Obstetrics and Gynaecology

Transcription

1 Purpose Pregnancy is associated with changes to insulin sensitivity which can lead to elevated maternal blood glucose levels (BGLs). When elevated BGLs are first diagnosed during pregnancy the mother has gestational diabetes mellitus (GDM). Also, if the mother has pre-existing diabetes (Type 1 or Type 2) the increase in maternal insulin resistance during pregnancy further increases BGLs and requires major increases in diabetes treatment. Elevated blood glucose levels in the mother cause foetal blood glucose levels to increase due to transplacental glucose transport. The resultant increase in foetal BGLs causes the foetus to overproduce insulin. The fetal hyperglycaemia and the resulting hyperinsulinaemia is thought to increase the risk of pre-eclampsia, foetal macrosomia, neonatal hypoglycaemia, hyperbilirubinaemia and respiratory distress syndrome. The incidence of these complications in the foetus can be decreased by treating the mother to ensure maternal BGLs are maintained in the near-normal range throughout pregnancy and labour. Pre-existing diabetes (Type 1 or Type 2 Diabetes) in pregnancy is also associated with other risks to the mother and developing foetus. Foetal risks include stillbirth, congenital malformations, macrosomia and birth injury, perinatal mortality, and postnatal adaptation problems such as hypoglycaemia 3. Miscarriage, pre-eclampsia, and pre-term labour are more common with pre-existing diabetes. Pre-existing complications of diabetes in the mother such as retinopathy 3 and nephropathy can worsen during pregnancy. Maternal and fetal outcomes in patients with pre-existing diabetes depend heavily on pre-pregnancy counseling and strict glycaemic control during pregnancy. Poor glycaemic control during labour is associated with neonatal hypoglycaemia due to the stimulation of fetal insulin release by maternal hyperglycemia 3,4. Maintenance of maternal BGLs in the normal range during labour decreases the risk of neonatal hypoglycaemia. Scope To provide information and guidance for staff on the antenatal, labour and postnatal management of patients with diabetes in pregnancy. This includes Gestational Diabetes and pre-existing Type 1 and Type 2 diabetes in pregnancy. Responsibilities Employer Peninsula Health acts to minimize risk by supporting adherence to Guidelines, occupational health and safety obligations and duty of care to staff and consumers through a comprehensive clinical governance system which includes the provision of and education in relation to evidence based Guidelines. al The Executive supports Heads in the monitoring and evaluation of Guidelines. Providing the necessary infrastructure and resource to facilitate compliance with Guidelines and assisting the Heads to facilitate education and enforce compliance with Guidelines. First created: 09/07/2015 Page 1 of 14 Last reviewed:

2 Head/Manager Heads/ Managers monitor compliance with Guideline via agreed evaluation methods and associated KPIs. Ensure all staff have easy access to relevant Guidelines and are kept informed of any updates or changes to Guidelines related to their employment and scope of practice. Facilitate education as appropriate in relation to the Guideline. Employee All employees must be familiar with and comply with Guidelines relevant to their employment and scope of practice. Guideline AIM To maintain BGL between 4-7mmol/L to help achieve optimal maternal and neonatal outcomes. On admission all histories should be reviewed for the plan of diabetes management. This policy will be divided into the following sections for easier practitioner reference. GDM DIET CONTROLLED GDM INSULIN REQUIRING TYPE 2 DIABETES - INSULIN REQUIRING TYPE 1 DIABETES ANTENATAL CARE FOR DIABETES IN PREGNANCY ANTENATAL CARE GESTATIONAL DIABETES The incidence rate for GDM in Australia is approximately 5% of all pregnancies, however there is an increased prevalence among Aboriginal and Torres Strait Islanders, Pacific Islanders, and women from the Indian subcontinent, East Asia and the Middle East 10 Risk of GDM is also elevated with BMI>30kg/m 2, family history of diabetes, previous GDM or macrosomia 3. GESTATIONAL DIABETES DIAGNOSIS Routine Screening: All pregnant women should be offered an OGTT at weeks gestation. Earlier testing of those at higher risk of GDM is advised. Table 1. Criteria for Diagnosis of GDM and Diabetes Mellitus in Pregnancy with a 2 hours Pregnancy Oral GTT (from 1 st January 2015) Diagnosis Fasting plasma glucose (mmol/l) 1 hour glucose (mmol/l following 75g oral glucose load Normal < 5.1 <10.0 <8.5 GDM Diabetes Mellitus in Pregnancy 7.0 * hours glucose (mmol/l) following 75g oral glucose load *There are no established criteria for the diagnosis of diabetes based on the 1 hour post load value. 10 First created: 09/07/2015 Page 2 of 14 Last reviewed:

