Download Management Plan for Women with Gestational

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Template then kept by the Document manager.
Section A : Information about the document
Title of document
Guidelines for the management of pregnant women with Diabetes
Document Number & Version
Number
CP/WC/AN/007
Version 1.1
Brief description of document
management of pregnant women with Diabetes
Key words
Diabetes
Author/ owner of document
H Broude, C Rice,
Target audience/ specialty(ies)
Midwives, obstetricians, Diabetologists, diabetic specialist nurses, dieticians, consultant paediatricians
Corporate
Clinical
Type/Classification of
document
Directorate
Clinical
Draft
Status:
Corporate Non
Clinical
X
Final
Divisional
Clinical
x
Divisional
Non Clinical
Directorate
Non clinical
Section B : information about approval of the document
Date of implementation
May 2010
Date of next review
July 2012
End date
(time limited documents only)
20th Jan 2013
Sponsoring Body
Maternity guideline and audit panel
Authorising Body/Persons
Women and children’s divisional governance
Date approved by Authorising Body/persons
19th May
Has document had an Equality Impact Assessment
Yes
Superseded document to be withdrawn.
Yes
Has superseded document(s) been archived? Specify paper or
electronic and where each is stored
Electronic version on trust doc control system
Paper copy maternity ROH archive filing cabinet
Section C : information about dissemination of document and monitoring compliance
Circulation arrangements
1. Sent to Document Control Manager
2. Placed on Maternity Services shelf of Trust Document Control System
3. Placed on Document Control page of Trust intranet under ‘documents recently added’
4. Email to all on circulation list informing of new ratified guideline
5. Poster to all wards & departments informing of new ratified guideline
6. One hard copy filed in Guideline folder on labour ward
Publish internally
Yes
No
Yes/No
Monitoring compliance:
1.
Audit of compliance completed
2.
If Yes reported to
3.
If No when will it be completed
Yes
Publish externally
Date
Section D : to be completed on electronic publication
Date loaded to intranet
Date loaded to external web site
Date superseded documents archived
from intranet
Yes
No
Details
Clinical incidents are identified using the NHSLA
‘trigger list’. Incidents are reported and processed as
described in the Clinical Incident Reporting Policy in
Maternity Services. The ‘top 5’ incidents are discussed
at the site based Labour Ward Council, Divisional
Maternity Risk Management and Divisional Governance
Committee meetings. Trends are identified, action plans
made, lessons learnt disseminated, and clinical audits
commissioned as appropriate. Audit results are fed back
to these groups
From external site
Pennine Acute Hospitals NHS Trust
Guidelines for the Management of Pregnant Women with Diabetes
CPWC107 V1.1
Guidelines for the Management of Pregnant
Women with Diabetes
This guideline relates to all pregnant women who have diabetes diagnosed before or
during pregnancy. It includes women who may or may not be on Insulin or
Metformin. It includes care for the mother and baby following birth.
Document Number:
Version Number:
Authorised by:
On behalf of the Women and
Children’s governance committee
Date authorised:
Next review date:
Expiry Date:
Document Author:
CPWC107
Version 1.1
Mr Amu (Clinical Lead Obstetrics &
Gynaecology)
& Cathy Trinick (Head of Midwifery) on
behalf of Women and Children’s
Divisional Governance Committee
July 2012
20/01/2013
Helena Broude, (Diabetes Specialist
Midwife),
Caroline Rice, (Clinical Lead Obstetrics)
Mark Savage, (Consultant Physician
Diabetes & Endocrine)
Written: 10/06
Reviewed: 12/09
Expiry Date: 20/01/2013
Please ensure you have the latest version of this document
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Pennine Acute Hospitals NHS Trust
Guidelines for the Management of Pregnant Women with Diabetes
CPWC107 V1.1
Pennine Acute Hospitals NHS Trust
Guidelines for the Management of Pregnant Women with Diabetes
Main Revisions from previous issue
Name of Previous Document:
Previous Document Number:
Guidelines for the management of
pregnant women with Diabetes
CPWC106
Previous Version Number:
1
Chapters, sections and pages
which have been changed
Reference number corrected &
instructions re Metformin & IOL
clearer
Circulation list:
Membership of Guideline Group
Miss Caroline Rice (NMGH)
Dr Brigid Hayden (Fairfield)
Mr A Boulos (ROH)
Dr S Ghoshal (Rochdale)
Miss C Mammen (Rochdale)
Mrs Viv Dickinson, Governance Team
Mrs Christine O’Loughlin, Governance Team
Mrs Helen Hindle, Governance Team
Mrs Cathy Trinick, Head of Midwifery
Supervisors of Midwives
Senior Midwifery Managers
Consultant Obstetricians
Diabetologists
Diabetic specialist nurses
Dieticians
Consultant Paediatricians
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Pennine Acute Hospitals NHS Trust
Guidelines for the Management of Pregnant Women with Diabetes
CPWC107 V1.1
Contents
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
11.0
12.0
13.0
14.0
15.0
16.0
17.0
Page
Introduction
4
Aims / Purpose
4
Abbreviations
4
Scope
5
Roles/responsibilities/accountability
5
Screening for Diabetes
6
Antenatal care
6-7
Complications
8 - 11
8.1
Hyperemesis Gravidarum
8
8.2
Pre-term Labour
8-9
8.3
Hyperglycaemia & Ketoacidosis
9 - 11
Intrapartum care
11 - 13
9.1
Gestational Diabetes - Diet Controlled
11
9.2
Type 1, Type 2 & Gestational Diabetes on Metformin or
11 - 12
Insulin
9.3
Spontaneous Labour
12
9.4
Induction of Labour with Prostin
12
9.5
Induction of Labour by ARM
13
9.6
Epidural
13
9.7
Elective C-section
13
9.8
Delivery in Obstetric Theatre
13
Fetal Death in Utero
13 - 14
Post Partum Care for mothers and neonates
14 - 15
Implementation/Dissemination Arrangements
15 - 16
Training Arrangements
16
Audit and Monitoring arrangements
16 - 17
Review Arrangements
17
References
17
Appendices
18 - 28
1
- Insulin Sliding scale for use with Betamethasone
18
2
- Insulin Sliding Scale
19
3
- Management Plan for Pregnant Women Who Use CSII
20 - 22
(PUMP)
4
- Management Plan for Women with Type 1 Diabetes
23
5
- Management Plan for Women with Type 2 diabetes who
24
are on Insulin
6
- Management Plan for Women with Type 2 diabetes who
25
are on Metformin
7
- Management Plan for Women with Gestational Diabetes 26
who are on Insulin
8
- Management Plan for Women with Gestational Diabetes 27
who are on insulin BUT do not require an insulin sliding
scale (i.e. not having more than 24 units of insulin in 24 hrs)
9
- Management Plan for women with gestational diabetes
28
who are on Metformin
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Pennine Acute Hospitals NHS Trust
Guidelines for the Management of Pregnant Women with Diabetes
CPWC107 V1.1
Guidelines for the management of pregnant women with Diabetes
1.0
Introduction
1.1
Diabetes is the most common pre-existing medical disorder complicating
pregnancy in the UK. This is associated with increased risks for both mother
and baby.
“These guidelines have been drawn up with the input of diabetes, obstetric,
midwifery and diabetes specialist nurse input from across Pennine Acute
Trust. They have been updated to incorporate the recently published NICE
guidelines on the management of diabetes in pregnancy. All those involved
hope they are easy to follow and, above all, useful and practical. We would be
happy to receive any comments for the next update”. (Dr Mark W Savage on
behalf of the Obstetric and Diabetes Departments Pennine Acute Trust)
2.0
Aims / Purpose
2.1
The guidelines focus on the management of women with diabetes and are
based on the National Service Framework for Diabetes, Standard 9 2003 and
CEMACH 2005, NICE 2008. They reflect the additional care that women with
diabetes require and should be used in conjunction with usual obstetric
practice. The aim of the management is to maintain a tight control of the blood
glucose in the antenatal period and during labour.
2.2
This guideline relates to all pregnant women who have diabetes diagnosed
before or during pregnancy. It includes women who may or may not be on
Insulin or Metformin. It includes care for the mother and baby following birth.
3.0
Abbreviations
ARM - Artificial rupture of the membranes
BMI – body mass index
CEMACH – Confidential enquiries into maternal and child health
CNST - Clinical Negligence Scheme for Trusts
CS11 - subcutaneous insulin infusion
CTG - Cardiotocograph
DKA - Diabetic Ketoacidosis
EDD – Expected Date of Delivery
FBC – Full Blood count
GTT – Glucose Tolerance Test
Hba1c - Haemoglobin a1c
KCL - potassium
Mmols/l – millimols per litre
NICE – National Institute for Clinical Excellence
PET - Pre-eclamptic Toxaemia
TSH – Thyroid Stimulating Hormone
U&E - Urea and Electrolyte
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Pennine Acute Hospitals NHS Trust
Guidelines for the Management of Pregnant Women with Diabetes
CPWC107 V1.1
4.0
Scope
4.1
This guideline is for use by all clinicians providing antenatal care to pregnant
women with diabetes. Any additional care to this plan must be individualised
and planned by the appropriate clinician.
5.0
Roles, Responsibilities and Accountabilities
5.1
Women with diabetes should be cared for by a multidisciplinary team this
comprises of the diabetes team (Diabetologist, Diabetes Specialist Nurse,
Diabetes Specialist Midwife, if available and Dietician) and the Obstetric team
(Obstetrician, Diabetes Specialist Midwife if available), (CEMACH 2002) Good
communication between all professionals is essential and should be flexible to
the needs of women and their families.
5.2
All midwifery and medical staff will:
 Ensure that they are familiar with the contents of this guideline. They will
 Know how to access the document on the hospital intranet and how to
view read and print off the guidance as appropriate. Clinicians have a
responsibility to
 Refer onto the most appropriate specialist where additional care is
required.
 Ensure that women are given verbal and where available written
information to support them in making informed decisions about their care
and treatment
 Ideally women with diabetes should have received pre-pregnancy care
advice
 Women with diabetes have an increased risk of their baby being
diagnosed with neural tube defects and should be given folic acid
supplement of 5mg. until 12 completed weeks
 An appointment in the joint diabetes/ antenatal clinic should be made as
soon as pregnancy is confirmed to enable blood glucose levels to be
monitored.
 All antenatal care should be undertaken at the hospital, with the
community midwife being informed of the pregnancy.
 Women with diabetes and their partners should be given sufficient
information to enable them to be involved with decisions about their care.
 A member of the Diabetes Team will document an individualised plan of
care in the Personal Maternity Record that will outline:
o Antenatal care including targets for glycaemic control
o The woman’s fluids and Insulin requirements for labour. Ideally this
should be done at 36 weeks of pregnancy and a copy also placed in
the hospital notes. (Appendix 4,5,6)
o Postnatal care up to 6 weeks
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Pennine Acute Hospitals NHS Trust
Guidelines for the Management of Pregnant Women with Diabetes
CPWC107 V1.1
6.0
Screening for Diabetes
6.1
It is known that certain risk factors are present in women who develop
diabetes. If a women presents with one or more of the risk factors below she
should be screened with an oral glucose tolerance test at 26 weeks. This can
be done up to 36 completed weeks:
 A 1st degree relative with diabetes (parent, sibling)
 Previous baby weighing above 4.5kg
 BMI above 35 at booking
 Family origin with a high prevalence of diabetes:
o South Asian, specifically where country of origin is Pakistan, India,
or Bangladesh
o Black Caribbean
o Middle Eastern
 Previous Gestational Diabetes
 All women who had gestational diabetes in previous pregnancies
should be referred to the multidisciplinary diabetes clinics as soon as
possible after booking. They will then be asked to do home blood
glucose monitoring. During this time they will be cared for by the
community midwife, with frequent contact by the diabetes specialist
nurse/midwife.
 If the blood glucose profile is within target i.e. 4-6 mmols/l pre meal and
no more than 7.8mmols/l 2 hours after meals they should have a GTT
at 26 weeks as per the guidelines
 If the blood glucose profile is not within target they will be referred back
to the multidisciplinary diabetes clinic
7.0
Antenatal care
7.1
Plan of care
 Care should be individualised for the needs of the women. The timetable is
based around the NICE guidance for low risk women and every scan
appointment. In addition to this the women attend 1–2 weekly as deemed
necessary to their individual circumstance. This management plan for the
pregnancy is documented in the hand held records
7.1.1 First appointment
 At the first appointment, which should be as soon as possible after the
pregnancy is confirmed, women should be seen by a member of the
multidisciplinary team. An early viability scan may be considered, but
should not delay attendance.
 For women with Type 1 diabetes discuss the risks of hypoglycaemia and
hypoglycaemia unawareness
 Targets are set for glycaemic control between 4-8 mmol/l.
 Hba1c
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Pennine Acute Hospitals NHS Trust



Guidelines for the Management of Pregnant Women with Diabetes
CPWC107 V1.1
Usual booking and screening bloods
U&E’s
TSH
7.1.2 Anaesthetic referral
Referrals should be made for:
 BMI greater than 35
 Any medical complications
7.1.3 Screening Tests
 16-18 Weeks
 Antenatal Serum screening for Downs Syndrome should be offered.
 Blood Tests
 HbA1C should be taken when required, but not routinely for gestational
diabetes unless clinically necessary
 FBC and antibody screen as usual in pregnancy
 Ultra sound Scans
 If any PV bleeding, a scan should be performed to check for viability.
Otherwise scans should be undertaken as follows: o Baseline 11- 12 weeks
o Anomaly and four chamber view of the fetal heart and out flow
tracts 20+ weeks
o Growth, for type 1, type 2 and for those who have gestational
diabetes on Metformin or insulin every 2 weeks after 28 weeks
o Diet controlled gestational diabetes, every 4 weeks after 28 weeks
 Eye Examination
 Women with Type 1 and Type 2 Diabetes should have a detailed
retinal assessment and a fundoscopy examination which should be
done at least once in each trimester, by referring them to the eye
screening service in their area. Direct opthalmoscopy should be done if
this is clinically indicated or the woman has not had her eyes
photographed.
 Retinal photography should take place in the first and third trimesters.
7.1.4 Infant Feeding
If the woman wishes to breast-feed it is advisable for the midwife to discuss
breast feeding to help her prepare for the birth of her baby. This should be
done around 36 weeks gestation and include instruction on hand expressing
the breasts and storage of expressed breast milk
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8.0
Complications
8.1
Hyperemesis Gravidarum
Guidelines for the Management of Pregnant Women with Diabetes
CPWC107 V1.1
8.1.1 Type 1 and Type 2 Diabetes
If a woman with diabetes is diagnosed with Hyperemesis she requires:
 Admission into hospital (investigate cause, obstetric or diabetes)
 Always be commenced on a pregnancy specific intravenous insulin sliding
scale.
 If one has not been written up, follow the sliding scale guidance, (Appendix
2).
 Commence IV fluids as detailed below
If admitted not tolerating any fluids or diet
 A strict fluid balance should be maintained; all intravenous fluids should
be calculated together
 U&E’s should be checked on admission and 6 hourly for the 1 st 24 hours
thereafter check at least daily.
 50 units of rapid acting in 50mls normal saline 0.9% given as per sliding
scale (Appendix 2).
 2 venflons, one for the sliding scale the other for fluids,
 1st venflon – 500 mls 10% glucose with 20mmols KCL at 40 mls per hour
 Do not use Hartmann’s solution
 It is very important to have an accurate fluid balance chart. i.e. input of all
fluids to equal output + 500mls.
 There needs to be a specific individual assessment for any additional
fluids
When the woman is able to tolerate an oral diet
 At the first proper meal give the subcutaneous insulin then half an hour
afterwards discontinue all intravenous infusions but only if she has
managed to tolerate food. If not continue on the sliding scale.
If admitted tolerating a small diet/fluids
 500mls 10% glucose with 20mmols KCL run over 6 hours, together with
the insulin sliding scale.
 Give supplementary insulin with food as advised or prescribed by the
diabetes team.
 Accurate fluid balance.
 When tolerating diet, give appropriate s/c insulin then ½ hour afterwards
discontinue the intravenous insulin and glucose infusion
8.2
Pre-term labour
 If more than 35 completed weeks follow intrapartum guidelines.
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

