Date of submission April 2016 Amended January 2018

Title of Guideline (must include the word Guideline (not protocol, policy, procedure etc) Guideline on management of pregnant women with diabetes (including gestational diabetes) Author: Contact Name and Job Title Dipanwita Kapoor, Consultant Obstetrician Carolyn Walley, Specialist Midwife in Diabetes Directorate & Speciality Family Health, Obstetrics Date of submission April 2016 Amended January 2018 Explicit definition of patient group to which it applies (e.g. inclusion and exclusion criteria, diagnosis) Version If this version supersedes another clinical guideline please be explicit about which guideline it replaces including version number. Statement of the evidence base of the guideline has the guideline been peer reviewed by colleagues? Evidence base: (1-6) 1 NICE Guidance, Royal College Guideline, SIGN (please state which source). 2a meta analysis of randomised controlled trials 2b at least one randomised controlled trial 3a at least one well-designed controlled study without 3b randomisation at least one other type of well-designed quasiexperimental study 4 well designed non-experimental descriptive studies (ie comparative / correlation and case studies) 5 expert committee reports or opinions and / or clinical experiences of respected authorities 6 recommended best practise based on the clinical experience of the guideline developer Consultation Process Ratified by: Date: Target audience Review Date: (to be applied by the Integrated Governance Team) Pregnant women with pre-existing diabetes and gestational diabetes Three The management of pregnant women with diabetes (including Gestational Diabetes) guideline, December 2012 1 (NICE guideline) Joint Diabetic/Obstetric Teams NUH Senior midwifery staff, Senior medical staff All midwives and diabetic nurses All medical staff 01/11/2021 A review date of 5 years will be applied by the Trust. Directorates can choose to apply a shorter review date, however this must be managed through Directorate Governance processes. This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date. 1

Index 1. Introduction 3 2. Roles and Responsibilities 3 3. Pre Conceptual Care 3 4. Antenatal care for women with pre-existing diabetes 5 5. Management of pregnant women with hypoglycaemia 8 6. Management of pregnant women with hyperglycaemia and diabetic ketoacidosis 8 7. Screening for Gestational Diabetes Mellitus 9 8. Gestational Diabetes Mellitus 11 9. Antenatal Admissions 13 10. Labour and Delivery 13 11. Postnatal Care for Women with Diabetes 14 References 17 Useful websites 17 Patient information leaflets 18 Appendix A. Insulin pump pregnancy guideline (2015) 19 Appendix B. Oral Glucose Tolerance Test (OGTT) 28 Apeendix C. GDM pathway 29 2

1. Introduction Approximately 700,000 women give birth in England and Wales each year, and up to 5% of these women have either pre-existing diabetes or gestational diabetes. Of women who have diabetes during pregnancy, it is estimated that approximately 87.5% have gestational diabetes (which may or may not resolve after pregnancy), 7.5% have Type 1 diabetes and the remaining 5% have type 2 diabetes. The incidence of diabetes including gestational diabetes has increased in recent years and is as a result of higher rates of obesity in the general population and more pregnancies in older women. Diabetes in pregnancy particularly pre-existing diabetes, is associated with risks to the woman and to the developing fetus. The risks include: miscarriage, congenital malformations, pre-eclampsia, preterm labour, macrosomia, birth injury including shoulder dystocia with its consequences, operative delivery, stillbirth, perinatal mortality and postnatal adaptation problems (such as hypoglycaemia). In addition, diabetic retinopathy and nephropathy can worsen rapidly during pregnancy. This guideline relates to all pregnant women who have diabetes diagnosed before or during pregnancy. 2. Roles and Responsibilities The pregnancy in women with diabetes is considered high-risk and therefore the majority of antenatal care will be in the hospital setting. Women with diabetes in pregnancy are cared for at Nottingham University Hospitals Trust (NUH) by a multidisciplinary team consisting of an endocrinologist, diabetes specialist nurse (DSN), diabetes specialist dietician, diabetes specialist midwife and obstetrician. Women and their partners should be considered as members of the team. 3. Pre Conceptual Care Women with diabetes, who are planning to become pregnant, should be referred to the joint diabetes/obstetric clinic for pre-conception care and advice before discontinuing contraception. QMC: 0115 9249924 appointment Extn. 61258 Fax 0115 8493331 CHN: 0115 9691169 appointment Extn. 55240 Fax 0115 8402659 3

Information given to women and their family members should cover: Glycaemic control Explain that a tight glycaemic control before conception and continuing this throughout pregnancy will reduce, but not eliminate, the risk of miscarriage, congenital malformation, stillbirth and neonatal death. - Aim for HbA1c (glycated haemoglobin) below 48mmol/mol (6.5%) if this is achievable without causing problematic hypoglycaemia. However, any reduction in HbA1c level towards the target of 48mmol/mol is likely to reduce the risk of congenital malformations. Women with HbA1c above 86mmol/mol (10%) should be strongly advised against pregnancy until better control of their diabetes is established. Offer monthly measurement of their HbA1c level. - Aim for fasting capillary plasma glucose levels of 5-7mmol/l on waking and 4-7 mmol/l before meals at other times of the day. However, individualized targets for self-monitoring of blood glucose may be set by the diabetes team. Discuss the risks of hypoglycaemia and impaired awareness of hypoglycaemia during pregnancy. Discuss how nausea and vomiting in early pregnancy can affect blood glucose control and increase the risk of hypoglycaemia. Explain that the poor glycaemic control increases the risk of having a macrosomic baby which in turn, will increase the likelihood of birth trauma and operative delivery. Continue contraception until optimal HbA1c is achieved. Choice of contraception should be based on their own preferences and any risk factors. Medications Medications for treating diabetes and medicines for complications of diabetes will need to be reviewed before and during pregnancy. - All oral hypoglycaemic agents except metformin should be discontinued before pregnancy and substituted with insulin. - Stop Incretin mimetics (Gylcagon-like peptide: GLP s) (Liraglutide and Exanatide) ideally 3 months before a planned pregnancy. - Angiotensin-converting enzyme inhibitors and angiotensin II receptor antagonists should be discontinued ideally before conception or once pregnancy is confirmed and substituted with alternative antihypertensive agents suitable for use during pregnancy. - Statins should be discontinued before pregnancy or as pregnancy is confirmed. 4

Advise to take folic acid (5 mg/day) until 12 weeks of gestation to reduce the risk of having a baby with a neural tube defect. Retinal and renal assessment Should have assessment for diabetic retinopathy (digital imaging with mydriasis using tropicamide) unless they have had an annual retinal assessment in the last 6 months Should have assessment for diabetic nephropathy before and during pregnancy. Refer to nephrologist, if serum creatinine is 120 micromol/litre, the urinary albumin: creatinine ratio is >30 mg/mmol or the estimated glomerular filtration rate (egfr) is <45 ml/minute/1.73m 2. Lifestyle changes Discuss optimal diet, exercise and appropriate weight loss necessary for good glycaemic control. For those who smoke cigarettes advise to stop. Risks to neonates and in later life Discuss the importance of good glycaemic control during labour and birth and feeding baby early to reduce the risk neonatal hypoglycaemia. Explain the possibility of temporary health problems in the baby after birth that may require admission to the neonatal unit. Discuss the risk of baby developing obesity and/or diabetes in later life. Pregnant women with pre-existing diabetes (Type 1 & Type 2), regardless of gestation, should be referred to the joint diabetes/obstetric clinic held on Tuesday mornings at CHN and Wednesday mornings at QMC. 4. Antenatal care for women with pre-existing diabetes An individualised care plan for every woman should be documented in the Part 1 records and maternity medway that covers the pregnancy and 6 weeks postdelivery. Explain to the woman that she will be seen frequently by the diabetes team throughout pregnancy to assess glycaemic control. The frequency of follow-up should be individualised and determined by the healthcare professionals and the patient together 4 weekly follow up is generally satisfactory if the diabetes is stable and well-controlled otherwise they may need to be seen weekly if necessary. 5

Many women will have attended a structured education course e.g. DAFNE (Dose Adjustment for Normal Eating). If an update is required, or a woman wishes for a structured education programme, access to these courses will be through the diabetes nurse specialist (DSN): Dundee House City 0115 9627621 or Extn. 56621 Diabetes Unit QMC 0115 9709215 or Extn. 61215 Dietetic review This is essential to ensure advice is given regarding diet to women to help them achieve good glycaemic control in pregnancy. Medications The medical team (obstetricians and endocrinologists) will review medicines for diabetes and its complications at the booking appointment: - Stop oral hypoglycaemic agents, apart from metformin. If on a sulfonylurea, dovetailing the reduction to prevent hyperglycaemia and hypoglycaemia is recommended. - Stop Incretin mimetics (Gylcagon-like peptide GLP s) (Liraglutide and Exanatide). - Rapid-acting insulin analogues (aspart and lispro) have advantages over soluble human insulin during pregnancy and consider their use. - Isophane (NPH) insulin is the first-choice long-acting insulin during pregnancy. - Stop angiotensin-converting enzyme inhibitors and angiotensin-ii receptor antagonists and consider alternative antihypertensives. - Stop statins. Prescribe folic acid 5mg at gestations less than 12 weeks, if they are not already taking this medicine. Continue until 12 weeks. Prescribe 75mg aspirin daily from 12 weeks gestation until birth, unless contraindicated as it has shown to reduce the risk of developing preeclampsia. Blood glucose monitoring and targets in pregnancy Monitoring blood glucose throughout pregnancy should be as follows: - Type 1 diabetes and Type 2 diabetes on multiple daily insulin injection regimen: pre-meal, 1-hour post-meal and bedtime - Type 2 diabetes on diet and exercise therapy or taking oral therapy or single-dose intermediate-acting or long-acting insulin: fasting and 1-hour post-meal 6

Diabetes team may consider continuous glucose monitoring for pregnant women on insulin therapy: - who have problematic severe hypoglycaemia (with or without impaired awareness of hypoglycaemia) - who have unstable blood glucose levels (to minimise variability) - to gain information about variability in blood glucose levels. Individualised targets for self-monitoring of blood glucose will be agreed, taking into account the risk of hypoglycaemia. However, it is advisable to maintain capillary plasma glucose below the following target levels, if these are achievable without causing problematic hypoglycaemia: - Fasting: 5.3 mmol/litre and - 1 hour after meals: 7.8mmol/litre or - 2 hours after meals: 6.4mmol/litre (not routinely tested but may be useful for women who forgets to test 1-hour post meal blood glucose) Women on insulin should also be advised to maintain their blood glucose levels above 4 mmol/litre. Measure HbA1c levels at the booking appointment to determine the level of risk for the pregnancy. Also consider measuring HbA1c levels in the second and third trimesters to assess the level of risk for the pregnancy. Retinal assessment Offer 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. Renal assessment Offer renal assessment at their first antenatal clinic appointment (unless they have had a renal assessment in the last 3 months). Referral to nephrologist should be considered if serum creatinine is 120 micromol/litre, the urinary albumin: creatinine ratio >30 mg/mmol or total protein excretion exceeds 0.5 g/day. Consider thromboprophylaxis for women with nephrotic range proteinuria i.e. 3 g/day or above. Fetal ultrasound scan Offer early viability and dating scan. Offer an ultrasound scan for detecting fetal structural abnormalities, including examination of the fetal heart (4 chambers, outflow tracts and 3 vessels), at 20 weeks. Offer ultrasound monitoring of fetal growth, amniotic fluid volume and fetal umbilical artery Dopplers every 4 weeks from 28 to 36 weeks. 7