3 Higher risk for GDM Women with higher risk factors for GDM should be tested with a 75gm Oral Glucose Tolerance Test (OGTT) at first visit or around weeks gestation. 5 Higher risk factors include; foetal macrosomia, polycystic ovarian syndrome, strong family history, glycosuria, obesity and previous GDM. 6 If result is normal the OGTT should be repeated weeks gestation. 1 ANTENATAL CARE GESTATIONAL DIABETES GDM Clinic All women diagnosed with GDM referred to GDM clinic as soon as possible. GDM Clinic consist of a team of heath care professionals (Endocrinologist, Endocrinology registrar, Diabetes Educators, Dietitian, ) Women are encouraged to take responsibility for making contact with the diabetes educators if they have 2 or more elevated BGL readings in a week. Insulin therapy should be considered if BGL s exceed target on two occasions in one week 5 It is not the usual practice in Australia to use oral hypoglycaemic agents in the treatment of GDM 5 1 All women should have a plan of management discussed and documented from 36/40 regarding timing of birth and management of medication in labour FREQUENCY OF VISITS - GDM Frequency of visits to GDM clinic. Routinely fortnightly reviews may be increased or decreased as required Frequency of visits to MWC/OBS CLINIC / SMCP: o If not receiving insulin then routine antenatal care is assumed. The following is the suggested regime: o 4/52 until 28 weeks, then 3/52 until 34 weeks, then 2 weekly until 38 weeks, then weekly until term Once insulin is administered the following is the suggested regime O As above, then weekly from 34/40 gestation TABLE OUTLINING ANTENATAL VISITS WITH GESTATIONAL DIABETES GESTATION VISIT WITH LABORATORY TESTS FETAL ASSESSMENT 0-12 weeks GP confirm pregnancy Obstetrician routine antenatal bloods OTHER As per routine pregnancy weeks Booking at hospital with midwife OGTT for high risk of GDM If normal repeat at 26/40 Ultrasound /blood test genetic abnormality screen Referral to GDM Clinic if positive OGTT First created: 09/07/2015 Page 3 of 14 Last reviewed:

4 18-20 weeks Midwife / SMCP /OB Review if requiring insulin Anatomy U/S 24 Midwife / SMCP /OB review 28 OBS review GDM Clinic as soon as diagnosed GTT weeks for all routine women routine care FBE antibody screen ± anti D Iron Study 30 Midwife / SMCP /OBS +/-GDM Clinic 32 OBS review Growth Scan if needed 34 OBS review +/-GDM Clinic 36 OBS review FBE ± anti D GBS swab 37 OBS review +/-GDM Clinic 38 OBS review +/-GDM Clinic offer U/S for fetal growth/ AFI if clinically indicated or baby > 80th percentile at 30/40 U/Sound Review blood glucose control Discuss mode and timing of birth with obstetrician Review blood glucose control Review blood glucose control If complicating factors present Consider If for planned Elective LUSCS -38/40 Review blood glucose control If for Planned C/S and good glycaemic control, book for First created: 09/07/2015 Page 4 of 14 Last reviewed:

5 39/40 39 OBS review +/-GDM Clinic CTG Review blood glucose control If good glycaemic control, on diet without Insulin, and no abnormal features, induce between weeks. TYPE 2 DIABETES PRE NATAL CARE- TYPE 2 DIABETES 9 Pre pregnancy counseling- review with endocrinologist, diabetes educator and dietitian. Recommend contraception until optimal glycaemic control (aim HbA1C 6-7%). Commence 5mg Folic Acid supplement one month prior to pregnancy and continue throughout first trimester. General Health Assessment including Rubella and Varicella test. Diabetes complications assessment (eyes, kidneys, nerves). Review of medications including diabetes tablets/insulin BP and lipid medication. Provide education regarding hypoglycaemia and sick days. ANTENATAL CARE- TYPE 2 DIABETES All women should have a plan of management discussed and documented from 36/40 regarding timing of birth and management of medication in labour FREQUENCY OF VISITS TYPE 2 DIABETES Frequency of visits to GDM clinic o As soon as pregnancy confirmed and then as needed o Routinely fortnightly reviews may be increased or decreased as required Frequency of visits to mid/obs as per table TYPE 1 DIABETES PRE NATAL CARE -TYPE 1 DIABETES 9 Pre pregnancy counseling- review with Endocrinologist, diabetes educator and dietitian. Recommend contraception until optimal glycaemic control (aim HbA1C 6-7%) Commence 5mg Folic Acid supplement one month prior to pregnancy and continue throughout first trimester General Health Assessment including Rubella and Varicella test. Diabetes complications assessment (eyes, kidneys, nerves).review of medications including diabetes tablets/insulin BP and lipid medication. Provide GlucaGen Script and education regarding hypoglycaemia, sick days and ketone testing First created: 09/07/2015 Page 5 of 14 Last reviewed:

6 ANTENATAL CARE- TYPE 1 DIABETES If Ketoacidosis is suspected during pregnancy -Immediate admission to level 2 critical care - ICU under combined obstetric and medical care as ketoacidosis is associated with 3, 11 foetal distress All women should have a plan of management discussed and documented from 36/40 regarding timing of birth and management of medication in labour Retinal assessment FREQUENCY OF VISITS TYPE 1 DIABETES Frequency of visits to GDM clinic- as soon as pregnancy confirmed and then as needed o Routinely fortnightly reviews may be increased or decreased as required Frequency of visits to mid/obs as per table TABLE OUTLINING SUBSEQUENT ANTENATAL VISTIS FOR TYPE 1 AND TYPE 2 DIABETES GESTATION VISIT WITH LABORATORY TESTS FETAL ASSESSMENT 0-12 weeks GP confirm pregnancy U/S to confirm Obstetrician routine antenatal dates Referral to GDM clinic bloods for endocrinologist, HbA1c dietitian and diabetes educator review OTHER weeks Booking at hospital with midwife U/S offering 4 chamber view of heart and outflow tracts 24 Midwife / SMCP routine care 28 OBS review FBE antibody screen ± anti D offer U/S for fetal growth/ AFI 31 Midwife SMCP offer U/S for fetal growth/ AFI ( if on insulin or have poor control) 34 OBS review HbA1c Weekly CTG commences 35 OBS review CTG Discuss mode and timing of birth with obstetrician First created: 09/07/2015 Page 6 of 14 Last reviewed:

7 36 OBS review FBE ± anti D GBS swab offer U/S for fetal growth/ AFI CTG x 2 per week Discuss mode and timing of birth with obstetrician 37 OBS review CTG x 2 per week 38 OBS review CTG x 2 per week if awaiting spontaneous labour 39 OBS review CTG x 2 per week if awaiting spontaneous labour 40 OBS review CTG x 2 week if awaiting spontaneous labour Offer IOL or LUSCS if indicated Commence expression of colostrum to assist in prevention of neonatal hypoglycaem a GDM DIET CONTROLLED DEFINITION GESTATIONAL DIABETES MELLITUS (GDM) GDM is defined as any degree of glucose intolerance recognized, with the onset of or during pregnancy. The definition applies whether managed by diet or insulin and whether or not the condition persists after pregnancy. AIM To maintain BGL within targets below for optimal maternal and fetal outcomes: Antenatal :Self blood glucose monitoring 4 times/day(fasting and 2hour post meals) Minimum goals for self BGL - fasting <5.2-2hr post meal <7.0 During Labour: To maintain BGL between 4 7mmol/L. ANTENATAL CARE See attached chart ANTENATAL CARE FOR DIABETES IN PREGNANCY If no abnormal features, induce between weeks LABOUR GDM - DIET CONTROLLED Check BGLs 1 hourly First created: 09/07/2015 Page 7 of 14 Last reviewed:

