Diabetes in pregnancy: Management of diabetes and its complications from pre-conception to the postnatal period

NICE guidelines [CG63] Published date:

1 Guidance

Units for reporting HbA1c have changed from % to mmol/mol since this guideline was published. The NICE Pathway on diabetes has been changed to reflect this. The guideline is being updated and the new version (to be published in 2015) will use mmol/mol.

The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance.

In this reissued guidance, the information on the therapeutic indications, contraindications and use in pregnancy and lactation of drugs used in diabetes management and retinal assessment (specifically insulins, the oral hypoglycaemic agents metformin and glibenclamide, and tropicamide) has been corrected to follow the relevant SPCs (July 2008). Changes have been made to the introduction, to recommendation 1.1.6.2 and to the footnotes of recommendations 1.1.6.1, 1.2.2.12 and 1.6.1.4. Footnotes have been deleted from recommendations 1.1.6.2, 1.1.6.3, 1.1.10.2, 1.3.3.1 and 1.3.4.1.

1.1 Pre-conception care

1.1.1 Outcomes and risks for the woman and baby

1.1.1.1 Healthcare professionals should seek to empower women with diabetes to make the experience of pregnancy and childbirth a positive one by providing information, advice and support that will help to reduce the risks of adverse pregnancy outcomes for mother and baby.

1.1.1.2 Women with diabetes who are planning to become pregnant should be informed that establishing good glycaemic control before conception and continuing this throughout pregnancy will reduce the risk of miscarriage, congenital malformation, stillbirth and neonatal death. It is important to explain that risks can be reduced but not eliminated.

1.1.1.3 Women with diabetes who are planning to become pregnant and their families should be offered information about how diabetes affects pregnancy and how pregnancy affects diabetes. The information should cover:

  • the role of diet, body weight and exercise

  • the risks of hypoglycaemia and hypoglycaemia unawareness during pregnancy

  • how nausea and vomiting in pregnancy can affect glycaemic 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 glycaemic control during labour and birth and early feeding of the baby in order to reduce the risk of neonatal hypoglycaemia

  • the possibility of transient morbidity in the baby during the neonatal period, which may require admission to the neonatal unit

  • the risk of the baby developing obesity and/or diabetes in later life.

1.1.2 The importance of planning pregnancy and the role of contraception

1.1.2.1 The importance of avoiding unplanned pregnancy should be an essential component of diabetes education from adolescence for women with diabetes.

1.1.2.2 Women with diabetes who are planning to become pregnant should be advised:

  • that the risks associated with pregnancies complicated by diabetes increase with the duration of diabetes

  • to use contraception until good glycaemic control (assessed by HbA1c[2]) has been established

  • that glycaemic targets, glucose monitoring, medications for diabetes (including insulin regimens for insulin-treated diabetes) and medications for complications of diabetes will need to be reviewed before and during pregnancy

  • that additional time and effort is required to manage diabetes during pregnancy and that there will be frequent contact with healthcare professionals. Women should be given information about the local arrangements for support, including emergency contact numbers.

1.1.3 Diet, dietary supplements, body weight and exercise

1.1.3.1 Women with diabetes who are planning to become pregnant should be offered individualised dietary advice.

1.1.3.2 Women with diabetes who are planning to become pregnant and who have a body mass index above 27 kg/m2 should be offered advice on how to lose weight in line with 'Obesity: guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children' (NICE clinical guideline 43).

1.1.3.3 Women with diabetes who are planning to become pregnant should be advised to take folic acid (5 mg/day) until 12 weeks of gestation to reduce the risk of having a baby with a neural tube defect.

1.1.4 Target ranges for blood glucose in the pre-conception period

1.1.4.1 Individualised targets for self-monitoring of blood glucose should be agreed with women who have diabetes and are planning to become pregnant, taking into account the risk of hypoglycaemia.

1.1.4.2 If it is safely achievable, women with diabetes who are planning to become pregnant should aim to maintain their HbA1c below 6.1%. Women should be reassured that any reduction in HbA1c towards the target of 6.1% is likely to reduce the risk of congenital malformations.

1.1.4.3 Women with diabetes whose HbA1c is above 10% should be strongly advised to avoid pregnancy.

1.1.5 Monitoring blood glucose and ketones in the pre-conception period

1.1.5.1 Women with diabetes who are planning to become pregnant should be offered monthly measurement of HbA1c.

1.1.5.2 Women with diabetes who are planning to become pregnant should be offered a meter for self-monitoring of blood glucose.

