
Change may be positive or negative

Communication Skills

19
Communicating feelings or attitudes
Watch your body language!

Verbal 7% Avoid looking like a school teacher!

Vocal 38%

Visual 55%
Mehrabian, 1999

"What you do speaks so loudly that I cannot hear

what you say."
Ralph Waldo Emerson

Tips for plain speaking Tips for plain speaking

Introduce your subject and state a purpose Use the active voice
Paint a picture, make it visual The person should be the subject of the
Keep it organised message

Move from simple to complex You may require medication to achieve target
blood glucose levels
Repetition is important three times
Vs
Summarise
Some women may require medication to
Evaluate
Belton, Simpson, 2010 achieve target blood glucose levels

20
Communication Develop listening skills

You cant talk when you listen

Open-ended question
At what time do you take your medication at home? Listen dont plan your response

Give the person your full attention

Paraphrase and ask if you heard correctly
Closed question
So, you are saying.

Do you take your medication on time at home?

It sounds like..

You are wondering if....

I hear you saying.

Reflective listening The teaching process

The words
the speaker
says

What the The words Assessment

speaker the listener
means hears
Planning
How the
listener
interprets
the words
Implementation
Evaluation

21
Assessment There is a difference

Goals

Establish trust Health professionals and women with GDM
may have different opinions on what is

Determine priorities important

Assess current health status, knowledge and self-
Ask the woman what is important to her.
care practices

Determine family role or other support

Identify available resources
Suhonen, Nenonen, Laukka, Valimaki, 2005

Identify barriers to learning and self-management Timmins, 2005

Giving the diagnosis Assessment

Will my baby be ok? 1st question often asked
Is this temporary? 2nd question
Questions provide an opportunity for teaching
Considerations

Should be non-threatening and non-judgemental

Must answer truthfully

Consider the cultural and health beliefs of the
Must convey importance of management during
person
pregnancy for healthy outcome but also for future
health of baby and mother
Consider physical environment

Risk of type 2

Risk of obesity
Building rapport takes time

22
Planning Planning

Develop together Objectives for each topic

What do you want to know? Reviewed and updated regularly

What must you know?
Objectives should be
Offer choices
Measurable

Individual
Timely

Classes

Specific
Write learning objectives together
Mutually agreed

Implementation Implementation

Communication is the key Determine priorities

Simple words
Begin with the learners wishes

Open-ended questions
Most important topics first and last

Encouragement Conducive environment

Positive feedback
Simple to complex

Positive, caring attitude

Active listening Be specific

Repetition Repeat! Repeat! Repeat!

Belton, Simpson, 2010 Belton, Simpson, 2010

23
Evaluation Evaluation

Integral part of programme management

Clear description
Through all phases
Objectives that are

Plans should include how and when to - Measurable

evaluate - Specific
- Centered on the person
Not an afterthought! - Timed

Evaluation 5 steps to self directed goal

setting for behaviour change

Individual evaluation
1. Identify the problem

Have objectives been met?

2. Explore feelings

Open-ended questions

How are skills used? 3. Set goals

Do you understand? is not a valid question 4. Make a plan

Ask the person with diabetes to explain information to 5. Evaluate the results
you teach-back

Belton, Simpson, 2010 Funnell, Anderson,2004

24
What is the problem? How do you feel?

What do you find the easiest thing to manage

in your diabetes?
What are your thoughts and feelings about?
What is the most difficult/worst thing about
caring for your diabetes? How will you feel if this doesnt change?

What are your greatest concerns/fears/ Do you feel ________ about _______?
worries?
What makes this so hard for you?
Why is that happening?

Funnell, Anderson,2004 Funnell, Anderson,2004

What do you want? What will you do?

How does this need to change for you to feel Can you/do you want to/will you?
better about it?
What might work?
What will you gain/give-up?
What has/hasnt worked?
What can you do?
What do you need to do to get started?
What do you want to do?
What one step can you take this week?
On a scale of 1-10, how important is this?

Funnell, Anderson,2004 Funnell, Anderson,2004

25
SMART behavioural goals How did it work?

Eat three meals What did you learn?

I will eat three meals every day starting tomorrow.

What barriers did you encounter?
I will walk more What support did you have?

I will walk for 10 minutes at my lunch hour for four days

next week What did you learn about yourself?
What would you do the same or differently next
time?

