DISCUSSION

Our clinical audit aimed at to review the management of Gestational Diabetes Mellitus
and care in Maternal and Child Health Clinic in Klinik Kesihatan Greentown, Ipoh, Perak. There
are several aspects to this study we would like to highlight upon. Firstly, the prevalence of
Gestational Diabetes Mellitus (GDM) mothers in Klinik Kesihatan Greentown is 0.5% from total
18,824 antenatal bookings in year 2014 to 2015. It is important to note about the prevalence of
GDM because it has a very strong risk factor for the development of type 2 diabetes mellitus
later in life [4]. This is agreed in published studies where 35-60% of GDM mothers develop type 2
diabetes after 10 years [11]. The reduction of prevalence of GDM could probably reduce the
prevalence of type 2 diabetes mellitus in future. Furthermore, This audit also requires a number
of structures that are needed to be measured, namely; registry for gestational diabetes mellitus
(GDM), written management protocol for GDM and functional glucometer in the health clinic.
However, there has not been any registry for GDM in the past years until it is introduced
this year. It is important to have the GDM cases registered and documented in order to calculate
the prevalence of GDM and to build up strategy to achieve specified glycemic targets in primary
care level. Written management protocol and glucometer on the other hand were present in the
health clinic thus has achieved 100% of target standard. Functional glucometer is vital as one of
the tool in Oral Glucose Tolerance Test (OGTT) in diagnosing GDM and is as well used in other
studies in United States of America regarding management of GDM, whereby they used the
glucometer for glucose challenge [7].
The processes that are required in this clinical audit are; recording of blood pressure
level, weight measurement, urine dipstick, risk assessment of GDM, OGTT performed or
ordered as soon as first booking, re-evaluation of high risk pregnant women who initially tested
negative, blood sugar profile monitoring, referral to dietician, commence of insulin therapy if
diet control failed, recording of ultrasound and amniotic fluid index (AFI).
Based on our clinical audit, it is found out that the blood pressure measurement was not
recorded at every visit as recommended in the Perinatal Care Manual [8]. It is assumed that the
blood pressure was measured, however was not recorded in the antenatal book, or not measured
and recorded at all. Thus achieved only 96.12% of target standard. Recording of blood pressure
is not only vital as a standard of good maternal health care, but also could provide information to
the health caregivers about the risk of developing pre-eclampsia. In Hyperglycemia and Adverse
Pregnancy Outcome (HAPO) study stated that one of its additional outcomes is pre-eclampsia,
other than pre-term delivery, sum of skinfolds >90th percentile, percent body fat >90th percentile,
hyperbilirubinemia, intensive neonatal care and shoulder dystocia [9].

Same goes to urine dipstick which achieved only 97.1% of target standard. Urine dipstick
should be performed during every antenatal visit to test for protein and glucose in urine. Urine
dipstick plays an important role both in diagnosing GDM or gestational hypertension and to
assess the patients control and compliance to our management plan. Moreover, the weight of the
patients was not recorded at every antenatal visit and achieved only 96.12% of target standard.
This may be due to under-recording of the weight or it was not performed at all to some of the
patients during any visit. Recording of maternal weight is very important because it is one of
component in the management of diabetes in pregnancy according to Clinical Practice
Guidelines (CPG) on Management of Type 2 Diabetes Mellitus [1] whereby there are energy
prescription, recommended carbohydrate intake and weight gain for GDM mothers. Even though
in the previous CPG on Diabetes Mellitus [10], the weight management is not yet commenced on
GDM, it is important to monitor as a good standard of care of maternal health as recommended
in the perinatal care manual [8].
On the other hand, the risk assessment for GDM must be done and recorded at first
antenatal visit/booking. The risk factors include BMI >27kg/m2, previous macrosomic baby,
previous GDM, first degree relative with diabetes, bad obstetrics history, glycosuria at the first
prenatal visit, current obstetric problems and age above 25 years old. However, based on our
clinical audit only 99.03% of GDM patients from year 2014 to 2015 have the risk assessment
recorded. It is very important to perform and record the risk assessment for GDM because it
affects on when to commence OGTT and management of GDM, and is consider compulsory
according to the CPG on Management of Diabetes Mellitus [1]. From our observations, the
antenatal books have different version of risk assessment whereby some books contain an
allocated page for GDM risk assessment while some others not, but they have general
assessment for colour-coding. Both are useful for recording the risk assessment, but somehow
some of the books risk assessment was left blank.
With Diabetic Mellitus rising at an alarming rate in Malaysia, screening for GDM as
early as the first antenatal booking especially in high risk mothers was highly recommended by
the Ministry of Health(1,8) as well as supported by local research(4). This is well explained
physiologically as organogenesis of the foetus takes place in the first trimester of pregnancy in
which there are possibility of congenital malformation and early spontaneous abortion.(13)
Presence of high blood glucose are known to contribute to this malformation with an increase
risk of 2-3 folds as compared to the general population with an incidence rate of as high as 8% in
uncomplicated diabetic pregnancies.(14) Therefore, it is strictly emphasise as part of the
management of GDM in Klinik Kesihatan Greentown with target level set to be 100% in addition
to the risk stratification of high risk mothers at booking. This is also consistent with various
national Guideline on Gestational Diabetes management such as American Diabetic Association
(ADA) and Royal College of Obstetric and Gynecology (RCOG).(15,16) In spite of this, only

