Diagnóstico y tratamiento de la diabetes en el embarazo (pregestacional y gestacional)

Objectives

Provide evidence-based, nationally adapted guidance for preventing, diagnosing and treating pre-existing and gestational diabetes across pregnancy, childbirth and the postnatal period, with the overarching aim of reducing maternal, fetal and perinatal morbidity and mortality through timely, appropriate and individualised care.[1][2][3]The guidance addresses women planning pregnancy or already pregnant, as well as fetuses and newborns, and is intended to support clinical decision-making rather than prescribe a single mandatory pathway.[4][5]

• Strengthen preconception planning for women at risk of, or living with, diabetes by improving glycaemic control, supporting healthy diet, weight management and exercise, counselling on pregnancy risks, and assessing retinal, renal, cardiovascular, hypertensive, lipid and thyroid conditions.[6][7][8]
• Establish risk-based screening and diagnosis of gestational diabetes, including early assessment at the first prenatal consultation and oral glucose tolerance testing at 24 to 28 weeks where indicated.[3][9][10][11]
• Deliver integrated management throughout six care stages: preconception care, gestational-diabetes care, prenatal care, intrapartum care, neonatal care and postnatal care.[6]
• Promote nutrition therapy, appropriate physical activity, glucose self-monitoring and individualised pharmacological treatment when lifestyle measures do not achieve glycaemic targets.[12][13][14]
• Prevent and manage maternal metabolic emergencies, fetal overgrowth, birth complications, neonatal hypoglycaemia and longer-term risks of recurrent gestational diabetes and type 2 diabetes.[15][16][17][18]
• Support informed decisions by taking account of women’s treatment preferences and improving communication through tailored, evidence-based written information.[2]

Implementation

Implement the guideline within Ecuador’s National Health System and Comprehensive Health Care Model, using primary care as the entry point for preconception care, screening and initial assessment, and referring women with metabolic abnormalities, inadequate glycaemic control or insulin needs to secondary or tertiary services.[2][19][20]The Ministry of Public Health, as health-system steward, coordinates the national framework, while care is delivered through multidisciplinary, continuous and integrated services centred on the woman, fetus and newborn.[2][21]

• Use a package of implementation instruments comprising the Clinical Practice Guideline, pocket guide, citizen guide and procedures manual.[2]
• Apply a tiered service model in which primary care undertakes screening and diagnosis, while higher-level facilities provide specialist interventions, treatment and care for complex cases.[5]
• Coordinate obstetric, gynaecological, diabetes, endocrinology, nutrition, anaesthetic, paediatric, neonatal, perinatal, midwifery and nursing expertise across antenatal, intrapartum and postnatal care.[5][21]
• Provide mandatory nutritional support at the first antenatal consultation, diabetes education at antenatal visits, advice on self-monitoring, and personalised glycaemic targets.[21][22][23]
• Use diet and moderate exercise as the principal initial treatment for gestational diabetes, escalating to specialist-supervised insulin or metformin when glycaemic control remains inadequate after lifestyle intervention.[22][13][14][24]
• Arrange structured antenatal assessment, including regular glucose checks, laboratory testing, retinal and renal review where needed, and scheduled ultrasound and fetal-wellbeing surveillance according to clinical risk.[21][22][16]
• Refer suspected diabetic ketoacidosis or hyperosmolar hyperglycaemia immediately to a tertiary facility with maternal and neonatal services, recognising these presentations as obstetric and endocrinological emergencies.[16]
• Maintain close glucose monitoring during labour and birth, manage insulin and dextrose where indicated, and involve obstetric, neonatal and diabetes or endocrinology specialists in intrapartum and immediate post-delivery care.[17][25]
• Continue postnatal follow-up through primary care and referral services, including glucose testing from six weeks postpartum or after breastfeeding, annual re-testing where results are normal, lifestyle counselling, future-pregnancy planning and eye follow-up for women diagnosed with diabetic retinopathy during pregnancy.[18]
• Support referral and counter-referral between health-system levels with written clinical information accompanying the patient.[26][27]
• Maintain evidence quality through adaptation of the National Institute for Health and Care Excellence diabetes-in-pregnancy guideline using the ADAPTE methodology, updated literature searches, peer review, multidisciplinary expert input and national consensus meetings.[1][19]
• Grade evidence and recommendations using the source grading systems, including the modified Shekelle classification and recommendation grades from A to D.[19][10]
• Update the guideline every two years from publication, or earlier when scientific advances require revision.[1]
• Use clinical monitoring activities, including glucose self-monitoring, glycated haemoglobin where appropriate, laboratory assessment and fetal surveillance; the supplied material does not specify programme-level implementation indicators, audit arrangements, reporting schedules or formal accountability mechanisms.[28][21][27]
• Finance guideline development through the United Nations Population Fund and the Ministry of Public Health’s National Directorate of Standardisation; no numerical implementation budget, allocation formula or quantified funding gap is specified.[1]