Funnell, Anderson,2004 Funnell, Anderson,2004

How to respond? Patient-Centered education

Interventions are more effective when

Tailored to individual preferences

Tailored to the persons social/cultural environment
Avoid judgments
Actively engage the person in goal-setting

Incorporate coping skills
Avoid minimising negative experiences

Provide follow-up support
Celebrate with - not for
Repeat process Piette, Weinberger, McPhee, 2000

26
Activity Activity
Imagine you have just been told you have
gestational diabetes

What do you feel is supportive behaviour from
Think of three things you would need to
change to manage your diabetes close family, friends, or the health professional?

What is not supportive?
Then ask yourself

What would be easiest for you?

If you had gestational diabetes, what would you

What would be hardest? expect from the people listed above?

Summary References (1 of 2)
Anderson, R.M., Funnell, M.M., Arnold, M.S). Using the empowerment approach to help patients change behavior. In Anderson, B. J., Rubin,
R.R., eds. Practical Psychology for Diabetes Clinicians, 2nd edition . Alexandria: American Diabetes Association; 2002.

Be selective Anderson, R.M., Funnell, M.M. The Art of Empowerment: Stories and Strategies for Diabetes Educators . 2nd ed. Alexandria: American
Diabetes Association; 2005.
Bastable, S. Nurse as Educator. 3rd ed. Sudbury, MA: Jones & Bartlett Publishers; 2008.

Be specific Barlow J, Wright C, Sheasby J, Turner A, Hainsworth J. Self -management approaches for people with chronic conditions: a review. Patient
Educ Couns 2002 (48) : 177- 87.
Belton AB, Simpson N. The How To of Patient Education. 2nd Ed . Streetsville, ON: RJ & Associates; 2010.
Brown SA. Interventions to promote diabetes self -management: State of the science. Diabetes Educ, 25(Suppl ) 1999: 5261.

Prioritise Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. 2008 Clinical Practice Guidelines for the Preven tion and
Management of Diabetes in Canada. Can J Diab. 32,(suppl 1); 2008 :S82 -83.
Duncan, I., Birkmeyer, C., Coughlin, S., Qijuan, (E)L., Sherr, D., & Boren, S. Assessing the value of diabetes education. The Diabetes Educator
2009; 35: 752-760.

Categorise Fisher EB, Brownson CA, OToole ML, Shetty G et al. Ecological Approaches to Self -Management: The Case of Diabetes, Am J Public Health
2005; 95:15231535.
Funnell MM, Anderson RM. Patient empowerment: A look back, a look ahead. Diabetes Educ, 2003; 29: 454-64.
Funnell MM, Anderson RM, Arnold MS, Barr PA, Donnelly MB, Johnson PD, Taylor -Moon D, White NH. (1991). Empowerment: An idea whos e
Repeat time has come in diabetes patient education. Diabetes Educ 1991; 17: 37-41.
Funnell MM, Anderson RM. Empowerment and self -management education. Clinical Diabetes 2004 ; 22:123-127.
Funnell, M.M., Brown, T.L., Childs, B.P., Haas, L.B., Hosey, G.M., Jensen, B., Maryniuk, M., Peyrot, M., Piette, J.D., Reader, D., Siminerio,
L.M., Weinger, K. and Weiss M.A. National Standards for Diabetes Self -management Education. Diabetes Care 2007; 30:1630-1637.
Reinforce

