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Document Control Information Template completed by the Lead Author in conjunction with the Document Control Administrator. 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governance Date approved by Authorising Body/persons 19th May Has document had an Equality Impact Assessment Yes Superseded document to be withdrawn. Yes Has superseded document(s) been archived?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Section D : to be completed on electronic publication Date loaded to intranet Date loaded to external web site Date superseded documents archived from intranet Yes No Details Clinical incidents are identified using the NHSLA ‘trigger list’.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 Page 2 of 29 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 Written: 10/06 Reviewed: 12/09 Expiry Date: 20/01/2013 Please ensure you have the latest version of this document Page 3 of 29 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 Written: 10/06 Reviewed: 12/09 Expiry Date: 20/01/2013 Please ensure you have the latest version of this document Page 4 of 29 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 Written: 10/06 Reviewed: 12/09 Expiry Date: 20/01/2013 Please ensure you have the latest version of this document Page 5 of 29 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 Written: 10/06 Reviewed: 12/09 Expiry Date: 20/01/2013 Please ensure you have the latest version of this document Page 6 of 29 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 Written: 10/06 Reviewed: 12/09 Expiry Date: 20/01/2013 Please ensure you have the latest version of this document Page 7 of 29 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 Written: 10/06 Reviewed: 12/09 Expiry Date: 20/01/2013 Please ensure you have the latest version of this document Page 8 of 29 Pennine Acute Hospitals NHS Trust 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. Written: 10/06 Reviewed: 12/09 Expiry Date: 20/01/2013 Please ensure you have the latest version of this document Page 9 of 29 Pennine Acute Hospitals NHS Trust 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. Written: 10/06 Reviewed: 12/09 Expiry Date: 20/01/2013 Please ensure you have the latest version of this document Page 10 of 29 Pennine Acute Hospitals NHS Trust 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) Written: 10/06 Reviewed: 12/09 Expiry Date: 20/01/2013 Please ensure you have the latest version of this document Page 11 of 29 Pennine Acute Hospitals NHS Trust 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 Written: 10/06 Reviewed: 12/09 Expiry Date: 20/01/2013 Please ensure you have the latest version of this document Page 12 of 29 Pennine Acute Hospitals NHS Trust 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. Written: 10/06 Reviewed: 12/09 Expiry Date: 20/01/2013 Please ensure you have the latest version of this document Page 13 of 29 Pennine Acute Hospitals NHS Trust 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) Written: 10/06 Reviewed: 12/09 Expiry Date: 20/01/2013 Please ensure you have the latest version of this document Page 14 of 29 Pennine Acute Hospitals NHS Trust 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. Written: 10/06 Reviewed: 12/09 Expiry Date: 20/01/2013 Please ensure you have the latest version of this document Page 15 of 29 Pennine Acute Hospitals NHS Trust 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 Written: 10/06 Reviewed: 12/09 Expiry Date: 20/01/2013 Please ensure you have the latest version of this document Page 16 of 29 Pennine Acute Hospitals NHS Trust 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 Written: 10/06 Reviewed: 12/09 Expiry Date: 20/01/2013 Please ensure you have the latest version of this document Page 17 of 29 Pennine Acute Hospitals NHS Trust 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 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 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. Written: 10/06 Reviewed: 12/09 Expiry Date: 20/01/2013 Please ensure you have the latest version of this document Page 18 of 29 Pennine Acute Hospitals NHS Trust 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 Written: 10/06 Reviewed: 12/09 Expiry Date: 20/01/2013 Please ensure you have the latest version of this document Page 19 of 29 Pennine Acute Hospitals NHS Trust 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. Written: 10/06 Reviewed: 12/09 Expiry Date: 20/01/2013 Please ensure you have the latest version of this document Page 20 of 29 Pennine Acute Hospitals NHS Trust 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 Written: 10/06 Reviewed: 12/09 Expiry Date: 20/01/2013 Please ensure you have the latest version of this document Page 21 of 29 Pennine Acute Hospitals NHS Trust 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 Written: 10/06 Reviewed: 12/09 Expiry Date: 20/01/2013 Please ensure you have the latest version of this document Page 22 of 29 Pennine Acute Hospitals NHS Trust Guidelines for the Management of Pregnant Women with Diabetes CPWC107 V1.1 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. Written: 10/06 Reviewed: 12/09 Expiry Date: 20/01/2013 Please ensure you have the latest version of this document Page 23 of 29 Pennine Acute Hospitals NHS Trust 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. Written: 10/06 Reviewed: 12/09 Expiry Date: 20/01/2013 Please ensure you have the latest version of this document Page 24 of 29 Pennine Acute Hospitals NHS Trust 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 Written: 10/06 Reviewed: 12/09 Expiry Date: 20/01/2013 Please ensure you have the latest version of this document Page 25 of 29 Pennine Acute Hospitals NHS Trust 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 Written: 10/06 Reviewed: 12/09 Expiry Date: 20/01/2013 Please ensure you have the latest version of this document Page 26 of 29 Pennine Acute Hospitals NHS Trust 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 Written: 10/06 Reviewed: 12/09 Expiry Date: 20/01/2013 Please ensure you have the latest version of this document Page 27 of 29 Pennine Acute Hospitals NHS Trust 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 Written: 10/06 Reviewed: 12/09 Expiry Date: 20/01/2013 Please ensure you have the latest version of this document Page 28 of 29 Pennine Acute Hospitals NHS Trust 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 Written: 10/06 Reviewed: 12/09 Expiry Date: 20/01/2013 Please ensure you have the latest version of this document Page 29 of 29