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Diabetes in Pregnancy Page 1 of 37

V2 Approved by Policy and Guideline Committee on 30.10.18 Trust Ref: B33/2008 Next Review: October 2021

NB: Paper copies of this document may not be most recent version. The definitive version is in the Policy and Guidelines

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DIABETES IN PREGNANCY

B33/2008

Contents

Introduction and who the guideline applies to .................................................................................. 3

Background ........................................................................................................................................... 3

Diabetes Care Team ........................................................................................................................ 4

Note Keeping .................................................................................................................................... 4

National Diabetes in Pregnancy Audit .......................................................................................... 4

Key priorities for implementation.................................................................................................... 5

Pre-conception care ..................................................................................................................... 5

Gestational diabetes .................................................................................................................... 5

Antenatal care ............................................................................................................................... 5

Intrapartum care ........................................................................................................................... 5

Neonatal care ................................................................................................................................ 6

Postnatal care ............................................................................................................................... 6

Pre-conception care ......................................................................................................................... 6

Information and advice ................................................................................................................ 6

Give advice and information on: ................................................................................................ 7

Care, assessment and review: ................................................................................................... 8

Gestational diabetes ...................................................................................................................... 10

Information and advice before screening and testing: .......................................................... 10

Screening and diagnosis: .......................................................................................................... 10

Interventions for gestational diabetes: .................................................................................... 12

Pre-existing Diabetes : Type 1 or Type 2 ................................................................................... 13

Antenatal care ............................................................................................................................. 13

Blood glucose targets and monitoring ..................................................................................... 14

Monitoring HbA1c ....................................................................................................................... 14

Women taking Insulin ................................................................................................................ 14




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Diabetic Ketoacidosis ................................................................................................................ 15

Intrapartum care ............................................................................................................................. 17

Information and advice: ............................................................................................................. 17

Care during labour and birth: .................................................................................................... 18

Care prior to elective Caesarean section: .............................................................................. 18

Neonatal care .................................................................................................................................. 19

Preventing, detecting and managing neonatal hypoglycaemia........................................... 19

Postnatal care ................................................................................................................................. 19

Information and advice .............................................................................................................. 19

Weeks of pregnancy .......................................................................................................................... 23

Antenatal clinic .................................................................................................................................... 23

Scans ............................................................................................................................................... 23

Bloods .............................................................................................................................................. 23

Weeks of pregnancy .......................................................................................................................... 26

Antenatal clinic .................................................................................................................................... 26

Scans ............................................................................................................................................... 26

Bloods .............................................................................................................................................. 26

DIabetes ketoacidosis in pregnancy diagnostic pathway .................................................................

Hba1c Conversion Table ................................................................................................................... 30

Antenatal steroids and diabetes ....................................................................................................... 31

Administration of antenatal steroids and diabetes ........................................................................ 32

Education and Training ..................................................................................................................... 33

Monitoring Compliance ...................................................................................................................... 33

Monitoring ........................................................................................................................................ 33

National Diabetes in Pregnancy Audit ........................................................................................ 33

The National Diabetes in Pregnancy ............................................................................................... 33

The Diabetes Care Team actively encourages women to consent to their data being

collected and submitted securely to the HSCIC. ........................................................................... 33

Supporting References: ..................................................................................................................... 33

Key Words ........................................................................................................................................... 33

Contact and review details ................................................................................................................ 34




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Development and approval record for this document ...................... Error! Bookmark not defined.

Appendix 1: Variable Rate insulin Infusion ..................................................................................... 35

Appendix 2: Variable Rate insulin Infusion ..................................................................................... 36

Appendix 3 : ........................................................................................................................................ 37

Introduction and who the guideline applies to

This guideline applies to the management of diabetes and its complications from pre-

conception to the postnatal period. This applies to obstetric, midwifery, neonatology

and diabetology staff.

Background

The National Institute for Health and Clinical Excellence (NICE) published clinical

guideline NG3, Diabetes in Pregnancy, in February 2015. (This replaces the

guideline CG63.) The guideline states:

“Diabetes is a disorder of carbohydrate metabolism that requires immediate changes

in lifestyle. In its chronic forms, diabetes is associated with long-term vascular

complications, including retinopathy, nephropathy, neuropathy and vascular disease.

Approximately 650 000 women give birth in England and Wales each year, and 2–

5% of pregnancies involve women with diabetes. Pre-existing type 1 diabetes and

pre-existing type 2 diabetes account for 0.27% and 0.10% of births respectively. The

prevalence of type 1 and type 2 diabetes is increasing. In particular, type 2 diabetes

is increasing in certain minority ethnic groups (including people of African, black

Caribbean, South Asian, Middle Eastern and Chinese family origin). There is a lack

of data about the prevalence of gestational diabetes, which may or may not resolve

after pregnancy. The clinical experience of the guideline development group (GDG)

suggests that the average prevalence in England and Wales is approximately 3.5%

(the precise figure varies from region to region, depending on factors such as ethnic

origin, with certain minority ethnic groups being at increased risk). Approximately

87.5% of pregnancies complicated by diabetes are, therefore, estimated to be due to

gestational diabetes, with 7.5% being due to type 1 diabetes and the remaining 5%

being due to type 2 diabetes.

Diabetes in pregnancy is associated with risks to the woman and to the developing

fetus. Miscarriage, pre-eclampsia and preterm labours are more common in women

with pre-existing diabetes. In addition, diabetic retinopathy can worsen rapidly during

pregnancy. Stillbirth, congenital malformations, macrosomia, birth injury, perinatal




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mortality and postnatal adaptation problems (such as hypoglycaemia) are more

common in babies born to women with pre-existing diabetes.”

This clinical guideline contains recommendations for the management of diabetes

and its complications in women who wish to conceive and those who are already

pregnant. The guideline builds on existing clinical guidelines for routine care during

the antenatal, intrapartum and postnatal periods. It focuses on areas where

additional or different care should be offered to women with diabetes and their

newborn babies.

Diabetes Care Team

The Diabetes Care Team consists of Consultant Obstetricians, Consultant

Diabetologists, Specialist Diabetes Midwives (DSM), Specialist Diabetes Nurses

(DSN) and Specialist Diabetes Dieticians (DSD).

Note Keeping

Information regarding blood glucose levels and insulin requirements, as well as

obstetric information, is recorded on specific green clinical sheets and filed in the

woman’s hospital notes. This information is also written in the handheld maternity

notes. An individualised management plan for labour, postnatal period and neonatal

care is recorded on designated forms in the woman’s hospital notes. DSN and DSD

contact is also recorded electronically on a specific database for diabetes in

pregnancy. This is also used to record any contact outside of the clinic (eg by

telephone).

National Diabetes in Pregnancy Audit

The National Diabetes in Pregnancy audit measures the quality of care given to

women with pre-existing diabetes during pregnancy. The audit is managed by the

Health and Social Care Information Centre (HSCIC), in collaboration with Diabetes

UK and Diabetes Health Intelligence and is part of the National Diabetes Audit. It is

expected that all Trusts with joint obstetric and diabetes services will participate.

Reliable annual reports benchmarked against all participating delivery units in

England and Wales will be produced. These can be used for service assurance,

prioritisation of areas for improvement and measurement of the effectiveness of

improvements initiatives.


collected and submitted securely to the HSCIC.Guidance




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Key priorities for implementation

Pre-conception care

Women with diabetes who are planning to become pregnant should be informed that

establishing good glycaemic control before conception and continuing this

throughout pregnancy will reduce the risk of miscarriage, congenital malformation,

stillbirth and neonatal death. It is important to explain that risks can be reduced but

not eliminated.

The importance of avoiding unplanned pregnancy should be an essential component

of diabetes education from adolescence for women with diabetes.

Women with diabetes who are planning to become pregnant should be offered pre-

conception care and advice before discontinuing contraception.

Gestational diabetes

- Diagnose gestational diabetes with a 75g 2-hour oral glucose tolerance

test

Refer to the Diabetes Specialist Midwife if:

- Fasting plasma glucose level is 5.6 mmol/l or above AND/OR

- 2-hour plasma glucose level is 7.8 mmol/l or above.

Antenatal care

If it is safely achievable, women with diabetes should aim to keep fasting capillary

blood glucose (CBG) concentrations below 5.3 mmol/l and 1-hour post meal CBG

below 7.8 mmol/l during pregnancy. In order to minimise the risks of maternal

hypoglycaemia women will be advised to regard 4.0 mmol/l as the safe lower limit.

Women with insulin-treated diabetes should be advised of the risks of

hypoglycaemia unawareness in pregnancy, particularly in the first trimester.

During pregnancy, test urgently for blood ketones if a pregnant woman with ANY

form of diabetes presents with hyperglycaemia or is unwell, to exclude diabetic

ketoacidosis. Women who are suspected of having diabetic ketoacidosis should be

admitted immediately to delivery suite or HDU for level 2 critical care, where they can

receive both medical and obstetric care.

Intrapartum care

Advise pregnant women with type 1 or type 2 diabetes and no other complications to

have an elective birth by induction of labour, or by elective caesarean section if

indicated, between 37+0 weeks and 38+6 weeks of pregnancy.




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Advise women with gestational diabetes to give birth no later than 40+6 weeks, and

offer elective birth (by induction of labour, or by caesarean section if indicated) to

women who have not given birth by this time.

Neonatal care

Babies of women with diabetes should be kept with their mothers unless there is a

clinical complication or there are abnormal clinical signs that warrant admission for

intensive or special care.

Babies must have 3 normal pre-feed CBG levels (> 2.0 mmols) before being allowed

home.

Postnatal care

For women who were diagnosed with gestational diabetes

Offer lifestyle advice (including weight control, diet and exercise).

Offer a fasting plasma glucose test 6–13 weeks after the birth to exclude diabetes

(for practical reasons this might take place at the 6-week postnatal check).

If a fasting plasma glucose test has not been performed by 13 weeks, offer an

HbA1c test and yearly thereafter.

Do not routinely offer a 75 g 2-hour OGTT.

Pre-conception care

Pre-conception care is currently provided by the Diabetes Care Team and by

General Practitioners. There is a monthly pre-conception clinic at the Leicester

General Hospital (LGH) run by a Consultant Diabetologist and a Consultant

Obstetrician.

Information and advice

Offer information, care and advice to women with diabetes who are planning to

become pregnant before they discontinue contraception.

Give pre-conception care in a supportive environment. Encourage the woman’s

partner or a family member to attend.

This should build on previous care given in routine appointments with healthcare

professionals, including the diabetes care team (see box 1).




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Box 1 Encouraging women with diabetes to seek pre-conception care

Starting from adolescence:

Healthcare professionals should give information about the benefits of

pre-conception glycaemic control at each contact with women of child-

bearing potential and with all types of diabetes.

The diabetes care team should record the woman’s intentions regarding

pregnancy and contraceptive use at each contact. Contraception should

be based on the woman’s own choice. Advise women that oral

contraceptives can be used in the absence of the standard

contraindications.

The importance of avoiding unplanned pregnancy should be an essential

component of diabetes education.

If women are planning pregnancy, they should be seen by healthcare

professionals with appropriate competence to give advice.

If women have additional medical or obstetric problems which further

increase risk in pregnancy, they should be referred to LGH for specialist

pre-pregnancy counselling.

Offer women a structured education course if they have not already

attended one.

Give advice and information on:

The risks of diabetes in pregnancy (see box 2) and how to reduce them with good

glycaemic control, diet and exercise, including weight loss for women with a body

mass index (BMI) over 27 kg/m2.