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References (2 of 2)
Gary, T.L., Genkinger, J.M., Guallar, E., Peyrot, M. & Brancati, F.L. Meta -analysis of randomized educational and behavioral interventions in
type 2 diabetes. The Diabetes Educator 2003;29:488 -501.
Harvey, J.N., Lawson, V. L. The importance of health belief models in determining self -care behaviour in diabetes, Diabetic Medicine
2009;26:513.
International Diabetes Federation. Standards for Diabetes Education, 4th ed. Brussels: IDF; 2009.
International Diabetes Federation. Diabetes Atlas, 3rd ed. Brussels: IDF; 2009.
Knowles, M. The Adult Learner: a neglected species. Houston, Gulf Publishing Co; 1984.
Mehrabian, A. In P. Bender. Secrets of Power Presentations. Webcom : Toronto The Achievement Group ;1999.
Norris, S.L., Lau, J., Smith, S.J., Schmid , C.H., Engelgau, M.M. Self -management education for adults with type 2 diabetes: A meta -analysis on
the effect on glycemic control. Diabetes Care 2002;25:1159 - 71.
Piette, J.D., Glasgow, R.E. Education and self -monitoring of blood glucose. In Gerstein HC, Haynes RB, eds. Evidence -based diabetes ca re.
Hamilton: B.C. Decker, Inc. 2001.
Piette, J.D., Weinberger, M., McPhee, S.J. The effect of automated calls with telephone nurse follow -up on patient-centered outcomes of
diabetes care: a randomized, controlled trial. Medical Care 2000;38:218 -30.
Roter, D.L., Hall, J.A., Merisca, R., Nordstrom, B., Cretin, D., Svarstad , B. Effectiveness of interventions to improve patient compliance: A meta -
analysis. Medical Care 1998;36:1138- 61.
Simmons, David. Personal barriers to diabetes care: Is it me, them or us? Diabetes Spectrum 2001:10 -12.
Skinner, T.C., Cradock, S., Arundel, F., Graham, W. Four theories and a philosophy: self -management education for individuals ne wly
diagnosed with type 2 diabetes. Diabetes Spectrum 2003;16:75 -80.
Suhonen, R., Nenonen, H., Laukka, A., Valimaki , M. Patients informational needs and information received in hospital. J Clin Nursing 2005;
14(10):1167-76.
Timmins, F. Contemporary issue in coronary care nursing. New York: Routledge ; 2005.
Von Kroff , M., Gruman, J., Schaefer, J., et al. Collaborative management of chronic illness. Ann Intern Med 1997;127(12):1097 -102.

28
 Objectives

Discuss factors that should be considered when doing a nutritional

Nutrition Therapy In Gestational Diabetes assessment
Part 1 Assessment Discuss appropriate balance of meals/snacks through the day
Part 2 Recommendations
Part 3 Education Discuss appropriate weight gain based on preconception weight

Discuss the value of a late night snack to prevent early morning

ketosis

Evaluate the importance of folic acid supplementation before and

during pregnancy

Discuss the value of multivitamin supplementation during pregnancy

Goals for MNT in GDM Assessing from an Interview

Optimal nutrition and weight gain for fetus and mother Age
Obstetric history
Maternal euglycemia
Weight History
Reduce the risk of diabetes related complications for Significant medical history (co-morbidities)
the mother and child Food preferences and eating habits
Minimize the maternal and infant morbidity and Food Allergies
mortality rates Individual psychological, social and physical
status
Integrate diet, activity and pharmalogic therapy Lifestyle, culture, and socio-economic status
Introducing healthy habits that can prevent or delay Oral health
onset of type 2 DM Readiness to change

29
Assessing from Clinical Information Body Mass Index (BMI)
Laboratory tests to determine clinical status Use pre pregnancy weight for calculations
OGTT, fasting glucose, HbA1c level
Weight and height measurements to calculate BMI:
SMBG
Urine ketones and proteins
BMI = weight in kg/(height in m)2
lipid profile (cholesterol HDL, LDL)
Haemoglobin, creatinine, thyroid function Standard BMI normograms:
Blood pressure
Asian ADA norms
Underweight <18.5 kg/m2
Anthropometric Data
Normal BMI 18.0-22.9 kg/m2 18.5-24.9 kg/m2
Height , Weight and BMI
Overweight 23.0-24.9 kg/m2 25.0-29.9 kg/m2
Current medications and nutrition supplements Obesity >25 kg/m2 > 30 kg/m2

Weight Gain Chart Nutrition Assessment

Plot weight on a prenatal weight
gain grid to obtain an accurate
assessment of total pregnancy
weight gain and rate of weight Nutrition history
gain.

usual food intake recorded through interview
Determine if weight gain is
above, at or below the
recommended range.