Guidelines for the Management of Pregnant Women with Diabetes
CPWC107 V1.1
If less than 34 completed weeks, administration of corticosteroids should
be considered (CEMACH 2004 recommends the use of steroids)
As steroids can lead to maternal hyperglycaemia, it is therefore necessary
to monitor and manage blood glucose control levels closely, to prevent
the development of diabetic ketoacidosis
8.2.1 Management of care in women who have a threatened pre-term labour
 The senior obstetrician should liaise with the on call medical registrar to
formulate a plan of care
 If not already written by the diabetes/obstetric team, the insulin sliding
scale for Betamethasone needs to be written up by the on call obstetric
SHO following the sliding scale regimen (Appendix 1)
 Should the women have a subcutaneous insulin infusion (CS11) (also
known as pump therapy) then please see Appendix 3.
 Expect the blood glucose levels to rise 9 - 15 hours after the first dose of
Betamethasone and it may also rise 8 - 15 hours after the second dose. It
may take as long as 18 - 30 hours to achieve normoglycaemia.
 Discharge when normal glycaemic levels have been achieved with close
consultation with the diabetes team
 If labour commences use sliding scale as per Appendix 2
8.2.2 Planned administration of Betamethasone
At home administration.
This will be decided by the lead diabetes physician on an individual basis, this
care may be at home as long as the woman is in close consultation with her
diabetes team, and can monitor carefully her blood glucose levels and adjust
her insulin accordingly.
In patient administration
 Administer the 1st dose of Betamethasone
 Record blood glucose levels 2 hourly
 If blood glucose levels pre-prandial are 6mmols/l or above recheck in 1
hour,
 If blood glucose on the 2nd occasion is above 6mmols/l
Commence Betamethasone specific insulin sliding scale (Appendix 1).
 Discharge when normal glycaemic levels have been achieved with close
consultation with the diabetes team
8.3
Hyperglycaemia and Ketoacidosis
 The diagnosis of Hyperglycaemia with or without ketoacidosis needs to be
made urgently
 A senior Obstetrician and Endocrinologist should be in attendance and
the Consultant Obstetrician and Endocrinologist informed.
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Guidelines for the Management of Pregnant Women with Diabetes
CPWC107 V1.1
8.3.1 Site of care:
 Unless delivery is expected manage on a high dependency unit where
they can receive both medical and obstetric care.
 If initially cared for on delivery suite prior transfer to a medical bed follow
these guidelines.
 Remember: monitor viable fetus continuously (breaks no longer than 10
minutes) with CTG
 If a women develops vomiting or severe infection, cannot tolerate diet, or
declines insulin, contact a member of the diabetes team, (out of hours
contact the on call medical registrar) immediately.
8.3.2 Hyperglycaemia
 Hyperglycaemia is determined by blood glucose above 13mmol/l on 2
occasions
8.3.3 Warning signs of imminent Ketoacidosis
 Not eating properly (if not consuming adequate carbohydrates or at least
two meals)
 Vomiting repeatedly
 Not taking Insulin
8.3.4 Ketoacidosis definition
 Severe ketonuria even if normoglycaemic (3 or more on urine dipstick)
 Measurement of ketones on the Exceed meter above 1.5mmols
 Acidosis determined by blood analysis.(bicarbonate <15mmol/l
NOTE
 Ketoacidosis can develop in the absence of hyperglycaemia
(“Euglycaemic Ketoacidosis)
 Pregnant women can get accelerated ketosis that can turn to Ketoacidosis
within a few hours. This is potentially life threatening, for the baby in
particular but also for the mother.
8.3.5 Early Management – Fluids / potassium / insulin
 Intravenous fluid
 Give 1 litre 0.9% sodium chloride immediately during the first hour
 Then: 1 litre over next hour
 2 litres over next 2 – 4 hours
 1 litre 4 – 6 hourly after that
 Reduce amount in mild DKA (bicarbonate >10). As more rapid infusion
increases risk of respiratory distress syndrome
 Switch to 5% glucose 1 litre 8 hourly once glucose <15mmol/l:
Continue simultaneous 0.9% saline if still volume depleted
 If serum sodium rises above 155mmol/l switch to glucose/saline (or
glucose 5% if blood glucose < 15)
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Guidelines for the Management of Pregnant Women with Diabetes
CPWC107 V1.1
 Potassium
 Serum potassium is often normal or high initially but total body
potassium is low
 Anticipate fall in potassium and replace, once first plasma potassium
known.
 Insulin
 Add 50 units of soluble insulin to 50ml 0.9% sodium chloride in a 50 ml
syringe
 Infuse intravenous insulin starting at 6 units/hour; give quick acting
insulin 10 units intramuscularly if delay in starting intravenous insulin
 Check venous glucose (laboratory) at 2 hour. If blood glucose has not
fallen check pump working and intravenous connections, then increase
insulin infusion to10 units/hour
 Measure blood glucose hourly using blood glucose meter
 Once glucose falling, adjust insulin infusion rate according to sliding
scale see Appendix 2
 Other measures
 Consider urinary catheter if no urine passed after 2 hours
 Screen for infection and give antibiotics if clinical evidence of infection
(white cell count may be markedly raised from DKA alone)
 Continue intravenous insulin and fluids acidosis reversed and patient
ready to eat and drink
 Discontinue sliding scale once subcutaneous insulin given
 Bicarbonate administration
 In most cases is NOT helpful and is potentially dangerous
 Only consider after discussion with consultant
9.0
Intrapartum care
9.1
Gestational diabetes - diet controlled
 Treat as normal in labour and delivery
 No need for maternal blood glucose testing unless specifically requested
by the diabetes team
9.2
Type 1, Type 2 and gestational diabetes on Metformin or insulin,
 The aim is to deliver up to or as near as possible to the scan EDD. This
will be a clinical judgement discussed with the team, based on the
individual needs of the woman
 These women are high risk and should therefore be nil by mouth in labour.
 The Diabetologist will have made an individualised plan for labour delivery
and the puerperium with regards to the insulin requirements and regimen
at about 36 weeks (see appendices 4 – 9). If a plan is not available please
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
9.3
Guidelines for the Management of Pregnant Women with Diabetes
CPWC107 V1.1
use the sliding scale, (Appendix 2).
The aim of the Insulin sliding scale regime is to maintain very tight control
of the blood glucose levels. This should be maintained between 4–6
mmols and is based on the current requirements of the woman.
Spontaneous labour
 In labour the middle grade obstetrician on call should be informed.
 There must be continuous fetal monitoring during labour.
 On admission, in addition to the routine assessment of the woman, a
capillary blood sample should be taken for glucose measurement.
o If the result is less than 5 mmol/l delay starting the IV
insulin/glucose regimen. then check blood glucose levels hourly
o If the result is greater than 5mmol/l start IV insulin/glucose regimen.
o If blood glucose levels continue to be within the normal range of 46 mmol/l start insulin infusion at the time the next meal would be
due
o NB If the result is within normal/acceptable ranges of 4- 6mmol/l
and delivery is likely to be soon (within 1 hour); there is no need to
start the insulin/glucose regimen. If delivery is not imminent,
commence regimen.
 Baseline potassium levels should be taken (with urea and electrolytes) and
then 6 hourly during labour.
9.3.1 Insulin/ Glucose Regimen
 500 mls of 10% Glucose with 10 mmols KCL run over 6 hours = 84 mls
per hour
 50 units rapid acting (e.g. Actrapid, Novorapid, Humalog, Apidra) using
specific insulin syringe, in 50mls normal saline 0.9% (1unit/1ml) via the
syringe driver, at rate requested by the Diabetologist in the sliding scale
(Appendix 2)
 Use a grey (16g) venflon.
 Both glucose and insulin to run via the same venflon
 A 2nd line should be established if any other intravenous fluids are
required e.g. Syntocinon
 Check blood glucose hourly or more frequently if Diabetologist requests it.
9.4
Induction of Labour with Prostin
 Woman can eat and drink as normal
 Usual dose of insulin until labour is established,
 Once labour established move to delivery suite.
 On delivery suite nil by mouth
 Commence insulin/glucose regime when blood glucose levels go above
5mmols/l, or when the next meal is due.
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Guidelines for the Management of Pregnant Women with Diabetes
CPWC107 V1.1
9.5
Induction of Labour by ARM
 Usual dose of insulin at breakfast
 Nil by mouth when on delivery suite
 Commence insulin/glucose regime when blood glucose levels go above
5mmols/l, or when the next meal is due
9.6
Epidural
 Diabetes is not a contraindication for epidural and it should be offered as
a choice of pain relief. It is advisable NOT to use Hartmann’s for women
with diabetes as it contains lactate. Normal saline should replace
Hartmann’s unless required, e.g. for PET. This should be done in close
consultation with a middle grade obstetrician or anaesthetist.
9.7
Elective Caesarean Section
 Women with diabetes should be first on the elective theatre list.
 The previous evening take insulin as normal, and a venflon to be put in.
 Nil by mouth from midnight. If hypoglycaemic during the night, call the on
call obstetric SHO, give 50 ml of 50% glucose via a large venflon in a
large vein.
 Repeat after 15 minutes. If still clinically hypoglycaemic or blood glucose
below 4 mmol/l start the insulin/glucose regime.
 Blood glucose levels to be taken hourly as per guidelines
 Otherwise start insulin/glucose regime at 7 am
9.8
Delivery in Obstetric Theatre
 Aim for blood glucose levels between 4 mmols/l – 6 mmols/l, to help
reduce frequency of hypoglycaemia in the neonate.
 During the time in theatre whether the woman is having a spinal or
general anaesthetic, blood glucose measurements should be taken every
30 minutes to avoid maternal hypoglycaemia.
 If symptomatically hypoglycaemic stop the insulin infusion for 20 minutes
only but continue the glucose infusion.
 Re check the blood glucose after 20 minutes and restart the infusion,
adjusting the insulin sliding scale (Appendix 2) one column to the left if the
woman is hypoglycaemic and one column to the right if the woman is
hyperglycaemic.
10.0 Fetal Death in Utero
10.1 Gestational diabetes
The insulin/glucose regimen is not started, as the extra demands made on the
woman’s metabolism are now removed as the fetus has died.
10.2 Type 1 Diabetes
Use pre pregnancy insulin requirements and refer to the sliding scale
(Appendix 2)
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Guidelines for the Management of Pregnant Women with Diabetes
CPWC107 V1.1
10.3 Type 2 Diabetes
Monitor blood glucose hourly, and if greater than 9mmols/l, start on insulin
sliding scale on scale 1 (Appendix 2).
Seek advice from senior obstetrician and Diabetologist.
11.0 Post Partum Care for mothers and neonates
Immediate Post Partum Management for:
11.1 Type 1 Diabetes
 After delivery of the placenta halve the insulin but continue the glucose
infusion
 If delivery is complicated and other fluids are required, e.g. blood etc.,
administer these in addition to the insulin/glucose regime according to
requirements. Any additional fluids must be given through a second line
separate from the insulin.
 When eating and drinking normally restart the subcutaneous insulin at the
next meal, stopping the IV insulin (sliding scale) 30 mins after the
subcutaneous insulin is given.
 Revert to pre pregnancy insulin requirements unless Diabetologist has
suggested otherwise.
 If patient is vomiting, continue with the sliding scale until patient is
tolerating diet.
 Check blood glucose four times daily, i.e. pre meal and bed-time.
11.2 Type 2 Diabetes
 Stop Insulin sliding scale
 Stop subcutaneous insulin
 Can continue on oral medication if prescribed by Diabetologist. (Metformin
can be used if breast feeding)
 Check blood glucose four times daily until discharge.
11.3 Gestational diabetes, on Insulin or Metformin
 Discontinue the insulin sliding scale and the IV glucose immediately after
the placenta is delivered.
 Stop subcutaneous insulin and /or Metformin
 Blood glucose measurements four times daily until discharge, or as
requested by the Diabetologist
 If blood glucose above 8mmols/s on 2 consecutive occasions contact a
member of the diabetes team
11.4
Care of babies for women who are on Insulin or Metformin during
pregnancy, including prevention and detection of hypoglycaemia
 Breast-feeding is recommended, but all mothers should be supported in
the feeding method of their choice.
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Guidelines for the Management of Pregnant Women with Diabetes
CPWC107 V1.1
The baby should remain with the mother and be admitted to the neonatal
unit only if there is a specific indication.
Babies should be treated as high risk according to the guidelines for
neonatal hypoglycaemia (CPWC003)
Early feeding, ideally within 1 hour of delivery, no more than 2 hours
Keep warm, skin-to–skin contact is preferable
Frequent feeding, ideally 2- 3 hourly
Check capillary blood glucose (haemacue) 4 hours after delivery and
earlier if clinically indicated
If capillary blood glucose above 2.6 mmols continue to do pre feed
capillary blood glucose and feed 3 hourly. If any deviations from this follow
the paediatric hypoglycaemia flow chart
If 3 consecutive capillary blood glucose above 2.6mmols discontinue blood
glucose measurement.
Feed on demand.
Maintain Neonatal Observation chart for 24 hours post delivery
Breast feeding mothers need to increase their daily carbohydrate intake by
approximately 50 gm, so that they do not become hypoglycaemic. (e.g. 4
plain biscuits or two thick slices of bread).
11.5
Care of babies for women who are diet controlled during pregnancy
 These babies do not need to follow the high-risk guidelines, unless there
are other contributing factors.
 Breast-feeding is recommended, but all mothers should be supported in
the feeding method of their choice.
 Close observation is still required for the babies of women who are diet
controlled during pregnancy; therefore they should be placed on a
neonatal observation chart.
 Early feeding required.
11.6
Post natal follow up for women
 Women with Type 1 and Type 2 diabetes should be given a 6/8 week
follow up appointment at the Young Persons clinic (or equivalent) at the
diabetes centre or the community diabetes service
 All women who have had gestational diabetes should have a repeat
glucose tolerance test at 6 weeks. This should be arranged prior to
discharge from the ward
12.0 Implementation /Dissemination