Anaesthetic assessment Refer women with diabetes and co-morbidities such as obesity or autonomic neuropathy for an anaesthetic assessment. Women with obesity should be managed as per NUH Guideline for the care of pregnant women with a body mass index (BMI) of 30 or more. Further advice can be sought from: Specialist midwife in diabetes: City 0115 9691169 Extn. 57562 QMC 0115 9249924 Extn. 66857 Mobile: 07812268062 5. Management of pregnant women with hypoglycaemia Refer to NUH Adult insulin prescription, guideline and blood glucose monitoring chart for pregnant women with diabetes and NUH Insulin pump pregnancy guideline (Appendix A). 6. Management of pregnant women with hyperglycaemia and Diabetic Ketoacidosis (DKA) Diagnosis and management of pregnant women with hyperglycaemia and DKA is set out in detail in NUH Adult insulin prescription, Management of diabetic ketoacidosis in Adults guideline and blood glucose monitoring chart for pregnant women with diabetes. Offer pregnant women with Type 1 diabetes blood ketone testing strips and a meter and advise them to test their ketone levels and seek urgent medical advice if they are hyperglycaemic or unwell. Also advise pregnant women with Type 2 diabetes or gestational diabetes mellitus to seek urgent medical advice if they become hyperglycaemic or unwell. Exclude DKA as a matter of urgency in pregnant women with diabetes who present with hyperglycaemia or are unwell. Consideration of DKA is necessary in an unwell woman with gestational diabetes as it is possible that she may have Type 1 diabetes that has been detected in pregnancy. 8

DKA is a complex disordered metabolic state characterised by: - hyperglycaemia (capillary blood glucose >11mmols/L), - acidosis (venous ph <7.3 and/or venous bicarbonate <15) and - ketonaemia or ketonuria (capillary ketones 3mmol/L or urine ketones 2+). All women being managed for hyperglycaemia should have a laboratory blood glucose and venous bicarbonate measured. Urine or blood ketones should also be measured. 7. Screening for Gestational Diabetes Mellitus (GDM) 7.1 Risk assessment At booking appointment, risk assessment for GDM should be carried out. Risk factors which requires testing for GDM are BMI >30 kg/m² Previous macrosomic baby weighing 4.5 kg or above First-degree relative with diabetes Minority ethnic family origin with a high prevalence of diabetes as not clearly defined in NICE Diabetes in pregnancy: management from preconception to the postnatal period (NG3) guideline, it has been agreed to screen all women regardless of risk factors with the exception of women from white European/ white European extraction backgrounds. Previous gestational diabetes Also consider testing for GDM in woman with Polycystic ovarian syndrome (PCOS) On long term steroids Previous unexplained stillbirth Raised HbA1c on haemoglobinopathy screen Glycosuria of 2+ or above on 1 occasion or of 1+ on 2 or more occasions detected by reagent strip testing during routine antenatal care Abdominal circumference (AC) or effective fetal weight (EFW) on scan above 95 th centile refer to NUH Guideline for the investigation of large for gestational (LGA)age and management of the large for gestational age fetus and polyhydramnios in women with a singleton pregnancy. Significant acceleration of growth velocity Polyhydramnios Women on antipsychotics 9

Women with previous gestational diabetes, who have had a fasting glucose test between pregnancies of 5.6mmol/l, should be referred directly to the joint Diabetes/Obstetric clinic. 7.2 Timing of Oral glucose tolerance test (OGTT) For 75g 2hour OGTT - refer to Appendix B. Before offering OGTT, women should be explained that: In some women, GDM will respond to changes in diet and exercise but the majority of women will need treatment either with oral blood glucose lowering agents and/ or insulin therapy. It GDM is not detected and controlled, there is a small increased risk of serious adverse birth complications e.g. shoulder dystocia. A diagnosis of GDM will lead to increased monitoring and may lead to increased interventions during pregnancy and labour. Women with 1 or more risk factors for GDM at booking should be offered OGTT as follows: Between 24-28 weeks An early OGTT should be offered as soon as possible after booking to women who have had GDM in a previous pregnancy or who have a booking BMI of 40kg/m 2 (as per NUH Guideline for the care of pregnant women with a body mass index (BMI) of 30 or more) and a further OGTT at 24-28wks, if the 1st OGTT is normal. Women on metformin for non-diabetes reasons (e.g. PCOS) should stop metformin for at least one week prior to OGTT. Postpone OGTT by one week for women who are having high dose steroids for fetal lung maturity and are due for the test. Women who are unwell or unable to eat and drink normally (e.g. due to vomiting) should have their OGTT delayed, as the results will not be reliable, until they have had a minimum of 3 days of normal diet. OGTTs at later gestation i.e. after 36 weeks: Women with suspected LGA fetus at or after 36 weeks needs a growth scan to assess the fetal size. If the scan confirms LGA fetus (AC or EFW above 95th centile), an OGTT is indicated. If the OGTT is abnormal (no reference ranges are available for OGTTs at this gestation but a pragmatic decision has been made to use the same diagnostic criteria as 26-28 weeks gestation), women will be seen by the specialist midwife in diabetes and dietician in their clinic but will remain under their own consultant. An appointment will also be made in the consultant ANC to discuss with the woman the risks associated with macrosomia i.e. birth trauma including shoulder dystocia, timing and mode of delivery - refer to NUH 10