If weight gain has already

Dietary recall
exceeded the recommended
food and drink consumed in previous 24
range, slow weight gain in order
to prevent further excess gain. hours (24-hour recall)

30
 Issues with Dietary Recalls
Activity
Think of things to check for Based on memory

when doing a dietary history. Based on willingness to disclose the truth to a

healthcare provider

Nutrient intake and long-term habits are not

represented

Accurate estimations of food quantities/ingredients

are difficult

Composition of Food and Drinks

Macro-nutrients
Nutrition Therapy In Gestational Diabetes
protein

carbohydrates
Part 1 Assessment
Part 2 Recommendations
fats
Part 3 Education
Micro-nutrients

vitamins

minerals

31
 Dietary Recommendations for GDM

Macronutrient composition

Nutrient % of daily calorie

intake
Carbohydrates 45-65%
Fats 20-35%
Protein 10-35%

Dietary fibre 28g/day

Institute Of Medicine 2002

Fluids Proteins

Essential for all body functions

Provide amino acids
40-60% of body weight is water
Help to build muscle mass
Important to drink adequate amounts
Animal sources
of fluid
Plant sources
Restrictions may be required in case
of pedal edema 1 g of protein gives 4 kcal energy

32
Protein Recommendations Carbohydrates

1.1 g protein per kg bodyweight per day

Provide main source of energy for
10-35% of total energy per day the body (45-65%) individualized
Animal protein often high in fat, Nutrient that most influences blood
especially saturated. glucose levels

Attention must be paid to meeting the Source of simple sugars glucose,

protein requirements of women who are fructose
vegetarians or vegans 1 g of carbohydrate provides 4 kcal

Carbohydrates And Meal Planning

Activity
Amount and source of carbohydrates is
considered when planning meals
Recommended source of carbohydrates is
Name some of the common mainly from
- whole grains: wheat, rice, pasta, bread, rice,
carbohydrates and staple foods wheat, barley, oats, maize and corn
- legumes, beans, pulses (bengal gram, black gram,
in your region. rajma)
- fruit and vegetables
- milk

33
Carbohydrate (CHO) content of common foods Benefits of Fibre
Food Amount Serving CHO (g)
Bread, whole wheat 28 g 1 slice 11
A high-fibre diet is healthy
Rice (cooked) 75 g 0.3 cup 13
Pasta 125 mL 0.5 cup 16 Mixture of soluble and insoluble fibre
Chappati 44 g 1 small 19 - slows absorption of glucose
Corn meal 45 mL 3 tbsps 16
- reduces absorption of dietary fats
Potato 84 g 1 small 15
Couscous, cooked 125 mL 0.5 cup 17 - retains water to soften stool
Lentils 250 mL 1 cup 15 - may reduce the risk of colon cancer
Banana 101 g 1 small 20 - may reduce the risk of heart disease

Fibre Recommendations Glycaemic Index (GI)

Recommended amounts of total fibre : 28

g per day
Sources of insoluble fibre include: wheat
bran, whole grains, seeds, fruits and
vegetables
Sources of soluble fibre: legumes (beans),
oat bran, barley, apples, citrus fruits
Ranks carbohydrate-rich foods
according to the increase in blood
glucose levels they cause in
comparison with a standard food (white
bread/glucose).

34
Glycaemic Response of Glucose Factors Affecting the Glycaemic Index
and Lentils

l
e
Type of sugar
v
e
l - glucose, fructose, galactose
e
s
o
c
u
Nature of starch
l
g - amylose, amylopectin
d
o
o
l
B Starch-nutrient interactions
Glucose Lentils - resistant starch

Reprinted with permission from CDA, 2004 Cooking/food processing

Factors Affecting The Glycaemic Index Glycaemic Index of Foods

Processing/form of the food

- gelatinization Low glycaemic Intermediate High glycaemic
index foods glycaemic index index
- particle size
- cellular structure Oats Multigrain bread White Bread

Presence of other food components Lentils/dhal Some rice (long White Rice
grain)
- fat and protein
- dietary fibre Yogurt Pasta Processed
breakfast cereal
Milk Bananas Glucose
Most Fruits and Grapes Mashed and
vegetables baked potatoes

Kalergis, De Grandpre, Andersons, 2005 CDA , 2006

35
Low GI - Advantages Fats

Promotes healthy eating The most concentrated source of

energy
Increases fibre intake
Foods may contain fat naturally or
Helps control have it added during cooking
- appetite
- blood glucose levels
1 g fat provides 9 kcal
- blood lipid levels

