1. بسم الله الرحمن الرحيم Management of diabetes in pregnancy.
NICE guidelines last update July 2018
Dr. Sallama Kamel Nasir
Assistant Prof. in OBS&GYN
College of Medicine/University of Sulaimani

2. Overview:
Up to 5% of pregnant women (in England and Wales) have either pre‑existing diabetes or gestational diabetes.
Of women who have diabetes during pregnancy, it is estimated that approximately:
87.5% have gestational diabetes.
7.5% have type 1 diabetes.
The remaining 5% have type 2 diabetes.
The prevalence of type 1 diabetes, and especially type 2 diabetes, has increased in recent years.
The incidence of gestational diabetes is also increasing as a result of higher rates of obesity in the general population and more pregnancies in older women.

3. Overview:
Diabetes in pregnancy is associated with many risks to the woman and to the developing fetus.
Pregnant women with pre‑existing diabetes have increased risks of:
- Miscarriage.
- Pre‑eclampsia.
- Preterm labour.
- In addition, diabetic retinopathy can worsen rapidly during pregnancy.
Babies born to women with pre‑existing diabetes are at increased risks of:
- Congenital malformations.
- Macrosomia.
- Stillbirth.
- Birth injury.
- Perinatal mortality and post-natal adaptation problems (such as hypoglycemia).

4. Pre-conception care of diabetic woman
- Aim to empower women with diabetes to have a positive experience of pregnancy and childbirth by providing information, advice and support that will help to reduce the risks of adverse pregnancy outcomes for mother and baby.
Explain to women with diabetes who are planning to become pregnant that establishing good blood glucose control before and throughout pregnancy will reduce the risk of:
Miscarriage.
Congenital malformation.
Stillbirth and neonatal death.
It is important to explain that risks can be reduced but not eliminated. 

5. Pre-conception care of diabetic woman
Give women with diabetes who are planning to become pregnant, and their family members, information about how diabetes affects pregnancy and how pregnancy affects diabetes. The information should cover:
The role of diet, body weight and exercise.
The risks of hypo-glycaemia and impaired awareness of hypo-glycaemia during pregnancy.
How nausea and vomiting in pregnancy can affect blood glucose control.
The increased risk of having a baby who is large for gestational age, which increases the likelihood of birth trauma, induction of labour and caesarean section.

6. Pre-conception care of diabetic woman
The importance of maternal blood glucose control during labour , and early feeding of the baby, in order to reduce the risk of neonatal hypo-glycaemia
The possibility of temporary health problems in the baby during the neonatal period, which may require admission to the neonatal unit.
The need for assessment of diabetic retinopathy before and during pregnancy.
The need for assessment of diabetic nephropathy before pregnancy.
Advise women with diabetes who are planning to become pregnant to take folic acid (5 mg/day) until 12 weeks of gestation to reduce the risk of having a baby with a neural tube defect. 

7. Target blood glucose and HbA1c levels in the preconception period:
Advise women with diabetes who are planning to become pregnant to aim for capillary plasma glucose target as:
A fasting plasma glucose level of 5–7 mmol/litre (90-126mg/dl) on waking.
A plasma glucose level of 4–7 mmol/litre ( mg/dl) before meals at other times of the day.
Advise women with diabetes who are planning to become pregnant to aim to keep their HbA1c level below (6.5%), if this is achievable without causing problematic hypo-glycaemia.
Reassure women that any reduction in HbA1c level towards the target of (6.5%) is likely to reduce the risk of congenital malformations in the baby.
Strongly advise women with diabetes whose HbA1c level is above (10%) not to get pregnant because of the associated risks.

8. Gestational diabetes: Risk assessment
At the booking appointment, determine the following risk factors for gestational diabetes:
Family history of diabetes (first‑degree relative with diabetes).
Body weight> 90kg or BMI above 30 kg/m.2
Minority ethnic family origin with a high prevalence of diabetes (south Asia, Black Caribbean and middle eastern including Iraq).
Previous macrosomic baby weighing 4.5 kg or above.
Previous gestational diabetes.
Previous un-explained IUFD.
Known case of PCOS.
Offer women with any one of these risk factors testing for gestational diabetes.

