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Diabetes in pregnancy: management from preconception to the postnatal period [NG3]

Measuring the use of this guidance

Recommendation: 1.1.11

Advise women with diabetes who are planning to become pregnant 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. [2008]

What was measured: The proportion of women with type 1 diabetes who were taking the recommended 5mg dose of folic acid prior to pregnancy.
Data collection end: December 2015
46.1%
Data collection end: December 2016
41.8%
Area covered: England and Wales
Source: NHS Digital. National Pregnancy in Diabetes Audit.
What was measured: The proportion of women with type 2 diabetes who were taking the recommended 5mg dose of folic acid prior to pregnancy.
Data collection end: December 2015
22.5%
Data collection end: December 2016
22.8%
Area covered: England and Wales
Source: NHS Digital. National Pregnancy in Diabetes Audit.
What was measured: The proportion of women with type 1 diabetes who were taking the recommended 5mg dose of folic acid prior to pregnancy.
Data collection end: December 2014
44.9%
Area covered: England and Wales
Source: NHS Digital. National Pregnancy in Diabetes Audit.
What was measured: Proportion of pregnant women with type 2 diabetes prescribed 5 mg/day folic acid from at least 3 months before conception.
Data collection end: December 2014
23.7%
Area covered: England and Wales
Source: NHS Digital. National Pregnancy in Diabetes Audit.

Recommendation: 1.1.18

Advise women with diabetes who are planning to become pregnant to aim to keep their HbA1c level below 48 mmol/mol (6.5%), if this is achievable without causing problematic hypoglycaemia.

What was measured: Proportion of pregnant women with type 2 diabetes who have a first trimester HbA1c level of <48mmol/mol.
Data collection end: December 2016
38.1%
Area covered: England and Wales
Source: NHS Digital. National Pregnancy in Diabetes Audit.
What was measured: Proportion of pregnant women with type 1 diabetes who have a first trimester HbA1c level of <48mmol/mol.
Data collection end: December 2016
14.9%
Area covered: England and Wales
Source: NHS Digital. National Pregnancy in Diabetes Audit.

Recommendation: 1.1.20

Strongly advise women with diabetes whose HbA1c level is above 86 mmol/mol (10%) not to get pregnant because of the associated risks.

What was measured: Proportion of pregnant women with type 2 diabetes who have a first trimester HbA1c level of >86mmol/mol.
Data collection end: December 2016
7.4%
Area covered: England and Wales
Source: NHS Digital. National Pregnancy in Diabetes Audit.
What was measured: Proportion of pregnant women with type 1 diabetes who have a first trimester HbA1c level of >86mmol/mol.
Data collection end: December 2016
12.5%
Area covered: England and Wales
Source: NHS Digital. National Pregnancy in Diabetes Audit.

Recommendation: 1.1.21

Women with diabetes may be advised to use metformin as an adjunct or alternative to insulin in the preconception period and during pregnancy, when the likely benefits from improved blood glucose control outweigh the potential for harm. All other oral blood glucose‑lowering agents should be discontinued before pregnancy and insulin substituted.

What was measured: Proportion of pregnant women with type 1 diabetes who were taking insulin and metformin only prior to pregnancy.
Data collection end: December 2016
5.2%
Area covered: England and Wales
Source: NHS Digital. National Pregnancy in Diabetes Audit.
What was measured: Proportion of pregnant women with type 2 diabetes who were taking insulin and metformin only prior to pregnancy.
Data collection end: December 2016
12%
Area covered: England and Wales
Source: NHS Digital. National Pregnancy in Diabetes Audit.
What was measured: Proportion of pregnant women with type 1 diabetes who were taking metformin only prior to pregnancy.
Data collection end: December 2016
0.3%
Area covered: England and Wales
Source: NHS Digital. National Pregnancy in Diabetes Audit.
What was measured: Proportion of pregnant women with type 2 diabetes who were taking metformin only prior to pregnancy.
Data collection end: December 2016
52.6%
Area covered: England and Wales
Source: NHS Digital. National Pregnancy in Diabetes Audit.
What was measured: Proportion of pregnant women with type 2 diabetes who were taking diabetic medications other than metformin or insulin prior to pregnancy.
Data collection end: December 2016
6.5%
Area covered: England and Wales
Source: NHS Digital. National Pregnancy in Diabetes Audit.
What was measured: Proportion of pregnant women with type 1 diabetes who were taking diabetic medications other than metformin or insulin prior to pregnancy.
Data collection end: December 2016
0%
Area covered: England and Wales
Source: NHS Digital. National Pregnancy in Diabetes Audit.

