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Diabetes in pregnancy: management from preconception to the postnatal period

This Guidelines summary includes recommendations that are relevant to the primary care setting. Please refer to the full guideline for the complete set of recommendations

Preconception planning and care

Information about outcomes and risks for mother and baby

  • 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 conception and continuing this 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
  • 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 hypoglycaemia and impaired awareness of hypoglycaemia 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
    • the need for assessment of diabetic retinopathy before and during pregnancy
    • the need for assessment of diabetic nephropathy before pregnancy
    • the importance of maternal blood glucose control during labour and birth and early feeding of the baby, in order to reduce the risk of neonatal hypoglycaemia
    • the possibility of temporary health problems in the baby during the neonatal period, which may require admission to the neonatal unit
    • the risk of the baby developing obesity and/or diabetes in later life

The importance of planning pregnancy and the role of contraception

  • Ensure that the importance of avoiding an unplanned pregnancy is an essential component of diabetes education from adolescence for women with diabetes
  • Explain to women with diabetes that their choice of contraception should be based on their own preferences and any risk factors (as indicated by UK medical eligibility criteria for contraceptive use [UKMEC] 2009)
  • Advise women with diabetes that they can use oral contraceptives (if there are no standard contraindications to their use)
  • Advise women with diabetes who are planning to become pregnant:
    • that the risks associated with pregnancy in women with diabetes increase with how long the woman has had diabetes
    • to use contraception until good blood glucose control (assessed by HbA1c level has been established
    • that blood glucose targets, glucose monitoring, medicines for treating diabetes (including insulin regimens for insulin‑treated diabetes) and medicines for complications of diabetes will need to be reviewed before and during pregnancy
    • that extra time and effort is needed to manage diabetes during pregnancy and that she will have frequent contact with healthcare professionals
  • Give women with diabetes who are planning to become pregnant information about the local arrangements for support during pregnancy, including emergency contact numbers

Diet, dietary supplements and body weight

Monitoring blood glucose and ketones in the preconception period

  • Offer women with diabetes who are planning to become pregnant monthly measurement of their HbA1c level
  • Offer women with diabetes who are planning to become pregnant a meter for self‑monitoring of blood glucose
  • If a woman with diabetes who is planning to become pregnant needs intensification of blood glucose‑lowering therapy, advise her to increase the frequency of self‑monitoring of blood glucose to include fasting levels and a mixture of pre‑meal and post‑meal levels
  • Offer women with type 1 diabetes who are planning to become pregnant blood ketone testing strips and a meter, and advise them to test for ketonaemia if they become hyperglycaemic or unwell

Target blood glucose and HbA1c levels in the preconception period

  • Agree individualised targets for self‑monitoring of blood glucose with women who have diabetes and are planning to become pregnant, taking into account the risk of hypoglycaemia
  • Advise women with diabetes who are planning to become pregnant to aim for the same capillary plasma glucose target ranges as recommended for all people with type 1 diabetes
  • Advise women with diabetes who are planning to become pregnant to aim to keep their HbA1c level below 48 mmol/mol (6.5%), if this is achievable without causing problematic hypoglycaemia
  • Reassure women that any reduction in HbA1c level towards the target of 48 mmol/mol (6.5%) is likely to reduce the risk of congenital malformations in the baby
  • Strongly advise women with diabetes whose HbA1c level is above 86 mmol/mol (10%) not to get pregnant because of the associated risks

Safety of medicines for diabetes before and during pregnancy

  • Women with diabetes may be advised to use metforminas an adjunct or alternative to insulin in the preconception period and during pregnancy, when the likely benefits from improved blood glucose control outweigh the potential for harm. All other oral blood glucose‑lowering agents should be discontinued before pregnancy and insulin substituted
  • Be aware that data from clinical trials and other sources do not suggest that the rapid‑acting insulin analogues (aspart and lispro) adversely affect the pregnancy or the health of the fetus or newborn baby
  • Use isophane insulin (also known as NPH insulin) as the first choice for long‑acting insulin during pregnancy. Consider continuing treatment with long‑acting insulin analogues (insulin detemir or insulin glargine) in women with diabetes who have established good blood glucose control before pregnancy

Safety of medicines for complications of diabetes before and during pregnancy

  • Angiotensin‑converting enzyme inhibitors and angiotensin‑II receptor antagonists should be discontinued before conception or as soon as pregnancy is confirmed. Alternative antihypertensive agents suitable for use during pregnancy should be substituted
  • Statins should be discontinued before pregnancy or as soon as pregnancy is confirmed

