Diabetes in pregnancyImplementing NICE guidance

2nd edition – March 2012

NICE clinical guideline 63

Guideline review

Guideline issue date: 2008

First review : 2011

2011 review recommendation

The guideline should be updated.

The consultation on the scope will take place in March/April 2012. The publication date for the updated guideline has not been confirmed.

What this presentation covers

Background

Risks of diabetes in pregnancy

Key priorities for implementation

Costs and savings

Discussion

NHS Evidence and NICE Pathway

Find out more

Background: prevalence

PrevalenceNumber of

pregnancies in England

Total singletonpregnancies

600,200

Type 1 diabetes 0.3% 1,800

Type 2 diabetes 0.2% 1,200

Gestational diabetes 3.5% 20,400

Total diabetes inpregnancy

23,400

Risks of diabetes in pregnancy

Pre-existing diabetes Gestational

miscarriage neonatal hypoglycaemia

congenital malformation perinatal death

stillbirth

neonatal death

fetal macrosomia

birth trauma (to mother and baby)

induction of labour or caesarean section

transient neonatal morbidity

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

Key priorities for implementation

Pre-conception care

Antenatal care

Neonatal care

Postnatal care

Inform women with diabetes who are planning to become pregnant 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.

Pre-conception care: 1

The importance of avoiding unplanned pregnancy should be an essential component of diabetes education from adolescence for women with diabetes.

Offer pre-conception care and advice to women with diabetes who are planning to become pregnant before discontinuing contraception.

Pre-conception care: 2

If it is safely achievable, women with diabetes should aim to keep fasting blood glucose between 3.5 and 5.9 mmol/litre and 1-hour postprandial blood glucose below 7.8 mmol/litre during pregnancy.

Advise women with insulin-treated diabetes of the risks of hypoglycaemia and hypoglycaemia unawareness in pregnancy, particularly in the first trimester.

Antenatal care: 1

Admit pregnant women who are suspected of having diabetic ketoacidosis immediately for level 2 critical care where they can receive both medical and obstetric care.

Offer women with diabetes antenatal examination of the four-chamber view of the fetal heart and outflow tracts at 18–20 weeks.

Antenatal care: 2

Antenatal care: 3

At the booking appointment screen for risk factors

associated with gestational diabetes.

Offer testing for gestational diabetes if any

one risk factor identified.

Neonatal careKeep babies of women with diabetes with their mothers unless there is a clinical complication

Admit the baby to a neonatal unit if he or she:

• is hypoglycemic with abnormal signs

• has respiratory distress or jaundice that requires monitoring or treatment

• has signs of cardiac decompensation, neonatal encephalopathy or polycythaemia

• needs intravenous fluids or tube feeding (unless adequate support is available on the postnatal ward)

• is born before 34 weeks (or between 34 and 36 weeks if dictated clinically).

Offer women who were diagnosed with gestational diabetes:

• lifestyle advice

• a fasting plasma glucose

measurement

Postnatal care

Costs and savings per 100,000 population

Recommendations with significant resource impact (costs/savings )

Costs/savings (£ in first year)

Screening for fetal anomalies 12,700

Screening for Down’s syndrome 6500

Screening and testing for gestational diabetes 2900

Treatment of gestational diabetes 1500

Avoidance of neonatal care for babies of women with diabetes – 2300

Estimated net cost of implementation 21,300

This slide also includes costs and savings for implementing the NICE guidance on antenatal care

Costs correct at March 2008. Costs not updated for 2nd edition

Discussion

How can we promote pre-conception services to support women with diabetes to plan for pregnancy?

How can we ensure women with risk factors for gestational diabetes are identified?

What more do we need to do to ensure appropriate referrals are made to joint diabetes and antenatal clinics?

What should we be doing to ensure that we are providing annual follow up of lifestyle advice and fasting blood glucose testing to women diagnosed with gestational diabetes?

NICE Pathway

The NICE Diabetes in pregnancy Pathway covers.

Click here to go to NICE Pathways website

NHS Evidence

Visit NHS Evidence for the best available evidence on all aspects of diabetes.

Click here to go to the NHS Evidence

website

To be added- the latest NHS evidence image

Find out more

Visit www.nice.org.uk/CG63 for:

•other guideline formats•costing report and template•audit support•online educational tool

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