1 Recommendations

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.

The wording used in the recommendations in this guideline (for example, words such as 'offer' and 'consider') denotes the certainty with which the recommendation is made (the strength of the recommendation). See about this guideline for details.

Blood glucose and plasma glucose

This guideline refers frequently to circulating glucose concentrations as 'blood glucose'. A lot of the evidence linking specific circulating glucose concentrations with particular outcomes uses 'plasma' rather than 'blood' glucose. In addition, patient‑held glucose meters (which use capillary blood samples) and monitoring systems are all calibrated to plasma glucose equivalents. However, the term 'blood glucose monitoring' is in very common use, so in this guideline we use the term 'blood glucose', except when referring to concentration values.

1.1 Preconception planning and care

Information about outcomes and risks for mother and baby

1.1.1 Aim to empower women with diabetes to have a positive experience of pregnancy and childbirth by providing information, advice and support that will help to reduce the risks of adverse pregnancy outcomes for mother and baby. [2008]

1.1.2 Explain to women with diabetes who are planning to become pregnant that establishing good blood glucose 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. [2008]

1.1.3 Give women with diabetes who are planning to become pregnant, and their family members, 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 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 neonatal unit

  • the risk of the baby developing obesity and/or diabetes in later life. [2008]

The importance of planning pregnancy and the role of contraception

1.1.4 Ensure that the importance of avoiding an unplanned pregnancy is an essential component of diabetes education from adolescence for women with diabetes. [2008, amended 2015]

1.1.5 Explain to women with diabetes that their choice of contraception should be based on their own preferences and any risk factors (as indicated by UK medical eligibility criteria for contraceptive use [UKMEC] 2009 [revised 2010]. [new 2015]

1.1.6 Advise women with diabetes that they can use oral contraceptives (if there are no standard contraindications to their use). [new 2015]

1.1.7 Advise women with diabetes who are planning to become pregnant:

  • that the risks associated with pregnancy in women with diabetes increase with how long the woman has had diabetes

  • to use contraception until good blood glucose control (assessed by HbA1c level[1] – see recommendation 1.1.18) has been established

  • that blood glucose targets, glucose monitoring, medicines for treating diabetes (including insulin regimens for insulin‑treated diabetes) and medicines for complications of diabetes will need to be reviewed before and during pregnancy

  • that extra time and effort is needed to manage diabetes during pregnancy and that she will have frequent contact with healthcare professionals. [2015]

1.1.8 Give women with diabetes who are planning to become pregnant information about the local arrangements for support during pregnancy, including emergency contact numbers. [2015]

Diet, dietary supplements and body weight

1.1.9 Offer women with diabetes who are planning to become pregnant individualised dietary advice. [2008]

1.1.10 Offer women with diabetes who are planning to become pregnant and who have a BMI above 27 kg/m2 advice on how to lose weight, in line with the NICE guideline on obesity: identification, assessment and management of overweight and obesity in children, young people and adults. [2008]

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]

Monitoring blood glucose and ketones in the preconception period

1.1.12 Offer women with diabetes who are planning to become pregnant monthly measurement of their HbA1c level[1]. [2008]

1.1.13 Offer women with diabetes who are planning to become pregnant a meter for self‑monitoring of blood glucose. [2008]

1.1.14 If a woman with diabetes who is planning to become pregnant needs intensification of blood glucose‑lowering therapy, advise her to increase the frequency of self‑monitoring of blood glucose to include fasting levels and a mixture of pre‑meal and post‑meal levels. [2008]

1.1.15 Offer women with type 1 diabetes who are planning to become pregnant blood ketone testing strips and a meter, and advise them to test for ketonaemia if they become hyperglycaemic or unwell. [new 2015]

Target blood glucose and HbA1c levels in the preconception period

1.1.16 Agree individualised targets for self‑monitoring of blood glucose with women who have diabetes and are planning to become pregnant, taking into account the risk of hypoglycaemia. [2008]

1.1.17 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 5–7 mmol/litre on waking and

  • a plasma glucose level of 4–7 mmol/litre before meals at other times of the day.

For more information, see the section on blood glucose targets in the NICE guideline on type 1 diabetes. [new 2015]

1.1.18 Advise women with diabetes who are planning to become pregnant to aim to keep their HbA1c level[1] below 48 mmol/mol (6.5%), if this is achievable without causing problematic hypoglycaemia. [new 2015]

1.1.19 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. [new 2015]

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 (see recommendation 1.1.2). [2015]

Safety of medicines for diabetes before and during pregnancy

1.1.21 Women with diabetes may be advised to use metformin[2] 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. [2008]

1.1.22 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. [2008]

1.1.23 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[3]. [2008, amended 2015]

Safety of medicines for complications of diabetes before and during pregnancy

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. [2008]

1.1.25 Statins should be discontinued before pregnancy or as soon as pregnancy is confirmed. [2008]

Removing barriers to the uptake of preconception care and when to offer information

1.1.26 Explain to women with diabetes about the benefits of preconception blood glucose control at each contact with healthcare professionals, including their diabetes care team, from adolescence. [2008]

1.1.27 Document the intentions of women with diabetes regarding pregnancy and contraceptive use at each contact with their diabetes care team from adolescence. [2008]

1.1.28 Ensure that preconception care for women with diabetes is given in a supportive environment, and encourage the woman's partner or other family member to attend. [2008, amended 2015]

Education and advice

1.1.29 Offer women with diabetes who are planning to become pregnant a structured education programme as soon as possible if they have not already attended one (see the education and information section in the NICE guideline on type 1 diabetes in adults, and the patient education section in the NICE guideline on type 2 diabetes in adults). [2008]

1.1.30 Offer women with diabetes who are planning to become pregnant preconception care and advice before discontinuing contraception. [2008]

Retinal assessment in the preconception period

1.1.31 Offer retinal assessment (see recommendation 1.1.32) 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. [2008]

1.1.32 Carry out retinal assessment by digital imaging with mydriasis using tropicamide, in line with the UK National Screening Committee's recommendations for annual mydriatic 2‑field digital photographic screening as part of a systematic screening programme. [2008]

1.1.33 Advise women with diabetes who are planning to become pregnant to defer rapid optimisation of blood glucose control until after retinal assessment and treatment have been completed. [2008]

Renal assessment in the preconception period

1.1.34 Offer women with diabetes a renal assessment, including a measure of albuminuria, before discontinuing contraception. If serum creatinine is abnormal (120 micromol/litre or more), the urinary albumin:creatinine ratio is greater than 30 mg/mmol 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. [2008, amended 2015]

1.2 Gestational diabetes

Risk assessment, testing and diagnosis

Risk assessment

1.2.1 So that women can make an informed decision about risk assessment and testing for gestational diabetes, explain that:

  • 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. [new 2015]

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]

1.2.3 Do not use fasting plasma glucose, random blood glucose, HbA1c, glucose challenge test or urinalysis for glucose to assess risk of developing gestational diabetes. [2015]

Glycosuria detected by routine antenatal testing

1.2.4 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 gestational diabetes. [new 2015]

Testing

1.2.5 Use the 2‑hour 75 g oral glucose tolerance test (OGTT) to test for gestational diabetes in women with risk factors (see recommendation 1.2.2). [2015]

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

  • early self‑monitoring of blood glucose or

  • a 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. [new 2015]

1.2.7 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. [2015]

Diagnosis

1.2.8 Diagnose gestational diabetes if the woman has either:

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

  • a 2‑hour plasma glucose level of 7.8 mmol/litre or above. [new 2015]

1.2.9 Offer women with a diagnosis of gestational diabetes a review with the joint diabetes and antenatal clinic within 1 week. [new 2015]

1.2.10 Inform the primary healthcare team when a woman is diagnosed with gestational diabetes (see also the NICE guideline on patient experience in adult NHS services in relation to continuity of care). [new 2015]

Interventions

1.2.11 Explain to women with gestational diabetes:

  • about the implications (both short and long term) of the diagnosis for her and her baby

  • that good blood glucose control throughout pregnancy will reduce the risk of fetal macrosomia, trauma during birth (for her and her baby), induction of labour and/or caesarean section, neonatal hypoglycaemia and perinatal death

  • that treatment includes changes in diet and exercise, and could involve medicines. [new 2015]

1.2.12 Teach women with gestational diabetes about self‑monitoring of blood glucose. [2015]

1.2.13 Use the same capillary plasma glucose target levels for women with gestational diabetes as for women with pre‑existing diabetes (see recommendations 1.3.5 and 1.3.6). [2015]

1.2.14 Tailor blood glucose‑lowering therapy to the blood glucose profile and personal preferences of the woman with gestational diabetes. [new 2015]

1.2.15 Offer women advice about changes in diet and exercise at the time of diagnosis of gestational diabetes. [new 2015]

1.2.16 Advise women with gestational diabetes to eat a healthy diet during pregnancy, and emphasise that foods with a low glycaemic index should replace those with a high glycaemic index. [new 2015]

1.2.17 Refer all women with gestational diabetes to a dietitian. [new 2015]

1.2.18 Advise women with gestational diabetes to take regular exercise (such as walking for 30 minutes after a meal) to improve blood glucose control. [new 2015]

1.2.19 Offer a trial of changes in diet and exercise to women with gestational diabetes who have a fasting plasma glucose level below 7 mmol/litre at diagnosis. [new 2015]

1.2.20 Offer metformin[2] to women with gestational diabetes if blood glucose targets are not met using changes in diet and exercise within 1–2 weeks. [new 2015]

1.2.21 Offer insulin instead of metformin to women with gestational diabetes if metformin is contraindicated or unacceptable to the woman. [new 2015]

1.2.22 Offer addition of insulin to the treatments of changes in diet, exercise and metformin[2] for women with gestational diabetes if blood glucose targets are not met. [new 2015]

1.2.23 Offer immediate treatment with insulin, with or without metformin[2], as well as changes in diet and exercise, to women with gestational diabetes who have a fasting plasma glucose level of 7.0 mmol/litre or above at diagnosis. [new 2015]

1.2.24 Consider immediate treatment with insulin, with or without metformin[2], as well as changes in diet and exercise, for 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. [new 2015].

1.2.25 Consider glibenclamide[4] 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. [new 2015]

1.3 Antenatal care for women with diabetes

This section should be read in conjunction with the NICE guideline on antenatal care for the healthy pregnant woman.

Monitoring blood glucose

1.3.1 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]

1.3.2 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]

1.3.3 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. [new 2015]

Target blood glucose levels

1.3.4 Agree individualised targets for self‑monitoring of blood glucose with women with diabetes in pregnancy, taking into account the risk of hypoglycaemia. [2008]

1.3.5 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. [new 2015]

1.3.6 Advise pregnant women with diabetes who are on insulin or glibenclamide to maintain their capillary plasma glucose level above 4 mmol/litre. [new 2015]

Monitoring HbA1c

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. [new 2015]

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. [new 2015]

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%). [new 2015]

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. [new 2015]

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. [2008]

Managing diabetes during pregnancy

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. [2008]

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]

1.3.14 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]

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. [2008, amended 2015]

1.3.16 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[5]. [2008]

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. [new 2015]

1.3.19 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. [new 2015]

Ketone testing and diabetic ketoacidosis

1.3.20 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]

1.3.21 Advise pregnant women with type 2 diabetes or gestational diabetes to seek urgent medical advice if they become hyperglycaemic or unwell. [new 2015]

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[6], where they can receive both medical and obstetric care. [2008]

Retinal assessment during pregnancy

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. [2008, amended 2015]

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. [2008]

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. [2008, amended 2015]

1.3.27 Diabetic retinopathy should not be considered a contraindication to vaginal birth. [2008]

Renal assessment during pregnancy

1.3.28 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). [2008, amended 2015]

Preventing pre‑eclampsia

1.3.29 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]

Detecting congenital malformations

1.3.30 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. [2008, amended 2015]

Monitoring fetal growth and wellbeing

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). [2008, amended 2015]

Organisation of antenatal care

1.3.34 Offer immediate contact with a joint diabetes and antenatal clinic to women with diabetes who are pregnant. [2008]

1.3.35 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]

1.3.36 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. [2008, amended 2015]

Table 1 Timetable of antenatal appointments

Appointment

Care for women with diabetes during pregnancy*

Booking appointment (joint diabetes and antenatal care) – 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).

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.

16 weeks

Offer retinal assessment at 16–20 weeks to women with pre‑existing diabetes if diabetic retinopathy was present at their first antenatal clinic visit.

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 second trimester.

20 weeks

Offer an ultrasound scan for detecting fetal structural abnormalities, including examination of the fetal heart (4 chambers, outflow tracts and 3 vessels).

28 weeks

Offer ultrasound monitoring of fetal growth and amniotic fluid volume.

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

Women diagnosed with gestational diabetes as a result of routine antenatal testing at 24–28 weeks enter the care pathway.

32 weeks

Offer ultrasound monitoring of fetal growth and amniotic fluid volume.

Offer nulliparous women all routine investigations normally scheduled for 31 weeks in routine antenatal care.

34 weeks

No additional or different care for women with diabetes.

36 weeks

Offer ultrasound monitoring of fetal growth and amniotic fluid volume.

Provide information and advice about:

  • 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.

37+0 weeks to 38+6 weeks

Offer induction of labour, or caesarean section if indicated, to women with type 1 or type 2 diabetes; otherwise await spontaneous labour.

38 weeks

Offer tests of fetal wellbeing.

39 weeks

Offer tests of fetal wellbeing.

Advise women with uncomplicated gestational diabetes to give birth no later than 40+6 weeks.

* Women with diabetes should also receive routine care according to the schedule of appointments in the NICE guideline on antenatal care, including appointments at 25 weeks (for nulliparous women) and 34 weeks, but with the exception of the appointment for nulliparous women at 31 weeks.

OGTT = oral glucose tolerance test.

Preterm labour in women with diabetes

1.3.37 Diabetes should not be considered a contraindication to antenatal steroids for fetal lung maturation or to tocolysis. [2008]

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. [2008, amended 2015]

1.3.39 Do not use betamimetic medicines for tocolysis in women with diabetes. [2008]

1.4 Intrapartum care

Timing and mode of birth

1.4.1 Discuss the timing and mode of birth with pregnant women with diabetes during antenatal appointments, especially during the third trimester. [new 2015]

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. [new 2015]

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. [2008]

Anaesthesia

1.4.8 Offer women with diabetes and comorbidities such as obesity or autonomic neuropathy an anaesthetic assessment in the third trimester of pregnancy. [2008]

1.4.9 If general anaesthesia is used for the birth in women with diabetes, monitor blood glucose every 30 minutes from induction of general anaesthesia until after the baby is born and the woman is fully conscious. [2008]

Blood glucose control during labour and birth

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]

1.4.11 Intravenous dextrose and insulin infusion should be considered for women with type 1 diabetes from the onset of established labour. [2008]

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. [2008, amended 2015]

1.5 Neonatal care

Initial assessment and criteria for admission to intensive or special care

1.5.1 Advise women with diabetes to give birth in hospitals where advanced neonatal resuscitation skills are available 24 hours a day. [2008]

1.5.2 Babies of women with diabetes should stay with their mothers unless there is a clinical complication or there are abnormal clinical signs that warrant admission for intensive or special care. [2008]

1.5.3 Carry out blood glucose testing routinely in babies of women with diabetes at 2–4 hours after birth. Carry out blood tests for polycythaemia, hyperbilirubinaemia, hypocalcaemia and hypomagnesaemia for babies with clinical signs. [2008]

1.5.4 Perform an echocardiogram for babies of women with diabetes 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. [2008]

1.5.5 Admit babies of women with diabetes to the neonatal unit if they have:

  • hypoglycaemia associated with abnormal clinical signs

  • respiratory distress

  • signs of cardiac decompensation from 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). [2008]

1.5.6 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. [2008]

Preventing and assessing neonatal hypoglycaemia

1.5.7 All maternity units should have a written policy for the prevention, detection and management of hypoglycaemia in babies of women with diabetes. [2008]

1.5.8 Test the blood glucose of babies of women with diabetes using a quality‑assured method validated for neonatal use (ward‑based glucose electrode or laboratory analysis). [2008]

1.5.9 Women with diabetes should feed their babies as soon as possible after birth (within 30 minutes) and then at frequent intervals (every 2–3 hours) until feeding maintains pre‑feed capillary plasma glucose levels at a minimum of 2.0 mmol/litre. [2008, amended 2015]

1.5.10 If capillary plasma glucose values are below 2.0 mmol/litre on 2 consecutive readings despite maximal support for feeding, if there are abnormal clinical signs or if the baby will not feed orally effectively, use additional measures such as tube feeding or intravenous dextrose. Only implement additional measures if one or more of these criteria are met. [2008, amended 2015]

1.5.11 Test blood glucose levels in babies of women with diabetes who present with clinical signs of hypoglycaemia, and treat those who are hypoglycaemic with intravenous dextrose as soon as possible. [2008, amended 2015]

1.6 Postnatal care

Blood glucose control, medicines and breastfeeding

1.6.1 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. [2008]

1.6.2 Explain to women with insulin‑treated pre‑existing diabetes that they are at increased risk of hypoglycaemia in the postnatal period, especially when breastfeeding, and advise them to have a meal or snack available before or during feeds. [2008]

1.6.3 Women who have been diagnosed with gestational diabetes should discontinue blood glucose‑lowering therapy immediately after birth. [2008]

1.6.4 Women with pre‑existing type 2 diabetes who are breastfeeding can resume or continue to take metformin[2] and glibenclamide[4] immediately after birth, but should avoid other oral blood glucose‑lowering agents while breastfeeding. [2008]