Removing barriers to the uptake of preconception care and when to offer information

  • Explain to women with diabetes about the benefits of preconception blood glucose control at each contact with healthcare professionals, including their diabetes care team, from adolescence
  • Document the intentions of women with diabetes regarding pregnancy and contraceptive use at each contact with their diabetes care team from adolescence
  • Ensure that preconception care for women with diabetes is given in a supportive environment, and encourage the woman's partner or other family member to attend

Education and advice

  • Offer women with diabetes who are planning to become pregnant a structured education programme as soon as possible if they have not already attended one (see guidance on the use of patient-education models for diabetes [NICE technology appraisal guidance 60])
  • Offer women with diabetes who are planning to become pregnant preconception care and advice before discontinuing contraception

Retinal assessment in the preconception period

  • Offer retinal assessment to women with diabetes seeking preconception care at their first appointment (unless they have had an annual retinal assessment in the last 6 months) and then annually if no diabetic retinopathy is found
  • Advise women with diabetes who are planning to become pregnant to defer rapid optimisation of blood glucose control until after retinal assessment and treatment have been completed

Renal assessment in the preconception period

  • Offer women with diabetes a renal assessment, including a measure of low‑level albuminuria (microalbuminuria), before discontinuing contraception. If serum creatinine is abnormal (120 micromol/litre or more), the urinary albumin:creatinine ratio is greater than 30 mg/mmol or the estimated glomerular filtration rate (eGFR) is less than 45 ml/minute/1.73 m2, referral to a nephrologist should be considered before discontinuing contraception

Gestational diabetes

Risk assessment, testing and diagnosis

Risk assessment

  • So that women can make an informed decision about risk assessment and testing for gestational diabetes, explain that:
    • in some women, gestational diabetes will respond to changes in diet and exercise
    • the majority of women will need oral blood glucose‑lowering agents or insulin therapy if changes in diet and exercise do not control gestational diabetes effectively
    • if gestational diabetes is not detected and controlled, there is a small increased risk of serious adverse birth complications such as shoulder dystocia
    • a diagnosis of gestational diabetes will lead to increased monitoring, and may lead to increased interventions, during both pregnancy and labour
  • Assess risk of gestational diabetes using risk factors in a healthy population. At the booking appointment, determine the following risk factors for gestational diabetes:
    • BMI above 30 kg/m2
    • previous macrosomic baby weighing 4.5 kg or above
    • previous gestational diabetes
    • family history of diabetes (first‑degree relative with diabetes)
    • minority ethnic family origin with a high prevalence of diabetes.
  • 
Offer women with any one of these risk factors testing for gestational diabetes
  • Do not use fasting plasma glucose, random blood glucose, HbA1c, glucose challenge test or urinalysis for glucose to assess risk of developing gestational diabetes

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

Testing

  • Use the 2‑hour 75 g oral glucose tolerance test (OGTT) to test for gestational diabetes in women with risk factors
  • Offer women who have had gestational diabetes in a previous pregnancy:
    • early self‑monitoring of blood glucose or
    • a 75 g 2‑hour OGTT as soon as possible after booking (whether in the first or second trimester), and a further 75 g 2‑hour OGTT at 24–28 weeks if the results of the first OGTT are normal
  • Offer women with any of the other risk factors for gestational diabetes a 75 g 2‑hour OGTT at 24–28 weeks

Diagnosis

  • Diagnose gestational diabetes if the woman has either:
    • a fasting plasma glucose level of 5.6 mmol/litre or aboveor
    • a 2‑hour plasma glucose level of 7.8 mmol/litre or above
  • Offer women with a diagnosis of gestational diabetes a review with the joint diabetes and antenatal clinic within 1 week
  • Inform the primary healthcare team when a woman is diagnosed with gestational diabetes (see also the NICE guideline on patient experience in adult NHS services in relation to continuity of care)

Interventions

  • Explain to women with gestational diabetes:
    • 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 hypoglycaemia and perinatal death
    • that treatment includes changes in diet and exercise, and could involve medicines
  • Teach women with gestational diabetes about self‑monitoring of blood glucose
  • Use the same capillary plasma glucose target levels for women with gestational diabetes as for women with pre‑existing diabetes
  • Tailor blood glucose‑lowering therapy to the blood glucose profile and personal preferences of the woman with gestational diabetes
  • 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 emphasise that foods with a low glycaemic index should replace those with a high glycaemic 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 7 mmol/litre at diagnosis
  • Offer metforminto 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 metforminfor women with gestational diabetes if blood glucose targets are not met
  • 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 7.0 mmol/litre or above at diagnosis
  • Consider immediate treatment with insulin, with or without metformin,as well as changes in diet and exercise, for women with gestational diabetes who have a fasting plasma glucose level of between 6.0 and 6.9 mmol/litre if there are complications such as macrosomia or hydramnios
  • Consider glibenclamidefor women with gestational diabetes:
    • in whom blood glucose targets are not achieved with metformin but who decline insulin therapy or
    • who cannot tolerate metformin