Hypoglycaemia and hyperglycaemia awareness

Pregnancy-related nausea/vomiting and glycaemic control.

Retinal and renal assessment.

When to stop contraception.

Taking folic acid supplements (5 mg/day) from pre-conception until 12 weeks

of gestation.

Review of, and possible changes to, medication, glycaemic targets and self-

monitoring routine.

Frequency of appointments and local support, including emergency telephone

numbers.




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Box 2 Risks of diabetes in pregnancy

Risks to women and babies include:

Fetal macrosomia

Birth trauma (to mother and baby)

Induction of labour or caesarean section

Miscarriage

Congenital malformation

Stillbirth

Transient neonatal morbidity

Neonatal death

Obesity and/or diabetes developing later in the baby’s life.

Pre-eclampsia

Care, assessment and review:

Offer:

Folic acid supplements (5 mg/day).

Blood glucose meter for self-monitoring.

Ketone testing strips and meter to women with type 1 diabetes and advise to

use if hyperglycaemic or unwell.

Diabetes structured education programme.

Regular HbA1c assessmemnt

Retinal assessment by digital imaging with mydriasis using tropicamide

(unless carried out in previous 6 months).

Renal assessment (including microalbuminuria) before stopping

contraception.

Consider:

Referral to a nephrologist if serum creatinine is 120 micromol/litre or more or

the urinary albumin:creatinine ratio is greater than 30 mg/mmol or the

estimated glomerular filtration rate (eGFR) is less than 45 ml/minute/1.73 m2.

Review:

Current medications for diabetes and its complications. (Box 3)

Glycaemic targets and glucose monitoring (see box 4).




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Box 3 Safety of medications before and during pregnancy

Metformin may be used before and during pregnancy, as well as or instead of

insulin.

Rapid acting insulin analogues (NovoRapid® insulin aspart and Humalog® insulin

lispro) are safe to use in pregnancy and have advantages over soluble human

insulin during pregnancy.

Evidence about the use of long-acting insulin analogues during pregnancy is

limited. Use Isophane (NPH) insulin as the first choice for long acting insulin in

pregnancy. Consider continuing treatment with long acting insulin Detemir or

Glargine in women who have established good blood glucose control before

pregnancy.

Before or as soon as pregnancy is confirmed:

Stop oral hypoglycaemic agents, apart from metformin, and commence insulin if

required.

Stop angiotensin-converting enzyme inhibitors and angiotensin-II receptor

antagonists and consider alternative antihypertensives.

Stop statins

Box 4 Blood glucose targets and monitoring

Agree individualised blood glucose targets for self-monitoring.

Advise women who need intensification of hypoglycaemic therapy to increase the

frequency of self-monitoring to include fasting and a mixture of pre- and post-meal

levels.

Offer regular HbA1c.

Advise women to aim for an HbA1c < 48 mmol/mol (6.5%) if possible.

Inform women that any reduction in HbA1c may reduce risks, even if this target is

not achievable.

Advise women with HbA1c above 86 mmol/mol (10%) to avoid pregnancy because

of the associated risks.

Do not offer rapid optimisation of glycaemic control until after retinal assessment




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and treatment are completed.


Information and advice before screening and testing:

Advise that:

There is a small risk of birth complications if gestational diabetes is not

detected or controlled.

Gestational diabetes will respond to changes in diet and exercise in some

women.

Insulin therapy or oral blood glucose lowering agents will be needed if diet

and exercise do not control blood glucose levels.

Extra monitoring and care will be needed during pregnancy and labour.

Box 5 Risk factors for screening at booking

BMI above 30 kg/m2 at booking.

Previous macrosomic baby weighing 4.5 kg or greater. .

First-degree relative with diabetes.

Family origin with a high prevalence of diabetes (South Asian, Black

Caribbean and Middle Eastern, Eastern European).

PCOS

If the following risk factors present- women to have OGTT at booking and

repeated at 26-28 weeks gestation

Previous gestational diabetes

Glycosuria

For women with:

BMI > 40 kg/m2 OGTT at 16-18 weeks and repeated 26 -28 weeks.

Screening and diagnosis:

Women with risk factors for gestational diabetes (Box 5) are offered an oral Glucose

Tolerance Test (OGTT).




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Normal values in pregnancy are:

Fasting glucose: <5.6 mmol/l

2-hour glucose: <7.8 mmol/l

Community Midwifes to electronically refer all abnormal OGTT via GDM Mailbox

If fasting glucose above 7.0 mmol/l or 2 hour glucose above 11.0 mmol/l, same day

telephone referral should be made to the diabetes team and electronic referral.

Inform the primary health care team when a woman is diagnosed with gestational

diabetes.

When to screen:

Screening for gestational diabetes between 26 – 28 weeks using risk factors (see

box 5) at the booking appointment.

Except if the woman has had gestational diabetes previously or has a BMI

>40 at booking

Offer a 2-hour 75g OGTT as soon as possible after booking in order to detect

diabetes that may have pre-dated conception. If the result is normal a further OGTT

at 26 - 28 weeks should be performed to detect a recurrence of gestational diabetes.

Glycosuria

If the women presents with glycosuria at booking an immediate OGTT should be

offered (due to the high prevalence of undiagnosed type 2 diabetes in the local

population).

Be aware that glycosuria of 2+ or above on 1 occasion or 1+ or above on 2 or more

occasions detected by reagent strip testing during routine antenatal care may

indicate undiagnosed gestational diabetes. If this is observed, consider further

testing to exclude gestational diabetes.

Before 32 weeks gestation, offer an OGTT

After 32 weeks gestation, offer a random blood glucose and HbA1c.

If HbA1c >6.1%/43mmol/l and / or and random blood glucose >7.8 mmols for referral

to ante-natal diabetes team.

