Key priorities for implementation

The following recommendations have been identified as priorities for implementation. The full list of recommendations is in section 1.

Preconception planning and care

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

    • a fasting plasma glucose level of 5–7 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]

Gestational diabetes

  • 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]

Antenatal care for women with diabetes

  • Advise pregnant women with any form of diabetes to maintain their capillary plasma glucose below the following target levels, if these are achievable without causing problematic hypoglycaemia:

    • fasting: 5.3 mmol/litre

      and

    • 1 hour after meals: 7.8 mmol/litre or

    • 2 hours after meals: 6.4 mmol/litre. [new 2015]

  • 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]

  • 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.

Intrapartum care

  • 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]

  • 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]

Postnatal care

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

    • Offer lifestyle advice (including weight control, diet and exercise).

    • Offer a fasting plasma glucose test 6–13 weeks after the birth to exclude diabetes (for practical reasons this might take place at the 6‑week postnatal check).

    • If a fasting plasma glucose test has not been performed by 13 weeks, offer a fasting plasma glucose test, or an HbA1c test if a fasting plasma glucose test is not possible, after 13 weeks.

    • Do not routinely offer a 75 g 2‑hour OGTT. [new 2015]

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

  • National Institute for Health and Care Excellence (NICE)