Diabetes, Pre-existing & Gestational: Part A Management of Antenatal Care Policy

Document ID: MATY025a Version: 1.0 Facilitated by: Jenny Rafferty, Midwife Last reviewed: April 2015 Approved by: Maternity Quality Committee Review date: April 2018 Diabetes, Pre-existing & Gestational: Part A Management of Antenatal Care Policy Hutt Maternity Policies provide guidance for the midwives and medical staff working in Hutt Maternity Services. Please discuss policies relevant to your care with your Lead Maternity Carer. Policy To ensure that all women presenting with pre-existing and gestational diabetes are appropriately monitored, managed and treated during their pregnancy, labour and postpartum period. Scope All midwifery and Obstetric medical staff All Hutt Valley District Health Board access holders Endocrinologists and Medical Registrars Diabetes Nurse Clinicians Dietician Definitions GDM- Gestational Diabetes is defined as any degree of glucose intolerance first recognised during pregnancy. This definition applies equally to those women who require insulin or metformin therapy and those who simply require dietary modification. Some of these women will be diagnosed post delivery to have Type 2 diabetes, pre-diabetes and occasionally Type 1 diabetes. Type 2 Diabetes the most common form of diabetes, it occurs when either the pancreas stops producing enough insulin, or the body becomes resistant to the insulin produced. It has been called Non Insulin Dependent Diabetes Mellitis or NIDDM in the past. It is a chronic disease developing over several years which may be treated using diet and exercise, oral medications such as metformin or glibenclamide, or may require insulin treatment. Type 1 Diabetes an autoimmune disease in which the pancreas s production of insulin decreases to very little or zero. It more commonly begins in childhood but can develop at any age. It used to be referred to as Insulin Dependent Diabetes Mellitis or IDDM. Pre-diabetes - The term pre-diabetes is controversial: in 1980 the World Health Organisation (WHO) recommended against its use as not all people with borderline glycaemic levels progress to diabetes. In 2006 the WHO again discouraged the use of the term pre-diabetes and instead suggested "intermediate hyperglycaemia" to signify impaired fasting glucose (IFG) and impaired glucose tolerance (IGT). 3 The

2012 NICE guidelines (United Kingdom) refer to "increased risk of type 2 diabetes" rather than pre-diabetes. (Chatterton H, Younger T, Fischer A, et al) Risks and precautions Fetal/neonatal Risks: Maternal Risks: Macrosomia, shoulder dystocia & Miscarriage birth injuries e.g. nerve palsies, fractures Hypoglycaemia UTI, candida infections Respiratory distress Raised risk of PET Hyperbilirubinaemia Increased risk of IOL and of C/S Congenital anomalies Birth trauma IUGR esp. with hypertensive or Type 2 Diabetes in later life vascular disorders Unexplained intrauterine death Future risk of obesity and diabetes Screening and Referral Women with pre-existing Type 1 and Type 2 Diabetes These women will be referred in the first trimester to the Secondary Care/AND clinic, usually by their GP, to enable early blood glucose control, early treatment with insulin or metformin as necessary, and timely screening as per normal A/N care. Women with known pre-diabetes (impaired glucose tolerance, IGT, or impaired fasting glucose, IFG) prior to pregnancy can be discussed with the AND clinic in the first trimester. However, if they do an HbA1c with booking bloods they will either be referred to the AND clinic or be asked to do a GTT at 14-16 weeks or at 24-28 weeks depending on the result. Gestational Diabetes Early pregnancy Healthy Lifestyle Advice: all pregnant women should be offered information covering the role of a healthy, balanced diet, body weight and exercise, including advice for at least 30 minutes per day, most days of the week. All pregnant women should be weighed & have their weight recorded at routine antenatal appointments. All pregnant women should be advised on avoiding excessive weight gain throughout their pregnancy. (Ministry of Health, 2014). Screening, Diagnosis and Management of Gestational Diabetes in New Zealand: A clinical practice guideline.) Screening for Diabetes in pregnancy All women are now offered an HbA1c non-fasting blood test with their booking bloods, or prior to 20 weeks. (Ministry of Health, 2014). Screening, Diagnosis and Management of Gestational Diabetes in New Zealand: A clinical practice guideline.) HbA1c 40 mmol/mol (normal): further testing for GDM at 24-28 weeks. Page 2 of 13

HbA1c 41-49 mmol/mol: offer GTT at 14-16 weeks as likely pre-diabetes and at increased risk of GDM. If this GTT is normal, she should still be offered a GTT at 24-28 weeks as this is when GDM is most likely to become apparent. HbA1c 50 mmol/mol: likely pre-existing diabetes, refer directly to the AND clinic via Secondary Care. Type 2 diabetes can go unrecognised for many years before symptoms appear. The risks associated with diabetes in pregnancy are known to be at least as high for Type 2 as for Type 1 diabetes. Cundy et al (2000) showed perinatal mortality with Type 2 significantly increased even over Type 1, mainly due to a greater level of late fetal death. Obesity may contribute to this. Early recognition of undiagnosed diabetes is important so treatment can be initiated to reduce its impact on pregnancy outcomes. Risk Factors for Type 2 Diabetes and GDM Previous GDM PCOS Morbid obesity (Ethnic specific: Indian/Asian BMI 32, Polynesian BMI 37, everyone else BMI 35) Previous macrosomia: customised birthweight > 97 th centile If no access to customised chart, 4700g Polynesian, 4400g European, 4000g Asian. Age over 40 years Two 1 st degree relatives with diabetes Previous unexplained stillbirth Persistant glycosuria Previous shoulder dystocia 24-28 weeks Women with a normal HbA1c 40 mmol/mol and no risk factors for diabetes (given above) should be offered a screening test, the non-fasting 50g Glucose Challenge, or Polycose test. If the GCT result is, 7.8mmol/l a fasting OGTT is required. Women with a normal HbA1c 40 mmol/mol but with one or more risk factors for diabetes should be offered a Glucose Tolerance Test rather than a GCT. The sensitivity of the Glucose Challenge has been reported as 80%, which means that 20% of women with GDM will have a GCT result <7.8mmol/l. Half of these women with a false negative result will have a result between 7.2-7.8mmol/l. It is recommended that if these women have a risk factor for GDM (as listed above, or macrosomia /polyhydramnios / increased weight gain) they should have a GTT. GDM is diagnosed with one or both of the following: Fasting glucose 5.5mmol/l Two hour glucose 9.0mmol/l If the two hour test result is >8.0mmol/l in a woman with a macrosomic baby or polyhydramnios, it would be appropriate to discuss with the Obstetrician or Page 3 of 13

endocrinologist in the AND regarding her management as she may be treated as having GDM and warrant dietary input and blood glucose monitoring. A GCT result of >11 can be referred directly to the Secondary Care/AND clinic (GTT not required prior to referral). A diagnosis of GDM is an indication for written obstetric referral to Secondary Care to attend the Combined Obstetric/ Antenatal Diabetes clinic. See Appendix 1 - Screening for Diabetes in Pregnancy flowchart Antenatal Care As a general rule, the secondary care obstetric team will have clinical responsibility for all women who require insulin/metformin treatment whereas women with well controlled diet controlled GDM can remain under the care of their LMC midwife. If a transfer of clinical responsibility occurs, then a three way conversation needs to occur between the obstetrician, the LMC and the woman. Midwifery care will be negotiable. Those women booking under a private obstetrician will continue to have their obstetric care with their obstetrician but will see the endocrinologist at the AND clinic 2-4 weekly or more frequently as their diabetes control warrants. The multidisciplinary team emphasises the importance of regular antenatal visits and strict adherence to dietary and medication regimes. Information on diet and exercise is provided. A letter stating the identity of the LMC, and a management plan, will be dictated at the first or second clinic visit by the obstetric team to the referring health care provider and LMC. In all cases, a copy is forwarded to the woman s general practitioner, the LMC and the woman herself. To enable women to self monitor their blood glucose, a blood glucose monitor is provided. There is a clear expectation that this will be returned at the end of the pregnancy. Management in Early Pregnancy: Type 1, Type 2 and some GDM (possible undiagnosed Type 2) Women diagnosed with GDM before 20/40 are at higher risk and should be managed as for a woman with Type 2 diabetes. This care will include: Accurate assessment of gestation using LMP and early USS. Usual MSS1 or 2 screening offered. Anatomy USS at 19-20 weeks. Consider detailed cardiac USS at 24 weeks. Consider aspirin (& calcium) as there is a raised risk of preeclampsia. Page 4 of 13

Careful control of glucose levels with regular phone contact with diabetes nurse educators between clinic visits every 2-4 weeks. Blood tests: HbA1c if not yet done, booking bloods, creatinine, LFTs, TFTs MSU and check need for HVS/chlamydia screen Management in later pregnancy: diet controlled GDM Following referral to the AND clinic with a diagnosis of GDM, women will be seen by the endocrinologist and diabetes nurse specialist and taught how to monitor their own blood glucose levels. They will also be seen by the secondary care obstetrician, who will review for potential complications such as macrosomia, polyhydramnios, IUGR and hypertensive disease. If dietary modifications and exercise are felt to be adequate in maintaining euglycaemia the woman will be referred back to her LMC midwife who will manage the rest of the pregnancy, referring back to secondary care if there are any concerns about fetal growth, diabetes control or other obstetric concerns as per the MoH Obstetric Referral Guidelines 2012. If the woman has not birthed by 40 weeks gestation, she is to be reviewed with an USS. If the woman has well controlled blood glucose levels with no obstetric concerns and wishes to await the spontaneous onset of labour, electronic foetal monitoring is performed twice weekly and labour is induced prior to 41 weeks. This plan will be clearly outlined in a letter to the LMC. It is recommended that women have a growth USS at 28/40 (or when referred if GDM) and again at 36/40 Women to be advised to monitor fetal movements from 28/40 and to report concerns to their LMC without delay. Management in Later pregnancy: Type 1, Type 2 and GDM on insulin or metformin Timing of clinic visits: From 28/40, women will be seen 2-3 weekly or more frequently if there are concerns i.e. fetal growth (particularly growth restriction), hypertension, and poor glucose control. From 36/40 weekly clinic visits Should have a growth USS at 28/40 (or when referred if GDM) and again at 36/40. More frequent scanning considered if concerns about growth restriction or preeclampsia. Consider HbA1c at referral around 28/40 for women with GDM then again at 36/40 to help assess the level of glucose control and to help decide whether early delivery is appropriate. Women to be advised to monitor fetal movements from 28/40 and to report concerns to their LMC without delay. Fetal Surveillance Women with well-controlled GDM and no other pregnancy complication are not at increased risk of an intrauterine fetal death. Women with suboptimal glycaemic control and / or requiring treatment to maintain glycaemic control: Page 5 of 13

Elevated fetal glucose results in increased fetal insulin production. This increases fetal growth, fat deposition and oxygen consumption. These factors put the fetus at risk of hypoxia. This is especially concerning at term and with maternal vascular disease or preeclampsia. Poor metabolic control increases the risk of neonatal morbidity and mortality but may be minimised by fetal surveillance during the third trimester. Assessment of regular fetal movements is a simple way of assessing fetal wellbeing. Any decrease or changes to the normal pattern of fetal movement will require increased monitoring. Weekly electronic foetal monitoring and two weekly USS are considered from 34 weeks onwards in women: Whose GDM is not well-controlled Fetal growth problems (significant macrosomia, growth restriction, reduced liquor) Who have other significant pregnancy complications With a history of intrauterine foetal death. NB: In specially selected cases, fetal surveillance may commence at an earlier gestation and / or electronic fetal monitoring may be performed more frequently. Diet The dietician will see the newly diagnosed woman to assess diet and provide education. The following dietary guidelines - (taken from the Diabetes in Pregnancy- Quick reference guide for health professionals on the screening, diagnosis and treatment of GDM in New Zealand, 2014) should be discussed with the woman by her midwife or obstetrician particularly before she has seen the dietician: Advise pregnant women with gestational diabetes that their dietary recommendations could include: Consuming a minimum of 175g carbohydrate per day Spreading carbohydrates evenly throughout the day between meals and snacks Reducing intake of saturated fats Consuming lean protein Keeping weight gain in pregnancy in line with Ministry of Health recommendations This recommendation is dependent on individual requirements. Exercise Exercise for example swimming, yoga and walking are ideal, allowing the workload to be increased safely without distress to the foetus. They should aim for about 30 minutes daily possibly split into 10 minute blocks. This is particularly effective after main meals. Women should avoid exercise in the supine position because it is associated with decreased cardiac output from pressure of the gravid uterus on the vena cava. Contraindications to exercise in pregnancy include Pregnancy-induced hypertension or pre-eclampsia Preterm rupture of membranes Threatened preterm labour Page 6 of 13

Cervical incompetence Persistent second / third trimester vaginal bleeding Intrauterine growth restriction Monitoring the blood sugar levels A blood sugar level (BSL) should be measured on waking and two hours after each meal in women with GDM or Type 2 diabetes. Diabetes nurses may contact the woman prior to her first clinic appointment to educate and start testing of BSL. Women with Type 1 will test before every meal as well as 2 hours after, plus during the night and before exercise as instructed. Two criteria should be met to assure that the degree of glycaemic control is adequate to prevent complications such as macrosomia and fetal hypoxia: The fasting BSL should be 4-5.0 mmol/l The two hour post prandial BSL should be 4-6.7mmol/L. Initiation of medical therapy Treatment should be initiated when the fasting BSLs are >5.0 mmol/l and the two hour post prandial BSLs are >6.7 mmol/l on at least 10% of the recordings despite dietary change. The choice of therapy is made by the physician in conjunction with the Obstetrician (considering factors such as fetal growth). Insulin The type of insulin and dose are individualised to each woman. Adjustments in the doses are based upon the results of BSL monitoring which is documented in the record book by the woman and downloaded from their glucose meter. Insulin resistance increases as the pregnancy proceeds therefore requiring an increase in insulin dose. Metformin If the fasting BSL is >6 it is unlikely that metformin alone will be adequate to manage blood sugars. Women need to be aware of gastrointestinal symptoms. Metformin should not be used if there are concerns of inadequate fetal growth or placental insufficiency as it may prevent adaptive responses to placental insufficiency. Metformin acts by improving the body s sensitivity to the insulin produced by the pancreas and also injected insulin. Metformin doesn t cause hypoglycaemia Timing and Mode of Delivery Timing of delivery is discussed with consideration of diabetes control, macrosomia and other obstetric factors i.e. PET. Accuracy of EDD also needs to be taken into consideration especially for those women booking late in pregnancy. There is no evidence supporting induced delivery before 40 weeks in women with GDM who are well controlled with diet and with a normally grown baby and no other complications i.e. hypertension, PET, macrosomia >90 th centile, maternal age >40 yrs. Page 7 of 13

Consideration is given to an anaesthetic consultation if this has not previously been organised. Decisions regarding the timing and mode of birth are made on a case-by-case basis after consultation with the obstetric consultant. This decision will balance the foetal risks including macrosomia, shoulder dystocia, birth trauma, IUGR, IUD and prematurity, as well as the maternal factors such as hypertension, birth trauma and caesarean section. Indications for delivery before 39 weeks gestation include poor glycaemic control and some foetal abnormalities, include macrosomia. Women with good glycaemic control and no other pregnancy complication (including macrosomia) should ideally have elective delivery planned no earlier than 40 weeks gestation. LMC s should be informed of planned delivery time (even if under secondary care) as midwifery care can be negotiated between LMC and DHB midwives Steroids Consideration as to whether steroids are given prior to elective caesarean section will be dependent on gestation. This will need to be planned in conjunction with the endocrine team and delivery suite as steroids will raise blood sugars usually increasing about 8 hours after the dose and may require insulin infusions or alterations in insulin doses. References ADHB. (2013, Dec). Diabetes in pregnancy: guideline. Retrieved May 19, 2015, from Auckland District Health Board: http://nationalwomenshealth.adhb.govt.nz/portals/0/documents/policies/diabetes%2 0in%20Pregnancy_.pdf. American Diabetes Association. (2002). Preconception care of women with diabetes. Diabetes Care, 25 (s). pp 82 84. Capital & Coast DHB. (2011). Gestational Diabetes: Antenatal fetal surveillance, delivery and postnatal care. protocol. Chatterton H, Younger T, Fischer A, et al. Risk identification and interventions to prevent type 2 diabetes in adults at high risk: summary of NICE guidance. BMJ 2012;345:e4624. Crowther, C. A., Hiller, J. E., Moss, J. R., McPhee, A. J., Jeffries, W. S., & Robinson, J. S. (2005). Effect of Treatment of Gestational Diabetes Mellitus on Pregnancy Outcomes. The ACHOIS randomised controlled trial. New Eng J Med, 352, 2477-2486. doi: 10.1056/NEJMoa042973 Cundy T, Gamble G, Townend K, Henley PG, Macpherson P, Roberts AB. Perinatal mortality in type 2 diabetes mellitus (2000). Diabet Med. 17: 33-9 Gestational Diabetes Mellitus in New Zealand Technical Report March 2007 from the Gestational Diabetes Mellitus Technical working Party. Facillitators: David Simmons, Page 8 of 13

Australian Diabetes in Pregnancy Society and Norma Campbell, New Zealand College of Midwives. Hutt Valley District Health Board (2013). Pre-existing and Gestational Diabetes: Part A Management of Antenatal Care, protocol. McAra-Couper, J., & Hunter, M. (2010). Is LSCS a normal delivery in the 21 st century? O&G Magazine. Birth, 12 (4) 16-18. Ministry of Health. (2014). Screening, Diagnosis and Management of Gestational Diabetes in New Zealand: A clinical practice guideline. Guideline, Ministry of Health, Wellington. Retrieved May 9, 2015, from http://www.health.govt.nz/publication/screening-diagnosis-and-managementgestational-diabetes-new-zealand-clinical-practice-guideline National Institute for Health and Care Excellence. (2015). Diabetes in pregnancy: management of diabetes and its complications from preconception to the postnatal period. Guideline. Retrieved from National Institute for Health and Care Excellence: http://www.nice.org.uk/guidance/ng3 Nicholson, W., Fox, H., Fleisher, L., Powe, N. (2005). Screening for gestational diabetes mellitus: A decision and cost-effectiveness analysis of four screening strategies. Diabetic Care. 28 (6) 1482-1485. Poyhonen, M., Teramo, K., Kaaja, R., Hiilesmaa, V. (2005). 50g oral glucose challenge test combined with risk factor-based screening for gestational diabetes. European Journal of ObstetGynaecol Reproductive Biology. 121 pp 34 37 Rowan, J., Hague, W., Gao, W., Battin, M., and Moore, P., for the MiG Trial Investigators (2008). Metformin versus Insulin for the Treatment of Gestational Diabetes. N Engl J Med, 358:2003-2015 Appendices Appendix 1: Flowchart Screening for Diabetes in Pregnancy Appendix 2: Management of hypoglycaemia BSL of less than 4 mmol/l Appendix 3: Blood glucose & insulin chart for ante and postnatal monitoring Page 9 of 13

Appendix 1: Flowchart Screening for Diabetes in Pregnancy Screening for Diabetes in Pregnancy >40 All women to be offered HbA1c with booking bloods or before 20/40 HbA1c 40 HbA1c 41-49 HbA1c 50 Low risk for GDM 50g Glucose Challenge at 24-28 wks Risk factors for GDM: Prev GDM Prev macrosomia Age over 40 yrs Morbid obesity (Indian/Asian BMI 32, Polynesian BMI 37, everyone else BMI 35) PCOS Two 1st degree relatives with diabetes Glycosuria On antipsychotic medication or prednisone 7.8-11.0 GTT at 14 20 wks Normal GTT Fasting glucose < 5.5 and 2 hr < 9. GTT at 24 28 wks Fasting glucose 5.5 or 2hr 9 Fasting glucose 5.5 or 2hr 9 GDM Some will Have Pre-existing Diabetes Refer to HVDHB Secondary Care/AND clinic <7.8 >11.0 Refer to AND/Secondary care Doesn t need GTT! Fasting glucose <5.5 & 2 hr <9.0 Normal Glucose Tolerance no GDM >30 wks if the baby is macrosomic, or unexplained polyhydramnios repeat GTT If in late pregnancy you are still concerned about unrecognised GDM, discuss with an obstetrician. Page 10 of 13

