Diabetes in Pregnancy

Diabetes in Pregnancy

This focuses on pregnant women with pre-existing diabetes.

Possible complications
Diabetes causes a rise in blood glucose above normal physiological levels.
Pregnancy causes a physiological reduction in insulin action.
This means that women with diabetes have an increased requirement for
insulin during pregnancy.
In pregnant women with diabetes if antihypertensives are required
methyldopa can be used.

Increased risk of complications of diabetes

Ketoacidosis may occur during the pregnancy.

Hypoglycaemia

Progression of microvascular complications

including retinopathy and nephropathy: poor glycaemic control in the first
trimester and pregnancy-induced or chronic hypertension are independently
associated with the progression of retinopathy. Worsening nephropathy can
affect maternal blood pressure, and nephropathy with superimposed preeclampsia is the most common cause of preterm delivery in women with
diabetes.

Congenital abnormalities such as neural tube defects and cardiac defects

are 3-4 times more common in established diabetics and is related to preconceptual glucose control.

Increased risk of obstetric complications

Pregnancy-induced hypertension:

Thromboembolism rates are higher.

Premature labour: babies are 5 times more likely to be delivered before 37

weeks.

Spontaneous abortion rates are higher

Obstructed labour: macrosomic and shoulder dystocia

Polyhydramnios

Maternal infection is more likely to occur.

Caesarean section

Higher incidence of UTI and endometritis

Diabetes in Pregnancy
Increased risk of foetal and neonatal complications

Late intrauterine death/stillbirth

Foetal distress can occur during labour. Foetal lungs are less mature in
diabetics.

Congenital malformation: neurological and cardiac abnormalities are

particularly common.

Fetal macrosomia and its associated complications can occur.

Hypoglycaemia and postnatal adaptation complications are more common in

babies born to mothers with pre-existing diabetes.

Respiratory distress syndrome is more likely.

Jaundice is more common.

Birth injury: Erb's palsy The infant is unable to:

Abduct the arm from the shoulder.

Rotate the arm externally from the shoulder.

Supinate the forearm.
This results in the classic 'porter's tip' or 'waiter's tip' appearance.
Increased perinatal mortality: the Confidential Enquiry showed a threefold
increased risk of perinatal mortality (ie death within the first month of life).

Pre-conception care
A review of the woman's diabetes should be conducted before pregnancy to
include glycaemic targets, glucose monitoring, medication and screening for
complications. Women planning to become pregnant should be offered a
structured education programme if they have not previously attended one. These
include 'Dose adjustment for normal eating (DAFNE)' for type 1 diabetes,
'Diabetes education and self management for ongoing and newly diagnosed type
2 diabetes (DESMOND)' and X-PERT for type 2 diabetes).
NICE advises the following:

Give advice about the avoidance of unplanned pregnancies. This should be

given regularly from adolescence.

Give advice about good glycaemic control before conception and during
pregnancy to reduce the risks of stillbirth, miscarriage, congenital
malformation and neonatal death:

The aim is to maintain HbA1c below 43 mmol/mol (6.1%) if that can

be safely achieved.

Diabetes in Pregnancy

Women with HbA1c above 86 mmol/mol (10%) should be strongly

advised to avoid pregnancy.

As well as self-monitoring of blood glucose, HbA1c testing should be

offered monthly.

Discuss how diabetes affects pregnancy and how pregnancy affects

diabetes, including:

The role of diet, weight and exercise: women with diabetes who are
planning to become pregnant and who have a body mass index >27
kg/m2, should be offered advice on how to lose weight.

Risks of hypoglycaemia and its unawareness during pregnancy.

Effects of nausea and vomiting on glycaemic control.

Increased risk of having a large for gestational age baby and the
possible complications of this (birth trauma, induction of labour,
Caesarean section).

Diabetic retinopathy and the importance of assessment for this

before pregnancy. It should then be offered every year if no retinopathy
is found.

Diabetic nephropathy and the importance of assessment for this

before and during pregnancy. This should include a measure
of microalbuminuria and serum creatinine/eGFR. If serum creatinine is
120 mol/L, or the eGFR is <45 ml/minute/1.73 m2, a referral should
be made to a nephrologist before contraception is discontinued.

Why it is important to achieve good glycaemic control for the

mother during labour and birth and the importance of early feeding of
the baby to reduce the risk of neonatal hypoglycaemia.

The possibility of admission to the neonatal unit for the baby during
the neonatal period, due to transient morbidity.

The risk of the baby developing obesity and/or diabetes in later life.

Discuss that the risks associated with pregnancy increase with the
duration of the diabetes.

Women should be advised that they will need frequent contact with health
professionals during their pregnancy.

Women with diabetes who are planning to become pregnant should take 5
mg folic acid daily until 12 weeks of gestation to reduce the risk of neural
tube defects.

Ketone testing strips should be offered to women, who should be advised

to test for ketonuria or ketonaemia if they become hypoglycaemic or unwell.
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Diabetes in Pregnancy
In addition, it may be good practice also to discuss:
Smoking cessation advice and support should be given as appropriate.

Advice on reducing or cutting down alcohol should be given as

appropriate.

Consider referral of the woman to a pre-conception diabetes clinic if

available, or to their local diabetes care team. Contraception should be
continued until the woman is seen.

Methyldopa could be considered if antihypertensives are still

needed. Labetalol and nifedipine can also be
used. Diuretics and betablockers are not advised in pregnancy and
should be discontinued/changed.

Explanation of the benefits of breast-feeding (improved blood glucose

control, easier weight loss) should be discussed.

Medication for diabetes and diabetic complications before and during pregnancy

Metformin should be used as an adjunct or alternative to insulin in the preconception period and during pregnancy, when the likely benefits from
improved glycaemic control outweigh the potential for harm.

All other hypoglycaemic agents should be discontinued before

pregnancy, and insulin substituted.

The rapid-acting insulin analogues (aspart and lispro) do not seem to

affect pregnancy or the health of the fetus or newborn baby adversely.

There is insufficient evidence about the long-acting insulin analogues

during pregnancy. Isophane insulin (neutral protamine Hagedorn (NPH)
insulin) is the first choice.

Statins should be stopped before pregnancy or as soon as pregnancy is

confirmed.

Antenatal care
Women with diabetes who are pregnant should be offered immediate contact
with a joint diabetes and antenatal clinic. They should be seen every 1-2 weeks
during pregnancy by the diabetes care team.
Glycaemic control and monitoring
If this can be safely done, the aim is:

To keep fasting glucose between 3.5 and 5.9 mmol/L

To keep 1-hour postprandial blood glucose below 7.8 mmol/L

Diabetes in Pregnancy

HbA1c should not be used routinely to assess glycaemic control in the 2nd
and 3rd trimesters.

Advise women to test fasting blood glucose and 1-hour postprandial levels
after every meal during pregnancy.

Women on insulin should also test their blood glucose before going to bed.

Women with type 1 diabetes should be offered ketone testing strips and
they should be advised to test for ketonuria or ketonaemia if they become
hypoglycaemic or unwell.

Screening for diabetes complications

Retinal assessment:

This should be offered to women with pre-existing diabetes at their first

antenatal clinic appointment if it has not been performed in the preceding
12 months.

If any diabetic retinopathy is present, an additional retinal assessment

should be offered at 16-20 weeks.

Assessment should be offered again at 28 weeks if the first assessment

was normal.
Renal assessment:

This should be arranged at the first contact in pregnancy if it has not been
carried out in the preceding 12 months.

If serum creatinine is 120 mol/L or if total protein excretion is >2 g/day,

consider referral to a nephrologist.

eGFR should not be used during pregnancy.

Thromboprophylaxis should be considered in women with proteinuria >5
g/day.

Screening and monitoring of the fetus

A scan should be offered at 7-9 weeks to confirm viability and gestational

age.

Women with diabetes should be offered antenatal examination of the fourchamber view of the fetal heart and outflow tracts at 18-20 weeks.

Ultrasound monitoring of fetal growth and amniotic fluid volume should be

performed every 4 weeks from 28 to 36 weeks.

At 38 weeks, regular (weekly) tests of foetal wellbeing should be offered to

women with diabetes who are awaiting spontaneous labour. (These may
include cardiotocography (CTG) or biophysical profiles).
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Diabetes in Pregnancy
Intrapartum care
Preterm labour:

If steroids are given for fetal lung maturation, additional insulin may
be needed by the mother and they should be closely monitored.

Betamimetic drugs should not be used for tocolysis in women with

diabetes.

At 38 completed weeks, women with a normally grown fetus should be

offered elective birth through induction of labour or elective Caesarean
section if indicated.

If the fetus is macrosomic, the woman should be informed of the risks and
benefits of vaginal birth, induction of labour and Caesarean section.

Blood glucose should be monitored hourly through labour and birth and
should be kept between 4 and 7 mmol/L.

If blood glucose cannot be kept between 4 and 7 mmol/L, an intravenous

(IV) infusion of insulin and dextrose is recommended.

If a women has type 1 diabetes, consider an IV infusion of insulin and

dextrose from the onset of established labour.

Care for the baby once delivered

The baby should only be admitted to a neonatal intensive care unit if there
is a specific complication (eg hypoglycaemia, respiratory distress, signs of
cardiac decompensation, neonatal encephalopathy).

Babies should feed as soon as possible after birth (within 30 minutes) and
then every 2-3 hours until pre-feed glucose levels are at least 2 mmol/L.

Blood glucose testing should be carried out routinely in babies of women

with diabetes, at 2-4 hours after birth.

Test blood glucose in babies who show signs of hypoglycaemia (abnormal

muscle tone, level of consciousness, fits or apnoea) and treat with IV
dextrose as soon as possible.

Babies should have an echocardiogram if they show clinical signs

associated with congenital heart disease or cardiomyopathy.

Babies should not be discharged from hospital care until they are at least
24 hours old, are maintaining blood glucose levels and are feeding well.

Postnatal care

If a woman is treated with insulin, her insulin should be reduced

immediately after birth and blood glucose levels monitored to find the
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Diabetes in Pregnancy
appropriate dose. They are at an increased risk of hypoglycaemia and should
be warned about this and how to treat it. (When the placenta has been
delivered, maternal insulin sensitivity improves. The insulin infusion rate is
likely to need reducing by up to 50% and blood glucose levels should be
monitored closely. Pre-pregnancy insulin doses are likely to be required
except if the woman is breast-feeding, when the insulin requirements will be
up to 30% less.

Breast-feeding affects glycaemic control.

Women with type 2 diabetes who are breast-feeding can resume or
continue to take metformin and glibenclamide immediately after birth.
Other oral hypoglycaemics should not be used.