Antenatal care for women with diabetes

Monitoring blood glucose

  • Advise pregnant women with type 1 diabetes to test their fasting, pre‑meal, 1‑hour post‑meal and bedtime blood glucose levels daily during pregnancy
  • Advise pregnant women with type 2 diabetes or gestational diabetes who are on a multiple daily insulin injection regimen to test their fasting, pre‑meal, 1‑hour post‑meal and bedtime blood glucose levels daily during pregnancy
  • Advise pregnant women with type 2 diabetes or gestational diabetes to test their fasting and 1‑hour post‑meal blood glucose levels daily during pregnancy if they are:
    • on diet and exercise therapy or
    • taking oral therapy (with or without diet and exercise therapy) or single‑dose intermediate‑acting or long‑acting insulin

Target blood glucose levels

  • Agree individualised targets for self‑monitoring of blood glucose with women with diabetes in pregnancy, taking into account the risk of hypoglycaemia
  • 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 hypoglycaemia:
    • fasting: 5.3 mmol/litre
and
    • 1 hour after meals: 7.8 mmol/litre or
    • 2 hours after meals: 6.4 mmol/litre
  • Advise pregnant women with diabetes who are on insulin or glibenclamide to maintain their capillary plasma glucose level above 4 mmol/litre

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
  • Be aware that level of risk for the pregnancy for women with pre‑existing diabetes increases with an HbA1c level above 48 mmol/mol (6.5%)
  • 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

Managing diabetes during pregnancy

Insulin treatment and risks of hypoglycaemia

  • Be aware that the rapid‑acting insulin analogues (aspart and lispro) have advantages over soluble human insulin during pregnancy and consider their use
  • Advise women with insulin‑treated diabetes of the risks of hypoglycaemia and impaired awareness of hypoglycaemia in pregnancy, particularly in the first trimester
  • Advise pregnant women with insulin‑treated diabetes to always have available a fast‑acting form of glucose (for example, dextrose tablets or glucose‑containing drinks)
  • Provide glucagon to pregnant women with type 1 diabetes for use if needed. Instruct the woman and her partner or other family members in its use
  • Offer women with insulin‑treated diabetes continuous subcutaneous insulin infusion (CSII; also known as insulin pump therapy) during pregnancy if adequate blood glucose control is not obtained by multiple daily injections of insulin without significant disabling hypoglycaemia

Continuous glucose monitoring

  • Do not offer continuous glucose monitoring routinely to pregnant women with diabetes
  • Consider continuous glucose monitoring for pregnant women on insulin therapy:
    • who have problematic severe hypoglycaemia (with or without impaired awareness of hypoglycaemia) or
    • who have unstable blood glucose levels (to minimise variability) or
    • to gain information about variability in blood glucose levels
  • Ensure that support is available for pregnant women who are using continuous glucose monitoring from a member of the joint diabetes and antenatal care team with expertise in its use

Ketone testing and diabetic ketoacidosis

  • Offer pregnant women with type 1 diabetes blood ketone testing strips and a meter, and advise them to test for ketonaemia and to seek urgent medical advice if they become hyperglycaemic or unwell
  • Advise pregnant women with type 2 diabetes or gestational diabetes to seek urgent medical advice if they become hyperglycaemic or unwell
  • Test urgently for ketonaemia if a pregnant woman with any form of diabetes presents with hyperglycaemia or is unwell, to exclude diabetic ketoacidosis
  • During pregnancy, admit immediately women who are suspected of having diabetic ketoacidosis for level 2 critical care,where they can receive both medical and obstetric care

Retinal assessment during pregnancy

  • Offer pregnant women with pre‑existing diabetes retinal assessment by digital imaging with mydriasis using tropicamide following their first antenatal clinic appointment (unless they have had a retinal assessment in the last 3 months), and again at 28 weeks. If any diabetic retinopathy is present at booking, perform an additional retinal assessment at 16–20 weeks
  • Diabetic retinopathy should not be considered a contraindication to rapid optimisation of blood glucose control in women who present with a high HbA1c in early pregnancy
  • Ensure that women who have preproliferative 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
  • Diabetic retinopathy should not be considered a contraindication to vaginal birth