Guideline for the investigation of large for gestational age and management of the large or gestational age fetus and polyhydramnios in women with a singleton pregnancy For women who have had OGTT already earlier in the pregnancy (e.g. 24-28 weeks), it is not necessary to repeat the test unless there are other features suggestive of diabetes e.g. glycosuria, weight loss. 7.3 Interpretation of OGTT results Diagnose gestational diabetes if the woman has either: A fasting plasma glucose of 5.6mmol/l or A 2-hour plasma glucose level of 7.8mmol/l 8. Gestational Diabetes Mellitus (GDM) Offer women with a new diagnosis of GDM a review with the Specialist Midwife in Diabetes and dietician in the new GDM clinic within 1 week of obtaining the results. To make appointments, contact QMC 0115 9249924 Extn. 61258; CHN 0115 9691169 Extn. 55240 NB If the next available appointment is not within a week of receiving the result contact the specialist midwife in diabetes. Further follow up will be in joint diabetes/obstetric clinic held on Tuesday at the CHN and Wednesday at QMC. Inform the primary health care team when a woman is diagnosed with GDM. 8.1 Intervention for GDM Explain to women that good glycaemic control throughout pregnancy will reduce the risk of fetal macrosomia, birth trauma, induction of labour, operative delivery, neonatal hypoglycaemia and perinatal death. All women diagnosed with GDM should be taught about self-monitoring of blood glucose levels. Women will need to test their pre-meal, 1-hour post-meal and bedtime blood glucose levels daily during pregnancy. However, for women who are not on multiple daily insulin injection regimens, reduction in monitoring to fasting and 1-hour post-meal blood glucose levels will be considered if blood glucose levels remain stable for a period of time. The same capillary blood glucose targets should be used as for those with pre-existing diabetes. 11

Measure HbA1c levels in all women with GDM at the time of diagnosis to identify those who may have pre-existing Type 2 diabetes. Treatment includes: Diet and exercise - Consider trial of changes in diet and exercise for women who have a fasting plasma glucose level <7mmol/l at diagnosis. Advise women to eat a healthy diet during pregnancy with the emphasis on replacing foods with a high glycaemic index with foods with a low glycaemic index and to take regular exercise (such as walking for 30 minutes after a meal) to improve blood glucose control. All women diagnosed with GDM should see a dietician. Medications - This must be tailored to individual blood glucose profiles and the personal preferences of the woman with GDM. Metformin - Consider starting metformin, if blood glucose targets are not being met using changes in diet and exercise within 1-2 weeks. Offer insulin therapy if metformin is contraindicated or declined by the woman. Offer insulin in addition to metformin, diet and exercise if blood glucose targets remain unmet. Insulin - Consider treatment with insulin with or without metformin for women who have a fasting plasma glucose level of 7mmol/l at diagnosis, if blood glucose targets are not being met using changes in diet and exercise within 1 week. - Consider treatment with insulin with or without metformin as well as changes to diet and exercise for women who have a fasting plasma glucose level between 6.0 7.0mmol/l if there are known complications i.e. macrosomia or polyhydramnios. 8.2 Obstetric care Offer ultrasound monitoring of fetal growth and amniotic fluid volume every 4 weeks from 28 to 36 weeks. Routine monitoring of fetal wellbeing (using methods such as fetal umbilical artery Doppler recording, fetal heart rate recording) before 38 weeks is not recommended, unless there is a risk of fetal growth restriction such as preeclampsia. 12

9. Antenatal Admissions During medical or obstetric admissions, diabetes obstetric team should be informed at the earliest opportunity. If admitted with threatened preterm labour and steroids are prescribed, refer to the section Women receiving high dose steroids in NUH Adult insulin prescription, guideline and blood glucose monitoring chart for pregnant women with diabetes and Insulin pump pregnancy guideline for women with Type 1 diabetes using an insulin pump.(appendix A). These women will require increased blood glucose monitoring and additional insulin. 10. Labour and Delivery Advise women with any form of diabetes to give birth in hospital: - to obtain an optimal glycaemic control for both the woman and the neonate - to allow continuous electronic fetal monitoring to detect fetal compromise due to the risks associated with macrosomia - due to the need to deliver at an earlier gestation. Each woman will have a cross town delivery plan/diabetes prescription chart from 36 weeks, having had a discussion about their labour and management of diabetes in the immediate postnatal period. 10.1 Timing of delivery Pre-existing diabetes Advise elective birth (induction of labour, or elective caesarean section if indicated) between 37+0 weeks and 38+6 weeks of pregnancy for women with no other complications. Consider elective birth before 37+0 weeks for women with metabolic or any other maternal or fetal complications. Offer weekly monitoring of fetal well-being (using methods such as fetal umbilical artery Doppler recording, fetal heart rate recording), if pregnancy is continued beyond 38 weeks. Gestational diabetes Advise women with no metabolic or any other maternal or fetal complications to give birth no later than 40+6 weeks. Consider elective birth after 38+0 weeks for women with complicated GDM (poor glycaemic control, on metformin or insulin, evidence of macrosomia, other risk factors for fetal growth restriction). 13