Fats
Fat Recommendations
Low in polyunsaturated fats (up to 10% of
total daily energy)
High in monounsaturated fats (>10%)
Low in saturated fats (<10%)
Trans or hydrogenated fat should be
avoided
Common sources of different fats
Polyunsaturated safflower oil, sunflower oil,
corn oil
Monounsaturated olive oil, canola oil, rape
seed oil, groundnut oil, mustard oil, sesame oil
Saturated red meats, butter, cheese,
margarine, ghee (clarified butter), whole milk,
cream, lard
Trans fats baked products, biscuits, cakes

36

Activity
Identify major sources of fats in
foods in your region.
Vitamin Recommendations
Daily multivitamin supplement should be added
as they are often not met by diet alone.
Multivitamin content varies depending on the
product used.
Women at higher risk for dietary deficiencies
include multiple gestation, heavy smokers,
adolescents, complete vegetarians, substance
abusers, and women with lactase deficiency.
37
Vitamins
Organic substances present in very
small amounts in food
Essential to good health
A balanced meal automatically
provides all necessary vitamins
Either fat-soluble or water-soluble
In some countries foods are
fortified with vitamins and minerals
Minerals
Substance present in bones, teeth, soft
tissue, muscle, blood and nerve cells
Help maintain physiological processes,
strengthen skeletal structures, preserve heart
and brain function and muscle and nerve
systems
Act as a catalyst to essential enzymatic
reactions
Low levels of minerals puts stress on
essential life functions
Minerals And Trace Elements Sodium Recommendations

Most people consume too much salt

A balanced diet supplies minerals and Sodium restriction may be advised in case of
trace elements uncontrolled hypertension and edema

Supplements are important as Targets for daily sodium intake

requirements are higher during Age Adequate
Intake
Upper limit
(mg/day)
pregnancy (mg/day)

Calcium supplementation 14-50 1500 2300
51-70 1300 2300

Iron supplementation over 70 1200 2300

Folic acid supplementation 0.4mg (should
be started three months prior to conception) Health Canada, 2005

Lowering Salt Intake Substance Use

The following substances should be avoided completely once

Sodium content is often high in restaurant foods
the woman plans a pregnancy
Encourage meal plans with
more fresh foods fruits and vegetable
Tobacco in any form
less processed, fast, convenience or canned foods
Alcohol
herbs and spices used when cooking instead of salt.
Drugs (street, illegal)

Teach people to read food labels.

Choose salt free, reduced or low in sodium foods

38
 Food Labels
Sweeteners

Sweeteners that increase blood glucose

Sugar, honey
Polydextrose & Sugar alcohols maltitol, sorbitol, Xylitol Nutrition facts
Sweeteners that do not increase blood glucose Serving size (if available)
Acesulfame potassium


Aspartame
Cyclamate*
*Must be avoided during Nutrient content
pregnancy
Saccharin*
Sucralose To check with Health care team Ingredients
prior to starting use of sweeteners

Nutrition information

Food labels
Activity
Nutrition Facts
Per 1 cup (250g)
Amount % Daily Value
Calories 100 Practice reading a food label
Fat 0g 0%
Saturated 0 g
+ Trans 0 g
Cholesterol 0 mg
0%
Calculate the following:
Sodium 3 mg
Carbohydrate 26 g
0%
8%

Serving size
Fibre 1 g 4%
Food labels may look
Number of calories in one serving
Sugars 23 g
different in different countries,
Protein 2 g
Number of carbohydrates in one serving
Vitamin A 20 % Vitamin C 170 % but the same information is
Calcium 2% Iron 2% usually available
Amount of fat in one serving

39
Summary of Dietary Recommendations

Carbohydrates: 45-65%
Nutrition Therapy in Gestational Diabetes
Dietary fibre: 28 g / day
Part 1 Assessment
Fats: 20-35% Part 2 Recommendations
Part 3 Education
Protein: 10-35% (1.1 g/kg/day)
Sodium: 1500 - 2300 mg/day

Meal Planning
Approach To Meal Planning
Before deciding on the content of meal plans,
consider:
A uniform approach to meal planning does
not work for everyone Food preferences and eating habits
Previous experience, knowledge and skills
A flexible plan or a variety of approaches is Current clinical, psychological and dietary status
necessary to address different needs Appropriate clinical and nutrition goals
Lifestyle factors

40
What to teach and when? Nutrition Education: Tools
Basic
Basic information about nutrition
Awareness of the basics of healthy
Nutrient requirements
eating/balance of good health
Healthy eating guidelines
Making healthy food choices Food Pyramid
Self-management training and use
of educational tools
The plate model