Gastric Surgery

Women who have had -

Gastric bypass or a gastric sleeve will be unable to tolerate an OGTT -




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Instead they should be referred to the diabetes antenatal team who will commence

CBG monitoring at booking or at 28/40 to be planned on an individual basis.

Women who have had a gastric band may be suitable for an OGTT – Please refer to

the antenatal diabetes team who will make and individual plan for these women.

Interventions for gestational diabetes:

Explain to the woman

The implications (both short and long term) of the diagnosis for both her and

her baby.

That good blood glucose control throughout pregnancy will reduce the risks to

the fetus (see box 6)

That treatment involves both diet and exercise and could include medications.

Teach self-monitoring of blood glucose and use the same capillary blood

glucose targets as women with pre-existing diabetes.

Refer all women to a Dietician on diagnosis.

Advise women to adopt a healthy diet with low GI foods as opposed to high GI foods.

Advise women to take regular exercise (such as walking for 30 minutes post meals)

to improve blood glucose control.

Offer a trial of change of diet and exercise to women with a fasting plasma glucose

below 7.0 mmol/l at diagnosis.

Offer immediate treatment with insulin and/or metformin, as well as changes to diet

and exercise, to women with a fasting plasma glucose above 7.0 mmols/l at

diagnosis.

Consider immediate treatment with insulin and/or metformin, as well as changes to

diet and exercise, to women with a fasting plasma glucose between 6.0 and 6.9

mmols/l at diagnosis if there are fetal complications such as macrosomia or

polyhydramnios.

Offer metformin if blood glucose targets are not met using changes in diet and

exercise after 1 – 2 weeks.

Offer insulin if metformin is contraindicated or unacceptable to the woman.

Offer additional insulin if blood glucose targets are not met using metformin, changes

in diet and exercise.




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Box 6 Risks of gestational diabetes

Risks to women and babies include:

Fetal macrosomia

Birth trauma (to mother and baby)

Induction of labour or caesarean section

Transient neonatal morbidity

Neonatal hypoglycaemia

Perinatal death

Obesity and/or diabetes developing later in the baby’s life.

Pre-existing Diabetes : Type 1 or Type 2

Antenatal care

This information is supplementary to routine antenatal care.

Offer:

Immediate referral to a joint diabetes and antenatal clinic at LGH (Tuesday am/pm)

or LRI (Wednesday pm/Thursday pm), by telephone to the Diabetic Specialist

Midwife.

Contact with the diabetes care team regularly based on individual need to assess

glycaemic control. Telephone contact will be used to facilitate this in order to avoid

additional visits to hospital.

Advice on where to give birth, which should be in a hospital with advanced neonatal

resuscitation skills available 24 hours a day.

Information and education at each appointment.

Care specifically for women with diabetes, in addition to routine antenatal care, see

page 23.

Commence Colecalciferol 20 microgram’s /800 units daily (Vitamin D in Pregnancy

UHL 2018)

Aspirin

Advise women with pre-existing diabetes to take 75 mg Aspirin daily from 12 weeks

gestation until delivery to reduce the risk of pre-eclampsia (NICE guideline CG107

Hypertension in Pregnancy)




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Blood glucose targets and monitoring

Measure HbA1c levels in all pregnant women with pre existing diabetes at the

booking appointment Determine the level of risk for the pregnancy.

Monitoring HbA1c

Consider measuring HbA1c levels in the second and third trimesters of pregnancy

for women with pre-existing diabetes to assess the level of risk for the pregnancy.

Be aware that level of risk for the pregnancy for women with pre-existing diabetes

increases with an HbA1c level above 48 mmol/mol (6.5%).

Measure HbA1c levels in all women with gestational diabetes at the time of

diagnosis to identify those who may have pre-existing type 2 diabetes.

Do not use HbA1c levels routinely to assess a woman's blood glucose control in the

second and third trimesters of pregnancy.

Women taking Insulin

Provide glucagon to pregnant women with type 1 diabetes for use if needed. Instruct

the woman and her partner or other family members in its use.

Agree individualised targets for self-monitoring.

Advise pregnant women with type 1 diabetes to test their fasting, pre-meal, one hour

post-meal and bedtime blood glucose levels daily during pregnancy.

Advise pregnant women with type 2 diabetes or gestational diabetes who are on a

multiple daily insulin injection regimen to test their fasting, pre-meal, one hour post-

meal and bedtime blood glucose levels daily during pregnancy.

Advise pregnant women with type 2 diabetes or gestational diabetes to test their

fasting and 1-hour post meal blood glucose levels daily during pregnancy if they are

on diet and exercise therapy or taking oral therapy (with or without diet and exercise

therapy) or single-dose intermediate-acting or long-acting insulin.

Typically advise women to aim for a fasting blood glucose of between 4.0 and 5.3

mmol/l and 1-hour post meal blood glucose below 7.8 mmol/l.

If the1-hour target is unachievable or hypoglycaemia occurs between meals,

consider a 2-hour target of 6.4 mmol/l.

The presence of diabetic retinopathy should not prevent rapid optimisation of

glycaemic control in women with a high HbA1c in early pregnancy.




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Advise pregnant women on the risks of hypoglycaemia and hyperglycaemia

unawareness, especially in the first trimester with particular reference to driving (see

box A).

Advise pregnant women with insulin-treated diabetes to always have available a fast-

acting form of glucose (for example, dextrose tablets or glucose-containing drinks).

Box A Safe driving when taking insulin

Keep glucose treatments and meter in the car within easy reach at all times.

Check CBG level immediately before driving and every 2 hours while driving.

DO NOT DRIVE if CBG level is less than 5 mmols/l.

Follow Instructions as per insulin and driving.

Continuous glucose monitoring

Do not offer continuous glucose monitoring routinely to pregnant women with

diabetes.