9. Glycosuria detected by routine antenatal testing:
Be aware that glycosuria of 2+ or above on 1 occasion,
or of 1+ or above on 2 or more occasions detected by reagent strip testing during routine antenatal care may indicate undiagnosed gestational diabetes.
If this is observed, consider further testing to exclude gestational diabetes.

10. What test to diagnose GDM:
Do not use
-Fasting plasma glucose.
-Random blood glucose.
-HbA1c.
-Glucose challenge test.
-Urinalysis for glucose.
To assess risk of developing gestational diabetes.

11. What test to diagnose GDM:
Use the 2‑hour 75 g oral glucose tolerance test (OGTT) to test for gestational diabetes in women with risk factors.
At which gestation we should test for GDM:
For women with history of GDM in previous pregnancy:
- Offer her early self‑monitoring of blood glucose. 
-Do 75 g 2‑hour OGTT as soon as possible after booking (whether in the first or second trimester), and repeat the OGTT at 24–28 weeks if the results of the first OGTT are normal.
2. Women with any of the other risk factors for gestational diabetes a 75 g 2‑hour OGTT should be done at 24–28 weeks.

12. Criteria for diagnosing GDM:
Diagnose gestational diabetes if the woman has either:
A fasting plasma glucose level of 5.6 mmol/litre(101mg/dl) or above.
 OR
A 2‑hour plasma glucose level of 7.8 mmol/litre(140mg/dl) or above.
Offer women with a diagnosis of gestational diabetes a review with the joint diabetes and antenatal clinic within 1 week. 

13. Organization of ante-natal care:
Offer immediate contact with a joint diabetes and antenatal clinic to women with diabetes who are pregnant. 
Ensure that women with diabetes have contact with the joint diabetes and antenatal clinic for assessment of blood glucose control every 1–2 weeks throughout pregnancy.

14. Management:
Explain to women with gestational diabetes( at time of diagnosis):
About the implications (both short and long term) of the diagnosis for her and her baby.
That good blood glucose control throughout pregnancy will reduce the risk of:
-Fetal macrosomia.
-Trauma during birth (for her and her baby).
-Induction of labour and/or caesarean section.
-Neonatal hypoglycemia and perinatal death.
Explain to her that treatment includes changes in diet and exercise, and could involve medicines.
Teach women with gestational diabetes about self‑monitoring of blood glucose.

15. Dietary advice :
Offer women advice about changes in diet and exercise at the time of diagnosis of gestational diabetes.
Advise women with gestational diabetes to eat a healthy diet during pregnancy, and emphasize that foods with a low glycemic index should replace those with a high glycemic index.
Refer all women with gestational diabetes to a dietitian. 
Advise women with gestational diabetes to take regular exercise (such as walking for 30 minutes after a meal) to improve blood glucose control. 
Offer a trial of changes in diet and exercise to women with gestational diabetes who have a fasting plasma glucose level below 126mg/dl at diagnosis. 

16. Glucose lowering agents:
Offer metformin to women with gestational diabetes if blood glucose targets are not met using changes in diet and exercise within 1– 2 weeks. 
Offer insulin instead of metformin to women with gestational diabetes if metformin is contraindicated or unacceptable to the woman. 
Offer addition of insulin to the treatments of changes in diet, exercise and metformin for women with gestational diabetes if blood glucose targets are not met.

17. When to start immediate insulin in GDM?
1. Offer immediate treatment with insulin, with or without metformin, as well as changes in diet and exercise, to women with gestational diabetes who have a fasting plasma glucose level of 126mg/dl or above at time of diagnosis. 
2.Consider immediate treatment with insulin, with or without metformin, as well as changes in diet and exercise, for women with gestational if there are complications such as macrosomia or hydramnios.