1.6.5 Women with diabetes who are breastfeeding should continue to avoid any medicines for the treatment of diabetes complications that were discontinued for safety reasons in the preconception period. [2008]

Information and follow-up after birth

Women with pre-existing diabetes

1.6.6 Refer women with pre‑existing diabetes back to their routine diabetes care arrangements. [2008]

1.6.7 Remind women with diabetes of the importance of contraception and the need for preconception care when planning future pregnancies. [2008]

Women diagnosed with gestational diabetes

1.6.8 Test blood glucose in women who were diagnosed with gestational diabetes to exclude persisting hyperglycaemia before they are transferred to community care. [2008]

1.6.9 Remind women who were diagnosed with gestational diabetes of the symptoms of hyperglycaemia. [2008]

1.6.10 Explain to women who were diagnosed with gestational diabetes about the risks of gestational diabetes in future pregnancies, and offer them testing for diabetes[7] when planning future pregnancies. [2008, amended 2015]

1.6.11 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. [new 2015]

1.6.12 For women having a fasting plasma glucose test as the postnatal test:

  • Advise women with a fasting plasma glucose level below 6.0 mmol/litre that:

    • they have a low probability of having diabetes at present

    • they should continue to follow the lifestyle advice (including weight control, diet and exercise) given after the birth

    • they will need an annual test to check that their blood glucose levels are normal

    • they have a moderate risk of developing type 2 diabetes, and offer them advice and guidance in line with the NICE guideline on preventing type 2 diabetes[8].

  • Advise women with a fasting plasma glucose level between 6.0 and 6.9 mmol/litre that they are at high risk of developing type 2 diabetes, and offer them advice, guidance and interventions in line with the NICE guideline on preventing type 2 diabetes[8]

  • Advise women with a fasting plasma glucose level of 7.0 mmol/litre or above that they are likely to have type 2 diabetes, and offer them a diagnostic test to confirm diabetes. [new 2015]

1.6.13 For women having an HbA1c test as the postnatal test:

  • Advise women with an HbA1c level below 39 mmol/mol (5.7%) that:

    • they have a low probability of having diabetes at present

    • they should continue to follow the lifestyle advice (including weight control, diet and exercise) given after the birth

    • they will need an annual test to check that their blood glucose levels are normal

    • they have a moderate risk of developing type 2 diabetes, and offer them advice and guidance in line with the NICE guideline on preventing type 2 diabetes[8].

  • Advise women with an HbA1c level between 39 and 47 mmol/mol (5.7% and 6.4%) that they are at high risk of developing type 2 diabetes, and offer them advice, guidance and interventions in line with the NICE guideline on preventing type 2 diabetes[8].

  • Advise women with an HbA1c level of 48 mmol/mol (6.5%) or above that they have type 2 diabetes and refer them for further care. [new 2015]

1.6.14 Offer an annual HbA1c test to women who were diagnosed with gestational diabetes who have a negative postnatal test for diabetes. [new 2015]

1.6.15 Offer women who were diagnosed with gestational diabetes early self‑monitoring of blood glucose or an OGTT in future pregnancies. Offer a subsequent OGTT if the first OGTT results in early pregnancy are normal (see recommendation 1.2.6). [2008, amended 2015]



[1] HbA1c values are reported in mmol/mol, using the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) standardised HbA1c test. The equivalent values in %, using the Diabetes Control and Complications Trial (DCCT)‑aligned HbA1c test, are reported in parentheses.

[2] Although metformin is commonly used in UK clinical practice in the management of diabetes in pregnancy and lactation, and there is strong evidence for its effectiveness and safety (presented in the full version of the guideline), at the time of publication (February 2015) metformin did not have a UK marketing authorisation for this indication. The summary of product characteristics 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. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information.

[3] At the time of publication (February 2015), long‑acting insulin analogues did not have UK marketing authorisation for use during pregnancy in women with diabetes. However, the summaries of product characteristics (SPCs) for insulin detemir and insulin glargine state that their use may be considered during pregnancy; see the SPCs of the individual products for details. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information.

[4] At the time of publication (February 2015) glibenclamide was contraindicated for use up to gestational week 11 and did not have UK marketing authorisation for use during the second and third trimesters of pregnancy in women with gestational diabetes. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information.

[5] 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.

[6] 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.

[8] Note that the threshold for defining a moderate risk of developing type 2 diabetes postnatally for women who have had gestational diabetes is different from that given in NICE guideline on preventing type 2 diabetes, because of the different populations.

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