72.8% of high risk mothers were either screened at initial booking or had appointment set in the
first booking to undergo mOGTT in the next 1-2weeks. The remaining high risk mother were
mostly set to be screened for GDM after the second appointment with a minority (2-3%) of
mothers that was only screened around the second trimester despite being early bookers. Since
screening were considered done when mOGTT is included as part of the written management in
the first antenatal records, mothers who defaulted for the test later on will not be taken into
account in explaining for the late mOGTT carried out by the medical staffs. Misconception of the
traditional way of screening diabetic mothers at second trimester may be the cause of these
delayed GDM screening especially among senior staff nurse who had practice the traditional way
Diagnostic criteria for GDM used in our audit project is based on Malaysia T2DM CPG
4th edition as the data interpreted were mainly on postnatal mothers in year 2014 and 2015.(10)
Fasting blood sugar of >5.6mmol/L and 2 hours postprandial of >7.8mmol/L with the 75g, 2 hour
OGTT were use as the diagnostic criteria for GDM. A mother with blood sugar level above the
diagnostic value in one reading will be considered and managed as GDM. These diagnostic
levels have been commonly use in practice in screening for GDM in Klinik Kesihatan
Greentown even till present and are well recommended by current guidelines such as American
Diabetes Association and National Institut for Health and Care Excellence UK (NICE).(15,17)
Currently there is a lack of international consensus regarding the diagnostic criteria for GDM and
levels varies across different national guidelines. Nevertheless, most diagnostic criteria were well
established based on the risk of adverse pregnancy outcomes that were taken from various
randomise control trial. On the contrary, reevaluation of high risk mother who initially tested
negative on top of screening for GDM in low risk mother at 24-28 weeks are universally
accepted. (1,8,9,18) Our study have shown 85.7% of high risk mothers who initially tested
negative were reevaluated with mOGTT repeated at 24 to 28 weeks which was 14.3% below the
target level set.These includes those who had written plans with mOGTT scheduled for a latter
date during that period of antenatal follow up. The remaining 14.3% had reevaluation either
scheduling of mOGTT written after 28 weeks or perform after 28 weeks without prior written
appointment. However, majority of the reevaluation of the latter group was mainly performed at
29 to 32weeks of gestation.
Besides that, monitoring of blood sugar level is essential to be carried out as frequent as
possible as stated in the perinatal care manual. Although there are no studies that shown benefits
of carrying out BSP regularly, yet it is a common practice for blood sugar profile of gestational
diabetic mother to be perform every 4 weekly in Malaysia.(8) Frequent measurement of BSP not
only helps in monitoring the progression of the mothers blood glucose level, but also helps
physician in deciding whether insulin therapy should be started early as part of optimal glycemic
control in GDM mothers. According to our result, approximately 80% of mothers had their blood
sugar level measured every month without failed till admission for delivery. Possible reasons for