Consider continuous glucose monitoring for pregnant women on insulin therapy who

have problematic severe hypoglycaemia (with or without impaired awareness of

hypoglycaemia) or who have unstable blood glucose levels (to minimise variability)

or to gain information about variability in blood glucose levels.

Ensure that support is available for pregnant women who are using continuous

glucose monitoring from a member of the joint diabetes and antenatal care team with

expertise in its use.

Diabetic Ketoacidosis

Detecting and managing diabetic ketoacidosis

If diabetic ketoacidosis (DKA)+ is suspected during pregnancy, admit women

immediately for high dependency care*, where both medical and obstetric care

are available. Admission is to the delivery suite or medical unit depending on

gestation (On call Diabetes/Medical SpR available 24 hours via switchboard)

Offer women with type 1 diabetes blood ketone testing strips and meter and

advise women to test their ketone levels if they are hyperglycaemic or unwell.

Advise pregnant women with type 2 diabetes or gestational diabetes to seek

urgent medical advice if they become hyperglycaemic or unwell.




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Test urgently for blood ketones if a pregnant woman with ANY form of diabetes

on insulin presents with hyperglycaemia and is unwell, to exclude diabetic

ketoacidosis (see DKA pathway page 25).

Although a trace of ketonuria in the fasting state is common in pregnancy, a

higher concentration of ketonuria is likely to indicate decompensation of

diabetes. It is possible to develop diabetic ketoacidosis in pregnancy with blood

glucose concentrations close to the normal range.

Related Guidelines

+Refer to UHL Diabetic Ketoacidosis (DKA) guideline.

*Refer to Enhanced Maternity Care UHL Obstetric guideline.

Retinal assessment for women with pre-existing diabetes

Offer pregnant women with pre-existing diabetes retinal assessment by digital

imaging with mydriasis using tropicamide following their first antenatal clinic

appointment (unless they have had a retinal assessment in the last 3 months), and

again at 28 weeks. If any diabetic retinopathy is present at booking, perform an

additional retinal assessment at 16–20 weeks.

Ensure that women who have preproliferative diabetic retinopathy or any form of

referable retinopathy diagnosed during pregnancy are given ophthalmological

follow-up for at least 6 months after the birth of the baby.

Renal assessment for women with pre-existing diabetes

Offer renal assessment at the first contact in pregnancy if it has not been

performed in the past 12 months.

Consider referral to a nephrologist if serum creatinine is 120 micromol/litre or more

or the urinary albumin:creatinine ratio is greater than 30 mg/mmol.

Thromboprophylaxis if proteinuria is above 5 g/day.

Do not offer eGFR during pregnancy.

Monitoring fetal growth and wellbeing

Ultrasound monitoring of fetal growth/ dopplers and amniotic fluid volume every 3-4

weeks from 26 weeks till delivery (as per fetal surveillance guideline)

Do not offer routine tests of fetal wellbeing before 38 weeks, unless there is a risk

of intrauterine growth restriction.




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4.2 Inpatient care

All of the women with any form of Diabetes will be self testing using meters that are

provided for them by the Diabetes team. It is vital that the following steps are taken

so that an appropriate audit trail can be provided whilst under inpatient care.

All women must have their own blood glucose monitoring meters validated against

the ward/delivery suite hospital meters. This must be then documented in the

patient’s notes.

All medications including insulin to be locked away as per medicine management

policy. (Leicester Medicines Code)

All women prescribed Insulin must have a green insulin drug chart in addition to the

standard UHL drug chart. All their CBG must be recorded accurately on the inside

pages of the Insulin drug chart

All women with Diabetes that are not treated with Insulin must have their CBG

accurately documented and kept in the hospital notes on the appropriate

paperwork. (Page 40)

Intrapartum care

Every woman with diabetes in pregnancy will have an intrapartum care plan for

delivery which is filed in the hospital notes. This is developed jointly by the

Obstetricians and Diabetologists in discussion with the woman usually from 36

weeks.

Information and advice:

Discuss the timing and mode of birth with pregnant women with diabetes during

antenatal appointments, especially during the third trimester including:

The risks and benefits of vaginal birth, induction of labour and caesarean

section if the baby has macrosomia identified by ultrasound.

The possibility of vaginal birth in women with diabetic retinopathy.

The possibility of vaginal birth after previous caesarean section.

Timing of delivery

Advise pregnant women with type 1 or type 2 diabetes and no other complications to

have an elective birth by induction of labour, or by elective caesarean section if

indicated, between 37+0 weeks and 38+6 weeks of pregnancy.

Consider elective birth before 37+0 weeks for women with type 1 or type 2 diabetes

if there are metabolic or any other maternal or fetal complications.




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Advise women with gestational diabetes to give birth no later than 40+6 weeks, and

offer elective birth (by induction of labour, or by caesarean section if indicated) to

women who have not given birth by this time.

Consider elective birth before 40+6 weeks for women with gestational diabetes if

there are maternal or fetal complications.

Care for preterm labour:

Consider antenatal steroids for fetal lung maturation in preterm labour or if early

elective birth is planned

Consider tocolytic medication (but not betamimetic drugs) to suppress labour if

indicated.

Monitor glucose levels of women taking steroids for fetal lung maturation closely and

advise on taking supplementary insulin according to an agreed protocol. (See Pre-

term labour guideline)

Care during labour and birth:

Monitor:

Blood glucose levels hourly for women on insulin, aiming to maintain blood glucose

levels between 4 and 7 mmol/l .

Commence variable rate insulin infusion and 5% Dextrose + 20mmol KCl in 500mls

at 100mls/hour.

For women with Type 1 DM from the onset of established labour (page 38)

Consider variable rate insulin infusion and 5% Dextrose + 20mmol KCl in 500mls at

100mls/hour

For women with Type 2 DM or GDM on insulin whose blood glucose is not

maintained between 4 and 7 mmol/l (page 39)

Care prior to elective Caesarean section:

Adjust insulin dosage to account for pre-operative fasting.