Offer monitoring of fetal well-being (using methods such as fetal umbilical artery Doppler recording, fetal heart rate recording), if pregnancy is continued beyond 38 weeks in women with complicated GDM or beyond 40 weeks in women with uncomplicated GDM. 10.2 Mode of delivery Inform women who have an ultrasound-diagnosed macrosomic fetus (estimated fetal weight >4500 gram or AC >95 th centile for gestation) about the risks and benefits of vaginal birth including the risk of shoulder dystocia and its consequences, and caesarean section. Diabetic retinopathy is not a contraindication to vaginal birth. 10.3 Intrapartum management of diabetes Refer to NUH Adult insulin prescription, guideline and blood glucose monitoring chart for pregnant women with diabetes and NUH Insulin pump pregnancy guideline (Appendix A). Consider DKA in the presence of blood or urine ketones in labour as a woman with GDM/ Type 2 diabetes may have undiagnosed Type 1 diabetes. Diagnosis of DKA is an obstetric emergency. 11. Postnatal care for women with diabetes 11.1 Management of diabetes Contact the diabetes specialist nurse, as matter of routine, post-delivery to inform them of the birth with regards to women with pre-existing diabetes. Dundee House City 0115 9627621 or Extn. 56621 Diabetes Unit QMC 0115 9709215 or Extn. 61215 Refer to NUH Adult insulin prescription, guideline, blood glucose monitoring chart for pregnant women with diabetes and Insulin pump pregnancy guideline (Appendix A) for immediate post-delivery care. Each woman will have a cross town delivery plan/diabetes prescription chart from 36 weeks, having had a discussion about their labour and management of diabetes in the immediate postnatal period. General principles are as follows: 14

Pre-existing diabetes Reduce insulin immediately after the birth in women who are treated with insulin before pregnancy. This reduction should be individualised and will depend on their previous diabetes control, breast feeding etc. Following delivery, blood glucose levels can be less tightly controlled. Monitor blood glucose levels carefully to establish the appropriate dose of insulin and inform women of the increased risk of hypoglycaemia in the postnatal period, especially if breast feeding (when a meal or snack before or during feeds is advisable). Speak to a member of the diabetes specialist team before resuming or continuing oral hypoglycaemic agents, including metformin, immediately after birth in women with pre-existing Type 2 diabetes. Gestational diabetes Discontinue hypoglycaemic therapy immediately after the birth in women who were diagnosed with gestational diabetes. Test their blood glucose to exclude persisting hyperglycaemia (i.e. pre-meal for first 24hrs after delivery) before transfer to community care. If a fasting blood glucose level is 7mmol or a random blood glucose level is >11 mmol/l confirm with a venous blood sample sent to the laboratory for blood glucose level. Pre-meal blood glucose levels should be continued and liaise with the diabetes specialist team. Remind women of the symptoms of hyperglycaemia (increased fatigue, headaches, difficulty concentrating, blurry vision, frequent urination). 11.2 Babies of women with diabetes (Refer to NUH guideline Screening and Management of Neonatal Hypoglycaemia and Detection and Management of Jaundice in Newborn infants) 15

11.3 Information and follow up Pre-existing diabetes If breastfeeding, continue to avoid any drugs for treating diabetes complications that were discontinued for safety reasons in the preconception period. All women booked at CHN will be seen in the joint diabetes/obstetric clinic at 6 weeks postnatal, before referring them back to their routine diabetes care. At QMC, women are not routinely followed up in joint diabetes/obstetric clinic postnatally but the ward midwife should ensure before discharge that follow up arrangements with the routine diabetes care have been made. Remind women of the importance of contraception and the need for preconception care when planning future pregnancies. Ensure that women who have preproliferative diabetic retinopathy or any form of referable retinopathy diagnosed during pregnancy have ophthalmological follow-up within 6 months of the birth of the baby. Gestational diabetes All women should be offered a postnatal assessment of glycaemia to determine whether glucose tolerance has normalised. This should be an offer of a HbA1c from 13 weeks following delivery, to be done by the G.P.(See Appendix C- GDM pathway Inform women of their increased risk of developing Type 2 diabetes in the future and explain this risk can be reduced by lifestyle changes i.e. diet, exercise and weight control. Recommend that they seek screening (HbA1c test) from their GPs on an annual basis. Discuss the symptoms of hyperglycaemia. Provide information about the risk of gestational diabetes in future pregnancies and advise to seek screening for diabetes from their GP when planning future pregnancies. Offer early OGTT in future pregnancies. 16

