NICE- Diabetes in pregnancy Flashcards
Timetable of antenatal appointments in Diabetes in pregnancy.
Booking appointment (joint diabetes and antenatal care) – ideally by 10 weeks 16 weeks 20 weeks 28 weeks 32 weeks 34 weeks 36 weeks 37+0-38+6 38 weeks 39 weeks
When to offer US in Diabetes in pregnancy
- Confirm viability of pregnancy and gestational age at 7–9 weeks.
- Offer ultrasound monitoring of fetal growth and amniotic fluid volume.
- 28 weeks
- 32 weeks
- 34 weeks
When to offer retinal assessment for women with pre‑existing diabetes
- Booking appointment by 10 weeks unless the woman has been assessed in the last 3 months.
- 28 weeks
What information to be provided at 36 weeks
- timing, mode and management of birth
- analgesia and anaesthesia
- changes to blood glucose‑lowering therapy during and after birth
- care of the baby after birth
- initiation of breastfeeding and the effect of breastfeeding on blood glucose control
- contraception and follow‑up.
How to screen Gestational diabetes
- 2‑hour 75 g OGTT to test for GDM with risk factors
- Offer: with any risk factors for GDM 75 g 2‑hour OGTT at booking & 24–28 weeks
1 - BMI above 30 kg/m2
2 - previous macrosomic baby weighing 4.5 kg or above
3 - previous gestational diabetes
4 - family history of diabetes (first‑degree relative with diabetes)
5 - minority ethnic family origin with a high prevalence of diabetes
Do not use fasting plasma glucose, random blood glucose, HbA1c, glucose challenge test or urinalysis for glucose to assess risk of developing gestational diabetes.
Diagnose gestational diabetes if the woman has either:
- fasting plasma glucose level of 5.6 mmol/litre or above or
- 2‑hour plasma glucose level of 7.8 mmol/litre or above
Offer women who have had gestational diabetes in a previous pregnancy:
- early self‑monitoring of blood glucose or
- 75 g 2‑hour OGTT, ASAP after booking (whether in first or second trimester), and further 75 g 2‑hour OGTT at 24–28 weeks if the results of first OGTT are normal.
Glycosuria detected by routine antenatal testing
Be aware that glycosuria of 2+ or above on 1 occasion or of 1+ or above on 2 or more occasions detected by reagent strip testing during routine antenatal care may indicate undiagnosed gestational diabetes. If this is observed, consider further testing to exclude GDM
At dianosis of GDM
- Offer women with a diagnosis of gestational diabetes a review with the joint diabetes and antenatal clinic within 1 week.
- Inform the primary healthcare team when a woman is diagnosed with gestational diabetes
informed decision about testing for gestational diabetes, explain that:
in some women, GDM will respond to changes in diet and exercise
- majority of women will need oral blood glucose‑lowering agents or insulin therapy if changes in diet and exercise do not control gestational diabetes effectively
- if gestational diabetes is not detected and controlled, there is a small increased risk of serious adverse birth complications such as shoulder dystocia
- a diagnosis of gestational diabetes will lead to increased monitoring, and may lead to increased interventions, during both pregnancy and labour.
SIGN & IADPSG = International Association of Diabetes and Pregnancy Study Groups dianosis of DM
Fasting: ≥5.1 mmol/l
1 hour: – ≥10.0 mmol/l
2 hour: ≥7.8 mmol/l
Offer ultrasound monitoring of fetal growth and amniotic fluid volume. in diabetes in pregnancy
Confirm viability of pregnancy and gestational age at 7–9 weeks
20 weeks:Offer an ultrasound scan for detecting fetal structural abnormalities, including examination of the fetal heart (4 chambers, outflow tracts and 3 vessels).
Offer ultrasound monitoring of fetal growth and amniotic fluid volume.at 28, 32 & 36 weeks
Offer tests of fetal wellbeing, diabetes in pregnancy
38 weeks & 39 weeks
Plannin birth in diabetes in pregnancy
37+0 weeks to 38+6 weeks: Offer IOL, or CS if indicated, to women with type 1 or type 2 DM; otherwise await spontaneous labour.