Monitor:

Consider antenatal steroids if elective caesarean section is planned prior to 39/40.

Blood glucose level prior to going to theatre

Consider variable rate insulin infusion and 5% Dextrose + 20mmol KCl in 500mls at

100mls/hour




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For women with poorly controlled Type 1 or Type 2 diabetes.

For women on insulin whose blood glucose is not maintained within 4 and 7 mmol/l.

If general anaesthesia is used for the birth in women with pre-existing diabetes,

monitor blood glucose every 30 minutes from induction of general anaesthesia until

after the baby is born and the woman is fully conscious.

Neonatal care

The baby should stay with the mother unless extra neonatal care is required.

Do not transfer babies into community care until they are at least 24 hours old,

maintaining their blood glucose levels and feeding well.

Preventing, detecting and managing neonatal hypoglycaemia

UHL has a written policy for the prevention and management of symptomatic or

significant hypoglycaemia in neonates.

Feeding

Women should feed their babies as soon as possible after birth and then at frequent

intervals (2–3 hours) until pre-feed blood glucose levels are maintained at 2 mmol/l

or more.

Test the baby’s blood glucose levels:

Before the 2nd, 3rd and 4th feed using a quality-assured method validated for neonatal

use (ward-based glucose electrode or laboratory analysis)

If he or she has signs of hypoglycaemia, refer urgently to the Neonatal Team.

Postnatal care

Information and advice

Breastfeeding

Women with diabetes who wish to breastfeed to avoid medication for complications

of diabetes that were discontinued for safety reasons in pregnancy (eg ACE

inhibitors / statins).

On the importance of contraception and pre-conception care when planning future

pregnancies.

Insulin treated Type 1 or 2 diabetes

Reduce insulin immediately after birth as advised by the diabetes team and to

monitor their blood glucose concentrations to establish correct dose.




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Warn about the risk of hypoglycaemia, especially while breastfeeding. Therefore,

the woman should have food available before or during breastfeeding.

As a guide –

Women with pre-existing diabetes (type 1 and 2) should return to their pre-

pregnancy medication regime immediately after delivery.

It is important to remember that once the baby and placenta is delivered insulin

requirements will drop very quickly.

A further reduction of pre-pregnancy insulin may be required

If breastfeeding insulin may need to be reduced by up to 40% (plan on an individual

basis)

It is acceptable for women to run with a higher CBG level post-delivery to avoid the

risk of hypoglycaemia aim for a fasting of 6 – 8 mmol/s.

Oral hypoglycaemics

Women with type 2 diabetes can resume or continue taking metformin while

breastfeeding. They should not to take any other oral hypoglycaemic agents while

breastfeeding.


Women with gestational diabetes should be advised:

To stop taking hypoglycaemic medication/insulin immediately after birth.

To stop blood glucose monitoring unless otherwise advised by the Diabetes

Team.

On weight control, diet and exercise.

On the symptoms of hyperglycaemia.

On the risks of gestational diabetes in subsequent pregnancies and the risks

of developing Type 2 diabetes.

About screening for diabetes when planning a pregnancy.

Transfer and follow-up

Explain to women who were diagnosed with gestational diabetes about the risks of

gestational diabetes in future pregnancies, and offer them testing for diabetes when

planning future pregnancies.

For women who were diagnosed with gestational diabetes and whose blood glucose

levels returned to normal after the birth, offer lifestyle advice (including weight

control, diet and exercise).




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Offer a fasting plasma glucose test 6–13 weeks after the birth to exclude diabetes

(for practical reasons this might take place at the 6-week postnatal check).

If a fasting plasma glucose test has not been performed by 13 weeks, offer an

HbA1c.

Women should have an annual HbA1c to assess the increased risk of Type 2 DM.

Do not routinely offer a 75 g 2-hour OGTT.

For women having a fasting plasma glucose test as the postnatal test:

Advise women with a fasting plasma glucose level below 6.0 mmol/l that:

they have a low probability of having diabetes at present and should continue

to follow the lifestyle advice (including weight control, diet and exercise) given

after the birth.

they will need an annual HbA1c to check that their blood glucose levels are

normal

they have a moderate risk of developing type 2 diabetes, and offer them

advice and guidance in line with the NICE guideline on preventing type 2

diabetes.

Advise women with a fasting plasma glucose level between 6.0 and 6.9 mmol/l that

they are at high risk of developing type 2 diabetes, and offer them advice, guidance

and interventions in line with the NICE guideline on preventing type 2 diabetes.

Advise women with a fasting plasma glucose level of 7.0 mmol/l or above that they

are likely to have type 2 diabetes, and offer them a diagnostic test to confirm

diabetes.

For women having an HbA1c test as the postnatal test:

Advise women with an HbA1c level below 39 mmol/mol (5.7%) that:

they have a low probability of having diabetes at present

they should continue to follow the lifestyle advice (including weight control,

diet and exercise) given after the birth

they will need an annual Hba1c to check that their blood glucose levels are

normal

they have a moderate risk of developing type 2 diabetes, and offer them

advice and guidance in line with the NICE guideline on preventing type 2

diabetes.

Advise women with an HbA1c level between 39 and 47 mmol/mol (5.7% and 6.4%)

that they are at high risk of developing type 2 diabetes, and offer them advice,




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guidance and interventions in line with the NICE guideline on preventing type 2

diabetes.

Advise women with an HbA1c level of 48 mmol/mol (6.5%) or above that they have

type 2 diabetes and refer them for further care.

Women with pre-existing diabetes:

Women with pre-existing diabetes should be referred back to routine diabetes care.

Remind women with diabetes of the importance of contraception and the need for

preconception care when planning future pregnancies.

