About this guideline

NICE clinical guidelines are recommendations about the treatment and care of people with specific diseases and conditions.

NICE guidelines are developed in accordance with a scope that defines what the guideline will and will not cover.

This guideline was developed by the National Collaborating Centre for Women's and Children's Health, which is based at the Royal College of Obstetricians and Gynaecologists. The Collaborating Centre worked with a Guideline Development Group, comprising healthcare professionals (including consultants, GPs and nurses), patients and carers, and technical staff, which reviewed the evidence and drafted the recommendations. The recommendations were finalised after public consultation.

The methods and processes for developing NICE clinical guidelines are described in the guidelines manual.

NICE produces guidance, standards and information on commissioning and providing high‑quality healthcare, social care, and public health services. We have agreements to provide certain NICE services to Wales, Scotland and Northern Ireland. Decisions on how NICE guidance and other products apply in those countries are made by ministers in the Welsh government, Scottish government, and Northern Ireland Executive. NICE guidance or other products may include references to organisations or people responsible for commissioning or providing care that may be relevant only to England.

Update information

This guideline updates and replaces NICE guideline CG63 (published March 2008).

It has not been possible to update all recommendations in this update of the guideline. Areas for review and update were identified and prioritised through the scoping process and stakeholder feedback. Areas that have not been reviewed in this update may be addressed in 2 years' time when NICE next considers updating this guideline. NICE is currently considering setting up a standing update committee for diabetes, which would enable more rapid update of discrete areas of the diabetes guidelines, as and when new and relevant evidence is published.

Recommendations are marked as [new 2015], [2015], [2008] or [2008, amended 2015]:

  • [new 2015] indicates that the evidence has been reviewed and the recommendation has been added or updated

  • [2015] indicates that the evidence has been reviewed but no change has been made to the recommended action

  • [2008] indicates that the evidence has not been reviewed since 2008

  • [2008, amended 2015] indicates that the evidence has not been reviewed since 2008, but either changes have been made to the recommendation wording that change the meaning or NICE has made editorial changes to the original wording to clarify the action to be taken (see below).

Recommendations from NICE guideline CG63 (2008) that have been amended

Recommendations are labelled [2008, amended 2015] if the evidence has not been reviewed but either:

  • changes have been made to the recommendation wording that change the meaning or

  • NICE has made editorial changes to the original wording to clarify the action to be taken.

Recommendation(s) in 2008 guideline

Recommendation(s) in current guideline

Reason for change

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. (1.1.6.3)

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[a]. [2008, amended 2015] (1.1.23)

The summaries of product characteristics for insulin detemir and insulin glargine now state that use during pregnancy may be considered. Some consultation comments raised concerns that women with good blood glucose control on long‑acting insulin analogues may have their glucose levels disrupted if they switch to isophane insulin.

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. (1.1.11.1)

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] (1.1.34)

The text 'the urinary albumin:creatinine ratio is greater than 30 mg/mmol' has been added because this is the threshold used to define severe chronic kidney disease (NICE guideline CG182).

The terminology has been amended for consistency with the NICE guideline on chronic kidney disease.

Minor editing changes to reflect current NICE style.

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). (4.3.1.1)

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] (1.2.2)

The verb has been changed because 'screen' and 'screening' are now used in NICE guidelines only in relation to national screening programmes.

The GDG advised that the sub‑bullets listing different family origin in the original recommendation did not cover all minority ethnic groups that have a high prevalence of diabetes. It is important that women in groups other than those that were listed are not overlooked for screening.

Minor editing changes to reflect current NICE style, and the verb has been changed (no change to meaning).

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. (1.3.3.3)

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] (1.3.14)

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] (1.3.15)

The GDG advised that the original recommendation no longer reflects usual clinical practice, and the changes take this into account. It was also felt that the information is clearer if it is divided into 2 recommendations because the actions are different in each.

Minor editing changes to reflect current NICE style.

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. (1.3.4.1)

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] (1.3.24)

All women with pre‑existing diabetes should have retinal assessment at booking (first antenatal appointment) and at 28 weeks, in accordance with the NHS Diabetic Eye Screening Programme. Thus 'if the first assessment is normal' has been removed because it implies that if the first reading is not normal the woman does not need to be tested at 28 weeks.

However, if a woman has had retinal assessment in the 3 months before her booking appointment, another one isn't needed at that time.

If retinopathy is present at booking, the woman should have an additional screen at 16–20 weeks (that is, as well as at 28 weeks).

Minor editing changes to reflect current NICE style.

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. (1.3.4.4)

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] (1.3.26)

The text 'or any form of referable retinopathy' was added as advised by the National Screening Programme. Retinopathy can worsen during pregnancy because of the acute effects of improved blood glucose control. The potential continues after the birth.

Minor editing changes to reflect current NICE style.

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). (1.3.5.1)

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] (1.3.28)

The time from the previous renal assessment has been changed from 12 months to 3 months because of the increased risk of pre‑eclampsia in women with moderately increased albuminuria ('microalbuminuria').

The text 'the urinary albumin:creatinine ratio is greater than 30 mg/mmol' has been added because this is the threshold used to define severe disease in the NICE guideline on chronic kidney disease.

Minor editing changes to reflect current NICE style.

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

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] (1.3.30)

When reviewing and updating the Table of antenatal appointments in recommendation 1.3.35, the GDG became aware of some inconsistencies between the recommendations about the use of ultrasound to detect structural abnormalities in the 2008 guideline. The relevant 2008 recommendations were recommendation 1.3.6.1 (listed) and the following wording in

Table 1 (recommendation 1.3.8.3): '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'.

However, the 2008 full guideline states that the ultrasound scan for detecting structural anomalies and anatomical examination of the four‑chamber view of the fetal heart plus outflow tracts should take place at 20 weeks. This was because visualisation of fetal cardiac anatomy, including the four‑chamber view, was better at 20 weeks than at 18 weeks.