This document will be uploaded onto the Trust’s Intranet Site via the
Document Management System – all staff will use this resource to access
guidelines.
Notification of upload will be added to the Trust’s weekly bulletin
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Guidelines for the Management of Pregnant Women with Diabetes
CPWC107 V1.1
A Poster will be placed in the clinical area
Notification of new guidelines will take place through meetings within the
directorate e.g., labour ward forum, risk management meeting and ward
managers meeting.
One hard copy filed in Guideline folder on labour ward
13.0 Training Arrangements
13.1
Refer to Divisional Policy: Standards for Education &Training in Maternity
Services DPWC012 (Training Needs and Analysis).
14.0 Audit and Monitoring Arrangements
14.1
Refer to Protocol for Audit & Monitoring of Maternity Guidelines & Clinical
Practice CPWC093.
To audit compliance with Standard 1.3.9 of the CNST maternity risk
management standards:
AUDIT
1.3.9a
Diabetes
The multidisciplinary team including the obstetrician, midwife, diabetes
physician, diabetes specialist nurse and dietician are involved in the provision
of care
1.3.9b
The timetable of antenatal appointments is followed
1.3.9c
&d
An individual management plan is documented in the health records and it
covers the pregnancy and postnatal period up to six weeks and targets for
glycaemic control
Women with type 1 diabetes are advised of the risks of hypoglycaemia and
hypoglycaemia unawareness in pregnancy
1.3.9e
1.3.9f
Women are offered antenatal ultrasound examination of the four chamber view
of the fetal heart and outflow tracts at 20 week
1.3.9g
Women who are suspected of having diabetic ketoacidosis are admitted
immediately to a high dependency unit
Process for monitoring
Frequency of audit
Responsible individual / group
Responsible group for review of results &
development of action plan
Responsible group / committee for monitoring of
action plans
Clinical Audit
In the second year following
ratification
NMGH diabetes team
Diabetes team meeting
Maternity Guideline & Audit Panel
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Guidelines for the Management of Pregnant Women with Diabetes
CPWC107 V1.1
To monitor compliance with Standard 1.5.4 of the CNST maternity risk management
standards
Monitoring
1.5.4 b
Neonates of women with diabetes are managed as per guideline
Process for monitoring
Quality ward monitoring programme
Frequency of audit
Bi monthly
Responsible individual / group
Designated midwife and post natal
ward manager
Responsible group for review of results &
Labour ward Forum
development of action plan
Responsible group / committee for monitoring of Divisional Ward Forum
action plans
15.0 Review Arrangements

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All guidelines will be reviewed three yearly
The document control administrator will inform the guideline group that the
guidelines require updating as per the scheduled review date
A nominated member of the guideline group will update the guideline
circulating it for comment as appropriate
The guideline will then agreed at the guideline group and ratified through
the divisional governance process.
16.0 References/ Bibliography
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Bailey B., Cardwell M. (1996), A Team Approach to Managing Existing
Diabetes Complicated by Pregnancy. The Diabetes Educator, Volume 22
no 2 p 111-112
Campbell K., Mc Pharland P.J., (1992), Diabetes Discovered in
Pregnancy, England Boehringer Manheim
CESDI (2001) Diabetes CESDI: Standards of Care. Notification Pack.
Manchester: CESDI UK
CEMACH 2002 – maternity services in 2002 for Type 1 and Type 2
diabetes
Department of Health (2003) National Service Framework for Diabetes:
Standard 9: Diabetes and Pregnancy. London: DOH
NICE March 2008- Diabetes in pregnancy: Management of diabetes and
its complications from pre-conception to the post natal period .NICE
clinical guideline 63
Pickup J., Williams G. (1997), Text Book of Diabetes (Second Ed.) Volume
1 and 2, Blackwell Science.
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Guidelines for the Management of Pregnant Women with Diabetes
CPWC107 V1.1
Appendix 1
Insulin Sliding scale for use with Betamethasone
This should be given in addition to the Subcutaneous Insulin already prescribed.
(If the woman is eating and drinking a glucose infusion is not required)
 50 units of rapid acting insulin (e.g. Actrapid or Novorapid) in 50 mls normal
saline 0.9% drawn up in a 50-ml syringe and is adjusted per sliding scale
using a specific insulin syringe
 The initial dosage regime is determined according to the current 24 hour
subcutaneous insulin requirement i.e. add total requirement of Insulin over a
twenty four hour period
 Take blood glucose measurements hourly and adjust the scale accordingly
(see sliding scale below).
 The Sliding scale is based upon the hourly insulin requirement of the woman.
In order to determine which column to use it is necessary to divide the total
daily insulin dose by 24 hours
E.g. if the total insulin daily dose is 48 units this should be divided by 24 hours
48 = 2
24
2 will therefore be equal to X and the second column be used for the sliding scale.
Sliding Scale for use with Betamethasone only
X=
1
2
3
4
6
8
0
0.5
1
1.5
2
3
0
1
2
3
4
6
0
2
3
4
6
8
0
3
5
7
10
13
0
4
7
9
14
18
0
5
9
11
18
24
Blood Glucose
Less than 6.0
6.1 – 7.0
7.1 – 8.0
8.1 – 9.0
9.1 – 10.0
Greater than 10

