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

2. 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 & < Immediate GTT + HbA1c (if not done)
RBG ≥ Refer to Antenatal Diabetic clinic
RBG ≥ Immediate GTT
Abnormal OGTT results (mmol/L)
Fasting ≥ 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
1 hour after meals ≤ 7.8
Fasting
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 week
Previous GDM
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 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

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

4. 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

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

6. 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 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 weeks (if negative at 16 weeks).
All women with previous GDM should have an OGTT at 16 weeks, and again at weeks if normal

7. 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.)

8. Routine care
RBG should be repeated at 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.

9. 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)

10. 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

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