Diabetes- pregnancy, labour and the puerperium guideline Summary for GPs Dr Emma Radcliffe, Clinical Lead, Maternity, THCCG

NEW Diabetes in Pregnancy Guidelines Effective 1st September, 2015 Key Changes Royal London Hospital NEW Diabetes in Pregnancy Guidelines Effective 1st September, 2015 Previous RLH Guidelines (2010) At booking Request Random Blood Glucose (RBG) Request RBG AND Request HbA1c if: ●Family History of Diabetes ● BMI ≥30 kg/m2, ●Previous GDM ●Previous Macrosomic Baby ≥ 4kg RBG result (mmol/L) RBG ≥ 7 & < 11.1 Immediate GTT + HbA1c (if not done) RBG ≥ 11.1 Refer to Antenatal Diabetic clinic RBG ≥ 7 Immediate GTT Abnormal OGTT results (mmol/L) Fasting ≥ 5.6 and/or 120 mins ≥ 7.8 Fasting > 5.8mmol/L At 120mins ≥7.8 (up to 30 w) ≥ 9.0 (after 30w) Target Blood Glucose Ranges (mmol/L) Fasting 4.0 - 5.5 1 hour after meals ≤ 7.8 Fasting 3.5 - 5.9 2 hours after ≤ 7.0 Monitoring of Blood Glucose 1 hour after meals 2 hours after meals 16 Week GTT Previous GDM if GTT normal repeat at 24-28 week Previous GDM 24-28 Week GTT 24-28 Week GTT for women that are at risk of GDM ( details refer to page 7 in the guidelines) 28 Week GTT Glycosuria 2+ on 1 occasion OR 1+ on 2 occasions Request RBS Twice after 20w and once before 20w → Request OGTT IOL GDM on diet 40 week + 4 days Aiming for delivery at 40w + 6 days Same as low risk IOL guideline HbA1c ≥5.9% (41mmol/mol) before 16w refer to ANC diabetes clinic

Pre-existing Diabetes Referred urgently to antenatal clinic Will be booked by DSMW Diabetes Specialist Midwife Rong Lu Tel 0776 870 2618 Care provided by joint diabetic-obstetric service

Glucose tolerance test Normal result: Fasting blood glucose <5.6 and or At 120 mins <7.8 No variation for gestation Do not perform after 36 weeks Normal values will be changed on results

Screening for diabetes Booking RBG: All HbA1c: previous history of GDM, family history of diabetes, BMI≥30 kg/m2 , previous baby weighing 4kg

Refer to diabetic antenatal clinic Results from booking Refer to diabetic antenatal clinic Random plasma glucose ≥11.1 mmol/l HbA1c 48 mmol/mol (likely overt diabetes) HbA1c 41- 47 mmol/l (likely impaired glucose tolerance) Fasting plasma glucose≥7.0 mmol/l Arrange GTT RBG ≥7.0 mmol/l and <11.1 mmol/l (and HbA1c if not already had one). If it is negative, repeat at 16 weeks, and again at 24-28 weeks (if negative at 16 weeks). All women with previous GDM should have an OGTT at 16 weeks, and again at 24-28 weeks if normal

Glucose tolerance test 24-28/40 BMI ≥ 30 kg/m2 Diabetes in 1st degree relative (NICE 2015) Previous unexplained stillbirth or IUD Previous baby weighing 4kg at birth Polyhydramnios >40 years of age Polycystic ovarian syndrome Minority family origin with high prevalence of diabetes (eg South Asian, Black African, African- Caribbean and Middle Eastern women.)

Routine care RBG should be repeated at 24-28 weeks for all pregnant women. If RBG≥7.0 mmol/l then proceed to GTT. Urine dipstick. All appts. If glycosuria 2+ or above on 1 occasion or 1+ or above on two occasions, then RBG should be taken. If ≥7.0 mmol/l then proceed to GTT. Do not perform GTT after 36 weeks and refer woman to Combined ANC. All GDM women in community pathway to have Fructosamine at 36 weeks.

Abnormal GTT Refer to Monday diet and education and meter reading session (Friday DSMW clinic if abnormal GTT <16/40  or >16 weeks or more and OGTT result of fasting≥ 6.0mmol/L and/ or 2hours 11.1mmol/L or more)

GDM management Twice daily monitoring according to the repeating pattern below: Before breakfast and 1 hour after 1 hour after lunch 1 hour after dinner Post-prandial CBG levels are >7.8 mmol/L on two or more occasions, or >9.0 mmol/L on one occasion, or fasting glucose is >5.5 mmol/L contact DSMW Fructosamine at 36 weeks

Delivery and postnatal GDM (diet) Induction 40+4 Postnatal GTT 6 weeks and DSMW In s