Renal assessment during pregnancy

  • If renal assessment has not been undertaken in the preceding 3 months in women with pre‑existing diabetes, arrange it at the first contact in pregnancy. If the serum creatinine is abnormal (120 micromol/litre or more), the urinary albumin:creatinine ratio is greater than 30 mg/mmol or total protein excretion exceeds 2 g/day, referral to a nephrologist should be considered (eGFR should not be used during pregnancy). Thromboprophylaxis should be considered for women with proteinuria above 5 g/day (macroalbuminuria)

Preventing pre‑eclampsia

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

Organisation of antenatal 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

Postnatal care

Blood glucose control, medicines and breastfeeding

  • 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 hypoglycaemia in the postnatal period, especially when breastfeeding, and advise them to have a meal or snack available before or during feeds
  • Women who have been diagnosed with gestational diabetes should discontinue blood glucose‑lowering therapy immediately after birth
  • Women with pre‑existing type 2 diabetes who are breastfeeding can resume or continue to take metforminand glibenclamideimmediately after birth, but should avoid other oral blood glucose‑lowering agents while breastfeeding
  • Women with diabetes who are breastfeeding should continue to avoid any medicines for the treatment of diabetes complications that were discontinued for safety reasons in the preconception period

Information and follow-up after birth

Women with pre-existing diabetes

  • 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

Women diagnosed with gestational diabetes

  • Test blood glucose in women who were diagnosed with gestational diabetes to exclude persisting hyperglycaemia before they are transferred to community care
  • Remind women who were diagnosed with gestational diabetes of the symptoms of hyperglycaemia
  • Explain to women who were diagnosed with gestational diabetes about the risks of gestational diabetes in future pregnancies, and offer them testing for diabeteswhen planning future pregnancies
  • 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)
    • if a fasting plasma glucose test has not been performed by 13 weeks, offer a fasting plasma glucose test, or an HbA1c test if a fasting plasma glucose test is not possible, after 13 weeks
    • do not routinely offer a 75 g 2‑hour OGTT
  • For women having a fasting plasma glucose test as the postnatal test:
    • advise women with a fasting plasma glucose level below 6.0 mmol/litre that:

      • they have a low probability of having diabetes at present
      • they should continue to follow the lifestyle advice (including weight control, diet and exercise) given after the birth
      • they will need an annual test to check that their blood glucose levels are normal
      • they have a moderate risk of developing type 2 diabetes, and offer them advice and guidance in line with the NICE guideline on preventing type 2 diabetes
  • Advise women with a fasting plasma glucose level between 6.0 and 6.9 mmol/litre that they are at high risk of developing type 2 diabetes, and offer them advice, guidance and interventions in line with the NICE guideline on preventing type 2 diabetes
  • Advise women with a fasting plasma glucose level of 7.0 mmol/litre or above that they are likely to have type 2 diabetes, and offer them a diagnostic test to confirm diabetes
  • For women having an HbA1c test as the postnatal test:
    • advise women with an HbA1c level below 39 mmol/mol (5.7%) that: 

      • they have a low probability of having diabetes at present
      • they should continue to follow the lifestyle advice (including weight control, diet and exercise) given after the birth
      • they will need an annual test to check that their blood glucose levels are normal
      • they have a moderate risk of developing type 2 diabetes, and offer them advice and guidance in line with the NICE guideline on preventing type 2 diabetes
  • Advise women with an HbA1c level between 39 and 47 mmol/mol (5.7% and 6.4%) that they are at high risk of developing type 2 diabetes, and offer them advice, guidance and interventions in line with the NICE guideline on preventing type 2 diabetes
  • Advise women with an HbA1c level of 48 mmol/mol (6.5%) or above that they have type 2 diabetes and refer them for further care
  • Offer an annual HbA1c test to women who were diagnosed with gestational diabetes who have a negative postnatal test for diabetes
  • Offer women who were diagnosed with gestational diabetes early self‑monitoring of blood glucose or an OGTT in future pregnancies. Offer a subsequent OGTT if the first OGTT results in early pregnancy are normal

© NICE 2015. Diabetes in pregnancy: management from preconception to the postnatal period.  Available from: www.nice.org.uk/guidance/NG3. All rights reserved. Subject to Notice of rights.

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. 

First included: June 2008, updated August 2015.