39 weeks: Advise women with uncomplicated GDM to give birth no later than 40+6 weeks.
34 weeks in diabetes in pregnancy
No additional or different care for women with diabetes.
36 weeks , Provide information and advice about:
- timing, mode and management of birth
- analgesia and anaesthesia
- changes to blood glucose‑lowering therapy during and after birth
- care of the baby after birth
- initiation of breastfeeding and effect of breastfeeding on blood glucose control
- contraception and follow‑up.
Offer retinal assessment to all women with pre‑existing diabetes.
1 - Booking appointment – ideally by 10 weeks: Offer unless been assessed in last 3 months.
2 - 16–20 weeks if diabetic retinopathy was present at their first antenatal clinic visit.
3 - 28 weeks
Women with diabetes should also receive routine care according to the schedule of appointments in the NICE guideline on antenatal care, including
- appointments at 25 weeks (for nulliparous women) and 34 weeks,
- but with the exception of the appointment for nulliparous women at 31 weeks.
Preterm labour in women with diabetes
- Diabetes not contraindication to antenatal steroids for fetal lung maturation or to tocolysis.
- In women with insulin‑treated diabetes who are receiving steroids for fetal lung maturation, give additional insulin according to an agreed protocol and monitor them closely.
- Do not use betamimetic medicines for tocolysis in women with diabetes
patient‑held glucose meters (which use capillary blood samples) and monitoring systems are all calibrated to
plasma glucose equivalents
good blood glucose control throughout pregnancy will reduce
1 - risk of fetal macrosomia, 2 - trauma during birth (for her and her baby), 3 - induction of labour 4 - and/or caesarean section, 5 - neonatal hypoglycaemia and 6 - perinatal death
Advise women with gestational diabetes to take regular exercise (such as
walking for 30 minutes after a meal) to improve blood glucose control.
Booking appointment (joint diabetes and antenatal care) – ideally by 10 weeks
Discuss information, education and advice about how diabetes will affect the pregnancy, birth and early parenting (such as breastfeeding and initial care of the baby).
If the woman has been attending for preconception care and advice, continue to provide information, education and advice in relation to achieving optimal blood glucose control (including dietary advice).
If the woman has not attended for preconception care and advice, give information, education and advice for the first time, take a clinical history to establish the extent of diabetes‑related complications (including neuropathy and vascular disease), and review medicines for diabetes and its complications.
Offer retinal assessment for women with pre‑existing diabetes unless the woman has been assessed in the last 3 months.
Offer renal assessment for women with pre‑existing diabetes if this has not been performed in the last 3 months.
Arrange contact with the joint diabetes and antenatal clinic every 1–2 weeks throughout pregnancy for all women with diabetes.
Measure HbA1c levels for women with pre‑existing diabetes to determine the level of risk for the pregnancy.
Offer self‑monitoring of blood glucose or a 75 g 2‑hour OGTT as soon as possible for women with a history of gestational diabetes who book in the first trimester.
Confirm viability of pregnancy and gestational age at 7–9 weeks.
Monitoring blood glucose
- Advise pregnant women with type 1 diabetes to test their fasting, pre‑meal, 1‑hour post‑meal and bedtime blood glucose levels daily during pregnancy. [new 2015]
- Advise pregnant women with type 2 diabetes or gestational diabetes who are on a multiple daily insulin injection regimen to test their fasting, pre‑meal, 1‑hour post‑meal and bedtime blood glucose levels daily during pregnancy. [new 2015]
- Advise pregnant women with type 2 diabetes or gestational diabetes to test their fasting and 1‑hour post‑meal blood glucose levels daily during pregnancy if they are:
on diet and exercise therapy or
taking oral therapy (with or without diet and exercise therapy) or single‑dose intermediate‑acting or long‑acting insulin.