failed BSP measurement in rest of 20% of mothers in our study could be due to patient factor in
which patient defaulted appointment either due to personal reasons, went outstation or got
admitted to hospital.
Diet control and lifestyle modification is one of the first line of treatment in the step
approach in controlling blood sugar level in GDM. A low glycemic index diet have proved to
reduced the needs for insulin and lower birth weight(19) whereas control of weight gain through
exercise improve glycemic control in mothers with GDM. These intervention are proved useful
in mothers who strictly adhere to the dietary advice and showed to have reduce prevalence of
developing Type 2 diabetes mellitus latter in life.(21) As all mothers with GDM are started with
these intervention, it is essential for all mothers with GDM to receive nutritional counselling
from experts such as a registered dietician.(13,15,17,22) The aim of counselling is mainly to
provide mother with sufficient calories for both maternal needs and foetal growth while avoiding
hyperglycaemia.(23) Nevertheless, the result from our study show an extremely poor outcome
with approximately half of the mother (53.4%) were referred to a dietician for further dietary
advice within a month after being diagnose with GDM.Less than 10% of mothers were found to
be referred to dietician after one month of diagnosis with no records of referral in the other 40%
of mother.
In Malaysia, insulin is said to be the gold standard treatment in the management of GDM
mothers who failed the initial lifestyle intervention(1) despite the fact that oral anti diabetic
medication such as metformin and glibenclamide show similar efficacy in controlling blood
sugar level in GDM and has recently been proved to be safe for mothers to use.(16,24) Overall,
23.6% of mothers were found to be started on insulin therapy after failed to achieve two
consecutive blood sugar profile measurement in our study. Blood sugar target level was monitor
based on Malaysia CPG 4th Edition for GDM(10) and 2 or more positive result out of 4
measurement recorded in a day was said to be undesirable with two consecutive occasion of this
will results in a mother being categorized as uncontrolled. The flexibility in setting this criteria
consider the fact that most mothers will have desire to continue with the non-pharmalogical
intervention despite being uncontrolled and ultimately contribute to the delay in starting insulin
therapy. Nevertheless, insulin therapy is recommended in patient with glycosuria exceeding
2mmol/L in 24 hours, fasting blood glucose is higher than 6.1mmol/L and when complication
such as polyhydramnios and macrocosmic foetus arises(18) Our study have shown 75.9% of
mothers that were found uncontrolled to be started on insulin therapy within 2 weeks interval
after being confirmed as uncontrolled. Among the 24.1% of uncontrolled mother who were not
started on insulin therapy, we found that majority of them continue to be on diet therapy
throughout pregnancy with only a minority (5-6%) had insulin started beyond 2 weeks. Delayed
insulin treatment in uncontrolled mother will contribute to prolonged exposure to
hyperglycaemia and ultimately increases the risk of developing adverse GDM complications. It

must be made aware that continuos adherence to diet control should be emphasise among GDM
mother in complementing insulin therapy.
Regular ultrasound scan done to monitor foetal growth and amniotic fluid index are
recomended. Complication such as polyhydramnios, macrsomnia, restricted fatal growth and
structural abnormalities of foetus which are common among GDM mothers develop can be
easily detected by experts with the use of an ultrasound. Hence, either transvaginal or abdominal
ultrasound should be perform at least once in the second or third trimester to identify any
maternal and foetal complication.(8,17) Even so, only 95.2% of GDM mothers had ultrasound
perform on them whereas another 5% of GDM mothers had no records of ultrasound nor
ultrasound scheduled to be perform at second or third trimester as part of managing them at
antenatal visit.
On the other hand, the outcome in our study mainly focus on the care towards diabetic
mothers. Criteria such as the blood sugar profile target levels, blood pressure readings and
complication develop during perinatal period was considered as part of the assessment of quality
of care towards Gestational Diabetic mothers in auditing Klinik Kesihatan Greentown. Mothers
anthropometric measurement, ultrasound results, blood pressure measurement and delivery
records of mother in antenatal reports were analyse in determining the possible complication
present in GDM mothers. Despite none of the process target was acheived, our study have shown
that Klinik Kesihatan Greentown manage to achieve all the target level set in the outcome.
The relationship of GDM and its existing complication is well establish by many
National research in addition to various randomised control trial. It is undeniable that good
glycemic control achieve whether by diet control, lifestyle modification or insulin therapy in
mothers with GDM lead to lower risk of adverse maternal and foetal hyperglycaemia-related
event such as large for gestational age, polyhydramnios, preeclampsia and prolonged labour.
(9,16-18) On top of that, post meal hyperglycaemia is found to be more closely related to foetal
macrosomnia as compared to preprandial hyperglycemia in pregnancy complicated by diabetes.
(16) Fortunately, a majority 93.9% of mothers with GDM in Klinik Kesihatan Greentown did not
develop any complication during their gestational period. Among the 6% of mothers who
develop complication, 55% had polyhydramnios, 10% was diagnosed with pre-eclampsia, 35%
had prolonged labour in which majority resorting to caesarian section and no records of
intrauterine growth restriction were found. The results were beyond doubt satisfactory,
nonetheless inadequacy of records regarding the course of labour in antenatal record profile may
contribute to the overestimation of uncomplicated GDM delivery.
While mOGTT is used in diagnosing GDM, blood sugar profile (BSP) are commonly
essential in monitoring of blood sugar levels ensuring optimal glycemic control. Target values