If Blood Glucose levels are greater than 10mmols/l for 2 consecutive hours then
the scale should be adjusted by one column to the right in order to increase the
amount of insulin administered.
 If Blood Glucose level is less than 4mmols/l for two consecutive hours then the
sliding scale should be adjusted to the left in order to reduce the amount of
insulin administered.
 Continue at least 12 hours after the 2nd steroid injection
 Discharge when normal glycaemic levels have been achieved with close
consultation with the diabetes team
 If labour commences revert to Appendix 2
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Guidelines for the Management of Pregnant Women with Diabetes
CPWC107 V1.1
Appendix 2
Insulin Sliding Scale (units/hour)
50 units of rapid acting insulin (e.g. Actrapid, Novorapid) in 50 mls normal saline
should be drawn up into a 50 ml syringe (adjust per sliding scale) using specific
insulin syringe
The initial dosage regime is determined according to the current 24 hour
subcutaneous insulin requirement i.e. add total requirement of insulin over a twenty
four hour period
Take blood glucose measurements hourly and adjust the scale accordingly (see
sliding scale below).
The sliding scale is based upon the hourly insulin requirement of the woman. In
order to determine which column to, use it is necessary to divide the total daily
insulin dose by 24 hours
E.g. if the total insulin daily dose is 48 units this should be divided by 24 hours.
49 = 2
24
2 will therefore be equal hot X and the second column be used for the sliding scale.
If total insulin daily requirement is less than 24 units advice must be sought from oncall medical middle grade if plan of care not already in place.
Sliding Scale
X=
1
2
3
4
6
8
Blood
Glucose
0 – 2.9
3 – 4.9
5–7
>7
0.0
1
2
3
0.5
2
3
4
1
3
5
7
1
4
6
8
1
6
9
12
1
8
12
16

If blood glucose levels are greater than 10mmls/l for 2 consecutive hours then
the scale should be adjusted by one column to the right in order to increase
the amount of insulin administered

If blood glucose levels are less than 4mmols/l for 2 consecutive hours then
the sliding scale should be adjusted to the left in order to reduce the amount
of insulin administered.
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Guidelines for the Management of Pregnant Women with Diabetes
CPWC107 V1.1
Appendix 3
Management Plan for Pregnant Women Who Use CSII (PUMP)
The goal of insulin therapy in diabetes management during pregnancy is to maintain
blood glucose levels as close to normal as possible in order to improve the outcome
of the pregnancy and reduce the risk to both mother and foetus. Continuous
subcutaneous insulin infusion (CSII) often referred to as pump therapy, is a method
for intensifying insulin therapy to achieve this level of control.
A hand off approach is required for everyone, the whole principal of CS11 patients is
that they are in charge of their pump; advice is given from a member of the diabetes
team. However the patient alters their own pump.
There is no out of hours or on call service available
In the event that staff are unable to contact diabetes team member for advice or
there is evidence of glycaemic deterioration or ketosis, CSII treatment must be
discontinued and intravenous insulin and Dextrose commenced according to
established protocols.
Situations which will require pump treatment to be discontinued will include:
o Patient unwell and cannot manage the pump
o Patient choice
o Failure to achieve glycaemia targets, 2 consecutive readings
o Significant blood ketones NOT ketonuria value above 1.5mmol/l by
using an Exceed meter
o Persistent hypoglycaemia
o Need for a general anaesthetic
Antenatal Care
 During the antenatal period obstetric care will follow established protocols for
patients with diabetes.
 The diabetes team is responsible for CSII management including glycaemic
control and for addressing any educational needs regarding pump therapy and
diabetes.
Anaesthetic, Midwifery and Obstetric Involvement
Apart from named individuals, anaesthetic, obstetric and midwifery staff are NOT
permitted to alter the insulin pump regimen.
In patient use of CSII
Pump therapy may continue, providing the patient or partner is able to self- manage
the pump and perform the required blood monitoring.
Inpatient use of steroids during pregnancy
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Guidelines for the Management of Pregnant Women with Diabetes
CPWC107 V1.1
CSII may continue, the diabetes team will instruct the patient regarding any change
in pump settings.
Patients will be responsible for the management of the pump and blood testing.
Patients will be required to test their blood sugars on a 2 hourly basis; levels of 4.0 –
8.0 mmol/l should be aimed for.
If glycaemia targets are not achieved, midwifery or obstetric staff should contact the
diabetes team, out of hours the pump should be discontinued and patient put on an
insulin sliding scale
Position of the pump cannula for labour or surgery
 Patient will be advised regarding the need to position their insulin pump cannula
in the upper abdominal/lateral areas or loin regions.
 The patient or their partner will be responsible for any repositioning of the
cannula.
Hypoglycaemia
During periods of fasting, prior to surgery under a spinal anaesthetic or during
labour, patients are permitted to use Dextrose tablets, for correction of
hypoglycaemia.
Patient suitability for the continued use of CSII during labour and delivery
 The decision regarding the patient’s suitability to self-manage the pump in the
above situation will be made by the diabetes team in the ante natal period and
documented in the patient’s hand held notes.
 In the ante natal period the diabetes team will discuss with the patient situations
where CSII treatment may need to be discontinued and traditional management
instigated
Induction of Labour
 Continue on the pump as discussed with the diabetes team in the ante natal
period
Labour and Delivery
 The pump may be used during labour and delivery. The patient and her partner
will be responsible for the management of the pump.
 Prior to the intrapartum period the diabetes team will instruct the patient
regarding the proposed pump settings and other management issues required for
labour and delivery.
 Patient blood glucose levels during labour should be performed on an hourly
basis by the patient or partner.
 Blood sugar levels between 4-8 mmol/l should be aimed for during labour and
delivery.
 All urine samples must be checked for ketones
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Patient suitability for the continued use of CSII during surgery under spinal
anaesthetic
 The decision regarding the patient’s suitability to self-manage the pump in the
above situations will be made by the diabetes team in the ante natal period and
documented in the patient’s hand held notes.
 In the ante natal period the diabetes team will discuss with the patient situations
where CSII treatment may need to be discontinued and traditional management
instigated
Surgical Intervention
 The patient may continue with CSII for surgery under a spinal anaesthetic,
providing that the patient or her partner can actively manage the pump.
 The anaesthetist is responsible for monitoring the blood glucose during the
procedure, however if the pump needs altering the patient or partner will do this
 If a general anaesthetic is required, CSII must be discontinued and an insulin
sliding scale commenced in line with established protocols.
Post Delivery
 Once the patient is able to self-manage the pump, CSII can be recommenced
 The patient does not need to wait until she is eating and drinking
 The diabetes team would have advised the patient in the ante natal period
regarding the appropriate insulin doses for their pump.
Breast Feeding
 The patient can continue to use the pump if breast-feeding.
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Guidelines for the Management of Pregnant Women with Diabetes
CPWC107 V1.1
Appendix 4
Management Plan for Women with Type 1 Diabetes
To go in hand held notes and hospital notes at 36 weeks
Patient’s details
For all deliveries
A grey (16 gauge) venflon to be put in each hand/arm.
1st one for the glucose and insulin,
2nd for any other fluids