Food Guides Healthy eating

Recommended Number of Food Guide Servings per Day

Australian Food Guide Eating Well with Age In Years 2-3

Children
4-8 9-13
Teens
14-18 19-50
Adults
51+

Canadas Food Guide Sex Girls and Boys Females Males Females Males Females Males

Vegetables
and fruits
4 5 6 7 8 7-8 8-10 7 7

Grain
Products 3 4 6 6 7 6-7 8 6 7

Milk and
Alternatives 2 2 3-4 3-4 34 2 2 3 3

Meat and
Alternatives
1 1 1-2 2 3 2 3 2 3

The chart above shows how many Food Guide Servings you need
from each of the four food groups every day.

Having the amount and tyoe of food recommended and following the
tips in Canadas Food Guide will help:

Meet your needs for vitamins, minerals and other nutrients.

Reduce your risk of obesity, type 2 diabetes, heart disease,
certain types of cancer and osteoporosis.

Contribute to your overall health and vitality.

41
Food pyramid India Balance of good health - UK eat well plate
Bread, cereals
Fruits and
and potatoes
vegetables

Meat, fish and Milk and

protein alternatives dairy products
Foods rich in
sugars and fat

Diabetes India, 2005 (Reproduced with kind permission of the Food Standards Agency)

These graphics will change

to be the same as the new
ones going in the booklets
Activity
Draw on a paper plate either:
The recommended proportions of foods
from your region
The proportions of what you ate last night

Healthy food plate Example of Healthy food plate with

(Source: Diabetes Education Modules 2011) South-Asian foods

42
Practical Advice/ 1 Practical Advice/ 2

Make healthy food choices At least five servings of fruit and vegetables per day
- Choose colourful fruits and vegetables
Avoid fatty foods - Choose whole fruits over juices
Use low-fat cooking methods Replace high calorie beverages with water
Substitute high fat foods with low fat options; Eat small frequent meals that are well spaced
e.g use low fat milk
Do not skip meals
Minimize consumption of sugar and salt
Calories should be restricted especially if overweight
Use fresh foods instead of preserved or
Eat free foods as desired, include in between major
canned foods meals

Practical Advice/ 3 References

American Diabetes Association. (2013). Clinical Practice Recommendations. Diabetes Care, 36, (supple 1).
Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. (2013). Canadian Diabetes
Association 2013. Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada.
Canadian Journal of Diabetes, 37(suppl 1).
Canadian Diabetes Association. (2006). Beyond the Basics. Toronto ON: Canadian Diabetes Association
Diabetes India. (2005). Diet Charts. Retreived September 13, 2010.
One low GI food at each meal
http://www.diabetesindia.com/diabetes/diet_chart.htm
Franz MJ, Evert AB (Eds.) American Diabetes Association Guide to Nutrition Therapy for Diabetes. 2nd Ed. 1012
Health Canada. Food and Nutrition. Sodium. Its Your Health. Available from: http://www.hc-sc.gc.ca/hl-
Mix high and low GI food = intermediate GI vs/iyh-vsv/food-aliment/sodium-eng.php
Health Canada. (2005). Food and Nutrition. The Issue of sodium. (Retrieved September 13, 2010)
meal
http://www.hc-sc.gc.ca/fn-an/nutrition/reference/table/ref_elements_tbl-eng.php
Institute of Medicine 2002
http://www.iom.edu/Global/News%20Announcements/~/media/C5CD2DD7840544979A549EC47E56A02B.a
Substitute high GI cereals/breads/rice with low shx
Institute Of Medicine 2009
GI cereals/bread/rice http://www.ncbi.nlm.nih.gov/books/NBK32799/table/summary.t1/?report=objectonly

Kalergis, M., De Grandpre, E., Andersons, C. (2005). The Role of Glycemic Index in the Prevention and
Eat low GI snacks instead of high GI snacks
Management of Diabetes: A Review and Discussion. Can J of Diab, 29(1), 27-38.
Misra A, Chowbey P, Makkar PM, Vikram NK, Wasir JS, Chadha D, et al. Consensus Statement for

(remember to choose lower fat snacks) Diagnosis of Obesity, Abdominal Obesity and the Metabolic Syndrome for Asian Indians and
Recommendations for Physical Activity, Medical and Surgical Management. JAPI 2009;57.