References Faculty of Sexual and Reproductive Healthcare (FSRH) (2009, revised 2010): UK Medical Eligibility Criteria for Contraceptive Use http://www.fsrh.org/pdfs/ukmec2009.pdf Joint British Diabetes Society for Inpatient Care Group (JBDS-IP) (2013): The Hospital Management of Hypoglycaemia in Adults with Diabetes Mellitus http://www.diabetologists-abcd.org.uk/subsite/jbds_ip_hypo_adults_revised.pdf Joint British Diabetes Society for Inpatient Care Group (JBDS-IP) (2013): The Management of Diabetic Ketoacidosis in Adults http://www.diabetologists-abcd.org.uk/jbds/jbds_ip_dka_adults_revised.pdf National Institute for Health and Clinical Excellence (NICE) (2008): Antenatal care for uncomplicated pregnancy. http:// nice.org.uk/guidance/cg62 National Institute for Health and Clinical Excellence (NICE) (2015): Diabetes in pregnancy: management of diabetes and its complications from preconception to the postnatal period. http://nice.org.uk/guidance/ng3 National Institute for Health and Clinical Excellence (NICE) (2010): Hypertension in pregnancy: diagnosis and management. http://nice.org.uk/guidance/cg107 National Institute for Health and Clinical Excellence (NICE) (2015): Type 1 diabetes in adults: diagnosis and management http://nice.org.uk/guidance/ng3 NUH guideline: Detection and Management of Jaundice in Newborn infants (2015) NUH guideline: Guideline for the care of pregnant women with a body mass index (BMI) of 30 or more (2016) NUH guideline: Guideline for the investigation of large for gestational age and management of the large or gestational age fetus and polyhydramnios in women with a singleton pregnancy (2016) NUH guideline: Screening and Management of Neonatal Hypoglycaemia (2012) Royal College of Obstetricians & Gynaecologists (RCOG) (2015): Thrombosis and Embolism during Pregnancy and the Puerperium, Reducing the Risk (Green-top Guideline No.37a) Useful websites http://www.diabetes.org.uk/ http://www.nottinghamdiabetes.nhs.uk/ 17

Patient information leaflets The following patient information leaflets produced by NUH diabetes unit are available for use to support pregnant women with diabetes in pregnancy: Gestational Diabetes Metformin in pregnancy Post Gestational diabetes Hypoglycaemia Travel Sick day rules Syringes, pens and needles Driving and insurance 18

Appendix A. Insulin pump pregnancy guideline (2015) Introduction Insulin pumps are used by people with Type 1 diabetes to provide a continuous supply of insulin. The pump will deliver insulin 24 hours a day providing a basal dose of insulin. When that person eats they will calculate how much carbohydrate (CHO) they are eating and then set the pump to deliver an extra amount of insulin to cover the CHO portion (bolus dose). The individual using the pump will be competent in use and should be able to selfmanage their own pump. They will in most cases have had a discussion with the diabetes team about how to adjust their pump during labour and post-delivery. The Intra-Partum Management of Patients Using Insulin Pump Therapy If diabetes is stable, and the patient or their partner are able to manage the insulin pump -continue with therapy. If problems arise either, ask the patient to / or actively remove the infusion set whilst it is still attached to the insulin pump, and start IV insulin/glucose as per the NUH Pregnancy Insulin prescription chart for women with diabetes. Call the Diabetes Team if there are any concerns. This will only be Mon Friday 9-5pm. If the diabetes team not available, please follow the Adult insulin prescription, guideline and blood glucose monitoring chart for pregnant women with diabetes (2014). Planning for delivery: Ensure midwives are aware that insulin pump therapy is being used. If for Lower Segment Caesarean Section (LSCS) inform surgeon, anaesthetist and theatre staff that insulin pump therapy is being used. Ensure the insulin pump infusion set is situated below the ribs, towards the back, to avoid potential LSCS site and the area to be cleansed. Ensure the insulin pump has new batteries, a full reservoir/cartridge, and that a new infusion set has been sited. It is advisable to have spare insulin pump supplies. The women will have been advised to do all this before they come on to the labour suite and will have been told to bring spare supplies with them. See section = Preparing for labour Tips for Insulin Pump Users 19

Intra-Partum: Patients on insulin pump therapy may continue to use their pump during labour, or caesarean section, provided their blood glucose levels are within the target range of 4 7mmol/L. Midwives must measure and document blood glucose levels at least hourly with the approved hospital blood glucose meter. The approved chart for documentation of infusion rates and monitoring must be used. Insert a cannula in case IV access is needed. Continue usual basal rate, aiming to keep blood glucose levels between 4 and 7mmol/L. Planned delivery by LSCS It is anticipated that the duration of time taken to undergo this procedure is short, i.e. less than 2 hours, therefore the following management structure is suggested: Bolus correction doses should be made by the patient via the insulin pump to maintain target blood glucose levels of less than 7mmols: If blood glucose greater than 7mmol/L advise a correction bolus dose, calculated by aiming for a blood glucose of 5mmol/L, using the individuals lady s correction dose or After 1 hour, if that correction bolus is ineffective i.e. blood glucose not less than 7.0mmol/L, give another correction bolus dose. After a further ½ hour and if not delivered yet or about to be and if blood glucose levels still not below 7.0mmol/L then consider switching to IV insulin using the Adult insulin prescription, guideline and blood glucose monitoring chart for pregnant women with diabetes (2014). After Delivery After delivery ask patient / partner to reduce basal rate on the pump by 50% of rate immediately prior to labour/lscs i.e. basal rate prior to any adjustment as advised above; or to pre pregnancy dose if known. They will normally have had this discussion with the diabetes team prior to labour/delivery and so be aware of what to do. If breastfeeding, this rate may need reducing by a further 10-20%. The basal rate for post-delivery should be written in the handheld notes used in antenatal clinic, and the patient should also have a record of this (see patient copy of Appendix 12.11) 20