8 Aim to keep BGLs between 4-7mmol/L whilst in labour. This will decrease the risk of neonatal hypoglycemia If BGL > 7.0 contact the endocrinology unit. An insulin infusion may be required If insulin is required follow insulin infusion protocol and call endocrine unit to inform and obtain further orders. CTG required if poorly controlled GDM or fetal macrasomia. Cease insulin infusion after delivery of placenta NO insulin will be required after delivery. IV fluids should be used with caution when using oxytocin or presence of pre-eclampsia due to risk of fluid overload. 8 A patient requiring an induction of labour should continue usual meals. CAESAREAN SECTION - GDM DIET CONTROLLED Wherever possible, caesarian section should be booked as the 1 st case on the morning theatre list. Check BGLs in the early morning prior to theatre and 2hrly until theatre. If BGL greater than 7mmol/L contact endocrinology unit as insulin therapy may be required POSTNATAL AND FOLLOW UP CARE GDM - DIET CONTROLLED Most women with GDM revert to normoglycaemia at the time of birth Monitor BGLs post-delivery for 24hrs (Pre-breakfast and 2hrs post-meals) Diabetes educator review where they will be advised of subsequent risk of GDM and Type 2 diabetes 75gm GTT 6 weeks post partum Review appointment booked for GDM clinic 8 weeks postpartum 1-2 yearly GTT if not pregnant Early GTT next pregnancy at first visit or weeks gestation 5 NEONATAL CARE GDM DIET CONTROLLED Infants of mothers with GDM managed with diet, born > 37 weeks and >2500 grams with out other complications may be cared for in Maternity Services Follow Pathway for Neonates of GDM on Diet GDM INSULIN REQUIRING DEFINITION GESTATIONAL DIABETES MELLITUS (GDM) managed with insulin. See definition for GDM AIM To maintain BGL within targets below for optimal maternal and fetal outcomes: Antenatal :Self blood glucose monitoring 4 times/day(fasting and 2hour post meals Minimum goals for self BGL - fasting <5.2-2hr post meal <7.0 During Labour: To maintain BGL between 4 7mmol/L. ANTENATAL CARE - GDM INSULIN REQUIRING See attached chart ANTENATAL CARE FOR DIABETES IN PREGNANCY First created: 09/07/2015 Page 8 of 14 Last reviewed:

9 LABOUR- GDM INSULIN REQUIRING ON ADMISSION Check Outpatient History for instructions from GDM Clinic See MR If patient has taken insulin and presents in spontaneous labour shortly after, monitor BGL s for hypoglycaemia. If patient is admitted the evening prior to induction or caesarean section, they should receive their normal insulin dose in the evening and withhold the morning dose of insulin. IOL: PROSTGLANDIN Continue current Antenatal management until in established labour SPONTANEOUS LABOUR / IOL - SYNTOCINON / ARM Withhold insulin in labour Monitor BGLs 1hrly during induction/labour Aim to keep BGL s between 4-7mmol/L whilst in labour. This will decrease the risk of neonatal hypoglycemia If BGL >or 7.0, contact the endocrinology unit. An insulin infusion may be required If insulin is required follow insulin infusion protocol and call endocrine unit to inform and obtain further orders. Continuous CTG monitoring in labour. Cease insulin infusion after delivery of placenta NO insulin will be required after delivery. IV fluids should be used with caution when using oxytocin or presence of pre-eclampsia due to risk of fluid overload. 8 CAESARIAN SECTION- GDM INSULIN REQUIRING Wherever possible caesarian section should be booked for the 1 st case on the morning theatre list. Usual BGL times unless an insulin infusion is in-situ If patient is admitted the evening prior to caesarean section, they should receive their normal insulin dose in the evening and withhold the morning dose of insulin. Measure BGL o Early morning pre-operatively, 2hrly until theatre and in theatre, prior to anaesthetic o If BGL s are > 7.0 mmol/l, notify endocrinologist and anaesthetist for ongoing management - insulin infusion may be required POSTNATAL AND FOLLOW UP CARE- GDM INSULIN REQUIRING Insulin requirements fall dramatically post partum. To avoid profound and prolonged hypoglycaemia, monitoring of blood glucose levels is required. If insulin infusion was required, this should be ceased at delivery of placenta. NO insulin will be required after delivery BGLs should be monitored QID (pre breakfast and 2hrs post meals) for 48hours. Contact endocrinology or if BGL over 10mmol Diabetes educator review where they will be advised of subsequent risk of GDM and type 2 diabetes 75gm GTT 6 weeks post partum and then yearly Review appointment GDM clinic or GP 8 weeks postpartum GTT at weeks in next pregnancy. First created: 09/07/2015 Page 9 of 14 Last reviewed:

10 NEONATAL CARE- GDM INSULIN REQUIRING Neonates born to mothers with gestational diabetes or diabetes mellitus are at increased risk of becoming hypoglycaemic. It is current practice at Peninsula Health that all infants born to mothers who have required insulin in their pregnancy should be admitted to SCN. Assessment on admission is required for incubator care or supplemental oxygen TYPE 2 DIABETES INSULIN REQUIRING DEFINITION- TYPE 2 DIABETES. Characteristics of type 2 diabetes: Less common than GDM in the pregnant population. Diabetes diagnosed at any time prior to pregnancy. Management of diabetes prior to pregnancy with diet or oral hypoglycaemic agents. Some may have been insulin requiring prior to pregnancy but it is important to distinguish these women from those with Type 1 diabetes. See definition for Type 1 diabetes. Type 2 diabetes is characterized by an insensitivity of target tissues to insulin, combined with an inadequate insulin response to hyperglycaemia. The pancreas still produces insulin, however it is not effectively utilized. Oral hypoglycaemic agents are not currently recommended for use in pregnancy. Insulin will be required to manage Type 2 diabetes in pregnancy. AIM To maintain BGL within targets below for optimal maternal and foetal outcomes: Antenatal: Self BGL monitoring 4 times per day (fasting and 2hr (or1hr) post meals) 1 Minimum goals for self BGL monitoring 2 : fasting 5.2, 1hr post meal <8.0, 2hr postmeal <7.0. During Labour: To maintain BGL between 4-7mmol/L ANTENATAL CARE- TYPE 2 DIABETES See attached chart ANTENATAL CARE FOR DIABETES IN PREGNANCY LABOUR- TYPE 2 DIABETES Poor glycaemic control during labour is associated neonatal hypoglycaemia 3 Stimulation of fetal insulin release by maternal hyperglycemia during labor significantly increases the risk of early hypoglycemia in these infants 4 PRE TERM LABOUR Use of corticosteroids for foetal lung maturity and ß-agonists in pre-term labour has been associated with hyperglycaemia 11 ON ADMISSION All women should have a plan of management discussed and documented from 36/40 regarding timing of birth and management of medication in labour See MR.. Contact urgently and inform endocrine unit of admission (after hours notify on call endocrine consultant) If patient is admitted the evening prior to induction or, they should receive their normal insulin dose in the evening and withhold the morning dose of insulin IOL: PROSTGLANDIN Continue current Antenatal management until in established labour SPONTANEOUS LABOUR / IOL : SYNTOCINON / ARM Withhold insulin in labour First created: 09/07/2015 Page 10 of 14 Last reviewed:

11 Monitor BGLs 1hrly during induction If BGL >or 7.0, contact the endocrinology unit. An insulin infusion may be required Aim to keep BGL s between 4-7mmol/L whilst in labour. This will decrease the risk of neonatal hypoglycemia If BGL >or 7.0, contact the endocrinology unit. An insulin infusion may be required If insulin is required follow insulin infusion protocol and call endocrine unit to inform and obtain further orders. Fetal monitoring continuously in labour. Cease insulin infusion after delivery of placenta NO insulin will be required after delivery. IV fluids should be used with caution when using oxytocin or presence of pre-eclampsia due to risk of fluid overload. 8 CAESARIAN SECTION - TYPE 2 DIABETES Wherever possible caesarian section should be booked for the 1 st case on the morning theatre list. If patient is admitted the evening prior to caesarean section, they should receive their normal insulin dose in the evening and withhold the morning dose of insulin. Usual BGL times unless an insulin infusion is in-situ Measure BGL o Early morning pre operatively, and if theatre is delayed 1hrly until in theatre and prior to anaesthetic o If BGLs are >7.0mmol/l, notify endocrinologist and anesthetist for ongoing management- insulin infusion may be required. POSTNATAL AND FOLLOW UP CARE- TYPE 2 DIABETES Insulin requirements fall dramatically postpartum. To avoid profound and prolonged hypoglycaemia, monitoring of blood glucose levels is required. If insulin infusion used cease insulin infusion after birth of placenta No insulin after delivery. QID BGL (pre breakfast and 2hrs post meals) notify endocrinology unit if BGL >10mmol Endocrinology review to assess insulin or oral hypoglycaemic agent requirements Diabetes Educator review advise risk of hypoglycaemia post delivery and after breastfeeding GDM clinic review 2-4 weeks Ongoing follow-up at Diabetes clinic or private endocrinologist NEONATAL CARE- TYPE 2 DIABETES Neonates born to mothers with gestational diabetes or diabetes mellitus are at increased risk of becoming hypoglycaemic. It is current practice at Peninsula Health that all infants born to mothers who have required insulin in their pregnancy should be admitted to SCN. Assessment on admission is required for incubator care or supplemental oxygen. TYPE 1 DIABETES DEFINITION - TYPE 1 DIABETES Characteristics of type 1 diabetes: Diabetes diagnosed at any time prior to pregnancy. First created: 09/07/2015 Page 11 of 14 Last reviewed:

12 Patient required insulin soon after diagnosis of diabetes May have had previous episodes of ketoacidosis. Type 1 diabetes is characterized by a cessation of the production and secretion of insulin in the pancreatic beta cells which is usually the result of an autoimmune disease. People with Type 1 diabetes require insulin to be administered everyday, even prior to pregnancy. Without sufficient insulin hyperglycaemia and ketoacidosis may occur. AIM To maintain BGL within targets below for optimal maternal and foetal outcomes: To avoid Ketoacidosis and minimize hypoglycaemia Antenatal: Self BGL monitoring 4-8 times per day Minimum goals for self BGL monitoring: 2 Fasting 5.2, 1hr post meal <8.0, 2hr post meal < 7.0 During Labour: To maintain BGL between 4-7mmol/L ANTENATAL CARE- TYPE 1 DIABETES See attached chart ANTENATAL CARE FOR DIABETES IN PREGNANCY LABOUR- TYPE 1 DIABETES Poor glycaemic control during labour is associated neonatal hypoglycaemia 3 Stimulation of fetal insulin release by maternal hyperglycemia during labor significantly increases the risk of early hypoglycemia in these infants 4 Patients who are on insulin pumps o o Urgently contact Endocrine Unit Patient may require cessation of insulin pump and need to commence dextrose and insulin infusions PRE TERM LABOUR Use of corticosteroids for foetal lung maturity and ß-agonists in pre-term labour has been associated with hyperglycaemia and increased risk of ketoacidosis 11 ON ADMISSION All women should have a plan of management discussed and documented from 36/40 regarding timing of birth and management of medication in labour Check Outpatient History for instructions from GDM Clinic Contact urgently and inform Endocrine unit of admission (after hours notify on call endocrine consultant) IOL / PROSTGLANDIN / SYNTOCINON / ARM If patient is admitted the evening prior to induction or caesarean section, they should receive their normal insulin dose in the evening and commence an insulin infusion in the morning- contact endocrinology unit. IN LABOUR Insulin must not be withheld Type 1 diabetes patients require glucose and insulin at all times Hourly BGLs in labour Patient will always require an insulin infusion (see attached guidelines) Continuous fetal monitoring whilst in labour IV fluids should be used with caution when using oxytocin or presence of pre-eclampsia due to risk of fluid overload. 8 First created: 09/07/2015 Page 12 of 14 Last reviewed:

