Diabetes with Pregnancy

Annotations:

• -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 GDM,  7.5% have type 1 diabetes   5% have type 2 diabetes.

1. Risks
   1. Maternal
   2. Fetal
   3. Neonatal
2. Recommendations
   1. 1-Preconception planning and care
      1. 1.1 Information about outcomes and risks for mother and baby

         Annotations:

         • -establishing good blood glucose control before conception and continuing this throughout pregnancy will reduce the risk of miscarriage, congenital malformation, stillbirth and neonatal death. -the role of diet, body weight and exercise -the risks of hypoglycaemia and impaired awareness of hypoglycaemia during pregnancy -how nausea and vomiting in pregnancy can affect blood glucose control -the increased risk of having a baby who is large for gestational age, which increases the likelihood of birth trauma, induction of labour and caesarean section -the need for assessment of diabetic retinopathy before and during pregnancy -the need for assessment of diabetic nephropathy before pregnancy -the importance of maternal blood glucose control during labour and birth and early feeding of the baby, in order to reduce the risk of neonatal hypoglycaemia -the possibility of temporary health problems in the baby during the neonatal period, which may require admission to the NNU -the risk of the baby developing obesity and/or diabetes in later life.
      2. 1.2 The importance of planning pregnancy and the role of contraception

         Annotations:

         • -women with diabetes  can use oral contraceptives -Use contraception until good blood glucose control 
      3. 1.3 Diet, dietary supplements and body weight

         Annotations:

         • -Woman who have a BMI above 27 kg/m2 advice on how to lose weight. -Folic acid (5 mg/day) until 12 weeks of gestation to reduce the risk of having a baby with a NTD.
      4. 1.4 Monitoring blood glucose and ketones in the preconception period

         Annotations:

         • *Offer women with diabetes who are planning to become pregnant: - A monthly measurement of their HbA1c level - A a meter for self‑monitoring of blood glucose. - Increase the frequency of self‑monitoring of blood glucose to include fasting levels and a mixture of pre‑meal and post‑meal levels. *Offer women with type 1 diabetes who are planning to become pregnant blood ketone testing strips
      5. 1.5 Target blood glucose and HbA1c levels in the preconception period

         Annotations:

         • *Advise women with diabetes who are planning to become pregnant to aim to keep their HbA1c < 48 mmol/mol (6.5%). *Reassure women that any reduction in HbA1c level towards the target of 48 mmol/mol (6.5%) is likely to reduce the risk of congenital malformations in the baby. *Strongly advise women with diabetes whose HbA1c level is above 86 mmol/mol (10%) not to get pregnant 
      6. 1.6 Safety of medicines for complications of diabetes before and during pregnancy

         Annotations:

         • Statins, ACE inhibitors and angiotensin‑II receptor antagonists should be discontinued before conception or as soon as pregnancy is confirmed.
         • -Women with diabetes may be advised to use metformin as an adjunct or alternative to insulin in the preconception period and during pregnancy. -Use isophane insulin (also known as NPH insulin) as the first choice for long‑acting insulin during pregnancy.  -Consider continuing treatment with long‑acting insulin analogues (insulin detemir or insulin glargine) in women with diabetes who have established good blood glucose control before pregnancy
      7. 1.7 Retinal assessment in the preconception period

         Annotations:

         • *Offer retinal assessment to women with diabetes seeking preconception care at their first appointment (unless they have had an annual retinal assessment in the last 6 months) and then annually if no diabetic retinopathy is found. *Carry out retinal assessment by digital imaging with mydriasis using tropic amide. *Defer rapid optimisation of blood glucose control until after retinal assessment and treatment have been completed.
      8. 1.8 Renal assessment in the preconception period

         Annotations:

         • *Offer women with diabetes a renal assessment, including a measure of low‑level albuminuria (microalbuminuria), before discontinuing contraception.  *If serum creatinine is abnormal (120 micromol/litre or more),  If the urinary albumin:creatinine ratio is > 30 mg/mmol or  If the eGFR is <45 ml/minute/1.73 m2, referral to a nephrologist should be considered before discontinuing contraception. 
   2. 2-GDM
      1. Risk assessment

         Annotations:

         • -in some women, gestational diabetes will respond to changes in diet and exercise -the 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.
         • Assess risk of gestational diabetes using risk factors in a healthy population. At the booking appointment, determine the following risk factors for gestational diabetes: -BMI above 30 kg/m2 -previous macrosomic baby weighing 4.5 kg or above -previous GDM -family history of diabetes (first‑degree relative with diabetes) -minority ethnic family origin with a high prevalence of diabetes. *Offer women with any one of these risk factors testing for gestational 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.
         • --Inprevious GDM do GTT @booking  if abnormal = GDM ..(review with the joint diabetes and antenatal clinic within 1 week.) If Normal ....Repeat GTT @ 24-28 w  --In All Other risk factors...do GTT @ 24-28 w 
         • 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 ANC may indicate undiagnosed GDM. If this is observed, consider further testing to exclude GDM. 
      2. Testing

         Annotations:

         • Use the 2‑hour 75 g oral glucose tolerance test (OGTT) to test for gestational diabetes in women with risk factors  Offer women who have had gestational diabetes in a previous pregnancy: early self‑monitoring of blood glucose ora 75 g 2‑hour OGTT as soon as possible after booking (whether in the first or second trimester), and a further 75 g 2‑hour OGTT at 24–28 weeks if the results of the first OGTT are normal.  Offer women with any of the other risk factors for gestational diabetes (see recommendation 1.2.2) a 75 g 2‑hour OGTT at 24–28 weeks.
      3. Diagnosis

         Annotations:

         • Diagnose gestational diabetes if the woman has either: a FBS level of 5.6 mmol/litre or above  OR  a 2‑hour plasma glucose level of 7.8 mmol/litre or above. Offer women with a diagnosis of gestational diabetes a review with the joint diabetes and antenatal clinic within 1 week.
      4. Interventions

         Annotations:

         • **Offer a trial of changes in diet and exercise to women with gestational diabetes who have a fasting plasma glucose level < 7 mmol/litre at diagnosis.  **Offer metformin to women with gestational diabetes if blood glucose targets are not met using changes in diet and exercise within 1–2 weeks. **Offer insulin instead of metformin to women with gestational diabetes if metformin is contraindicated or unacceptable to the woman.  **Offer addition of insulin to the treatments of changes in diet, exercise and metformin for women with gestational diabetes if blood glucose targets are not met.  **Offer immediate treatment with insulin, with or without metformin, as well as changes in diet and exercise, to: 1-women with gestational diabetes who have a fasting plasma glucose level of 7.0 mmol/litre or above at diagnosis. 2- women with gestational diabetes who have a fasting plasma glucose level of between 6.0 and 6.9 mmol/litre if there are complications such as macrosomia or hydramnios. **Consider glibenclamide for women with gestational diabetes:in whom blood glucose targets are not achieved with metformin but who decline insulin therapy or who cannot tolerate metformin.
   3. 3- ANC
      1. Monitoring blood glucose

         Annotations:

         • Type I  -FBS            -Pre meal             -1 h            -Bed time  Type II / GDM ( on insulin)                  -FBS                            -Pre meal                             -1 h                             -Bed time Type II/ GDM ( dite + excersice/ Oral/ or insulin single dose)                 -FBS                 1h 
      2. Target blood glucose levels

         Annotations:

         • 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 >4 mmol/litre.
      3. Monitoring HbA1c

         Annotations:

         • 1.3.7 Measure HbA1c levels in all pregnant women with pre‑existing diabetes at the booking appointment to determine the level of risk for the pregnancy.  1.3.8 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.  1.3.9 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%).  1.3.10 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. 1.3.11 Do not use HbA1c levels routinely to assess a woman's blood glucose control in the second and third trimesters of pregnancy.
         • Measure HbA1c :  pre-existing diabetes......Booking , 2nd and 3rd trimester GDM.....at time of diagnosis
      4. Managing diabetes during pregnancy

         Annotations:

