Diabetes in Pregnancy Western Cape Guidelines

8/10/2019 Diabetes in Pregnancy Western Cape Guidelines

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DIABETES IN PREGNANCY

Guideline for the management ofdiabetes and its complications from

pre-conception to the postnatalperiod


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Diabetes in pregnancy

ContentsA. Introduction...................................................................................... 3

B. Background ..................................................................................... 3

C. Target group.................................................................................... 3

D. Levels of evidence........................................................................... 3

E. Methods used to collect evidence .................................................... 4

F. Guideline development ................................................................... 4

G. Introduction to the guideline............................................................. 5

1.1 Pre-conception care......................................................................... 9

1.2 Gestational diabetes....................................................................... 13

1.3 Antenatal care ................................................................................ 17

1.4 Intra-partum care............................................................................ 21

1.5 Neonatal care................................................................................. 22

1.6 Postpartum care ............................................................................. 23

Protocol A: Gestational diabetes ................................................................ 25

Protocol B: NIDDM..................................................................................... 30

Protocol C: IDDM ....................................................................................... 34

Protocol D: Management of diabetic keto-acidosis ..................................... 38

Table 1: Specific antenatal care ................................................................. 40

Table 2: Available insulin............................................................................ 41


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subsequently revised by a sub-committee of the Society for Maternal and Fetal Medicine in

South Africa after input from all the members of that society. The full NICE guideline

(www.nice.org.uk/CG063fullguideline) gives details of the methods and the evidence used to

develop the guidance as well as the full literature review on which this was based. The NICE

guideline was published in March 2008, and refers to the ongoing HAPO and ACHOIS

studies, final results of which were published in May 2008 and included in this review.

E. Methods used to collect evidence

The MEDLINE database was searched for all English language publications using the key

words Diabetes, Pregnancy, Metformin, insulin, keto-acidosis, HAPO and ACHOIS

(accessed at www.ncbi.nlm.nih.gov ). Related articles were found through the linkage

function inherent in the Medline search engine as well as through the reference section of

accessed publications. All Cochrane reviews related to pregnancy and childbirth were

perused in the Cochrane library issue 3 of 2010, (full-text accessed through Wiley

InterScience at www.mrw.interscience.wiley.com). The repositories of data of the following

colleges were accessed online: Royal College of Obstetrics and Gynaecology (

www.rcog.org.uk ), American College of Obstetrics and Gynecology ( www.acog.org ) the

Royal Australian and New-Zealand College of Obstetrics and Gynaecology

(www.ranzcog.edu.au) and the Society of Obstetricians and Gynaecologists of Canada

(www.sogc.org). The World Health Organisation resource guides were accessed at

www.iwhc.org/resources and further literature searches for reviews and consensus

statements were performed using Google Scholar ( www.scholar.google.com ).

F. Guideline development

This guideline constitutes a review of the most recent (up to June 2010) literature as well as

an adaptation of the NICE guideline on diabetes in pregnancy. It was developed through a

process of review by

o The Maternal Guidelines Reference Group

o External review by experts from both academic hospitals and secondary

hospitals in the Western Cape Province.

o In addition the guidelines were discussed, reviewed and submitted for

endorsement by the Society for Maternal and Fetal Medicine in South Africa.


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External expert reviewers:

The guideline was additionally sent for peer review to two general obstetrician

gynaecologists working at secondary level hospitals, medical officers working in obstetrics at

district level, midwives at all levels of care and patient representatives.

The Maternal Guidelines Reference Group: Members (for this document)

Coordinator/Chair:

Ms E Arends: Assistant Director Maternal Child & Womans Health Sub-Directorate.

Editors:

Dr S Gebhardt Principal Specialist & Head of Department Obstetrics & Gynaecology, PaarlHospital and Clinical Coordinator, Obstetrics and Gynaecology, PGWC.

Prof E Coetzee: Principal Specialist, Department of Obstetrics & Gynaecology, University of

Cape Town and Groote Schuur Hospital.

Members:

Prof G Theron: Chief Specialist, Department of Obstetrics & Gynaecology, University ofStellenbosch and Tygerberg Hospital.

Dr C Oettl: Principal Specialist & Head of Department Obstetrics & Gynaecology, EbenDnges Hospital Worcester.