1.1.5.3 Women with diabetes who are planning to become pregnant and who require intensification of hypoglycaemic therapy should be advised to increase the frequency of self-monitoring of blood glucose to include fasting and a mixture of pre- and postprandial levels.

1.1.5.4 Women with type 1 diabetes who are planning to become pregnant should be offered ketone testing strips and advised to test for ketonuria or ketonaemia if they become hyperglycaemic or unwell.

1.1.6 The safety of medications for diabetes before and during pregnancy

1.1.6.1 Women with diabetes may be advised to use metformin[3] as an adjunct or alternative to insulin in the pre-conception period and during pregnancy, when the likely benefits from improved glycaemic control outweigh the potential for harm. All other oral hypoglycaemic agents should be discontinued before pregnancy and insulin substituted.

1.1.6.2 Healthcare professionals should be aware that data from clinical trials and other sources do not suggest that the rapid-acting insulin analogues (aspart and lispro) adversely affect the pregnancy or the health of the fetus or newborn baby.

1.1.6.3 Women with insulin-treated diabetes who are planning to become pregnant should be informed that there is insufficient evidence about the use of long-acting insulin analogues during pregnancy. Therefore isophane insulin (also known as NPH insulin) remains the first choice for long-acting insulin during pregnancy.

1.1.7 The safety of medications for diabetic complications before and during pregnancy

1.1.7.1 Angiotensin-converting enzyme inhibitors and angiotensin-II receptor antagonists should be discontinued before conception or as soon as pregnancy is confirmed. Alternative antihypertensive agents suitable for use during pregnancy should be substituted.

1.1.7.2 Statins should be discontinued before pregnancy or as soon as pregnancy is confirmed.

1.1.8 Removing barriers to the uptake of pre-conception care and when to offer information

1.1.8.1 Women with diabetes should be informed about the benefits of pre-conception glycaemic control at each contact with healthcare professionals, including their diabetes care team, from adolescence.

1.1.8.2 The intentions of women with diabetes regarding pregnancy and contraceptive use should be documented at each contact with their diabetes care team from adolescence.

1.1.8.3 Pre-conception care for women with diabetes should be given in a supportive environment and the woman's partner or other family member should be encouraged to attend.

1.1.9 Self-management programmes

1.1.9.1 Women with diabetes who are planning to become pregnant should be offered a structured education programme as soon as possible if they have not already attended one (see 'Guidance on the use of patient-education models for diabetes', NICE technology appraisal guidance 60[4]).

1.1.9.2 Women with diabetes who are planning to become pregnant should be offered pre-conception care and advice before discontinuing contraception.

1.1.10 Retinal assessment in the pre-conception period

1.1.10.1 Women with diabetes seeking pre-conception care should be offered retinal assessment as detailed in recommendation 1.1.10.2 at their first appointment (unless an annual retinal assessment has occurred within the previous 6 months) and annually thereafter if no diabetic retinopathy is found.

1.1.10.2 Retinal assessment should be carried out by digital imaging with mydriasis using tropicamide, in line with the UK National Screening Committee's recommendations for annual mydriatic two-field digital photographic screening as part of a systematic screening programme.

1.1.10.3 Women with diabetes who are planning to become pregnant should be advised to defer rapid optimisation of glycaemic control until after retinal assessment and treatment have been completed.

1.1.11 Renal assessment in the pre-conception period

1.1.11.1 Women with diabetes should be offered a renal assessment, including a measure of microalbuminuria, before discontinuing contraception. If serum creatinine is abnormal (120 micromol/litre or more) or the estimated glomerular filtration rate (eGFR) is less than 45 ml/minute/1.73 m2, referral to a nephrologist should be considered before discontinuing contraception.

1.2 Gestational diabetes

1.2.1 Risk factors for gestational diabetes

1.2.1.1 Healthcare professionals should be aware that the following have been shown to be independent risk factors for gestational diabetes:

  • body mass index above 30 kg/m2

  • previous macrosomic baby weighing 4.5 kg or above

  • previous gestational diabetes

  • family history of diabetes (first-degree relative with diabetes)

  • family origin with a high prevalence of diabetes:

    • South Asian (specifically women whose country of family origin is India, Pakistan or Bangladesh)

    • black Caribbean

    • Middle Eastern (specifically women whose country of family origin is Saudi Arabia, United Arab Emirates, Iraq, Jordan, Syria, Oman, Qatar, Kuwait, Lebanon or Egypt).

1.2.2 Screening, diagnosis and treatment for gestational diabetes

The following recommendations, numbered 1.2.2.1, 1.2.2.2 and 1.2.2.3, are taken from 'Antenatal care: routine care for the healthy pregnant woman' (NICE clinical guideline 62).

1.2.2.1 Screening for gestational diabetes using risk factors is recommended in a healthy population. At the booking appointment, the following risk factors for gestational diabetes should be determined:

  • body mass index above 30 kg/m2

  • previous macrosomic baby weighing 4.5 kg or above

  • previous gestational diabetes

  • family history of diabetes (first-degree relative with diabetes)

  • family origin with a high prevalence of diabetes:

    • South Asian (specifically women whose country of family origin is India, Pakistan or Bangladesh)

    • black Caribbean

    • Middle Eastern (specifically women whose country of family origin is Saudi Arabia, United Arab Emirates, Iraq, Jordan, Syria, Oman, Qatar, Kuwait, Lebanon or Egypt).

      Women with any one of these risk factors should be offered testing for gestational diabetes (see recommendation 1.2.2.4).

1.2.2.2 In order to make an informed decision about screening and testing for gestational diabetes, women should be informed that:

  • in most women, gestational diabetes will respond to changes in diet and exercise

  • some women (between 10% and 20%) will need oral hypoglycaemic agents or insulin therapy if diet and exercise are not effective in controlling gestational diabetes

  • if gestational diabetes is not detected and controlled there is a small risk of birth complications such as shoulder dystocia

  • a diagnosis of gestational diabetes may lead to increased monitoring and interventions during both pregnancy and labour.

1.2.2.3 Screening for gestational diabetes using fasting plasma glucose, random blood glucose, glucose challenge test and urinalysis for glucose should not be undertaken.

1.2.2.4 The 2-hour 75 g oral glucose tolerance test (OGTT) should be used to test for gestational diabetes and diagnosis made using the criteria defined by the World Health Organization[5]. Women who have had gestational diabetes in a previous pregnancy should be offered early self-monitoring of blood glucose or an OGTT at 16–18 weeks, and a further OGTT at 28 weeks if the results are normal. Women with any of the other risk factors for gestational diabetes (see recommendation 1.2.2.1) should be offered an OGTT at 24–28 weeks.

1.2.2.5 Women with gestational diabetes should be instructed in self-monitoring of blood glucose. Targets for blood glucose control should be determined in the same way as for women with pre-existing diabetes.

1.2.2.6 Women with gestational diabetes should be informed that good glycaemic control throughout pregnancy will reduce the risk of fetal macrosomia, trauma during birth (to themselves and the baby), induction of labour or caesarean section, neonatal hypoglycaemia and perinatal death.

1.2.2.7 Women with gestational diabetes should be offered information covering:

  • the role of diet, body weight and exercise

  • 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 importance of maternal glycaemic control during labour and birth and early feeding of the baby in order to reduce the risk of neonatal hypoglycaemia

  • the possibility of transient morbidity in the baby during the neonatal period, which may require admission to the neonatal unit

  • the risk of the baby developing obesity and/or diabetes in later life.

1.2.2.8 Women with gestational diabetes should be advised to choose, where possible, carbohydrates from low glycaemic index sources, lean proteins including oily fish and a balance of polyunsaturated fats and monounsaturated fats.

1.2.2.9 Women with gestational diabetes whose pre-pregnancy body mass index was above 27 kg/m2 should be advised to restrict calorie intake (to 25 kcal/kg/day or less) and to take moderate exercise (of at least 30 minutes daily).

1.2.2.10 Hypoglycaemic therapy should be considered for women with gestational diabetes if diet and exercise fail to maintain blood glucose targets during a period of 1–2 weeks.

1.2.2.11 Hypoglycaemic therapy should be considered for women with gestational diabetes if ultrasound investigation suggests incipient fetal macrosomia (abdominal circumference above the 70th percentile) at diagnosis.