         • Insulin treatment and risks of hypoglycaemia: 1.3.12 Be aware that the rapid‑acting insulin analogues (aspart and lispro) have advantages over soluble human insulin during pregnancy and consider their use.  1.3.13 Advise women with insulin‑treated diabetes :--of the risks of hypoglycaemia and impaired awareness of hypoglycaemia in pregnancy, particularly in the first trimester. [2008] --to always have available a fast‑acting form of glucose (for example, dextrose tablets or glucose‑containing drinks). --continuous subcutaneous insulin infusion (CSII) during pregnancy if adequate blood glucose control is not obtained by multiple daily injections of insulin without significant disabling hypoglycaemia 1.3.15 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. 
         • Continuous glucose monitoring 1.3.17 Do not offer continuous glucose monitoring routinely to pregnant women with diabetes. [new 2015]1.3.18 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.
         • Ketone testing and diabetic ketoacidosis 1.3.20 Offer pregnant women with type 1 diabetes blood ketone testing strips and a meter, 1.3.21 Advise pregnant women with type 2 diabetes or gestational diabetes to seek urgent medical advice if they become hyperglycaemic or unwell.1.3.22 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]1.3.23 During pregnancy, admit immediately women who are suspected of having diabetic ketoacidosis for level 2 critical care.
      5. Retinal assessment during pregnancy

         Annotations:

         • 1.3.24 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.  ( preexisting ....asses at 1st ANC unless done in last 3 m...if retinopathy ..repeat at 16-20w ..then after 6m postnatal) 1.3.25 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. not like in preconception care where women with diabetes who are planning to become pregnant are advised to defer rapid optimisation of blood glucose control until after retinal assessment and treatment have been completed. 1.3.26 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. 1.3.27 Diabetic retinopathy should not be considered a contraindication to vaginal birth
      6. Renal assessment during pregnancy

         Annotations:

         • --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 > 30 mg/mmol or total protein excretion > 2 g/day, referral to a nephrologist should be considered  --(eGFR should not be used during pregnancy).  --Thromboprophylaxis should be considered for women with proteinuria > 5 g/day (macroalbuminuria).
      7. Preventing pre‑eclampsia

         Annotations:

         • Aspirin 
      8. Monitoring fetal growth and wellbeing

         Annotations:

         • 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.
         • 1.3.31 Offer pregnant women with diabetes ultrasound monitoring of fetal growth and amniotic fluid volume every 4 weeks from 28 to 36 weeks. [2008] 1.3.32 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] 1.3.33 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).
      9. Preterm labour in women with diabetes

         Annotations:

         • 1.3.37 Diabetes should not be considered a contraindication to antenatal steroids for fetal lung maturation OR to tocolysis.  1.3.38 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.  1.3.39 Do not use betamimetic medicines for tocolysis in women with diabetes.
   4. 4-Intrapartum care
      1. Timing and mode of birth

         Annotations:

         • 1.4.2 Advise pregnant women with type 1 or type 2 diabetes and no other complications to have an elective birth by induction of labour, or by elective caesarean section if indicated, between 37+0 weeks and 38+6 weeks of pregnancy.  1.4.3 Consider elective birth before 37+0 weeks for women with type 1 or type 2 diabetes if there are metabolic or any other maternal or fetal complications. [new 2015] 1.4.4 Advise women with gestational diabetes to give birth no later than 40+6 weeks, and offer elective birth (by induction of labour, or by caesarean section if indicated) to women who have not given birth by this time. [new 2015] 1.4.5 Consider elective birth before 40+6 weeks for women with gestational diabetes if there are maternal or fetal complications. [new 2015] 1.4.6 Diabetes should not in itself be considered a contraindication to attempting vaginal birth after a previous caesarean section. [2008] 1.4.7 Explain to pregnant women with diabetes who have an ultrasound‑diagnosed macrosomic fetus about the risks and benefits of vaginal birth, induction of labour and caesarean section.
      2. Blood glucose control during labour and birth

         Annotations:

         • 1.4.10 Monitor capillary plasma glucose every hour during labour and birth in women with diabetes, and ensure that it is maintained between 4 and 7 mmol/litre.  .4.11 Intravenous dextrose and insulin infusion should be considered for women with type 1 diabetes from the onset of established labour.  1.4.12 Use intravenous dextrose and insulin infusion during labour and birth for women with diabetes whose capillary plasma glucose is not maintained between 4 and 7 mmol/litre. 
   5. 5-Neonatal care

      Annotations:

      • Do not transfer babies of women with diabetes to community care until they are at least 24 hours old, and not before you are satisfied that the baby is maintaining blood glucose levels and is feeding well.
   6. 6-Postnatal care