Recommendation: 1.1.24

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.

What was measured: Proportion of pregnant women with type 1 diabetes who were taking an ACE inhibitor or ARB prior to pregnancy.
Data collection end: December 2016
0.9%
Area covered: England and Wales
Source: NHS Digital. National Pregnancy in Diabetes Audit.
What was measured: Proportion of pregnant women with type 2 diabetes who were taking an ACE inhibitor or ARB prior to pregnancy.
Data collection end: December 2016
4%
Area covered: England and Wales
Source: NHS Digital. National Pregnancy in Diabetes Audit.

Recommendation: 1.1.25

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

What was measured: Proportion of pregnant women with type 1 diabetes who were taking a statin prior to pregnancy.
Data collection end: December 2016
1.1%
Area covered: England and Wales
Source: NHS Digital. National Pregnancy in Diabetes Audit.
What was measured: Proportion of pregnant women with type 2 diabetes who were taking a statin prior to pregnancy.
Data collection end: December 2016
5%
Area covered: England and Wales
Source: NHS Digital. National Pregnancy in Diabetes Audit.

Recommendation: 1.2.2

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 gestational diabetes - 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 (see recommendations 1.2.5–1.2.7). [2008, amended 2015]

What was measured: Proportion of maternity units using NICE recommended screening criteria for gestational diabetes.
Data collection end: June 2012
83%
Number that met the criteria: 85 / 102
Area covered: England
Source: Sukumaran, S. Madhuvrata, P. Bustani, S. Song, S. Farrell T A. (2014) Screening, diagnosis and management of gestational diabetes mellitus: A national survey, Obstetric Medicine, Vol 7 (3), 111-115

Recommendation: 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%).

What was measured: Proportion of pregnant women with type 1 diabetes with a HbA1c <48mmol/mol in late pregnancy (24 weeks+).
Data collection end: December 2016
41.3%
Area covered: England and Wales
Source: NHS Digital. National Pregnancy in Diabetes Audit.
What was measured: Proportion of pregnant women with type 2 diabetes with a HbA1c <48mmol/mol in late pregnancy (24 weeks+).
Data collection end: December 2016
75.4%
Area covered: England and Wales
Source: NHS Digital. National Pregnancy in Diabetes Audit.

Recommendation: 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]

What was measured: Proportion of units offering growth scans every 4 weeks from 28 weeks onwards.
Data collection end: June 2012
97%
Number that met the criteria: 99 / 102
Area covered: England
Source: Sukumaran, S. Madhuvrata, P. Bustani, S. Song, S. Farrell T A. (2014) Screening, diagnosis and management of gestational diabetes mellitus: A national survey, Obstetric Medicine, Vol 7 (3), 111-115

Recommendation: 1.3.34

Offer immediate contact with a joint diabetes and antenatal clinic to women with diabetes who are pregnant.

What was measured: Proportion of pregnant women with type 1 diabetes who had contact with the joint diabetes antenatal team before 10+0 weeks gestation.
Data collection end: December 2016
76%
Area covered: England and Wales
Source: NHS Digital. National Pregnancy in Diabetes Audit.
What was measured: Proportion of pregnant women with type 2 diabetes who had contact with the joint diabetes antenatal team before 10+0 weeks gestation.
Data collection end: December 2016
58.1%
Area covered: England and Wales
Source: NHS Digital. National Pregnancy in Diabetes Audit.
What was measured: Proportion of women with diabetes, who had experienced an intrapartum stillbirth or intrapartum-related neonatal death and were managed in a joint diabetes and antenatal clinic in accordance with NICE guidance.
Data collection end: December 2015
50%
Number that met the criteria: 4 / 8
Area covered: UK
Source: Maternal, Newborn and Infant Clinical Outcome Review Programme. Perinatal Confidential Enquiry.

Recommendation: 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. [2008, amended 2015]

What was measured: Proportion of women with diabetes that had their capillary plasma glucose monitored every hour during labour and birth.
Data collection end: June 2015
45%
Area covered: UK
Source: A Twins and Multiple Birth Association (TAMBA) - NCT Joint Report. Maternity Services and Multiple Births.

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