Diabetes in Pregnancy

 

Approximately 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 gestational diabetes (which may or may not resolve after pregnancy), 7.5% have type 1 diabetes and the remaining 5% have type 2 diabetes. The prevalence of type 1 diabetes, and especially type 2 diabetes, has increased in recent years. The incidence of gestational diabetes is also increasing as a result of higher rates of obesity in the general population and more pregnancies in older women

Diabetes in pregnancy is associated with risks to the woman and to the developing fetus. Miscarriage, pre-eclampsia and preterm labour are more common in women with pre-existing diabetes. In addition, diabetic retinopathy can worsen rapidly during pregnancy. Stillbirth, congenital malformations, macrosomia, birth injury, perinatal mortality and postnatal adaptation problems (such as hypoglycaemia) are more common in babies born to women with pre-existing diabetes

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Preconception planning and care

Advise women with diabetes who are planning to become pregnant to aim for the same capillary plasma glucose target ranges as recommended for all people with type 1 diabetes:

  • a fasting plasma glucose level of 5–7mmol/litre on waking and
  • a plasma glucose level of 4–7 mmol/litre before meals at other times of the day

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Gestational diabetes

Diagnose gestational diabetes if the woman has either:

  • a fasting plasma glucose level of 5.6mmol/litre or above or
  • a 2-hour plasma glucose level of 7.8mmol/litre or above

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Antenatal care for women with diabetes

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: 7.8mmol/litre or
  • 2 hours after meals: 6.4mmol/litre

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Test urgently for ketonaemia if a pregnant woman with any form of diabetes presents with hyperglycaemia or is unwell, to exclude diabetic ketoacidosis

At antenatal appointments, provide care specifically for women with diabetes, in addition to the care provided routinely for healthy pregnant women.  At each appointment, offer the woman ongoing opportunities for information and education

Timetable for antenatal appointments

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Intrapartum care

  1. 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
  2. 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

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Postnatal care

For women who were diagnosed with gestational diabetes and whose blood glucose levels returned to normal after the birth:

  • Offer lifestyle advice (including weight control, diet and exercise)
  • Offer a fasting plasma glucose test 6–13 weeks after the birth to exclude diabetes (for practical reasons this might take place at the 6-week postnatal check)
  • If a fasting plasma glucose test has not been performed by 13 weeks, offer a fasting plasma glucose test, or an HbA1c test if a fasting plasma glucose test is not possible, after 13 weeks
  • Do not routinely offer a 75 g 2-hour OGTT

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Offer an annual HbA1c test to women who were diagnosed with gestational diabetes who have a negative postnatal test for diabetes

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Blood tests / Phlebotomy

If your practice does not have a practice nurse who is trained to take bloods, you can refer a patient to the Pathology Department at East Kent Hospitals for a blood test (find details here)

Alternatively, Buckland Hospital (Dover) and the Royal Victoria Hospital (Folkestone) both operate a walk-in service where no appointment is necessary, except for if the patient requires a Glucose Tolerance Test (GTT).  In the event that a GTT is required, please call 01304 222552 (for Buckland) and 01303 854484 (for Royal Victoria) to arrange a suitable appointment

Please ensure that the patient remembers to take with them their blood test form to the walk-in centres

Advice and Guidance is being made available for all specialties, and is being provided by consultant specialists at East Kent Hospitals.  To make a request or to check to if a query has been answered, you will need to log in via the electronic Referral System (eRS)

Click here for the "how to access" e-Referral Advice and Guidance Manual for instructions on how to make a request and check responses

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