18. Other oral hypoglycemic drugs:
Consider glibenclamide for women with gestational diabetes:
1. When blood glucose targets are not achieved with metformin but who decline insulin therapy.
 OR
2. Women who cannot tolerate metformin.

19. Insulin therapy:
The total first dose of insulin is calculated according to the patient’s weight as follow:
In the first trimester  weight x 0.7U
In the second trimester  weight x 0.8 U
In the third trimester  weight x 0.9 U
Obese patient usually require 0.1 u above the recommended dose in each trimester.
Insulin should be added to patients who have fasting hyperglycemia despite their dietary regimen
Patients require insulin injection at least twice daily.
A mixture of short acting and medium acting insulin is given20-30 minutes before breakfast and dinner the dose is determined based on body weight, trimester of pregnancy & sugar level.

20. INSULIN THERAPY 1/3rd of dose in evening short acting
Given as 2 injections/day (some require 3- 4 injections)
2/3rd of dose in morning
1/3rd of dose in evening
2/3 of
dose
intermediat
1/3rd
short
acting

21. Available insulin preparations
Type
Onset
Peak (hours)
Duration (hours)
Rapid
Lispro*
Aspart*
Glulisine
< 15 min
1 – 2
3 – 4
Short
regular insulin
0.5 – 0.7 hour
2 – 4
5 – 8
Intermediate
NPH(neutral protamine hagedorn)
Lente
1 – 2 hours
6 – 12
18 – 24
Long acting
Ultralente
Glargine*
4 – 6 hours
2 – 4 hours
16 – 18
peakless
20 – 36

22. Frequency of monitoring blood glucose:
Advise pregnant women with type 1 diabetes, and type 2 diabetes or gestational diabetes who are on a multiple daily insulin injection regimen, to test their blood glucose level at the following times daily during pregnancy:
Fasting.
Pre‑meal.
1 or 2hour post‑meal.
At bedtime.
So she need to test their blood glucose level 8 times daily.

23. Monitoring blood glucose:
While pregnant women with type 2 diabetes or gestational diabetes who are on diet and exercise therapy only. 
Or taking oral therapy (with or without diet and exercise therapy)
Or single‑dose intermediate‑acting or long‑acting insulin:
Are advised to test their fasting and 1‑hour post‑meal blood glucose levels daily during pregnancy (4 measurment daily).

24. Target blood glucose level:
Advise pregnant women with any form of diabetes to maintain their capillary plasma glucose below the following target levels, if these are achievable without causing problematic hypoglycemia:
Fasting: 96mg/dl (5.3 mmol/litre)
1 hour after meals: mg/dl (7.8 mmol/litre).
2 hours after meals: mg/dl (6.4 mmol/litre)
Advise pregnant women with diabetes who are on insulin or glibenclamide to maintain their capillary plasma glucose level above 72mg/dl. 

25. Monitoring HbA1c:
Measure HbA1c levels in all pregnant women with pre‑existing diabetes at the booking appointment to determine the level of risk for the pregnancy. 
Consider measuring HbA1c levels in the second and third trimesters of pregnancy for women with pre‑existing diabetes to assess the level of risk for the pregnancy.
Measure HbA1c levels in all women with gestational diabetes at the time of diagnosis to identify those who may have pre‑existing type 2 diabetes. 
Do not use HbA1c levels routinely to assess a woman's blood glucose control in the second and third trimesters of pregnancy.

26. Detecting congenital malformations
Offer women with diabetes an ultrasound scan for detecting fetal structural abnormalities, including examination of the fetal heart (4 chambers, outflow tracts and 3 vessels), at 20 weeks of pregnancy. 

27. Monitoring fetal growth and wellbeing
Offer pregnant women with diabetes ultrasound monitoring of fetal growth and amniotic fluid volume every 4 weeks from 28 to 36 weeks. 