43
 Objectives

After completing this Module the participant

Exercise in will be able to

Gestational Diabetes

Discuss the value of regular activity

Recognize the limitations regarding exercise especially
during the third trimester

Background
Types of Exercise
Physical activity can prevent or delay type 2 DM in Aerobic Exercise:
individuals at risk
Aerobic means using oxygen for energy.
Studies show that pre-pregnancy exercise helps to
prevent GDM during pregnancy.
use large muscles (legs, shoulders, chest, and arms)
can be performed continuously
More intensity equals more benefits.
burns calories and is critical to losing fat and keeping it off.
Any activity has more benefit than no physical activity in
prevention of GDM.

Resistance Training
helps in increasing the number of Insulin receptors
Improves sensitivity of insulin receptors in skeletal muscle
maintains muscle while losing fat.
Oken et al, 2006, Zhang et al, 2006, Dempsey JC et al 2004

Upper arm resistance training shown to lower blood glucose

44
Benefits of Exercise in GDM Where to start
Exercise causes significant decrease in:
Activity should be discussed with a medical
practitioner

fasting plasma glucose

1hour plasma glucose

Start with light to moderate exercise, i.e. 10 minute walk

HbA1c after meals, upper body exercises while seated

insulin requirement
30 minutes a day total is recommended

Appropriate exercise
Jovanovic-Peterson et al 1989; Brankston et al, 2004.
Low-impact aerobics, swimming, yoga, light weights

Medical contraindications for exercise in Relative contraindications for exercise in

pregnancy pregnancy
Haemodynamically significant heart disease, eg. Mod- Severe anaemia
Unevaluated cardiac
severe valvular heart disease, cardiomyopathy, cyanotic
arrhythmia
heart disease
Chronic bronchitis
Restrictive lung disease
Poorly controlled type 1
Preclampsia diabetes
Incompetent cervix/ cerclage Extreme morbid obesity (BMI >
40)
Multiple gestation at risk for premature labour
Extreme Underweight (BMI<
Persistent second or third trimester bleeding 12)
Placenta praevia after 26 weeks gestation Exercise in multiple gestation
Ruptured membranes should be supervised
History of extreme sedentary
lifestyle
Poorly controlled hypertension
Orthopedic limitations
Poorly controlled seizure
disorder
Poorly controlled
hyperthyroidism
Heavy smoker
Intrauterine growth restriction
in current pregnancy

ACOG Committee on Obstetric Practice, 2002. ACOG Committee on Obstetric Practice, 2002.

45
Caution Education before exercise

Avoid exercise in supine position after 2nd trimester (due

Strenuous exercise could cause to possibility of supine hypotension)

Fetal distress Heart rate should not exceed 140 bpm

Uterine contractions Stop activity if contractions are felt

Maternal hypertension If on insulin

Increased risk of soft tissue injury avoid exercising when insulin is peaking
know how to recognize and treat hypoglycemia
carry fast acting glucose
Need to monitor

Blood glucose before and after exercise for women on

insulin or sulphonylureas Harris, White, 2005

Summary References Contd....

Any physical activity is better than no physical activity during
pregnancy
Even lower levels of physical activity have shown benefit in
control of blood sugars.
Aerobic activity of moderate intensity for 30mins/day on most
days of the week has shown benefits in metabolic control.
Upper body resistance training in addition to aerobic activity
has probable synergistic effects in lowering blood sugars.
Brankson gN, Mitchell BF, Ryan EA, Okun NB. Resistance exercise decreases
the need for insujlin in overeight women with gestational diabetes mellitus. Am.
J. Obstet Gynecol 2004; 190:188-93.
Dempsey JC, Butler CL, Sorenson TK et al. A case-control study of maternal
recreational physical activity and risk of gestational diabetes mellitus. Diabetes
Res Clin Practi 2004;66 203-215.
Jovanovic-Peterson L, Durak EP, Peterson CM, Randomised trial of diet
versus diet plus cardiovascular conditioning on glucose levels in gestational
diabetes. Am. J. Obstet Gynecol. 1989; 161: 415-419.