13 CAESARIAN SECTION Caesarian Section should be booked for the 1 st case on the morning theatre list. Administer usual insulin and meals the night before C/S until fasting commences Usual BGL monitoring times unless an insulin infusion is in-situ Morning of C/S withhold usual insulin and commence infusions of dextrose and insulin Measure BGLs o pre operatively and in theatre prior to anesthetic o If BGL s are >7.0 mmol/l, notify endocrinologist and anesthetist for ongoing management POSTNATAL AND FOLLOW UP CARE Reduce insulin infusion to 20% at delivery. (e.g. if rate at 5 units/hr, reduce to 1 unit/hr) All doses of insulin post delivery to be reduced to 20% of pregnancy dose. (e.g. if all insulin doses total up to 100 units per day, reduce to total of 20 units per day) If restarting insulin pump- rates and ratios to be reduced to 20% (contact Endocrinology unit) Endocrinology review to assess insulin requirements Ongoing insulin doses will NEED TO BE REDUCED to 20% of previous dose DO NOT withhold insulin or glucose even if not eating QID BGLs pre-meals notify endocrinology if BGL>10 mmol/l Diabetes Educator review to advise risk of hypoglycaemia post delivery and after breastfeeding GDM clinic review in 2-4 weeks Ongoing follow up at diabetes clinic or private endocrinologist NEONATAL CARE Neonates born to mothers with gestational diabetes or diabetes mellitus are at increased risk of becoming hypoglycaemic. It is current practice at Peninsula Health that all infants born to mothers who have required insulin in their pregnancy should be admitted to SCN. Assessment on admission is required for incubator care or supplemental oxygen ADDITIONAL INFORMATION FOR INSULIN INFUSION PREPARATION Prepare as per Insulin Infusion Order MR/013 (18b) Prepare Dextrose infusion first o 10% dextrose should be commenced at a 12 hourly rate when BGL s are less that 15 mmol/l INSULIN is a sticky protein and will adhere to plastic coating until it is fully coated, so it is essential to make up an initial solution of 10 units of (Actrapid insulin) in 10mls of normal saline and to prime the infusion line with all of this solution, prior to the commencement of the actual insulin infusion of 50units/50mls To prepare insulin infusion draw up 50 mls of normal saline solution and add 50 units of Actrapid insulin to this. This will create a solution of 1unit/ml of insulin per solution Connect both the insulin infusion and the dextrose infusion to the same cannulae via a Y-lumen connector. This ensure the patient receives both of the infusions and not one alone, in cases of extravasation of intravenous sites First created: 09/07/2015 Page 13 of 14 Last reviewed:

14 The insulin infusion rate will be determined by the endocrinologist dependent on the patients BGLs Follow hypoglycaemic treatment regime designated by endocrinologist for patient. Key Aligned Documents Peninsula Health Policy Hand Hygiene & Aseptic Technique Nursing - Blood Glucose Monitoring Nursing - Insulin Infusion Paediatrics - Blood glucose monitoring - Neonate References [1] IDF Clinical Guidelines Task Force 2009, Global Guideline on Pregnancy and Diabetes Brussells International Diabetes Federation. [2] Potter, C and Kicklighter S (2009) Infant of Diabetic Mother, Retrieved from emedicine.medscape.com [3] Nankervis A (2007) Gestational Diabetes. Diabetes Management Vol 19 June 2007 [4] Royal Women s Hospital (2008) - Diabetes Mellitus: Management of gestational diabetes [5] Royal Women s Hospital, Melbourne. s. December 4, 2008 retrieved from [6] Royal Womens Hospital, Melbourne. Diabetes in pregnancymanagement in labour. 22 April, 2008 [7] Diabetes Australia Vic, ADIPS Type 1 Diabetes Network(2002), Can I have a Healthy Baby?- Diabetes and Pregnancy, NDSS. [8] Barrett, H and McElduff A, How to Treat Gestational Diabetes, Australian Doctor, March 2010 p31-38 [9] kamalakannan,d et al (2002) Diabetic Ketoacidosis in Pregnancy, Postgrad Med Journal 79: [10] RANZCOG, diagnosis of gestational diabetes mellitus, [11] Royal West Sussex NHS Trust. England Diabetic Pregnancy Guidelines Document management Position Document Coordinator: Clinical Director Women s Health Executive Sponsor: Chief Operating Officer Frankston Hospital Approved by: Women s Health Executive Date created/revised in archived system: 03/2015 First created: 09/07/2015 Page 14 of 14 Last reviewed: