The Rotherham NHS Foundation Trust Pregnancy & pre-existing diabetes Obstetrics & Gynaecology patientinformation Your health,your life,your choice,our passion
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The team l Consultant Obstetrician l Diabetes Specialist Midwife l Consultant Diabetologist l Diabetes Specialist Nurse l Diabetes Specialist Dietitian Welcome This leaflet has been designed to help guide you through your care from planning to have a baby, achieving pregnancy, giving birth and beyond. Your care will be provided in the Antenatal Clinic at Rotherham Hosptial. Planning a pregnancy The most important step is to contact your Diabetes Specialist Team and plan your pregnancy. At least 3 months before becoming pregnant you must ensure that your blood glucose levels are as near to the agreed targets as possible, with a long term blood glucose test (HbA1c) of less than 7.0% / 53mmol/mol (or less than 6.1% / 43mmol/mol if this can be achieved safely without hypos). This is often the hardest work. Preconception: l Before meals your blood glucose should be Less than 5.9 mmol/l l 2 hours after food your blood glucose should be Less than 7.8 mmol/l 3
If you are taking tablets for your diabetes or for other reasons, such as high blood pressure or high cholesterol, please check with your GP or the Diabetes Team that they are safe to take during pregnancy. Folic Acid Taking folic acid at the higher dose of 5mg/per day is recommended. This needs to be prescribed by your Doctor as it cannot be bought over the counter Why do I need to do this? Research has shown that having near-normal blood glucose levels before and during the first 12 to 14 weeks of pregnancy offers the best chance of avoiding complications for you and your baby. The complications for your baby include miscarriage, spinal deformities and cardiac (heart) disease, but can extend to other malformations. These can be discussed in more detail with the Diabetes Team. Who can help? The Diabetes Team is aware of how difficult it can be to get your blood glucose levels under control and can offer support and guidance. Meeting the team before you become pregnant gives the opportunity for you and your partner to get to know people who will care for you during and after your pregnancy. 4
Your visits to the Diabetes Antenatal Clinic As soon as you think you are pregnant you should contact the Diabetes Specialist Midwife or Diabetes Nurse. (Contact numbers are provided at the back of this leaflet). You will be invited to attend the Antenatal Clinic for an appointment with members of the Diabetes Team. Please be prepared for a lengthy visit. This appointment will give you the chance to discuss your pregnancy and ask any questions you may have. It will also provide you with enough time for a plan of care to be developed. It is important to keep a record of your insulin doses just before your become pregnant, as they will give an idea of how much insulin you will need after the birth of your baby. Hypoglycaemia Hypoglycaemia (hypo) is when your blood glucose drops to a low level, usually 3.5mmol/L or below, although you should aim to keep your blood glucose level above 4.0mmol/L Your blood glucose levels will change during your pregnancy because your hormone levels change. You are more likely to have an unexpected hypo because of this, especially in the first 12 weeks of pregnancy. 5
Sometimes you can have a hypo and not realise it. You might not recognise the symptoms (which can be different from one hypo to the next), or you might not get any symptoms at all. This is called hypoglycaemia unawareness, and is more common during pregnancy. Hypoglycaemia in pregnancy does not harm your baby but you need to be safe and therefore it needs to be corrected. More information will be given about this at your clinic appointment. Here is a quick guide to treatment: l Always check your blood glucose level before doing something where you may put yourself or others at risk if you were to become unwell or feel faint (e.g. driving) l Your blood glucose should always be more than 5mmol/l before you drive you need to test before driving l Always check your blood glucose level before and after increased activity levels Always carry some quick acting glucose with you which is easy to take if you feel hypo. Examples of these are: l A 150 ml can of sugary drink l 5-6 glucose tablets (which are available from pharmacy) l 4 jelly babies l 2 x 25g tubes of glucose gel (e.g. glucogel which can be prescribed) l 120mls of Lucozade 6
If your next meal is not due within the next hour eat a slow releasing carbohydrate snack. Examples of these are: l 1 slice toast l 2 digestive biscuits l 1 banana Let your Diabetes Team know if you are starting to experience more frequent hypos. If you are having frequent hypo s you may need to stop driving, especially if you become hypoglycaemic unaware. You must not start again until your family doctor or specialist confirms that it is safe to start driving again. Diabetic Ketoacidosis In pregnancy it is especially important to check for ketones if your blood glucose level is more than 11mmol/lL The diabetes Team will teach you how to do this. If you are vomiting, feeling short of breath or have abdominal pain, you need to come in to hospital immediately. Maintaining good blood glucose control (see target box) including frequent blood glucose and ketone testing can help to avoid the risk of developing ketoacidosis. If you test positive for ketones follow the instructions given by your Diabetes Team or call your Team for advice straight away. You may need to contact A&E or out of hours service on a weekend or evening. 7
Follow this advice if you are ill l Never stop taking your insulin or tablets (you may need to adjust the dose and you will be taught this by your Diabetes Team) l Monitor your blood glucose levels more frequently (at least every 4 hours). If you do not feel up to it, ask a relative or friend to help you l If your blood glucose level is unexpectedly higher than 11mmol/L you may need to test your blood for ketones (this will be discussed with you) l Drink more fluids than normal; clear fluids are best, but any sugar free fluids will do, aim for 100mls each hour l Rest as much as possible l If you do not feel like eating replace meals with liquids or alternatives like yogurts l If you are confident to adjust your insulin to maintain control, then do so, otherwise speak to your Diabetes Team about making adjustments l Contact your Diabetes Team for advice straight away if you are vomiting l Remember if ketones are present you will need to test blood glucose and ketones every 2 hours and give additional insulin doses, even throughout the night 8
Your Care Conception to 12 Weeks During these early weeks when your baby s brain, spine and vital organs are developing, you can expect to attend the clinic every one to two weeks. It is vital that your blood glucose levels are as near normal as possible and you may need extra help to do this. From 12 Weeks As your pregnancy progresses, you will receive expert antenatal care from the Diabetes Specialist Team. This will mean more regular blood tests and ultrasound scans to check your baby s growth and development. The Midwife will perform antenatal checks and will need you to provide a urine sample at every visit. Your diabetes control will be monitored closely by the Diabetologist and Diabetes Specialist Nurse. Often your glucose levels are difficult to control due to the demands of your pregnancy. Sometimes your insulin requirements will increase. This will mean regular reviews of your insulin therapy and requirements. Any problems with your injection technique or sites can be addressed. 9
Your eyes If you are registered with a Rotherham GP, you will be offered appointments with the eye screening team in the Diabetes Centre at least twice during your pregnancy, otherwise alternative appointments will be made. We will make the referral for you. Any eye problems you already have might get worse during pregnancy. You may hear this referred to as diabetic retinopathy. You will be offered a follow up eye appointment within six months of your baby s birth if any problems with your eyes are detected. Dietitians You will be able to see the Diabetes Specialist Dietitian at any stage during your pregnancy. They can advise on problems with morning sickness, food fads, weight gain/ loss, achieving good blood glucose control and offer advice for breast feeding. If you are on multiple insulin injections the Dietitian can also advise you on carbohydrate counting to ensure you are taking the appropriate insulin doses for the food you are eating. If at any time you require additional support during your pregnancy the Diabetes Dieticians will be happy to organise to see you in addition to your clinic appointments. 10
The Big Day The Obstetrician (Maternity Specialist Doctor) will discuss options for delivery with you well in advance. If your diabetes is well controlled and you have no other problems such as high blood pressure, induction of labour (starting your labour off) will be planned for 38 to 39 weeks. If you are experiencing any problems, the Obstetrician will discuss with you the best time for you to be admitted for delivery of your baby. You will be advised straight away if it may be necessary to deliver your baby earlier than expected. What can I expect during labour and delivery? Unless your baby is very large you shouldn t have problems giving birth naturally. However, complications during delivery can be more common if you have diabetes before pregnancy. Your Diabetes Team will discuss this with you. You may have your labour induced if the Obstetrician (after discussion with you) feels this is the best option. During your labour, it is essential that your blood glucose levels remain normal (between 4-7mmol/L). As soon as your labour begins you will be put onto an intravenous infusion (drip) of glucose and insulin. The rate of insulin will be adjusted according to your blood glucose levels. You will have your blood glucose checked at least every hour. 11
If you have an insulin pump you may be able to continue using this during labour and delivery. This will be discussed with you on an individual basis. Caesarean section It is more common for women with diabetes to have a caesarean section. Up to 6 out of 10 women will require this. Unless it is an emergency situation, you will have been able to discuss this, given all the relevant information, and have been given the date of your caesarean section. Please feel free to discuss any concerns you have about any aspect of your labour or delivery with the Diabetes Specialist Midwife or Obstetrician. 12 Following Delivery You You will remain on a drip until you are able to eat and drink normally. Although your insulin requirements may have increased in the latter part of your pregnancy, they usually fall to your normal pre-pregnancy doses following the birth of your baby. Make sure you have a record of your pre-pregnancy insulin doses, as a guide to the amount you will need. If you are planning to breast feed the dose will need to reduced by a further 20% - 30% and you will need more regular carbohydrate snacks. Your postnatal care on the ward will be the same as that of all new mothers.