Prof S Clow: Associate Professor, Division of Nursing & Midwifery, University of Cape Town.

Dr L Schoeman, Senior Specialist, Department of Obstetrics & Gynaecology, University ofCape Town and Groote Schuur Hospital.

Dr F Patel: Senior Specialist and Head of Department, Obstetrics and Gynaecology, KarlBremer Hospital.

Prof C Nikodem: Senior Lecturer, University of Western Cape.

Ms W Kamfer: Deputy Director Maternal Neonatal & Womens Health Westcoast WinelandsRegion.

Ms S Neethling: Chief Professional Nurse; Maternal & Womans Health; Boland/Overberg

Region.

Ms L Krynauw: Chief Professional Nurse, Obstetrics and Gynaecology, Tygerberg Hospital.

Ms V Adriaans: Assistant Director Maternal Neonatal & Womens Health Metropole RegionalOffice.

Ms M Petersen: Chief Professional Nurse, Education Deptartment Mowbray MaternityHospital.


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The members of the sub-committee of the Society for Maternal and Fetal Medicine in SouthAfrica were:

Prof D Hall: Principal Specialist, Department of Obstetrics & Gynaecology, University ofStellenbosch and Tygerberg Hospital

Dr H Lombaard: Principal Specialist, Department of Obstetrics & Gynaecology, Universityof Pretoria.

Dr M Conradie: Principal Medical Officer, Division of Endocrinology, Tygerberg hospitaland Stellenbosch University


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The importance of avoiding unplanned pregnancy should be an essential component of

diabetes education from adolescence for women with diabetes.

Women with diabetes who are planning to become pregnant should be offered pre-

conception care and advice before discontinuing contraception.

Antenatal care

If it is safely achievable, women with diabetes should aim to keep fasting blood glucose

between 3.5 - 5.5 mmol/l and a 2-hour post-prandial level below 7mmol/l during

pregnancy. Post-prandial monitoring should be instituted when insulin is administered 2

times per day. The HbA1c should be measured every four weeks with the aim of

maintaining this value below 6.1%.

Women with insulin-treated diabetes should be advised of the risks of hypoglycaemia and

hypoglycaemia unawareness in pregnancy, particularly in the first trimester.

During pregnancy, women who are suspected of having diabetic ketoacidosis should be

admitted immediately to a tertiary hospital (or the nearest secondary hospital in rural

areas), where they can receive both medical and obstetric care.

Women with pre-gestational diabetes should be offered nuchal translucency (NT)

ultrasound scan at 12 weeks and a fetal anomaly scan at 20 weeks.

Neonatal care

Babies of women with diabetes should be kept with their mothers unless there is a clinical

complication or there are abnormal clinical signs that warrant admission for intensive or

high care.

Postnatal care

Women who were diagnosed with gestational diabetes should be offered lifestyle advice

(including weight control, diet and exercise) and offered at least a glucose profile (as

described on page 26) at the 6-week postnatal check and annually thereafter.


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Guidance

1.1 Pre-conception care

1.1.1 Outcomes and risks for the woman and baby

1.1.1.1 Healthcare professionals should seek to empower women with diabetes

to make the experience of pregnancy and childbirth a positive one by

providing information, advice and support that will help to reduce the

risks of adverse pregnancy outcomes for the mother and the baby.

1.1.1.2 Women with diabetes who are planning to become pregnant should be

informed that establishing good glycaemic 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 these risks can be reduced but not eliminated.

1.1.1.3 Women with diabetes who are planning to become pregnant and their

families should be offered 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 hypoglycaemia unawareness during

pregnancy

how nausea and vomiting in pregnancy can affect glycaemic 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 glycaemic control during labour and birth and early

feeding of the baby in order to reduce the risk of neonatal hypoglycaemia

the possibility of transient morbidity 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.


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1.1.2 The importance of planning pregnancy and the role of contraception

1.1.2.1 The importance of avoiding unplanned pregnancy should be an

essential component of diabetes education from adolescence for

women with diabetes.


advised:

that the risks associated with pregnancies complicated by diabetes increase

with the duration of diabetes

to use contraception until good glycaemic control (assessed by HbA1c) has

been established

that glycaemic targets, glucose monitoring, medications for diabetes (including

insulin regimens for insulin-treated diabetes) and medications for

complications of diabetes will need to be reviewed before and duringpregnancy

that additional time and effort is required to manage diabetes during

pregnancy and that there will be frequent contact with healthcare

professionals. Women should be given information about the local

arrangements for support, including emergency contact numbers.