ACOG Committee on Obstetric Practice. ACOG committee opinion. Number

267, January 2002: exercise during pregnancy and the postpartum period. Inj.
Dempsy et al 2004, Liu et al 2008,Jovanovic -Peterson et al, 1989,
ACOG Committee on Obstetric Practice, 2002 J. Gynecal Obstet 2002; 77: 79-81.

46
References
Artal R, OToole M. Guidelines of the American College of Obstetricians and
Gynecologists for exercise during pregnancy and the postpartum period. Br J
Sports Med. 2003 February;37(1):612. doi: 10.1136/bjsm.37.1.6

Harris, GD, White, RD. Diabetes management and exercise in pregnant

patients with diabetes. Clinical Diabetes. 2005;23(4):165-168.

Metzger BE, Buchanan TA, Coustan DR, De Leiva A, Hadden DR, Hod M.
Summary and recommendations of the fifth international workshop-conference
on gestational diabetes mellitus, Diabetes Care. 2007; 30(suppl 2):S251-260.

Oken E, Ning Y, Rifas-Shiman SI, Radesky JS, Rich-Edwards JW, Gillman

MW. Association of physical activity and inactivity before and during pregnancy
with glucose tolerance. Obstet Gynecol 2006; 208: 2100-7.

Zhang C, Solomon CG, Manson JE, Hu FB. A prospective study of pregravid

physical activity and sedentary behaviours in relation to the risk of gestational
diabetes mellitus. Arch Intern Med. 2006; 166: 543-8
Contd.....

47
 Objectives
After completing this Module the participant
will be able to

Monitoring During Discuss the benefit of self monitoring of blood

glucose (SMBG) when available
Pregnancy Determine appropriate timing of SMBG depending
on availability of strips
Decide on expected target values for fasting and
post prandial BG
Discuss methods of fetal monitoring

Daily monitoring provides immediate feedback to the mother and is the ideal.
Woman must know targets
Must know how to respond to results out of target range

When resources are limited

Once weekly monitoring until targets reached
nd
When targets reached check once per month until late in the 2 trimester
Then increase to every 1 - 2 weeks

48
Targets
Fasting: <95 mg/dl ( < 5.3 mmol/l)
1 hour PP : < 140 mg/dl ( < 7.8 mmol/L)
2 hour PP : < 120 mg/dl ( < 6.7 mmol/L)
Metzger, Buchanan et al 2007
Seshiah Balaji, 2006
ADA 2015
HbA1C during pregnancy?
May be valuable in determining those who had
undiagnosed diabetes prior to pregnancy
May give indication of overall control during
pregnancy BUT
Not valuable for day-to-day management during
pregnancy
May give falsely low results
Other factors such as anemia make it unreliable
HbA1C during pregnancy?
May be valuable in determining those who had
undiagnosed diabetes prior to pregnancy
May give indication of overall control during
pregnancy BUT
Not valuable for day-to-day management during
pregnancy
May give falsely low results
Other factors such as anemia make it unreliable
Fetal movement counting
The rationale - decreased fetal movements may signal
decreased oxygenation which often precedes fetal
demise
Reduction of activity associated with chronic fetal distress
Among inactive fetuses, approximately 50% are either
stillborn, tolerate labor poorly or require resuscitation at
birth
1
Lalor et al 2008
49

Fetal movement counting
The rationale - decreased fetal movements may signal
decreased oxygenation which often precedes fetal
demise
Reduction of activity associated with chronic fetal distress
Among inactive fetuses, approximately 50% are either
stillborn, tolerate labor poorly or require resuscitation at
birth
Lalor et al 2008
FETAL MOVEMENT
Inexpensive, involving the mother, easy to
use
Foetal movements related to maternal
glucose levels
Patients taught generally from late third
trimester - after 35 weeks at routine ANC
Reduced activity needs to be evaluated by
NST (non stress test)

Other parameters Ultrasound fetal measurement

Blood pressure every visit
Values above 140/90 mm Hg are of concern Early pregnancy scan - 7-8 weeks
If > 140/90 re measure same day; If > 150/100 initiate
therapy Dating and viability
If BP > 140/90 check urine for albuminuria
Dating important to offer appropriate timing for
Estimate Urine albumin / sugar dip stick antenatal visits/ scans and delivery
Though urine sugar not of value in a known GDM, albumin is
important as sometimes predates BP in preeclampsia Accurate dating prevents iatrogenic prematurity

50