Your Baby Your baby s blood glucose level may drop shortly after it is born. It is therefore very important to feed your baby within 1 hour of delivery to try to prevent this from happening. For the first 24 hours we recommend feeding your baby every 2-3 hours. This will help to prevent your baby from becoming a hypoglycaemic. After this initial period we recommend feeding your baby 8-12 times daily. It will be necessary for the Midwives to keep a check on your baby s blood glucose levels by doing a heel prick test during the first 24 hours following the birth, as this is a good way of detecting hypoglycaemia. If there are any concerns about your baby, they may need to go to our Special Care Baby Unit (SCBU). The Diabetes Team will discuss feeding your baby with you in detail during your third trimester. This will include: l Antenatal expression: The Diabetes Specialist Midwife will discuss beginning to express colostrum after 36 weeks of pregnancies which you store at home and then bring into hospital with you when you have your baby. l Reducing your insulin requirements: We recommend a reduction of basal and bolous insulin by 20-30%. This will be assessed on an individual basis. 13
l Food choices and breast feeding: We recommend 50g of carbohydrate spaced throughout the day in 10-15g snacks also in order to ensure you get all the nutrients you need we encourage calcium rich foods. Extra fluids during this time are also advised. l Vitamin D requirements: It is recommended that all breast feeding mothers take a Vitamin D supplement of 10mcg/day We recommend all mothers breast feed their babies. Breast feeding is the healthiest way to feed your baby and has lots of benefits for you as well. These include reducing the chances your baby developing diabetes in their lifetime. Your Midwife will be able to give you more information about this and you can attend Preparation for breast feeding sessions within the hospital. Sometimes if your baby s blood glucose level drops we may have to recommend an additional supplement of expressed colostrum or formula milk given by a small feeding cup or feeding syringe. 14
Going Home You will receive an appointment to attend Antenatal Clinic to see the Diabetes Team, this will probably be around 6 weeks from the birth of your baby. This will allow you to discuss any problems or concerns you may have and make sure you are back on a suitable regime for your diabetes management. You will then be discharged back to your GP or Diabetologist for your regular diabetes reviews. Do not worry if your blood glucose levels are somewhat erratic for several months after giving birth. This is due to the hormone and lifestyle changes of having a new baby. The main aim is to avoid hypoglycaemia or frequent high blood glucose levels (above 13mmol/L) and it is often recommended to keep blood glucose levels between 6-12mmol/L during the postnatal period. The Community Midwives will provide you and your baby s postnatal care at home as with any other new mother. Card/Bracelet It is important that you carry some form of identification to tell people you have diabetes in case you become ill / or are unable to communicate. Your Specialist Diabetes Midwife can provide you with this. 15
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How to contact us Diabetes Specialist Midwife Telephone 01709 424347 Diabetes Specialist Nurse Telephone 01709 427910 Diabetes Specialist Dietitian Telephone 01709 427121 Consultant Obstetrician Telephone 01709 424324 or Telephone 01709 424239 Infant Feeding Coordinator Telephone 01709 424265 Switchboard Telephone 01709 820000 Useful contact numbers NHS 111 Service Telephone 111 Health Info Telephone 01709 427190 Stop Smoking Service Telephone 01709 422444 A&E Telephone 01709 424455 Reshape Telephone 01709 427694 For GP out of hours, contact your surgery Useful websites www.diabetes.org.uk www.nhs.uk www.gov.uk www.therotherhamft.nhs.uk We value your comments If you have any comments or concerns about the care we have provided please let us know, or alternatively you can write to: Patient Services The Rotherham NHS Foundation Trust Rotherham Hospital Moorgate Road Oakwood Rotherham S60 2UD Telephone 01709 424461 Email complaints@rothgen.nhs.uk Produced by Claire Heeley, February 2012. Revised March 2014. Revision due March 2016. Version: 4.0. The Rotherham NHS Foundation Trust 2014. All rights reserved. 18
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