1.1.3 Diet, dietary supplements, body weight and exercise


offered individualised dietary advice.

1.1.3.2 Women with diabetes who are planning to become pregnant and who

have a body mass index above 27 kg/m2should be offered advice on

how to lose weight.


advised to take folic acid (5 mg/day) from three months before the

pregnancy until at least 12 weeks of gestation to reduce the risk of

having a baby with a neural tube defect.

1.1.4 Target ranges for blood glucose in the pre-conception period

1.1.4.1 Individualised targets for self-monitoring of blood glucose should be

agreed with women who have diabetes and are planning to become

pregnant, taking into account the risk of hypoglycaemia.


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1.1.4.2 If it is safely achievable, women with diabetes who are planning to

become pregnant should aim to maintain their HbA1c below 6.1%.

Women should be reassured that any reduction in HbA1c towards this

target is likely to reduce the risk of congenital malformations.

1.1.4.3 Women with diabetes whose HbA1c is above 10% should be strongly

advised to avoid pregnancy.

1.1.5 Monitoring blood glucose and ketones in the pre-conception period


offered monthly measurement of HbA1c.


offered a meter for self-monitoring of blood glucose.

1.1.5.3 Women with diabetes who are planning to become pregnant and whorequire intensification of hypoglycaemic therapy should be advised to

increase the frequency of self-monitoring of blood glucose (up to seven

times per day) to include fasting and a mixture of pre- and postprandial

levels.

1.1.5.4 Women with type 1 diabetes who are planning to become pregnant

should be offered ketone testing strips and advised to test for ketonuria

or ketonaemia if they become hyperglycaemic or unwell.

1.1.6 The safety of medications for diabetes before and during pregnancy

1.1.6.1 Women with diabetes may be advised to use metformin or

glibenclamide as an adjunct or alternative to insulin in the pre-

conception period and during pregnancy, when the likely benefits from

improved glycaemic control outweigh the potential for harm. All other

oral hypoglycaemic agents should be discontinued before pregnancy

and insulin substituted.

1.1.6.2 Healthcare professionals should be aware that the rapid-acting insulinanalogues (e.g. insulin human lispro; only available on a named patient

basis in the central hospitals) are safe to use during pregnancy.


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1.1.6.3 Women with insulin-treated diabetes who are planning to become

pregnant should be informed that there is insufficient evidence about the

use of long-acting insulin analogues during pregnancy. Therefore

isophane insulin (Protaphane HM/ Humulin N) remains the first choice

for intermediate/long-acting insulin during pregnancy.

1.1.7 The safety of medications for diabetic complications before and during

pregnancy

1.1.7.1 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.

1.1.7.2 Statins should be discontinued before pregnancy or as soon as

pregnancy is confirmed.

1.1.8 Removing barriers to the uptake of pre-conception care and when to offer

information

1.1.8.1 Women with diabetes should be informed about the benefits of

pre-conception glycaemic control at every contact with healthcare

professionals, including their diabetes care team, from adolescence.

1.1.8.2 The intentions of women with diabetes regarding pregnancy and

contraceptive use should be documented at each contact with theirdiabetes care team from adolescence.

1.1.8.3 Pre-conception care for women with diabetes should be given in a

supportive environment and the womans partner or another family

member should be encouraged to attend.

1.1.9 Self-management programmes

1.1.9.1 Women with diabetes who are planning to become pregnant

should be offered pre-conception care and advice before discontinuing

contraception.

1.1.10 Retinal assessment in the pre-conception period

1.1.10.1 Women with type 1 or full-blown type II diabetes seeking pre-conception

care should be offered retinal assessment at that time (unless an annual

retinal assessment has occurred within the previous 6 months) and

annually thereafter if no diabetic retinopathy is found.


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advised to defer rapid optimisation of glycaemic control until after retinal

assessment and treatment have been completed.

