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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
Library
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
Diabetes in Pregnancy Page 2 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
Library
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
Diabetes in Pregnancy Page 3 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
Library
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
Diabetes in Pregnancy Page 4 of 37
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Library
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.
The Diabetes Care Team actively encourages women to consent to their data being
collected and submitted securely to the HSCIC.Guidance
Diabetes in Pregnancy Page 5 of 37
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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.
Diabetes in Pregnancy Page 6 of 37
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Library
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).
Diabetes in Pregnancy Page 7 of 37
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Library
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.
Diabetes in Pregnancy Page 8 of 37
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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.
Gestational diabetes
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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Library
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 -
Diabetes in Pregnancy Page 12 of 37
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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.
Diabetes in Pregnancy Page 13 of 37
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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.
Diabetes in Pregnancy Page 16 of 37
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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.
Gestational diabetes
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.
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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
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18 - 22 weeks
See above as
necessary
�
(if
needed)
Anomaly Scan including 4
chamber, 3 vessels and
outflow tract cardiac scan.
23 - 27 weeks See above as
necessary
Growth scan from 26/40
every 3-4 weeks till
delivery
28 - 31 weeks See above as
necessary �
Growth Scan FBC & antibody
screen (Empath
bloods) if not already
taken
Anti-D if required
32 - 35 weeks See above as
necessary
� Growth Scan Documentation of FBC and
Empath bloods
36 - 37 weeks See above as
necessary
Growth Scan FBC
Discuss and document birth
plan. Arrange IOL/ELCS for
37-38+6/40. Consider
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<37/40 if maternal/fetal
complications
38 - 39 weeks See above as
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
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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
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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
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PREGNANT WITH DIABETES ON INSULIN
WELL UNWELL
BG level above 13 mmol/mol
DIABETES KETOACIDOSIS IN PREGNANCY DIAGNOSTIC PATHWAY
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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.
The Diabetes Care Team actively encourages women to consent to their data being
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: