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

Transcription

1 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 Information and advice before screening and testing: Screening and diagnosis: Interventions for gestational diabetes: Pre-existing Diabetes : Type 1 or Type Antenatal care Blood glucose targets and monitoring Monitoring HbA1c Women taking Insulin Diabetes in Pregnancy Page 1 of 37

2 Diabetic Ketoacidosis Intrapartum care Information and advice: Care during labour and birth: Care prior to elective Caesarean section: Neonatal care Preventing, detecting and managing neonatal hypoglycaemia Postnatal care Information and advice Weeks of pregnancy Antenatal clinic Scans Bloods Weeks of pregnancy Antenatal clinic Scans Bloods DIabetes ketoacidosis in pregnancy diagnostic pathway... Hba1c Conversion Table Antenatal steroids and diabetes Administration of antenatal steroids and diabetes Education and Training Monitoring Compliance Monitoring National Diabetes in Pregnancy Audit The National Diabetes in Pregnancy The Diabetes Care Team actively encourages women to consent to their data being collected and submitted securely to the HSCIC Supporting References: Key Words Contact and review details Diabetes in Pregnancy Page 2 of 37

3 Development and approval record for this document... Error! Bookmark not defined. Appendix 1: Variable Rate insulin Infusion Appendix 2: Variable Rate insulin Infusion Appendix 3 : Introduction and who the guideline applies to This guideline applies to the management of diabetes and its complications from preconception 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 (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 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 3 of 37

4 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 4 of 37

5 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 preconception 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 weeks and weeks of pregnancy. Diabetes in Pregnancy Page 5 of 37

6 Advise women with gestational diabetes to give birth no later than 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 6 of 37

7 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 childbearing 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/m 2. 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 selfmonitoring routine. Frequency of appointments and local support, including emergency telephone numbers. Diabetes in Pregnancy Page 7 of 37

8 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: Consider: Review: 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. 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 m 2. Current medications for diabetes and its complications. (Box 3) Glycaemic targets and glucose monitoring (see box 4). Diabetes in Pregnancy Page 8 of 37

9 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 Diabetes in Pregnancy Page 9 of 37

10 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/m 2 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 weeks gestation Previous gestational diabetes Glycosuria For women with: BMI > 40 kg/m 2 OGTT at weeks and repeated weeks. Screening and diagnosis: Women with risk factors for gestational diabetes (Box 5) are offered an oral Glucose Tolerance Test (OGTT). Diabetes in Pregnancy Page 10 of 37

11 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 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 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 11 of 37

12 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 12 of 37

13 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) Diabetes in Pregnancy Page 13 of 37

14 Blood glucose targets and monitoring Measure HbA1c levels in all pregnant women with pre existing diabetes at the 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 postmeal 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 HbA1 c in early pregnancy. 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. Diabetes in Pregnancy Page 14 of 37

15 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 fastacting 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 15 of 37

16 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 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. Diabetes in Pregnancy Page 16 of 37

17 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. Diabetes in Pregnancy Page 17 of 37

18 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 Preterm 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 Diabetes in Pregnancy Page 18 of 37

19 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 2 nd, 3 rd and 4 th 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. Diabetes in Pregnancy Page 19 of 37

20 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 prepregnancy 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). Diabetes in Pregnancy Page 20 of 37

21 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, Diabetes in Pregnancy Page 21 of 37

22 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. Diabetes in Pregnancy Page 22 of 37

23 MANAGEMENT OF TYPE 1 AND TYPE 2 DIABETES WEEKS OF PREGNANCY ANTENATAL CLINIC Retinal screenin g HbA1c SCANS BLOODS INFORMATION Diabetes and pregnancy weeks See DSM, Diabetologist, Obstetrician, DSN & Dietitian Viability scan U&E, Creatinine, TFT, urine ACR, Book with Community Midwife 1 Advise Folic Acid 5mg od Commence Cocalciferol 20 micrograms/ 800units od weeks See above as necessary Dating Scan/ Nuchal Translucency Scan (NT weeks)] Further tests at discretion of diabetes/obstetric teams. Start Aspirin 75 mg od. Documentation of booking bloods weeks See above as necessary Give results of NT scan Diabetes in Pregnancy Page 23 of 37

24 18-22 weeks See above as necessary (if needed) Anomaly Scan including 4 chamber, 3 vessels and outflow tract cardiac scan weeks See above as necessary Growth scan from 26/40 every 3-4 weeks till delivery weeks See above as necessary Growth Scan FBC & antibody screen (Empath bloods) if not already taken Anti-D if required weeks See above as necessary Growth Scan Documentation of FBC and Empath bloods weeks See above as necessary Growth Scan FBC Discuss and document birth plan. Arrange IOL/ELCS for /40. Consider Diabetes in Pregnancy Page 24 of 37

25 <37/40 if maternal/fetal complications 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 Diabetes in Pregnancy Page 25 of 37

26 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 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 weeks See DSM, (Obstetrician, Diabetologist, DSN or Dietitian as necessary) Growth Scan Documentation of blood results Diabetes in Pregnancy Page 26 of 37

27 35-37 weeks See DSM, Obstetrician, Diabetologist, Growth Scan FBC Discuss and document birth plan. Arrange IOL at weeks for insulin controlled diabetes. Arrange ELCS (if indicated) at weeks for all women. Documentation of FBC weeks See as above Growth scan 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 Diabetes in Pregnancy Page 27 of 37

28 DIABETES KETOACIDOSIS IN PREGNANCY DIAGNOSTIC PATHWAY PREGNANT WITH DIABETES ON INSULIN WELL UNWELL BG level above 13 mmol/mol Diabetes in Pregnancy Page 28 of 37

29 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 Ketoacidosis (DKA) in Adults UHL guideline Diabetes in Pregnancy Page 29 of 37

30 Hba1c Conversion Table Diabetes in Pregnancy Page 30 of 37

31 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 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. Diabetes in Pregnancy Page 31 of 37

32 ADMINISTRATION OF ANTENATAL STEROIDS AND DIABETES Type1 and Type 2 diabetes on insulin Type 2 & Gestation Diabetes Mellitus (GDM) Recommend admission Increase all insulin by 40% at the time of the first steroid injection. Maintain this dose for 24 hrs after the 2 nd 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 Do not require admission Following the first dose of steroid monitor blood glucose (BG) levels prebreakfast 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 As the effect of the steroids reduces (12 to 24 hrs after the 2 nd dose), insulin dose may need to be reduced in response to BG levels As the effect of the steroids reduces (12 to 24 hrs after the 2 nd dose), treatment may need to be reduced in response to BG levels if it has previously been increased Diabetes in Pregnancy Page 32 of 37

33 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 Diabetes in Pregnancy Page 33 of 37

34 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 Diabetes in Pregnancy Page 34 of 37

35 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 postnatal Ensure that all Insulin medications are reduced by 25% from repregnancy dosages If breastfeeding May need a 40% reduction from pre pregnancy dosages If in doubt discuss with Diabetes Team women are at very high risk of hypoglycaemic episodes if their medication is not reduced Diabetes 1. Administer Pregnancy s/c rapid acting insulin prior to food as prescribed Page 35 of 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

36 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 postnatal Ensure that all Insulin medications are reduced by 25% from repregnancy dosages If breastfeeding May need a 40% reduction from pre 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 Diabetes in Pregnancy Page 36 of 37

37 Appendix 3: Diabetes in Pregnancy Page 37 of 37