1. HEFT - Good Hope Gestational diabetes service

2. HEFT – Good Hope, Birmingham Heartlands and Solihull Hospitals Two very different patient populations >12000 births per year >600 complicated by diabetes 8–15 new GDMs per week >300 insulin starts per year Nurse/midwife-led GDM clinic Midwife and dietitian led antenatal group (BHH) Midwife Diabetes education workshops

3. Gestational Diabetes Defined as diabetes developing in pregnancy Usually occurs >20 weeks Usually remits after delivery Gestational diabetes is defined by the World Health Organization as “carbohydrate intolerance resulting in hyperglycemia of variable severity with onset or first recognition during pregnancy”. “carbohydrate intolerance resulting in hyperglycemia of variable severity with onset or first recognition during pregnancy”.

4. Incidence and prevalence Gestational diabetes occurs in 2–9% of all pregnancies, but will vary in direct proportion with the prevalence of type 2 diabetes in a given population or ethnic group. (WHO, 1999) Gestational diabetes occurs in 2–9% of all pregnancies, but will vary in direct proportion with the prevalence of type 2 diabetes in a given population or ethnic group. (WHO, 1999) Good Hope – 2.2% of pregnancies are GDM (80 pregnancies) - 31 Lifestyle modification - 19 Metformin - 30 Insulin 101 diabetes related births in 2012 10 – 20 ante natal reviews & 4-6 post natal reviews per month

5. GHH GDM pathway Joint diabetes & antenatal clinic weekly Midwife led clinics twice weekly New referrals Ante natal checks Scans Teaching BGM Insulin initiation Education Post natal GTT’s Arranging eye screening

6. Screening and diagnosis Screening at booking as per NICE risk factors Early SMBG if previous GDM (on treatment) or GTT if previous GDM (not on treatment) GTT 24–28 weeks if any other risk factors or RBG ≥6.0 mmol/L Diagnosis of GDM confirmed: FBG ≥6.1 mmol/L 2 hr ≥7.8 mmol/L

7. Treatment Initially lifestyle (food choices and exercise) Blood glucose monitoring (pre breakfast and 1 hour post meals) If lifestyle changes do not maintain blood glucose targets/if ultrasound shows fetal macrosomia then therapy indicated (in 10–20% of women) Metformin (informed consent because use will be off license) Insulin isophane initially with bolus if BG targets not achieved Reviewed in dedicated Diabetes Specialist Midwife clinics Dedicated patient information Eye screening

8. Post delivery Women with GDM stop oral agents after delivery Blood glucose checked before discharge home NICE – fasting blood glucose at 6 week postnatal check usually at GP surgery Advice long-term – lifestyle and risk of development of type 2 diabetes mellitus Advice regarding GDM in future pregnancies Advice regarding seeking preconception care in future pregnancies if required insulin therapy Advice regarding contraception Contact cards for self referral

9. Pre-conception Clinic Contact Helen DSM or Jackie DSN on ~ 0121 424 7701 / 1176 ~ If you want to get pregnant Remember the 3 P’s : Planning, Pre-conception clinic And Preparation

10. Summary Review team were encouraged by the level of care for ante natal ladies at GHH. The benefits of a Diabetes Specialist Midwife who can also perform scans was highlighted as an area of good practice, providing seamless care. Patients have described the service as a one-stop- shop. Additionally WMQRS cited the quality of the written information provided.