1.1.11 Renal assessment in the pre-conception period

1.1.11.1 Women with diabetes should be offered a renal assessment, including a

measure of microalbuminuria, before discontinuing contraception. If

serum creatinine is abnormal (120 micromol/litre or more), referral to a

nephrologist should be considered before discontinuing contraception.

1.2 Gestational diabetes

1.2.1 Risk factors for gestational diabetes

1.2.1.1 Healthcare professionals should be aware that the following can be

independent risk factors for gestational diabetes in a South African

population:

Previous gestational diabetes

Unexplained intra-uterine death with a previous pregnancy

Previous macrosomic baby > 4.5 kg

Body Mass Index at booking >40 kg/m2

Maternal age >40 years

Family history of diabetes (first-degree relative with diabetes)

Family origin with a high prevalence of diabetes (Asiatic) Acanthosis nigricans

Polycystic ovarian syndrome

1.2.2 Screening for gestational diabetes

1.2.2.1 It is only worthwhile screening for any condition if an effective therapy is

available and if that therapy is cost-effective and prevents morbidity and

mortality. In the ACHOIS study women with IGT were randomised to

treatment or no treatment. This study clearly indicated that the rate of

serious perinatal complications was significantly lower among the

infants of the treated (or intervention) group. Patients who had diabetes

according to the criteria of the 1985 WHO technical report was not

randomised and the diagnosis was revealed to their supervising

physician. The ACHOIS results therefore pertain only to mothers with

mild carbohydrate abnormalities (IGT) but still demonstrated a clinical

improvement in perinatal results for the treated pregnancies.


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1.2.3.2.1. Identify high risk parameters (detailed in

1.2.2.1), especially for Type 2 DM, and do 75g OGTT on those

mothers.

1.2.3.3 Glycosuria can be used as an indication for selective screening, but the

renal threshold for glucose re-absorption is frequently lower and most

pregnant women will have glycosuria intermittently during their

pregnancy. Repeated glycosuria or fasting glycosuria may therefore be

more appropriate.

1.2.4 The argument against selective screening is that 50% of all possible GDM cases

can be missed. As these studies were mainly done in the developed world this

may not be correct in a population where Type 2 DM is more prevalent. It is

unlikely that most poorly resourced countries would be able to afford universal

screening. The following is recommended:

1.2.4.1 Screening for gestational diabetes using risk factors combined with

testing of the urine for glucose is recommended in resource challenged

settings.

Do a urine test for glucose at each antenatal visit

1+ glucose or more on diagnostic strips: do a random blood glucose test

In addition,the following patients must be screened (with a glucose profile or, preferably,

with the 75g OGTT at the 26-28 weeks visit even if the urinary diagnostic strips remain

negative for glucose):

Previous gestational diabetes (do OGTT already at booking)

Unexplained intra-uterine death with a previous pregnancy

Previous macrosomic baby > 4.5 kg

Body Mass Index at booking >40 kg/m2

Maternal age >40 years

Family history of diabetes (first-degree relative with diabetes)

Family origin with a high prevalence of diabetes (Asiatic)

Acanthosis nigricans

Polycystic ovarian syndrome


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1.2.4.2 In order to make an informed decision about screening and testing for

gestational diabetes, women should be informed that:

in most women, gestational diabetes will respond to changes in diet and

exercise

some women (between 10% and 20%) will need oral hypoglycaemic agents or

insulin therapy or both if diet and exercise are not effective in controlling

gestational diabetes

if gestational diabetes is not detected and controlled there is a small but

increased risk of birth complications such as shoulder dystocia

a diagnosis of gestational diabetes may lead to increased monitoring and

interventions during both pregnancy and labour.

1.2.4.3 The 2-hour 75 g oral glucose tolerance test (OGTT) should be used to

test for gestational diabetes. The diagnosis is made using the criteria

defined by the World Health Organization (summarised below). Women

who have had gestational diabetes in a previous pregnancy should be

offered an OGTT at booking and a further OGTT at 26-28 weeks if the

results are normal. Women with any of the other risk factors for

gestational diabetes (see above) should be offered an OGTT at the

latest at 28 weeks.

Diagnostic values:

A fasting value

5.5 mmol/l (alternative 6 mmol/l) and a 2-hour value of < 7.8 mmol/l

(alternative 8 mmol/l) excludes gestational diabetes.