Monitoring & Evaluation

Monitoring is principally clinical and patient-level, covering glycaemic control, maternal complications, fetal development and postnatal diabetes risk. The guideline also draws on Ecuador’s annual epidemiological notification system and official statistics to describe the burden of gestational diabetes, but the supplied material does not establish a comprehensive programme-level performance, reporting or accountability framework.[29][2]

• Use annual epidemiological notification to track gestational diabetes; reported rates rose from 142 to 1,084 per 100,000 inhabitants between 1994 and 2009, continued increasing from 2009 to 2013, and were higher among women in coastal areas, particularly Manabí.[29][2]
• Use National Institute of Statistics and Census data to contextualise the policy problem: gestational diabetes ranked sixth among causes of maternal-fetal morbidity and mortality in 2009, and excess birth weight was among the ten leading causes of childhood morbidity in 2012.[2]
• Apply evidence-quality and recommendation-strength grading, preserving original source systems in which evidence is classified numerically and recommendations alphabetically in descending strength; a separate symbol identifies expert-agreed good clinical practice where evidence is insufficient.[19][3]
• Use a modified Shekelle evidence classification ranging from 1a, based on meta-analyses of randomised clinical studies, to 4, based on expert committees, reports, opinions or clinical experience; grade recommendations from A to D.[10]
• Validate national adaptation through peer review by an interprofessional, multidisciplinary expert group coordinated by the Ministry of Public Health’s National Directorate of Standardisation, and update the guideline every two years or earlier when scientific advances justify this.[1]
• Monitor preconception care through plasma glucose and glycated haemoglobin measurement, aiming for glycated haemoglobin below 7% without hypoglycaemia; assess renal function, blood pressure and thyroid status before pregnancy.[7][8]
• Use risk-based antenatal screening, including fasting glucose at the initial consultation for high-risk women and a 75-gram oral glucose tolerance test at 24 to 28 weeks for moderate-risk women and eligible high-risk women.[9]
• Apply oral glucose tolerance test thresholds of fasting glucose below 92 milligrams per decilitre, one-hour glucose below 180 milligrams per decilitre and two-hour glucose below 153 milligrams per decilitre; diagnose gestational diabetes when one or more values are abnormal.[9]
• Support glucose self-monitoring, personalised glycaemic targets and at least weekly glucose checks during pregnancy, with clinical review every two weeks until week 34 where indicated and weekly thereafter.[15][21][14][23]
• Monitor nutritional and physical-activity management through fasting glucose below 90 milligrams per decilitre and two-hour post-prandial glucose below 120 milligrams per decilitre; use stricter targets when fetal growth is at or above the 90th percentile.[13]
• Monitor maternal and fetal wellbeing through scheduled antenatal consultations, laboratory assessment, glycated haemoglobin testing, retinal and renal assessment, ultrasound examinations, fetal growth assessment, amniotic-fluid assessment and fetal wellbeing testing.[21][22]
• Monitor glucose hourly during labour and birth, or every 30 minutes under general anaesthesia, maintaining maternal glucose between 70 and 120 milligrams per decilitre and adjusting insulin accordingly.[30][17][25]
• Reclassify women with gestational diabetes or impaired glucose tolerance from six weeks postpartum or after breastfeeding using a 75-gram oral glucose tolerance test, repeat testing annually when normal, and maintain primary-care follow-up for later diabetes risk.[18]
• Monitor women diagnosed with diabetic retinopathy during pregnancy through an eye examination at least six months after delivery.[18][20]
• Recognise that the supplied material does not specify implementation targets, formal programme indicators, audit arrangements, reporting schedules, evaluation methods, surveillance targets or explicit accountability mechanisms beyond clinical monitoring, referral and follow-up.[19][3][9][15][26][27]

Costing & Financing

Financing information is limited. The guideline identifies institutional funding sources for its development, but provides no numerical implementation budget, expenditure plan, allocation formula, quantified funding gap, resource-mobilisation strategy or economic model.[5][1]

• Identify the United Nations Population Fund as a financing source for guideline development.[5][1]
• Identify Ecuador’s Ministry of Public Health, through its National Directorate of Standardisation, as a financing source for guideline development.[5][1]
• Consider cost and local practical realities when adapting international recommendations, as these may constrain adoption in Ecuador.[20]
• Recognise metformin as typically more convenient and less costly than insulin, while noting that no price, procurement cost or comparative cost-effectiveness estimate is provided.[24]
• Note that clinical quantities for insulin, dextrose, glucose testing, nutrition support, specialist review, ultrasound and laboratory monitoring are care requirements rather than stated financial allocations.[21][12][25]
• Recognise that the supplied material does not specify funding gaps, budgets, unit costs, economic assumptions, financial responsibility for service delivery, or resources required to implement monitoring and referral arrangements.[12][13][14][23]