Induction of / Spontaneous Labour The time interval from the onset of induction or spontaneous labour to delivery is anticipated to be variable and lengthy. The following is a guideline to assist in maintaining target glycaemic control. Blood glucose levels may rise and/or fall outside the target range. As a result, adjustments will need to be made on the pump to manage these situations. Management of Hypoglycaemia If blood glucose < 4.0mmol/L treat hypoglycaemia as per hospital policy or advise the women to treat her hypoglycaemia as she would do normally e.g. Gluco juice, 5 jelly babies, 4 wine gums etc. If the woman has more than one hypoglycaemic event, ask her to reduce her basal rate on the pump to 50% using a temporary basal rate setting. The basal rate setting should then continue as this throughout the remainder of the labour, and should not be increased back to the full 100% basal rate. 21

Management of Hyperglycaemia BG above 7.0 mmol/l Give 1st Correction Dose calculated by aiming for a blood glucose of 5mmol/L, using the women s usual correction dose (or if they cannot remember using 1 unit of insulin to reduce blood glucose levels by 2.5mmol/L) AFTER ONE HOUR BG less than 7.0mmol/l Resume normal management BG 7.0-10.00mmol/l Give second dose of correction BG over 10mmol/l Give second dose of correction and check for ketone AFTER ONE HOUR AFTER HALF HOUR BG less than 7mmol/l BG 7-10mmol/l BG less than 7mmol/l BG above 7mmol/l Resume usual management Give 2 nd dose of correction Resume usual management Change to IV insulin infusion (VRIII) AFTER HALF HOUR BG less than 7mmol/l Resume usual management If BG above 7mmol/l Change to IV insulin infusion (VRIII) 22

After Delivery After delivery ask patient / partner to reduce basal rate by 50% of rate immediately prior to labour/lscs i.e. basal rate prior to any adjustment as advised above; or to pre pregnancy dose if known. The women should have had a discussion about what to do and which basal rate to use in antenatal clinic prior to EDD. If breastfeeding, this rate may need reducing by a further 10-20%. The basal rate for post-delivery should be written in the women s hand held record at the antenatal clinic, and the patient should also have a record of this. References Harrogate Pump Guidelines (2010), Harrogate and District NHS Foundation Trust. Lancaster Park Rd, Harrogate. NICE (2008) (modified 2014), Continuous subcutaneous insulin infusion for treatment of diabetes mellitus, Nice technology appraisal guidance, TA-151 Diabetes. 23

Appendix 1 of insulin pump pregnancy guideline Insulin Pump rates and blood glucose monitoring during labour Stick patients Printed label here If label not available NAME: DOB: HOSPITAL NUMBER Date Time Basal Rate units/hr * Blood glucose mmol/l Food bolus Dose units Correction Bolus Dose Temporary Basal Rate used Ketones Signature *The women will have pre written basal rate the pump is running at prior to delivery. Please ensure insert into Pregnancy Insulin prescription chart for women with diabetes. 24

Appendix 2 of insulin pump pregnancy guideline Preparing for labour Tips for Insulin Pump Users (Please bring this with you to the hospital) Spare sets of batteries x 2 Reservoirs / cartridges x 2 Vial of rapid-acting insulin x 1 What to pack in your hospital bag? Infusion sets (including lines) x 5 and inserter device (if using) Insulin pens and cartridge for long acting and rapid acting insulin Or Insulin syringes and Vial of long-acting insulin Hypo treatment of your choice e.g. Glucotabs /Glucogel /Lucozade, wine gums Carbohydrate snacks Top Tips for using the insulin pump during labour At onset of labour please check the following: New batteries are put in to the pump Fill a new reservoir / cartridge with insulin for the pump Put in a new infusion set (including a new line) Locate the infusion site below your rib cage and towards the back the day before admission, so that it is out of the way in case emergency intervention is required Check that you have written down, or have inputted as a second basal rate, your pre-pregnancy basal rates. (Please use the table over the page help you record this if you need too) This needs to be ready so that you can change to this immediately after the baby is delivered. If you were not on a pump prior to this pregnancy, then the Diabetes Team will have advised you on what to reduce your basal rates to at a previous appointment. If not, then use a temporary basal rate of 50% until you have seen a member of the Diabetes Team. Blood glucose monitoring will be done more regularly on labour suite and the midwives may do this for you particularly in the later stages of labour and if having a section. You will need to record your blood glucose levels on the chart provided as well as the amount of insulin your pump is delivering per hour and when eating. Please make sure you bring plenty of blood glucose strips with you. 25

Appendix 3 of insulin pump pregnancy guideline Your blood glucose rates for the pump AFTER DELIVERY Time Basal Rate Time Basal rate 00.00-01.00 12-00-13.00 01.00-02.00 13.00-14.00 02.00-03.00 14.00-15.00 03.00-04.00 15.00-16.00 04.00-05.00 16.00-1700 05.00-06.00 17.00-18.00 06.00-07.00 18.00-19.00 07.00-08.00 19.00-20.00 08.00-09.00 20.00-21.00 09.00-10.00 21.00-22.00 10.00-11.00 22.00-23.00 11.00-12.00 23.00-24.00 26

