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Bushra's NICE guidline > NICE- Diabetes in pregnancy > Flashcards

NICE- Diabetes in pregnancy Flashcards

1
Q

Timetable of antenatal appointments in Diabetes in pregnancy.

A 
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
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2
Q

When to offer US in Diabetes in pregnancy

A
  • 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
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3
Q

When to offer retinal assessment for women with pre‑existing diabetes

A
  • Booking appointment by 10 weeks unless the woman has been assessed in the last 3 months.
  • 28 weeks
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4
Q

What information to be provided at 36 weeks

A
  • 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.
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5
Q

How to screen Gestational diabetes

A
  • 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.

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6
Q

Diagnose gestational diabetes if the woman has either:

A
  • fasting plasma glucose level of 5.6 mmol/litre or above or

- 2‑hour plasma glucose level of 7.8 mmol/litre or above

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7
Q

Offer women who have had gestational diabetes in a previous pregnancy:

A
  • 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.
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8
Q

Glycosuria detected by routine antenatal testing

A

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

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9
Q

At dianosis of GDM

A
  • 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
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10
Q

informed decision about testing for gestational diabetes, explain that:

A

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.
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11
Q

SIGN & IADPSG = International Association of Diabetes and Pregnancy Study Groups dianosis of DM

A

Fasting: ≥5.1 mmol/l
1 hour: – ≥10.0 mmol/l
2 hour: ≥7.8 mmol/l

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12
Q

Offer ultrasound monitoring of fetal growth and amniotic fluid volume. in diabetes in pregnancy

A

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

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13
Q

Offer tests of fetal wellbeing, diabetes in pregnancy

A

38 weeks & 39 weeks

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14
Q

Plannin birth in diabetes in pregnancy

A

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.

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15
Q

34 weeks in diabetes in pregnancy

A

No additional or different care for women with diabetes.

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16
Q

36 weeks , Provide information and advice about:

A
  • 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.
17
Q

Offer retinal assessment to all women with pre‑existing diabetes.

A

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

18
Q

Women with diabetes should also receive routine care according to the schedule of appointments in the NICE guideline on antenatal care, including

A
  • appointments at 25 weeks (for nulliparous women) and 34 weeks,
  • but with the exception of the appointment for nulliparous women at 31 weeks.
19
Q

Preterm labour in women with diabetes

A
  • 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
20
Q

patient‑held glucose meters (which use capillary blood samples) and monitoring systems are all calibrated to

A

plasma glucose equivalents

21
Q

good blood glucose control throughout pregnancy will reduce

A 
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
22
Q

Advise women with gestational diabetes to take regular exercise (such as

A

walking for 30 minutes after a meal) to improve blood glucose control.

23
Q

Booking appointment (joint diabetes and antenatal care) – ideally by 10 weeks

A

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.

24
Q

Monitoring blood glucose

A
  • 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.

25
Q

Target blood glucose levels

A
  • Agree individualised targets for self‑monitoring of blood glucose with women with diabetes in pregnancy, taking into account the risk of hypoglycaemia.
  • Advise pregnant women with any form of diabetes to maintain their 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: 7.8 mmol/litre or

2 hours after meals: 6.4 mmol/litre.

  • Advise pregnant women with diabetes who are on insulin or glibenclamide to maintain their capillary plasma glucose level above 4 mmol/litre.
26
Q

Monitoring HbA1c

A
  • Measure HbA1c levels in all pregnant women with pre‑existing diabetes at the booking appointment to determine the level of risk for the pregnancy. [new 2015]
  • Consider measuring HbA1c levels in the second and third trimesters of pregnancy for women with pre‑existing diabetes to assess the level of risk for the pregnancy. [new 2015]
  • Be aware that level of risk for the pregnancy for women with pre‑existing diabetes increases with an HbA1c level above 48 mmol/mol (6.5%). [new 2015]
  • Measure HbA1c levels in all women with gestational diabetes at the time of diagnosis to identify those who may have pre‑existing type 2 diabetes. [new 2015]
  • Do not use HbA1c levels routinely to assess a woman’s blood glucose control in the second and third trimesters of pregnancy.
27
Q

Insulin treatment and risks of hypoglycaemia

A
  • Be aware that the rapid‑acting insulin analogues (aspart and lispro) have advantages over soluble human insulin during pregnancy and consider their use. [2008]
  • Advise women with insulin‑treated diabetes of the risks of hypoglycaemia and impaired awareness of hypoglycaemia in pregnancy, particularly in the first trimester. [2008]
  • Advise pregnant women with insulin‑treated diabetes to always have available a fast‑acting form of glucose (for example, dextrose tablets or glucose‑containing drinks). [2008, amended 2015]
  • Provide glucagon to pregnant women with type 1 diabetes for use if needed. Instruct the woman and her partner or other family members in its use. [2008, amended 2015]
  • Offer women with insulin‑treated diabetes continuous subcutaneous insulin infusion (CSII; also known as insulin pump therapy) during pregnancy if adequate blood glucose control is not obtained by multiple daily injections of insulin without significant disabling hypoglycaemia
28
Q