use in determining blood sugar level in our clinical audit are based on 4 daily measurement
which includes preprandial and postprandial levels as suggested in MOH Diabetic Mellitus 4th
Edition(10). Our study demonstrate a higher than expected percentage of 71.8% of GDM
mothers who had optimal glycemic control in their last 3 consecutive BSP measurement. ADA
study have found an increase risk of intrauterine foetal death in the presence of fasting blood
sugar of more than 5.8 mmol/l during the last 48 weeks of pregnancy.(25) Hence, achieving
target blood sugar level is an important aspect of care that should be assess thoroughly in
determining adequacy of management towards GDM mother especially towards the end o
gestational period.
Aside from blood sugar profile, blood pressure measurements is also considered in
determining the care towards GDM mothers. Previous studies have shown an increase frequency
of developing maternal hypertensive disorder in GDM mothers as compared to healthy mothers.
Besides that, previous study by Yogev et al demonstrated that the prevalence of preeclampsia
was significantly higher in GDM mothers with poor glycemic control as well as shown positive
correlation with the severity of GDM.(26-28) Klinic Kesihatan Greentown manage to achieve an
outstanding result of 94.7% of mothers with blood pressure below the hypertensive range of
140/90 mm/Hg in their last perinatal visit as shown in our study. The result was far beyond the
target level of 70% set and 2 out of the 7 mothers who had high blood pressure at perinatal
period was diagnosed with pre-eclampsia which is 2% overall. This result is satisfactory as
compared to the prevalence of 16% of mother with preeclampsia in general population found in
2005.(29)
Though the outcomes of this audit of Klinik Kesihatan Greentown is quite satisfactory
considering all outcomes were achieve beyond the target level, however there are still much
more room for improvement in terms of adherence to the present antenatal management of
mother with GDM.

Justification

Indicator of Care

Justification

Structure

Gestational Diabetic

To ensure that adequate data of GDM patients was recorded for

Registry

prevalence, morbidity and mortality data. It is also useful for recall

and follow up system.

Written management

To ensure that the health care givers in the health centre are

protocol

managing GDM cases according to the protocol

Glucometer

Functional glucometer is an important tool for OGTT and monitor

of Blood Sugar Profile

Process

Blood pressure level

The blood pressure must be measured and recorded during every

visit according to Perinatal Care Manual [8] as part of good
standard of maternal health care.

Weight measurement

The weight of the mothers must be measured and recorded during

every visit according to Perinatal Care Manual [8] as part of good
standard of maternal health care.

Urine dipstick

The urine dipstick test must be performed and recorded during

performed

every visit according to Perinatal Care Manual [8] as part of good

standard of maternal health care.

Risk assessment for

The risk assessment must be done during the first antenatal visit

Gestational Diabetes

according to Perinatal Care Manual [8] as the OGTT must be

done at first antenatal

performed or ordered as soon as first visit for those who are at risk

visit/ booking and

[1]

recorded

Oral Glucose

OGTT must be done or ordered as early as first visit (before 13

Tolerance Test

weeks gestation or as soon as possible thereafter) according to

(OGTT) as screening

Clinical Practice Guidelines on Management of Diabetes Mellitus

for Gestational

Type 2 [1]. Screening early in pregnancy reduces the risk of

Diabetes

congenital malformation and spontaneous abortion due to

hyperglycaemia.(12)

Re-evaluation of high
risk pregnant women
who initially tested
negative at 24 to 28
weeks.

Reevaluation at period of 24 to 28 weeks of gestation is

Blood sugar profile

performed at least
once a month

Perform every 4 weekly as suggested in the Perinatal Care Manual

(8) helps to ensure adequate blood sugar control.

Referred to a dietician All mothers with Gestational Diabetes are recommended to be

seen by dietician for nutritional advice as diet control is the first
line of approach in managing GDM. This aim to provide both
adequate calories for foetal growth while avoiding
hyperglycaemia.(23)

Insulin therapy started Insulin therapy should be started in all mother who failed to
achieve optimal glycemic control with diet control and lifestyle
if diet control failed.
modification. The ultimate aim of management is to achieve the
targeted blood sugar level which is associated with lower adverse
Failed diet control is
pregnancy outcome.(1,9,15,17)
defined as failure to
achieve 2 consecutive
satisfactory blood
sugar profile.

universally practiced and recommended in most international

guideline such as World Health Organization.(1,8,15,17)

10 Ultrasound

Must be perform at least once during second or third trimester to

examine for any diabetic complication such as polyhydramnios,
foetal macrosomnia, and intrauterine growth restriction.(18)

Outcome

Target level for prepradial or 2 hour

postprandial of blood
sugar profile
achieved.

Blood sugar profile includes preprandial and postprandial glucose

level is recommended to do as frequent as possible in order to
monitor and achieve optimal glycemic control, thus reducing risk
of complication.(1,15,17)) Uncontrolled blood sugar level
during perinatal period are highly associated with
adverse maternal and foetal outcomes.(28)

Blood pressure level

of 140/80 mmHg
achieved at last visit

A well controlled blood pressure level at perinatal period is

essential for a better outcome for the mother and child. Moreover,
the chances of preeclampsia complicating GDM in diagnosed
mothers are found to be higher as compare to healthy mothers.
(26,27)

Development of

Established relationship has been proven between GDM and its

perinatal complication complication towards both mother and foetus with higher risk
found in those with uncontrolled blood sugar level during
such as:
pregnancy.(20,30)
Pre-eclampsia
Polyhydramnios
Large for
gestational age
Prolonged labour
Caesarian section
Restricted
intrauterine growth

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