Ophthalmological follow-up:

For women who have preproliferative diabetic retinopathy diagnosed in pregnancy

an appointment with the Ophthalmology Department will automatically sent.



NB: Paper copies of this document may not be most recent version. The definitive version is in the Policy and Guidelines Library

MANAGEMENT OF TYPE 1 AND TYPE 2 DIABETES

WEEKS OF

PREGNANCY

ANTENATAL

CLINIC Retinal

screenin

g

HbA1c SCANS BLOODS INFORMATION

4 – 11 weeks

See DSM,

Diabetologist,

Obstetrician,

DSN & Dietitian � � Viability scan

U&E, Creatinine, TFT,

urine ACR,

Diabetes and pregnancy.

Book with Community

Midwife1

Advise Folic Acid 5mg od

Commence Cocalciferol 20

micrograms/ 800units od.

11+2 - 15

weeks

See above as

necessary

Dating Scan/

Nuchal Translucency

Scan

(NT 11+2 – 14+1 weeks)]

Further tests at

discretion of

diabetes/obstetric

teams

.

Start Aspirin 75 mg od.

Documentation of booking

bloods

16 - 17 weeks See above as

necessary �

Give results of NT scan




18 - 22 weeks

See above as

necessary

�

(if

needed)

Anomaly Scan including 4

chamber, 3 vessels and

outflow tract cardiac scan.


necessary

Growth scan from 26/40

every 3-4 weeks till

delivery


necessary �

Growth Scan FBC & antibody

screen (Empath

bloods) if not already

taken

Anti-D if required


necessary

� Growth Scan Documentation of FBC and

Empath bloods


necessary

Growth Scan FBC

Discuss and document birth

plan. Arrange IOL/ELCS for

37-38+6/40. Consider




<37/40 if maternal/fetal

complications


necessary Growth Scan

Discuss postnatal care and

follow-up including PN

insulin doses.

Every woman is encouraged to keep in contact with her community midwife for routine care and parentcraft information.

Telephone contact is maintained between appointments with the Diabetes Specialist Nurse and/or Diabetes Specialist

Midwives if required




MANAGEMENT OF GESTATIONAL DIABETES*

Women who have an abnormal OGTT at 8 – 16 weeks will follow the same care pathway as women with pre-existing diabetes

WEEKS OF

PREGNANC

Y

ANTENATAL

CLINIC

HbA1c

SCANS BLOODS INFORMATION

24 – 30

weeks

See DSM, DSN

and Dietitian �

Growth Scan

every From 26

weeks every 3-4

weeks till delivery

FBC & antibody screen

(Empath bloods) if not

already taken.

Anti-D if required

Diabetes and pregnancy. Dietary Advice

Home CBG monitoring

Insulin start if indicated

31 – 34

weeks

See DSM,

(Obstetrician,

Diabetologist,

DSN or Dietitian

as necessary)

Growth Scan

Documentation of blood results




35 - 37

weeks

See DSM,

Obstetrician,

Diabetologist,

Growth Scan FBC

Discuss and document birth plan. Arrange IOL

at 38 – 39 weeks for insulin controlled

diabetes. Arrange ELCS (if indicated) at 38 –

39 weeks for all women.

38 - 39

weeks

See as above Growth scan

Documentation of FBC

Discuss and document birth plan. Arrange IOL

before 40+6 weeks for diet controlled diabetes.

Consider <39+6 if complications

Care returned to CM/MW

Every woman is encouraged to keep in contact with her community midwife for routine care and parentcraft information.

Telephone contact is maintained between appointments with the Diabetes Specialist Nurse and/or Diabetes Specialist

Midwives if required




PREGNANT WITH DIABETES ON INSULIN

WELL UNWELL

BG level above 13 mmol/mol

DIABETES KETOACIDOSIS IN PREGNANCY DIAGNOSTIC PATHWAY




Test for blood ketones Test for blood ketones

If less than 1.5 mmol/L If 1.5 mmol/L or more If less than 1.5 mmol/L If 1.5 mmol/L or

more

Advise women to

adjust insulin doses or Admit to MAU for further Follow sick day rules and Admit to MAU for

further

seek telephone advice investigation seek telephone advice from investigation

from Diabetes Team Diabetes Team

(Please seek review from senior SpR Obstetric / SpR Anaesthetic) - For further guidance see http://insitetogether.xuhl-

tr.nhs.uk/pag/pagdocuments/Diabetic Ketoacidosis (DKA) in Adults UHL guideline




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Hba1c Conversion Table




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ANTENATAL STEROIDS AND DIABETES

Antenatal steroids have been shown to reduce the morbidity and mortality of

respiratory distress syndrome (hyaline membrane disease) (RDS) in pre-term

infants.

The Royal College of Obstetricians and Gynaecologists (RCOG) suggests that

corticosteroids should be given to all women at risk of spontaneous or elective

delivery up to 34 weeks gestation and those booked for planned caesarean prior to

38+6 weeks.

It is recommended that women receive two doses of corticosteroid 12 hours apart,

with an optimum administration to delivery interval of more than 24 hours and less

than 7 days.

It is recognised that infants of mothers with diabetes are at higher risk of RDS.

However, the corticosteroids given to help prevent RDS increase the hepatic and

blood glucose levels in these women.

The National Institute for Health Care excellence (NICE) states that diabetes should

not be considered a contraindication for antenatal steroids and recommends that

women with insulin–treated diabetes receiving steroids should have additional insulin

according to an agreed protocol and be closely monitored. Neither NICE or the

RCOG offer a specific protocol or insulin management plan for these women.

Several Trusts have developed their own differing plans as some guidance and more

recently the Joint British Diabetes Societies (JBDS) 2014 have produced a specific

plan for steroid treatment in pregnancy.

The following pathway reflects both the JBDS and NHS Tayside Diabetes protocols.