1.2.2.12 Hypoglycaemic therapy for women with gestational diabetes (which may include regular insulin, rapid-acting insulin analogues [aspart and lispro] and/or oral hypoglycaemic agents [metformin[3] and glibenclamide[6]]) should be tailored to the glycaemic profile of, and acceptability to, the individual woman.

1.3 Antenatal care

This section should be read in conjunction with 'Antenatal care: routine care for the healthy pregnant woman' (NICE clinical guideline 62).

1.3.1 Target ranges for blood glucose during pregnancy

1.3.1.1 Individualised targets for self-monitoring of blood glucose should be agreed with women with diabetes in pregnancy, taking into account the risk of hypoglycaemia.

1.3.1.2 If it is safely achievable, women with diabetes should aim to keep fasting blood glucose between 3.5 and 5.9 mmol/litre and 1-hour postprandial blood glucose below 7.8 mmol/litre during pregnancy.

1.3.1.3 HbA1c should not be used routinely for assessing glycaemic control in the second and third trimesters of pregnancy.

1.3.2 Monitoring blood glucose and ketones during pregnancy

1.3.2.1 Women with diabetes should be advised to test fasting blood glucose levels and blood glucose levels 1 hour after every meal during pregnancy.

1.3.2.2 Women with insulin-treated diabetes should be advised to test blood glucose levels before going to bed at night during pregnancy.

1.3.2.3 Women with type 1 diabetes who are pregnant should be offered ketone testing strips and advised to test for ketonuria or ketonaemia if they become hyperglycaemic or unwell.

1.3.3 Management of diabetes during pregnancy

1.3.3.1 Healthcare professionals should be aware that the rapid-acting insulin analogues (aspart and lispro) have advantages over soluble human insulin during pregnancy and should consider their use.

1.3.3.2 Women with insulin-treated diabetes should be advised of the risks of hypoglycaemia and hypoglycaemia unawareness in pregnancy, particularly in the first trimester.

1.3.3.3 During pregnancy, women with insulin-treated diabetes should be provided with a concentrated glucose solution and women with type 1 diabetes should also be given glucagon; women and their partners or other family members should be instructed in their use.

1.3.3.4 During pregnancy, women with insulin-treated diabetes should be offered continuous subcutaneous insulin infusion (CSII or insulin pump therapy) if adequate glycaemic control is not obtained by multiple daily injections of insulin without significant disabling hypoglycaemia[7].

1.3.3.5 During pregnancy, women with type 1 diabetes who become unwell should have diabetic ketoacidosis excluded as a matter of urgency.

1.3.3.6 During pregnancy, women who are suspected of having diabetic ketoacidosis should be admitted immediately for level 2 critical care[8], where they can receive both medical and obstetric care.

1.3.4 Retinal assessment during pregnancy

1.3.4.1 Pregnant women with pre-existing diabetes should be offered retinal assessment by digital imaging with mydriasis using tropicamide following their first antenatal clinic appointment and again at 28 weeks if the first assessment is normal. If any diabetic retinopathy is present, an additional retinal assessment should be performed at 16–20 weeks.

1.3.4.2 If retinal assessment has not been performed in the preceding 12 months, it should be offered as soon as possible after the first contact in pregnancy in women with pre-existing diabetes.

1.3.4.3 Diabetic retinopathy should not be considered a contraindication to rapid optimisation of glycaemic control in women who present with a high HbA1c in early pregnancy.

1.3.4.4 Women who have preproliferative diabetic retinopathy diagnosed during pregnancy should have ophthalmological follow-up for at least 6 months following the birth of the baby.

1.3.4.5 Diabetic retinopathy should not be considered a contraindication to vaginal birth.

1.3.5 Renal assessment during pregnancy

1.3.5.1 If renal assessment has not been undertaken in the preceding 12 months in women with pre-existing diabetes, it should be arranged at the first contact in pregnancy. If serum creatinine is abnormal (120 micromol/litre or more) or if total protein excretion exceeds 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 above 5 g/day (macroalbuminuria).

1.3.6 Screening for congenital malformations

1.3.6.1 Women with diabetes should be offered antenatal examination of the four-chamber view of the fetal heart and outflow tracts at 18–20 weeks.

1.3.7 Monitoring fetal growth and well-being

1.3.7.1 Pregnant women with diabetes should be offered ultrasound monitoring of fetal growth and amniotic fluid volume every 4 weeks from 28 to 36 weeks.

