The St. Vincent Declaration aim for pregnancy is: "To achieve pregnancy outcome in the diabetic woman that approximates that of the non-diabetic woman". This can be achieved by a dedicated Pregnancy Diabetes Clinic, where a specialist team including a named physician(s) and a named obstetrician(s) should see all pregnant diabetic women in a combined clinic in a hospital with a neonatal intensive care unit. A routine busy antenatal clinic cannot give the same standards of care given by a dedicated clinic.

The Diabetic Pregnancy Joint Clinic was restructured in October 1998, after the criteria of referral and management were reviewed by the Department of Obstetrics & Gynaecology and the Diabetes Clinic. The Diabetic Pregnancy Joint Clinic is managed jointly by the Obstetric Department [Prof. C. Savona-Ventura] and the Diabetes Clinic. Consultations with the dietitian would be arranged after the first visit and subsequently if deemed necessary.
The scope of the Diabetic Pregnancy Joint Clinic is to ensure that all diabetic women have:

• Tight control of diabetes during pregnancy
• Education about treatment of hypoglycaemia and avoidance of ketoacidosis
• Access to a specialist team
• Quality ultrasound scanning to assess gestation and fetal growth
• Fetal monitoring, particularly if at very high risk
• Regular examination of fundi and assessment of renal function.

All patients who are diagnosed to suffer from any form of significant carbohydrate intolerance during their pregnancy should be referred to the Diabetic Pregnancy Joint Clinic. These patients include:

• Pre-existing Diabetes Mellitus/I.G.T. who have become pregnant;
• Gestational Diabetes Mellitus [oGTT 2-hr blood glucose value >=11.0 mmol/l];
• Mild Gestational DM [oGTT 2-hr blood glucose value 8.6-10.9 mmol/l].

All patients with pre-existing diabetes should ensure that they enter pregnancy in an optimum state of health and metabolic control. This help prevent congenital anomalies and deterioration of maternal diabetic complications. Pre-conception care was sought in only 29% of our patients; there has however been a minimal change in malformation rates since 1983-1986 [6.8%] -> 1999-2004 [4.7%].

• Check for and treat any proliferative retinopathy found in 8.2% of our patients - deteriorating retinopathy in 5.1%
• Assess kidney function - deteriorating nephropathy in 1.02% of our patients
• Assess thyroid function
• Blood pressure control
• Stop ACE inhibitors; change to methyldopa, apresoline, nifedipine
• Start folic acid - 400 mcg/day - three months before pregnancy
• Cardiac evaluation
• Neurological evaluation
• Review hypoglycaemic agents being used
• Stop smoking

Contraindication to pregnancy include:

1. Severe nephropathy
2. Uncontrolled hypertension
3. Unmanageable retinopathy
4. Active coronary disease

The precise roles of different members of the diabetes pregnancy care team cannot be clearly defined as all members of the team are involved, each adding their own contribution. It is planned that patients will be seen by the Diabetic Team at specific times during their pregnancy in line with the standard schedule given to antenatal patients and in harmony with the routine antenatal care being given to these patients either in the Hospital Antenatal Clinic or by their private specialists.

Visits will be scheduled for:

• 12-14 weeks
• 20-22 weeks
• 28-30 weeks
• 34 weeks
• 36 weeks
• 38 weeks and
• 6 weeks postpartum.

Of course the scheduled visits will depend on the stage of pregnancy that diagnosis is made. It is thus envisaged that patients with pre-existing disorders would attend all the scheduled visits, whereas patients diagnosed during the pregnancy would attend for visits scheduled during the last trimester. Interim antenatal visits are generally carried out by the attending Specialist Obstetrician unless the clinical condition requires more frequent metabolic follow-up.

There is no need for routine admission in early or late pregnancy, other than when diabetic or obstetric complications of pregnancy are present. However admission may be necessary for those patients with gestational carbohydrate metabolism problems who find it difficult to self-assess their blood glucose levels.

Referral to the Diabetic Pregnancy Joint Clinic will further ensure that these patients are reviewed in the postpartum period, and long-term metabolic advice given accordingly.

It is to be emphasized that the overall responsibility for the patient care and management will remain that of the original attending Specialist Diabetologist and Specialist Obstetrician.

The role of the Joint Clinic is to facilitate and organize regular metabolic and obstetric assessments, including investigations to assess carbohydrate metabolism, renal function, and fetal growth and well-being.

It must be emphasized that the visit regimen proposed above by the Diabetes Pregnancy Joint Clinic is not a comprehensive antenatal regimen since further interim visits to the attending Specialist Obstetrician and diabetologist should be scheduled. In addition, monitoring for fetal well-being in the last month of pregnancy may need to be done more frequently (even twice weekly) that the regimen proposed herein.

• Avoid destroying the normal experience of pregnancy through over zealous application of medical technology.
• The routine admission of patients in early or late pregnancy is not essential, especially when the patient is undertaking self-monitoring of blood glucose regularly and reliably.
• All pregnant diabetic women should be seen in a dedicated multidisciplinary combined clinic. The Specialist Team should include a named physician(s) and named obstetrician(s) with a special interest in diabetic pregnancy. These consultants should lead a team and liaison with the dietitian, the diabetes teaching nurse/midwife, and other specialists [neonatologist, ophthalmologist] as required. It is not acceptable for women to have to go to separate clinics on different days.
• The precise role of the different members of the diabetes pregnancy care team cannot be clearly defined as all members of the team are involved, each adding their own contribution.

All women should carry out regular blood glucose monitoring. The frequency can be individualized, but pre-prandial testing four times a day - before breakfast, before lunch, before evening meal and before late night snack - is recommended. Occasionally it may be desirable to suggest some post-prandial or night tests. Self-monitoring of blood glucose with a reliable system is the optimum, but this may not be suitable for those women diagnosed as diabetic for the first time late in pregnancy.

The target blood glucose should be as close to normal as possible, while avoiding hypoglycaemia. Each individual should therefore be encouraged to run their blood glucose levels at between 4 and 7 mmol/l [Fasting blood glucose 3.5-5.3 mmol/l or 60-100 mg/dl; 2-hour Post-prandial blood glucose 5.0-7.0 mmol/l or 90-125 mg/dl].