Pregnancy and Diabetes
Pre-pregnancy care
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Pre-pregnancy counselling must be offered to all women, of childbearing age who have type 1 or type 2 diabetes. Care prior to conception is of the greatest importance in order to reduce the risks to the mother and her unborn child.
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Women should be advised not to get pregnant until they have achieved good metabolic control for 3 months prior to conception.
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Normal healthy outcomes of pregnancy for all women with diabetes will be dependent on good metabolic control.
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The combined diabetes and obstetric teams in secondary care give care during pregnancy. If you have any particular concerns, especially regarding patients with diabetes who are planning a pregnancy, please refer them to the secondary care diabetes team prior to conception
Pre-existing type 1 diabetes
Before conception:
• Give appropriate pre-conception contraceptive advice until good glycaemic control is achieved
• Screen for complications of diabetes.
• Refer to dietician.
• Refer to secondary care :- Consultant Diabetologist. Diabetes specialist Nurse.
• Refer to Obstetrician for pre-pregnancy advice.
• HbA1c should be <7.5 % for 3 months prior to conception.
• Check patient's blood testing technique.
• Check blood glucose meter is appropriate and quality assurance checks are performed on meter.
• Aim for blood sugars :- pre-prandial=3.5-5.5 mmol/l; post prandial <7.5 mmol/l
• Advise patient of the commitment that is required to maintain good blood glucose control throughout the pregnancy.
• Advise about the susceptibility of hypoglycaemia during pregnancy.
• Impress upon the patient, the need for good glycaemic control to avoid foetal abnormality and problems associated with pregnancy and diabetes.
• Prescribe Folic acid 5 mgs and continue for first 12 weeks of pregnancy.
• Check injection technique and injection sites.
• Review knowledge of diabetes paying attention to:-
- Hypos / Ketones / Care during illness / Contact numbers / where to get help / Blood Testing / Injection technique / Injection sites.
Confirmed pregnancy
• When pregnancy is confirmed, refer to the hospital based diabetes team and to the obstetric team
• Anti-hypertensive and Lipid lowering therapy should be stopped
• During the pregnancy regular screening, which will include fundoscopy, will be undertaken by the combined Diabetes / Obstetric teams
• Women treated with insulin during pregnancy are more likely to become hypoglycaemic. The degree and frequency of hypos can vary but some women may lose consciousness
• Spouse or partner should be taught to administer Glucagon for incidences of severe hypoglycaemia
Pre-existing type 2 diabetes
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Women requiring oral hypoglycaemic agents to control their blood glucose should be converted to insulin therapy prior to conception where possible.
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Thereafter follow care of women with type 1 diabetes
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Most women will not require insulin treatment immediately following the birth of the baby
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Women requiring insulin during the pregnancy and who continue with insulin therapy will continue to be cared for by the DSN / Diabetic team until they return to oral therapy and / or discharged back to their G.P for ongoing care
Gestational diabetes
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Vulnerable groups of women will be screened in the antenatal clinic in Secondary care if they have any of the following risk factors:
Previous GDM
Previous large baby >4 kg
BMI >30
Family history of type 2 diabetes -
Asian or Afro-Caribbean ethnic group
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Women in vulnerable groups should undergo OGTT in the first trimester and again early in the second trimester if the first test was normal
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Diabetes is confirmed if the fasting plasma venous glucose is >7 mmol/l or the 2 hour glucose is >7.8 mmol/l after a 75g OGTT
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A fasting venous plasma glucose in the range 6.1-7.0 mmol/l indicates Impaired Fasting Glucose which should be managed in the same way as for GDM
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Women will be monitored by secondary care teams during the pregnancy. Frequency of blood testing may not be as frequent as those with type 1 or 2 diabetes. This will be decided at the specialist nurses' discretion, depending on need
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Women who have had GDM or IGT will have an OGTT performed 6 weeks following the birth. This will be arranged before the woman is discharged home. The woman and her G.P will be forwarded of the result. The OGTT needs to be repeated annually by the GP
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Women are advised that they are at risk of developing type 2 diabetes in the future and are encouraged to maintain a normal weigh in the future.
They are also advised that they may develop GDM in any future pregnancy
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Practices are advised to keep a register of women who have had Gestational diabetes as they are at risk of developing Type 2 diabetes in the future.
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Women who have diabetes during their pregnancy should be advised that their baby might be BIG! They should consider the size of baby clothes for a new born
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Warn women that the if they needed insulin during pregnancy the baby may need to spend a short time in SCBU, until the babies blood sugars settle
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Encourage breast-feeding
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Although vaginal delivery is the aim, a large proportion of deliveries are by caesarean section (insulin treated women).
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There is an excellent range of information for patients on the Diabetes U.K web-site. This can be downloaded and given to patients.