1.3.7.2 Routine monitoring of fetal well-being before 38 weeks is not recommended in pregnant women with diabetes, unless there is a risk of intrauterine growth restriction.

1.3.7.3 Women with diabetes and a risk of intrauterine growth restriction (macrovascular disease and/or nephropathy) will require an individualised approach to monitoring fetal growth and well-being.

1.3.8 Timetable of antenatal appointments

1.3.8.1 Women with diabetes who are pregnant should be offered immediate contact with a joint diabetes and antenatal clinic.

1.3.8.2 Women with diabetes should have contact with the diabetes care team for assessment of glycaemic control every 1–2 weeks throughout pregnancy.

1.3.8.3 Antenatal appointments for women with diabetes should provide care specifically for women with diabetes, in addition to the care provided routinely for healthy pregnant women (see 'Antenatal care: routine care for the healthy pregnant woman' [NICE clinical guideline 62]. Table 1 describes where care for women with diabetes differs from routine antenatal care. At each appointment women should be offered ongoing opportunities for information and education.

Table 1 Specific antenatal care for women with diabetes

Appointment

Care for women with diabetes during pregnancy a

First appointment (joint diabetes and antenatal clinic)

Offer information, advice and support in relation to optimising glycaemic control.

Take a clinical history to establish the extent of diabetes-related complications.

Review medications for diabetes and its complications.

Offer retinal and/or renal assessment if these have not been undertaken in the previous 12 months.

7–9 weeks

Confirm viability of pregnancy and gestational age.

Booking appointment (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).

16 weeks

Offer retinal assessment at 16–20 weeks to women with pre-existing diabetes who showed signs of diabetic retinopathy at the first antenatal appointment.

20 weeks

Offer four-chamber view of the fetal heart and outflow tracts plus scans that would be offered at 18–20 weeks as part of routine antenatal care.

28 weeks

Offer ultrasound monitoring of fetal growth and amniotic fluid volume.

Offer retinal assessment to women with pre-existing diabetes who showed no diabetic retinopathy at their first antenatal clinic visit.

32 weeks

Offer ultrasound monitoring of fetal growth and amniotic fluid volume.

Offer to nulliparous women all investigations that would be offered at 31 weeks as part of routine antenatal care.

36 weeks

Offer ultrasound monitoring of fetal growth and amniotic fluid volume.

Offer information and advice about:

  • timing, mode and management of birth

  • analgesia and anaesthesia

  • changes to hypoglycaemic therapy during and after birth

  • management of the baby after birth

  • initiation of breastfeeding and the effect of breastfeeding on glycaemic control

  • contraception and follow-up.

38 weeks

Offer induction of labour, or caesarean section if indicated, and start regular tests of fetal well-being for women with diabetes who are awaiting spontaneous labour.

39 weeks

Offer tests of fetal well-being.

40 weeks

Offer tests of fetal well-being.

41 weeks

Offer tests of fetal well-being.

aWomen with diabetes should also receive routine care according to the schedule of appointments in 'Antenatal care: routine care for the healthy pregnant woman' (NICE clinical guideline 62), including appointments at 25 weeks (for nulliparous women) and 34 weeks, but with the exception of the appointment for nulliparous women at 31 weeks

1.3.9 Preterm labour in women with diabetes

1.3.9.1 Diabetes should not be considered a contraindication to antenatal steroids for fetal lung maturation or to tocolysis.

1.3.9.2 Women with insulin-treated diabetes who are receiving steroids for fetal lung maturation should have additional insulin according to an agreed protocol and should be closely monitored.

1.3.9.3 Betamimetic drugs should not be used for tocolysis in women with diabetes.

1.4 Intrapartum care

This section should be read in conjunction with 'Intrapartum care: care of healthy women and their babies during childbirth' (NICE clinical guideline 55). This guideline includes information on timing and mode of birth for uncomplicated births at term.

1.4.1 Timing and mode of birth

1.4.1.1 Pregnant women with diabetes who have a normally grown fetus should be offered elective birth through induction of labour, or by elective caesarean section if indicated, after 38 completed weeks.

1.4.1.2 Diabetes should not in itself be considered a contraindication to attempting vaginal birth after a previous caesarean section.

1.4.1.3 Pregnant women with diabetes who have an ultrasound-diagnosed macrosomic fetus should be informed of the risks and benefits of vaginal birth, induction of labour and caesarean section.