Continuous glucose monitoring

A
  • Do not offer continuous glucose monitoring routinely to pregnant women with diabetes. [new 2015]
  • Consider continuous glucose monitoring for pregnant women on insulin therapy:

who have problematic severe hypoglycaemia (with or without impaired awareness of hypoglycaemia) or

who have unstable blood glucose levels (to minimise variability) or

to gain information about variability in blood glucose levels. [new 2015]

  • Ensure that support is available for pregnant women who are using continuous glucose monitoring from a member of the joint diabetes and antenatal care team with expertise in its use.
29
Q

Ketone testing and diabetic ketoacidosis

A
  • Offer pregnant women with type 1 diabetes blood ketone testing strips and a meter, and advise them to test for ketonaemia and to seek urgent medical advice if they become hyperglycaemic or unwell. [new 2015]
  • Advise pregnant women with type 2 diabetes or gestational diabetes to seek urgent medical advice if they become hyperglycaemic or unwell. [new 2015]
  • Test urgently for ketonaemia if a pregnant woman with any form of diabetes presents with hyperglycaemia or is unwell, to exclude diabetic ketoacidosis. [new 2015]
  • During pregnancy, admit immediately women who are suspected of having diabetic ketoacidosis for level 2 critical care[6], where they can receive both medical and obstetric care
30
Q

Retinal assessment during pregnancy

A
  • Offer pregnant women with pre‑existing 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. [2008, amended 2015]
  • Diabetic retinopathy should not be considered a contraindication to rapid optimisation of blood glucose control in women who present with a high HbA1c in early pregnancy. [2008]
  • Ensure that women who have preproliferative diabetic retinopathy or any form of referable retinopathy diagnosed during pregnancy have ophthalmological follow‑up for at least 6 months after the birth of the baby. [2008, amended 2015]
  • Diabetic retinopathy should not be considered a contraindication to vaginal birth.
31
Q

Renal assessment during pregnancy

A
  • If renal assessment has not been undertaken in the preceding 3 months in women with pre‑existing diabetes, arrange it at the first contact in pregnancy. If the serum creatinine is abnormal (120 micromol/litre or more), the urinary albumin:creatinine ratio is greater than 30 mg/mmol or total protein excretion exceeds 0.5 g/day, referral to a nephrologist should be considered (eGFR should not be used during pregnancy). Thromboprophylaxis should be considered for women with nephrotic range proteinuria above 5 g/day (albumin:creatinine ratio greater than 220 mg/mmol)
32
Q

Preventing pre‑eclampsia

A
  • For guidance on using antiplatelet agents to reduce the risk of pre‑eclampsia in pregnant women with diabetes, see recommendation 1.1.2.1 in the NICE guideline on hypertension in pregnancy. [new 2015]
33
Q

Detecting congenital malformations

A
  • Offer women with diabetes an ultrasound scan for detecting fetal structural abnormalities, including examination of the fetal heart (4 chambers, outflow tracts and 3 vessels), at 20 weeks.
34
Q

Monitoring fetal growth and wellbeing

A
  • Offer pregnant women with diabetes ultrasound monitoring of fetal growth and amniotic fluid volume every 4 weeks from 28 to 36 weeks. [2008]
  • Routine monitoring of fetal wellbeing (using methods such as fetal umbilical artery Doppler recording, fetal heart rate recording and biophysical profile testing) before 38 weeks is not recommended in pregnant women with diabetes, unless there is a risk of fetal growth restriction. [2008, amended 2015]
  • Provide an individualised approach to monitoring fetal growth and wellbeing for women with diabetes and a risk of fetal growth restriction (macrovascular disease and/or nephropathy).
35
Q

Organisation of antenatal care

A
  • Offer immediate contact with a joint diabetes and antenatal clinic to women with diabetes who are pregnant. [2008]
  • Ensure that women with diabetes have contact with the joint diabetes and antenatal clinic for assessment of blood glucose control every 1–2 weeks throughout pregnancy. [2008, amended 2015]
  • At antenatal appointments, provide care specifically for women with diabetes, in addition to the care provided routinely for healthy pregnant women (see the NICE guideline on antenatal care). Table 1 describes how care for women with diabetes differs from routine antenatal care. At each appointment, offer the woman ongoing opportunities for information and education.
36
Q

Preterm labour in women with diabetes

A
  • Diabetes should not be considered a contraindication to antenatal steroids for fetal lung maturation or to tocolysis. [2008]
  • 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. [2008, amended 2015]
  • Do not use betamimetic medicines for tocolysis in women with diabetes

Bushra's NICE guidline (2 decks)

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