28. Prevention of pre-eclampsia:
Advise pregnant woman with type 1 and type 2 diabetes to take 75mg aspirin from 12 weeks till birth of her baby to reduce the risk of pre-eclampsia.

29. Preterm labour in women with diabetes
Diabetes should not be considered a contra-indication to antenatal steroids for fetal lung maturation or to tocolysis. 
In women with insulin‑treated diabetes who are receiving steroids for fetal lung maturation, give additional insulin according to an agreed protocol and monitor them closely. 
Do not use beta-mimetic medicines for tocolysis in women with diabetes. 

30. Timing and mode of birth
The timing and mode of birth is individualized according to the type of DM, any maternal or fetal complications and should be discussed with the pregnant woman during the 3rd trimester.  
Pregnant women with type 1 or type 2 diabetes:
With no other complications should have an elective birth by induction of labour, or by elective caesarean section (if indicated), between 37+0 and 38+6 weeks of pregnancy.
If there are metabolic or any other maternal or fetal complications then consider elective birth before 37+0 weeks of gestation.
Women with gestational diabetes:
With no any maternal or fetal complication should give birth no later than 40+6 weeks.
Consider elective birth before 40+6 weeks for women with gestational diabetes if there are maternal or fetal complications. 

31. Explain to pregnant women with diabetes who have an ultrasound‑diagnosed macrosomic fetus about the risks and benefits of vaginal birth, induction of labour and caesarean section.
Diabetes should not in itself be considered a contraindication to attempting vaginal birth after a previous caesarean section. 

32. Intrapartum monitoring:
The plasma glucose level should be monitored every hour during labour in women with diabetes.
Ensure that plasma glucose level is maintained between mg/dl (4-7 mmol/l).
Intravenous dextrose and insulin infusion should be considered for women with type 1 diabetes from the onset of established labour.
Use intravenous dextrose and insulin infusion during labour and birth for women with diabetes whose capillary plasma glucose is not maintained between mg/dl (4-7 mmol/l).
If general anesthesia is used for the birth in women with diabetes, monitor blood glucose every 30 minutes from induction of general anesthesia until after the baby is born and the woman is fully conscious

33. Postnatal care for women with gestational diabetes
Women who have been diagnosed with gestational diabetes should discontinue blood glucose lowering therapy immediately after birth.
Test blood glucose in women who were diagnosed with gestational diabetes to exclude persisting hyperglycemia before they are transferred to community care
For women who were diagnosed with gestational diabetes and whose blood glucose levels returned to normal after the birth: Offer lifestyle advice (including weight control, diet and exercise).
Offer a fasting plasma glucose test 6–13 weeks after the birth to exclude diabetes (for practical reasons this might take place at the 6-week postnatal check).
Remind women who were diagnosed with gestational diabetes of the symptoms of hyperglycemia and the risk of gestational diabetes in future pregnancy.
Offer an annual HbA1c test to women who were diagnosed with gestational diabetes who have a negative postnatal test for diabetes.

34. Postnatal care for women with pre-existing diabetes
Women with insulin-treated pre-existing diabetes should reduce their insulin immediately after birth and monitor their blood glucose levels carefully to establish the appropriate dose.
Explain to women with insulin-treated pre-existing diabetes that they are at increased risk of hypoglycemia in the postnatal period, especially when breastfeeding.
Advise the woman to have a meal or snack available before or during breast feeds.
Women with pre-existing type 2 diabetes who are breastfeeding can resume or continue to take metformin and glibenclamide immediately after birth,
But should avoid other oral blood glucose-lowering agents while breastfeeding.

35. Information and follow-up after birth
Refer women with pre-existing diabetes back to their routine diabetes care arrangements.
Remind women with diabetes of the importance of contraception and the need for preconception care when planning future pregnancies.
Ensure that women who have pre-proliferative diabetic retinopathy or any form of referable retinopathy diagnosed during pregnancy have ophthalmological follow-up for at least 6 months after the birth of the baby

36. Thank you