1.4.2 Analgesia and anaesthesia

1.4.2.1 Women with diabetes and comorbidities such as obesity or autonomic neuropathy should be offered an anaesthetic assessment in the third trimester of pregnancy.

1.4.2.2 If general anaesthesia is used for the birth in women with diabetes, blood glucose should be monitored regularly (every 30 minutes) from induction of general anaesthesia until after the baby is born and the woman is fully conscious.

1.4.3 Glycaemic control during labour and birth

1.4.3.1 During labour and birth, capillary blood glucose should be monitored on an hourly basis in women with diabetes and maintained at between 4 and 7 mmol/litre.

1.4.3.2 Women with type 1 diabetes should be considered for intravenous dextrose and insulin infusion from the onset of established labour.

1.4.3.3 Intravenous dextrose and insulin infusion is recommended during labour and birth for women with diabetes whose blood glucose is not maintained at between 4 and 7 mmol/litre.

1.5 Neonatal care

1.5.1 Initial assessment and criteria for admission to intensive or special care

1.5.1.1 Women with diabetes should be advised to give birth in hospitals where advanced neonatal resuscitation skills are available 24 hours a day.

1.5.1.2 Babies of women with diabetes should be kept with their mothers unless there is a clinical complication or there are abnormal clinical signs that warrant admission for intensive or special care.

1.5.1.3 Blood glucose testing should be carried out routinely in babies of women with diabetes at 2–4 hours after birth. Blood tests for polycythaemia, hyperbilirubinaemia, hypocalcaemia and hypomagnesaemia should be carried out for babies with clinical signs.

1.5.1.4 Babies of women with diabetes should have an echocardiogram performed if they show clinical signs associated with congenital heart disease or cardiomyopathy, including heart murmur. The timing of the examination will depend on the clinical circumstances.

1.5.1.5 Babies of women with diabetes should be admitted to the neonatal unit if they have:

  • hypoglycaemia associated with abnormal clinical signs

  • respiratory distress

  • signs of cardiac decompensation due to congenital heart disease or cardiomyopathy

  • signs of neonatal encephalopathy

  • signs of polycythaemia and are likely to need partial exchange transfusion

  • need for intravenous fluids

  • need for tube feeding (unless adequate support is available on the postnatal ward)

  • jaundice requiring intense phototherapy and frequent monitoring of bilirubinaemia

  • been born before 34 weeks (or between 34 and 36 weeks if dictated clinically by the initial assessment of the baby and feeding on the labour ward).

1.5.1.6 Babies of women with diabetes should not be transferred to community care until they are at least 24 hours old, and not before healthcare professionals are satisfied that the babies are maintaining blood glucose levels and are feeding well.

1.5.2 Prevention and assessment of neonatal hypoglycaemia

1.5.2.1 All maternity units should have a written policy for the prevention, detection and management of hypoglycaemia in babies of women with diabetes.

1.5.2.2 Babies of women with diabetes should have their blood glucose tested using a quality-assured method validated for neonatal use (ward-based glucose electrode or laboratory analysis).

1.5.2.3 Babies of women with diabetes should feed as soon as possible after birth (within 30 minutes) and then at frequent intervals (every 2–3 hours) until feeding maintains pre-feed blood glucose levels at a minimum of 2.0 mmol/litre.

1.5.2.4 If blood glucose values are below 2.0 mmol/litre on two consecutive readings despite maximal support for feeding, if there are abnormal clinical signs or if the baby will not feed orally effectively, additional measures such as tube feeding or intravenous dextrose should be given. Additional measures should only be implemented if one or more of these criteria are met.

1.5.2.5 Babies of women with diabetes who present with clinical signs of hypoglycaemia should have their blood glucose tested and be treated with intravenous dextrose as soon as possible.

1.6 Postnatal care

This section should be read in conjunction with 'Postnatal care: routine postnatal care of women and their babies' (NICE clinical guideline 37). This guideline includes information on the care that all women and babies should receive in the first 6–8 weeks after birth (including information about breastfeeding).

1.6.1 Breastfeeding and effects on glycaemic control

1.6.1.1 Women with insulin-treated pre-existing diabetes should reduce their insulin immediately after birth and monitor their blood glucose levels carefully to establish the appropriate dose.