Appendix 4 of insulin pump pregnancy guideline Management of Diabetes and dexamethasone for women on insulin pumps whilst pregnant. If a woman is competent with her pump and feels able to self-manage changes to her pump doses the following guidelines could follow: After administration of dexamethasone, you may need to adjust your insulin doses as follows: 6 24 hours (day of first steroid injection) put a temporary increase on the basal rate of 125% Day 2-3 put the temporary increase on the basal rate up to 140%, and increase the patient s usual bolus doses by 40% Day 4 put the temporary increase on the basal rate down to 120%, and increase the patient s usual bolus doses by 20% Day 5 put the temporary increase on the basal rate down to 110%, and increase the patient s usual bolus doses by 10% During days 6 and 7, the insulin doses should return to their levels before treatment, however, the blood glucose levels should still be closely monitored and additional correction doses of rapid-acting insulin given if required. Please ensure that you record your blood glucose levels on your diabetes chart. Whilst you are on steroids you will need to monitor your blood glucose levels 1-2 hourly until they are stable again. If a woman on an insulin pump feels unable to manage the above herself, please use the guidelines for dexamethasone in the Adult insulin prescription, guideline and blood glucose monitoring chart for pregnant women with diabetes (2014). 27

Appendix B: Oral Glucose Tolerance Test (OGTT) Test pregnant woman in early pregnancy as soon as possible after booking if she had gestational diabetes mellitus in a previous pregnancy or her BMI 40kg/m2, otherwise test at 24-28 weeks gestation. Procedure: 1. Confirm patient ID and gestation. 2. Confirm no food has been consumed from 20.30hrs the previous night. Also confirm that she has been eating and drinking normally in the few days prior to the test, not had steroids for fetal lung maturation within the past week and is not taking metformin (for non-diabetes reasons such as PCOS) within the past week. 3. Ask her to wash her hands, without using soap. 4. Assess finger prick capillary sample using blood glucose monitor. (Only if test being performed in ANC at City and Queens Campus as the community phlebotomists do not have the necessary equipment to perform a capillary blood glucose sample) If the first finger prick sample is above 9mmol/L do not continue with the test, ie do not give Rapilose. Take a venous sample (Fasting Blood Sugar FBS) (grey top bottle) to confirm a high FBS. 5. Take venous sample FBS: grey top bottle (label bottle 1 st sample, and date) 6. Use request form for an antenatal glucose tolerance test (AGTT), document sample 1 and time taken 7. Take further blood samples as required eg antibodies, FBC 8. Give 300 ml of Rapilose (1 pouch). The woman has 10 minutes to drink the Rapilose. Log the time when next sample due, 2 hours and 10 minutes after 1 st venous sample. The woman must not eat or drink anything during these two hours. 9. Repeat venous sample: grey top bottle (label bottle 2 nd sample ). 10. Document the 2 nd sample and time on form. 11. Log the AGTT has been taken and NB If the woman vomits during the Oral Glucose test, ensure comfort and safety of the patient and advise them that the test will not continue that day. Offer the woman a further appointment. Obtain laboratory results within 24-48hrs Diagnose gestational diabetes mellitus (GDM): Fasting blood glucose > 5.6mmols/l and/or 2hr blood glucose >7.8mmols/l Request the next available appointment for women with newly diagnosed with GDM in the appropriate New GDM clinics. If the next available appointment is not within a week of receiving the result contact the Specialist Midwife in Diabetes based in ANC. Contact QMC 0115 9709258 Ex61258; City 0115 9627710 Ex55240 28

Appendix C GDM Pathway Nottinghamshire pathway for women with Gestational Diabetes FIRST APPOINTMENT (8 to 12 Weeks) First Antenatal appointment with Community Midwife who will determine if an OGTT appointment is required If 1x or more risk factor identified patient will be offered OGTT OGTT appointment at 24-28 weeks of pregnancy with midwife in the community CARE PLAN UNTIL DELIVERY Appointment booked with the Diabetes Service Letter sent to GP (by hand/electronic) with Read Code L1808 added to patient record. Once letter has been received by GP staff must ensure that the Read Code L1808 is added to patient record Request from NUH to prescribe and provide equipment for testing and reviewed by NUH Antenatal clinic until delivery. Patient will not be seen in hospital clinic after delivery (hyperglycaemia will improve following delivery) POST DELIVERY (6 Weeks after delivery) Practice Nurse Assessment in Primary Care at 6 weeks: Please note patients will not be invited back to NUH for a postnatal GTT at 6weeks Inform patient of increase risk of developing Type 2 diabetes in the future Risk can be reduced by lifestyle changes Recommend HbA1c screening annually from their GP Discuss symptoms of hyperglycaemia Book 13 week HbA1c test (13 Weeks after Delivery) HbA1c test booked with patients registered GP Practice 13 weeks after delivery TOP TIP: Consider taking the HbA1c test around the time of the child s second treatment of vaccinations TEST RESULTS HbA1c below 39 mmol/mol Low probability to moderate risk of developing Type 2 Diabetes HbA1c level between 39 and 41 mmol/mol: High risk of developing T2 Diabetes Pre-Diabetic HbA1c level between 42 and 47 mmol/mol Patient diagnosed with Pre-Diabetes from HbA1c test Advice, guidance, referral Healthcare professional to advise patient to continue to follow a healthy lifestyle, providing information, interventions and support to prevent Type 2 Diabetes Referral to NHS Diabetes Prevention Programme and other lifestyle/weight services Follow Up Annual screening appointment offered for Diabetes/pre-diabetes (As outlined in NICE guidance 2015) NG3 Diabetes in Pregnancy E-Healthscope: any cases where a patient has not had an HbA1c test in the last year will be stored in the practices workflow. This is the main priority group for GP s to focus on. The remainder of patients will have had their annual test. In order to view Gestational Diabetes (GDM) navigate to the case findings register and access reports. You will see a pull down box on the top left corner of the system where you can select Gestational Diabetes where the information will be stored. 29 Published: Sept 2017

30