10mmols of KCL in 500mls 10% Glucose given over 6 hours via an infusion
pump = 84mls/per hour
50 units of rapid acting insulin (e.g. Actrapid, Novorapid) in 50mls of normal
saline 0.9% via the syringe driver (adjust per sliding scale)




Immediately the Placenta is delivered, halve the insulin rate but continue the
glucose infusion.
When tolerating food, give the subcutaneous insulin (when due) with a meal,
stopping the Insulin sliding scale 30 minutes after the s/c insulin is given
(follow the regimen below)
If the woman is vomiting, continue with the sliding scale until she is next due
her Insulin and tolerating food.
Continue to monitor the blood glucose levels QDS.
Insulin Regimen
Contact a member of the diabetes team for a review on day 1
Drs. Signature
Please ensure a 6 week follow up appointment is made with the diabetes
service.
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Guidelines for the Management of Pregnant Women with Diabetes
CPWC107 V1.1
Appendix 5
Management Plan for Women with Type 2 diabetes who are on
Insulin
To go in hand held notes and hospital notes at 36 weeks
Patient’s details
For all deliveries
A grey (16 gauge) venflon to be put in each hand/arm.
1st one for the glucose and insulin,
2nd for any other fluids
 10mmols of KCL in 500mls 10% Glucose given over 6 hours via an infusion
pump = 84mls/per hour
 50 units of insulin in 50mls of normal saline 0.9% via the syringe driver (adjust
per sliding scale)
If on insulin prior to pregnancy
 Immediately the Placenta is delivered halve the insulin rate but continue the
glucose infusion.
 When tolerating food (aim for the next meal time) give the prescribed
subcutaneous insulin, stopping the Insulin sliding scale 30 minutes after the
s/c insulin is given (follow the regimen below)
 If the woman is vomiting, continue with the sliding scale until she is next due
her insulin and tolerating food.
 Continue to monitor her blood glucose levels QDS
Insulin Regimen:
If not on insulin prior to pregnancy
 Discontinue the insulin sliding scale and glucose infusion immediately
following the delivery of the Placenta.
 Start oral medication as prescribed by the Diabetologist
 Blood glucose levels need to be checked pre meal and pre bed (QDS) for at
least………. hours
Oral medication:
Contact a member of the diabetes team for a review on day 1
Drs. Signature
Please ensure a 6 week follow up appointment is made with the diabetes
service
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Guidelines for the Management of Pregnant Women with Diabetes
CPWC107 V1.1
Appendix 6
Management Plan for Women with Type 2 diabetes who are on
Metformin
To go in the hand held notes at 36 weeks
Patient’s details
For all deliveries
1. Metformin to be stopped the night before the section
2. Metformin to be continued until ARM performed or in established labour

For 2 hourly blood glucose levels during labour, if on 2 consecutive occasions
the levels are above 8 mmols please start the insulin sliding scale on scale 1

For neonatal blood glucose levels
Drs. Signature
Please ensure a 6 week follow up appointment is made with the diabetes
service
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Guidelines for the Management of Pregnant Women with Diabetes
CPWC107 V1.1
Appendix 7
Management Plan for Women with Gestational Diabetes who are on
Insulin
To go in hand held notes at 36 weeks
Patient’s details
For all deliveries
A grey (16 gauge) venflon to be put in each hand / or arm
1st one for the glucose and insulin,
2nd for any other fluids example Syntocinon or Normal Saline 0.9%.


10mmols of KCL in 500mls 10% Glucose given over 6 hours via an infusion
pump = 84mls/per hour
50 units of rapid acting insulin (e.g. Actrapid, Novorapid) in 50mls of normal
saline 0.9% via the syringe driver (adjust per sliding scale)

Discontinue Insulin sliding scale and glucose infusion immediately
following the delivery of the Placenta.

Blood glucose levels need to be checked pre meal and pre bed (QDS) for at
least …………… hours

If blood glucose is above 10mmols/l on more than 2 consecutive occasions
please contact a member of the diabetes team
.
Drs. Signature
Please ensure an appointment for a post natal OGTT is arranged made prior to
discharge
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Guidelines for the Management of Pregnant Women with Diabetes
CPWC107 V1.1
Appendix 8
Management Plan for Women with Gestational Diabetes who are on
insulin
BUT do not require an insulin sliding scale
(i.e. not having more than 24 units of insulin in 24 hours)
To go in hand held notes at 36 weeks
Patient’s details
For all deliveries
Delete as appropriate:
1. Treat as normal in labour and delivery
Or
2. For 2 hourly blood glucose levels during labour, if on 2 consecutive
occasions the levels are above 8 mmols please start the insulin sliding scale
on scale 1

For neonatal blood glucose levels
Drs. Signature
Please ensure an appointment for a post natal GTT is arranged made prior to
discharge
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Guidelines for the Management of Pregnant Women with Diabetes
CPWC107 V1.1
Appendix 9
Management Plan for women with gestational diabetes who are on
Metformin
To go in the hand held notes at 36 weeks
Patient’s details
For all deliveries
1. Metformin to be stopped the night before the section
2. Metformin to be continued until ARM performed or in established
labour

For 2 hourly blood glucose levels during labour, if on 2 consecutive occasions
the levels are above 8 mmols please start the insulin sliding scale on scale 1

For neonatal blood glucose levels
Drs. Signature
Please ensure an appointment for a post natal GTT is arranged made prior to
discharge
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