1.6.1.2 Women with insulin-treated pre-existing diabetes should be informed that they are at increased risk of hypoglycaemia in the postnatal period, especially when breastfeeding, and they should be advised to have a meal or snack available before or during feeds.

1.6.1.3 Women who have been diagnosed with gestational diabetes should discontinue hypoglycaemic treatment immediately after birth.

1.6.1.4 Women with pre-existing type 2 diabetes who are breastfeeding can resume or continue to take metformin[3] and glibenclamide[6] immediately following birth but other oral hypoglycaemic agents should be avoided while breastfeeding.

1.6.1.5 Women with diabetes who are breastfeeding should continue to avoid any drugs for the treatment of diabetes complications that were discontinued for safety reasons in the pre-conception period.

1.6.2 Information and follow-up after birth

1.6.2.1 Women with pre-existing diabetes should be referred back to their routine diabetes care arrangements.

1.6.2.2 Women who were diagnosed with gestational diabetes should have their blood glucose tested to exclude persisting hyperglycaemia before they are transferred to community care.

1.6.2.3 Women who were diagnosed with gestational diabetes should be reminded of the symptoms of hyperglycaemia.

1.6.2.4 Women who were diagnosed with gestational diabetes should be offered lifestyle advice (including weight control, diet and exercise) and offered a fasting plasma glucose measurement (but not an OGTT) at the 6-week postnatal check and annually thereafter.

1.6.2.5 Women who were diagnosed with gestational diabetes (including those with ongoing impaired glucose regulation) should be informed about the risks of gestational diabetes in future pregnancies and they should be offered screening (OGTT or fasting plasma glucose) for diabetes when planning future pregnancies.

1.6.2.6 Women who were diagnosed with gestational diabetes (including those with ongoing impaired glucose regulation) should be offered early self-monitoring of blood glucose or an OGTT in future pregnancies. A subsequent OGTT should be offered if the test results in early pregnancy are normal (see recommendation 1.2.2.4).

1.6.2.7 Women with diabetes should be reminded of the importance of contraception and the need for pre-conception care when planning future pregnancies.



[2] Diabetes Control and Complications Trial (DCCT)-aligned haemoglobin A1c (HbA1c) test.

[3] Metformin is used in UK clinical practice in the management of diabetes in pregnancy and lactation. There is strong evidence for its effectiveness and safety, which is presented in the full version of the guideline. This evidence is not currently reflected in the SPC (July 2008). The SPC advises that when a patient plans to become pregnant and during pregnancy, diabetes should not be treated with metformin but insulin should be used to maintain blood glucose levels. Informed consent on the use of metformin in these situations should be obtained and documented.

[4] 'Type 2 diabetes: the management of type 2 diabetes' (NICE clinical guideline 66) updates the information on type 2 diabetes in this technology appraisal.

[5] Fasting plasma venous glucose concentration greater than or equal to 7.0 mmol/litre or 2-hour plasma venous glucose concentration greater than or equal to 7.8 mmol/litre. World Health Organization Department of Noncommunicable Disease Surveillance (1999) Definition, diagnosis and classification of diabetes mellitus and its complications. Report of a WHO consultation. Part 1: diagnosis and classification of diabetes mellitus. Geneva: World Health Organization.

[6] Glibenclamide is used in UK clinical practice in the management of diabetes in pregnancy and lactation. There is strong evidence for its effectiveness and safety, which is presented in the full version of the guideline. This evidence is not currently reflected in the SPC (July 2008). The SPC advises that there is insufficient/limited information on the excretion of glibenclamide in human or animal breast milk. Informed consent on the use of glibenclamide during lactation should be obtained and documented.

[7] For the purpose of this guidance, 'disabling hypoglycaemia' means the repeated and unpredicted occurrence of hypoglycaemia requiring third-party assistance that results in continuing anxiety about recurrence and is associated with significant adverse effect on quality of life.

[8] Level 2 critical care is defined as care for patients requiring detailed observation or intervention, including support for a single failing organ system or postoperative care and those 'stepping down' from higher levels of care.

NICE has accredited the process used by the Centre for Clinical Practice at NICE to produce guidelines. Accreditation is valid for 5 years from September 2009 and applies to guidelines produced since April 2007 using the processes described in NICE's 'The guidelines manual' (2007, updated 2009). More information on accreditation can be viewed at www.nice.org.uk/accreditation
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