In view of this duplication of recommendations and inconsistency in gestational age, the GDG felt that it would be better to bring together the separate recommendations about screening for congenital abnormalities (scanning for structural abnormalities in general, scanning the four‑chamber view of the fetal heart and performing the ultrasound scan at 20 weeks [rather than the usual 18 weeks in a non‑diabetic pregnancy]) into 1 recommendation for greater clarity.

The recommendation was further amended from 'Offer an ultrasound scan for detecting structural anomalies and examination of the four chamber view of the fetal heart and outflow tracts' to 'Offer women with diabetes an ultrasound scan for detecting fetal structural abnormalities including examination of the fetal heart (four chambers, outflow tracts and three vessels) at 20 weeks' as these views are recommended as part of the Fetal Anomaly Screening Programme.

Minor editing changes to reflect current NICE style.

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

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] (1.3.32)

Details have been added to the recommendation to make it clear which types of monitoring are being referred to – this recommendation does not refer to standard checks carried out by midwives. The term 'intrauterjne growth restriction' is outdated and has been replaced by 'fetal growth restriction'.

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.

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. (1.3.35) [2008, amended 2015]

The term 'joint diabetes and antenatal clinic' has been used for consistency and clarity.

1.3.8.3

1.3.36

Details in table 1 (Timetable of antenatal appointments) have been amended to match changes to recommendations elsewhere in the guideline.

Minor editing changes to reflect current NICE style.

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. (1.5.2.5)

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] (1.5.11)

The GDG recommended adding the text 'those who are hypoglycaemic' for clarity.

Minor editing changes to reflect current NICE style.

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. (1.6.2.5)

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

The text '(including those with ongoing impaired glucose regulation)' has been removed because it did not make sense: women with 'ongoing impaired glucose regulation' need ongoing surveillance and care from the diabetes care team. This recommendation was intended for women who have no evidence of glucose intolerance after birth.

A verb has been changed because 'screen' and 'screening' are now used in NICE guidelines only in relation to national screening programmes.

The text '(OGTT or fasting plasma glucose)' has been removed and a footnote giving a link to WHO criteria for diagnosing diabetes has been added. This is for consistency with current practice for diagnosing diabetes.

Minor editing changes to reflect current NICE style.

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). (1.6.2.6)

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] (1.6.15)

The text '(including those with ongoing impaired glucose regulation)' has been removed because it did not make sense: anyone with 'ongoing impaired glucose regulation' needs ongoing surveillance and care from the diabetes care team. This recommendation was intended for women who have no evidence of any glucose intolerance after birth.

The text 'the test results in early pregnancy' has been changed to 'the first OGTT results in early pregnancy' to clarify which test is meant. A subsequent OGTT is not needed if the woman is self‑monitoring.

1.1.2.1, 1.1.8.3, 1.3.4.4, 1.3.7.3, 1.3.9.2, 1.4.3.1, 1.4.3.3, 1.5.2.3, 1.5.2.4

1.1.4, 1.1.28, 1.3.33, 1.3.38, 1.4.10, 1.4.12, 1.5.9, 1.5.10

NICE has made editorial changes to the original wording to clarify the action to be taken (no change to meaning): a verb has been added, or the verb used has been changed.

[a] 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.

Strength of recommendations

Some recommendations can be made with more certainty than others. The Guideline Development Group makes a recommendation based on the trade‑off between the benefits and harms of an intervention, taking into account the quality of the underpinning evidence. For some interventions, the Guideline Development Group is confident that, given the information it has looked at, most patients would choose the intervention. The wording used in the recommendations in this guideline denotes the certainty with which the recommendation is made (the strength of the recommendation).

For all recommendations, NICE expects that there is discussion with the patient about the risks and benefits of the interventions, and their values and preferences. This discussion aims to help them to reach a fully informed decision (see also patient-centred care).

Interventions that must (or must not) be used

We usually use 'must' or 'must not' only if there is a legal duty to apply the recommendation. Occasionally we use 'must' (or 'must not') if the consequences of not following the recommendation could be extremely serious or potentially life threatening.

Interventions that should (or should not) be used – a 'strong' recommendation

We use 'offer' (and similar words such as 'refer' or 'advise') when we are confident that, for the vast majority of patients, an intervention will do more good than harm, and be cost effective. We use similar forms of words (for example, 'Do not offer…') when we are confident that an intervention will not be of benefit for most patients.

Interventions that could be used

We use 'consider' when we are confident that an intervention will do more good than harm for most patients, and be cost effective, but other options may be similarly cost effective. The choice of intervention, and whether or not to have the intervention at all, is more likely to depend on the patient's values and preferences than for a strong recommendation, and so the healthcare professional should spend more time considering and discussing the options with the patient.

Recommendation wording in guideline updates

NICE began using this approach to denote the strength of recommendations in guidelines that started development after publication of the 2009 version of 'The guidelines manual' (January 2009). This does not apply to any recommendations ending [2008] (see 'Update information' above for details about how recommendations are labelled). In particular, for recommendations labelled [2008] the word 'consider' may not necessarily be used to denote the strength of the recommendation.

Other versions of this guideline

The full guideline, 'Diabetes in pregnancy: management of diabetes and its complications from preconception to the postnatal period', contains details of the methods and evidence used to develop the guideline. It is published by the National Collaborating Centre for Women's and Children's Health.

The recommendations from this guideline have been incorporated into a NICE pathway.

We have produced information for the public about this guideline.

Implementation

Implementation tools and resources to help you put the guideline into practice are also available.

ISBN: 978-1-4731-0993-3

  • National Institute for Health and Care Excellence (NICE)