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ADMINISTRATION OF ANTENATAL STEROIDS AND DIABETES

Type 2 & Gestation Diabetes

Mellitus (GDM)

• Do not require admission

• Following the first dose of steroid

monitor blood glucose (BG) levels pre-

breakfast and 1 hour post meals

• If BG levels >12mmols on 2 occasions

in 24 hours

Consider treatment or titrate

treatment to correct hyperglycaemia

• Inform Diabetes Team

Type1 and Type 2 diabetes on

insulin

• Recommend admission

• Increase all insulin by 40% at the time

of the first steroid injection.

• Maintain this dose for 24 hrs after the

2nd injection

• Monitor blood glucose levels pre and

post meals

• If BG > 10mmols check ketones and

adjust insulin further.

• If BG levels > 12mmols and/ or blood

ketones > 0.6 mmol transfer to Labour

Ward for variable rate insulin infusion

(VRII)

• Inform Diabetes team of admission to

Labour Ward

As the effect of the steroids

reduces (12 to 24 hrs after the 2nd

dose), treatment may need to be

reduced in response to BG levels if

it has previously been increased

As the effect of the steroids

reduces (12 to 24 hrs after the 2nd

dose), insulin dose may need to

be reduced in response to BG

levels




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Education and Training

All Midwives must complete insulin safety training every 2 years.

Monitoring Compliance

Monitoring

This is based on a review of incident forms by the Quality and Safety Manager in

conjunction with the clinical lead, and will include trend analysis if considered

necessary, and referred to the Perinatal Risk Group where appropriate. All staff to

continue using the DATIX reporting system as required. Any action points / plans will

then be referred to the Maternity Service or Neonatal Governance Group.

National Diabetes in Pregnancy Audit

The National Diabetes in Pregnancy audit measures the quality of care given to

women with pre-existing diabetes during pregnancy. The audit is managed by the

Health and Social Care Information Centre (HSCIC), in collaboration with Diabetes

UK and Diabetes Health Intelligence and is part of the National Diabetes Audit. It is

expected that all Trusts with joint obstetric and diabetes services will participate.

Reliable annual reports benchmarked against all participating delivery units in

England and Wales will be produced. These can be used for service assurance,

prioritisation of areas for improvement and measurement of the effectiveness of

improvements initiatives.


collected and submitted securely to the HSCIC.

Supporting References:

NICE – Diabetes in Pregnancy 2015

Key Words

Diabetes in pregnancy, insulin, blood glucose monitoring




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CONTACT AND REVIEW DETAILS

Guideline Lead (Name and Title) H Maybury,

Consultant Obstetrician

Executive Lead C Fox

• Details of Changes made during review:

• Addition of new risk factors for GDM for women for screening at booking ,

• Addition of electronic referrals by community midwives via GDM mailbox

• Clarification of action for post 32 week glycosuria

• Addition of guidance for women who have undergone bariatric surgery

• Addition of scans as per GROW pathway

• Addition of section for Inpatient care

• Clarification of IV fluids to be used with variable rate insulin infusions

• Addition of guidance for changes to post natal insulin regimes

• Addition of guidance – how to commence and discontinue variable rate insulin

infusions




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Appendix 1: Variable Rate insulin Infusion

Type 1 Diabetes Mellitus

NIL BY MOUTH or INTRAPARTUM – requires hourly CBG testing

Continue Basal Insulin as prescribed

Commence Variable Rate Insulin Infusion as per green Insulin chart always use an

Insulin syringe to draw up any Insulin

50 Units of Human Actrapid in 49.5 mls of 0.9% Sodium Chloride – via a syringe driver

500mls of 5% Dextrose with 20mmols KCI at 100mls-hour – via a IVAC pump

Always use a two way IV cannula needs 12 hourly U and E’S

To discontinue Variable rate Insulin Infusion

First check prescribed medication

If breastfeeding – May need a 40% reduction from pre pregnancy dosages

If postnatal – Ensure that all Insulin medications are reduced by 25% from re-

pregnancy dosages

If in doubt discuss with Diabetes Team – women are at very high risk of hypoglycaemic episodes

if their medication is not reduced

1. Administer s/c rapid acting insulin prior to food as prescribed

2. Continue variable rate insulin infusion for 30 mins following s/c rapid acting insulin then discontinue both

IV Insulin and IV Dextrose

3. Continue to check CBG as recommended and document




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Appendix 2: Variable Rate insulin Infusion

Type 2 Diabetes Mellitus or GDM on Insulin – if CBG >9mmols on 2 occasions

NIL BY MOUTH or INTRAPARTUM – require hourly CBG testing

Continue Basal Insulin as prescribed

Commence Variable Rate Insulin Infusion as per green Insulin chart

Always use an Insulin syringe to draw up any Insulin

50 Units of Human Actrapid in 49.5 mls of 0.9% Sodium Chloride – via a syringe driver

500mls of 5% Dextrose with 20mmols KCI at 100mls-hour – via a IVAC pump

Always use a two way IV cannula - need 12 hourly U and E’S

To discontinue Variable rate Insulin Infusion

First check prescribed medication

If breastfeeding – May need a 40% reduction from pre pregnancy dosages

If postnatal – Ensure that all Insulin medications are reduced by 25% from re-

pregnancy dosages

If in doubt discuss with Diabetes Team – women are at very high risk of hypoglycaemic episodes

if their medication is not reduced

1. Administer s/c rapid acting insulin prior to food as prescribed

2. Continue variable rate insulin infusion for 30 mins following s/c rapid acting insulin then

discontinue both IV Insulin and IV Dextrose

3. Continue to check CBG as recommended and document




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Appendix 3:

Documents

Diabetes in Pregnancy 21 11 18 - Home - Library... · Diabetes in Pregnancy Page 1 of 37 ... Women who are suspected of having diabetic ketoacidosis should be ... Offer lifestyle