Appendix 2: Management of hypoglycaemia - BSL of less than 4 mmol/l Hypoglycaemia is a BSL outside the lower limit of the woman s target range, typically less than 4.0mmol/L that may or may not be associated with symptoms such as paleness, sweating, hunger or nausea, trembling and palpitations, irritability, a personality change, drowsiness, fitting or coma. Pre-packaged hypoglycaemia treatment kit Pre-packaged hypoglycaemic treatment kits for oral treatment of the conscious patient are available in all wards. Each kit consists of a white plastic container containing La Vita tablets, hypofit sachets and jellybeans. Written instructions for using the hypoglycaemic treatment kit are enclosed in the kit. If the woman is conscious and not nil by mouth Hypoglycaemia is defined as a blood sugar level below 4 mmol/l. It should be treated immediately at the onset of symptoms or if the BSL is less than 4 mmol/l without symptoms. (NB: women with longstanding diabetes may have no symptoms despite being hypoglycaemic). Check the BSL first. If it is less than 4 mmol/l or the woman is symptomatic follow the three-step treatment: 1. Give a simple carbohydrate: 3-4 Vita tabs or 2 3 teaspoons sugar in water or 100ml sweet drink / fruit juice 2. Recheck BSL after 5 10 minutes and repeat the above prn. 3. Once the BSL is greater than 4 mmol/l give complex carbohydrate: 1 sandwich or 3 crackers and cheese or 3 plain biscuits with a glass of milk Recheck the BSL after 20 minutes. The diabetic team should be informed the next working day so that appropriate alterations to the woman s diabetes therapy can be made. Do not withhold subsequent diabetes tablets or insulin but consider reducing the dose (if insulin is withheld, hyperglycaemia will inevitably ensue and in particular, women with Type 1 diabetes can rapidly develop a potentially life threatening diabetic ketoacidosis within a few hours). The BSL should ideally be greater than 4 mmol/l during the daytime and greater than 6-7 mmol/l overnight. If the BSL is still below 4 mmol/l after giving the glucose solution 3 times, summon the Obstetric SHO / Registrar for medical assistance. The Diabetes team should also be informed the next working day so that appropriate alterations to the woman s diabetes therapy can be made. Ascertain cause of hypoglycaemia if possible Adjust diabetes tablet or insulin dose, diet, activity as appropriate Test the woman s BSL according to the advice of the specialist, registrar or diabetes nurse clinician. Page 11 of 13

Ensure that the woman can manage her usual diet. Note: Review current knowledge, provide further management and education as necessary or refer to inpatient diabetes nurse. If the woman is unconscious or nil by mouth Do not attempt to administer food or liquids due to risk of aspiration to the lung. Place the woman in the recovery position. Summon the Obstetric SHO or Registrar for immediate assistance. An intravenous cannula must be inserted immediately (if not already present). 1. Give a simple carbohydrate IV Dextrose 100mls of 10% dextrose intravenously as a slow push or 50mls of 20% dextrose intravenously. If no intravenous cannula, give IM glucagon 1mg NGT 100ml sweet fluid 2. Recheck BSL after 5 10 minutes and repeat the above prn 3. Once >4.0mmol/L give complex carbohydrate IV fluid with 6 10gm dextrose per hour Enteral feed containing carbohydrates Page 12 of 13

Informed Consent The right of a consumer to make an informed choice and give informed consent, including the right to refuse medical treatment, is enshrined in law and in the Code of Health and Disability Consumers Rights in New Zealand. This means that a woman can choose to decline treatment, referral to another practitioner, or transfer of clinical responsibility. If this occurs follow the process map on page 18 of the Referral Guidelines (Ministry of Health, 2012). Page 13 of 13