A fasting value >5.5 mmol/l (alternative 6 mmol/l) or a 2-hour value 7.8 mmol/l

(alternative 8 mmol/l), venous samples after a 75g g OGTT is regarded as positive for

gestational diabetes.

An advantage of the above criteria is the correlation with treatment goals.

1.2.4.4 Women with gestational diabetes should be instructed in self-monitoring

of blood glucose levels. Targets for blood glucose control should bedetermined in the same way as for women with pre-existing diabetes.

1.2.4.5 Women with gestational diabetes should be informed that good

glycaemic control throughout pregnancy will reduce the risk of fetal

macrosomia, trauma during birth (to themselves and the baby),

induction of labour or caesarean section, neonatal hypoglycaemia and

perinatal death.


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1.2.4.6 Women with gestational diabetes should be offered information

covering:

the role of diet, body weight and exercise

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 importance of maternal glycaemic control during labour and birth and early

feeding of the baby in order to reduce the risk of neonatal hypoglycaemia

the possibility of transient morbidity 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.

1.2.4.7 Women with gestational diabetes should be advised to choose, where

possible, carbohydrates from low glycaemic index sources, leanproteins including oily fish and a balance of polyunsaturated fats and

monounsaturated fats.

1.2.4.8 Women with gestational diabetes whose pre-pregnancy body mass

index was above 27 kg/m2should be referred to a dietician to counsel

on calorie intake and be advised to partake in moderate exercise (of at

least 30 minutes daily).

1.2.4.9 Hypoglycaemic therapy should be considered for women with

gestational diabetes if diet and exercise fail to maintain blood glucose targets

during a period of 12 weeks.

1.2.4.10 Hypoglycaemic therapy should be considered for women with

gestational diabetes if ultrasound investigation suggests incipient fetal

macrosomia (abdominal circumference above the 75th percentile) at diagnosis.

1.3 Antenatal care

1.3.1 Target ranges for blood glucose during pregnancy1.3.1.1 Individualised targets for self-monitoring of blood glucose should be

agreed with women with diabetes in pregnancy, taking into account the

risk of hypoglycaemia.

1.3.1.2 If it is safely achievable, women with diabetes should aim to keep

fasting blood glucose between 3.5 and 5.5 mmol/litre and 2-hour


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postprandial blood glucose below 7.0 mmol/litre during pregnancy.

Alternative values are 6 and 8 mmol/litre.

1.3.1.3 HbA1cshould ideally be performed every 4 weeks to monitor glycaemic

control with the aim of maintaining this value below 6.1%.

1.3.2 Monitoring blood glucose and ketones during pregnancy

1.3.2.1 Ideally women using insulin should be advised to test fasting blood

glucose levels and blood glucose levels 2 hours after every meal during

pregnancy. For women using oral agents, a fasting level and

measurement of HbA1c is sufficient.

1.3.2.2 Women with insulin-treated diabetes should be advised to test blood

glucose levels before going to bed at night during pregnancy.

1.3.2.3 Women with type 1 diabetes who are pregnant should be offered ketonetesting strips and advised to test for ketonuria or ketonaemia if they

become hyperglycaemic or feel unwell.


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1.3.3 Management of diabetes during pregnancy

1.3.3.1 Women with insulin-treated diabetes should be advised of the risks of

hypoglycaemia and hypoglycaemia unawareness in pregnancy,

particularly in the first trimester.

1.3.3.2 During pregnancy, women with insulin-treated diabetes should have

quick access to a concentrated glucose solution (Super-C tablets or

honey) and women with type 1 diabetes should also be given a

glucagon device for home administration. Women and their partners or

other family members should be instructed in the use of the latter.

1.3.3.3 During pregnancy, women with type 1 diabetes who become unwell

should have diabetic ketoacidosis excluded as a matter of urgency.

1.3.3.4 During pregnancy, women who are suspected of having diabetic

ketoacidosis should be admitted immediately in a secondary (if in rural

regions) or tertiary hospital for critical care, where they can receive both

medical and obstetric care.

1.3.4 Retinal assessment during pregnancy

1.3.4.1 Pregnant women with pre-existing diabetes should be offered retinal

assessment.

1.3.4.2 If retinal assessment has not been performed in the preceding

12 months, it should be offered as soon as possible after the first

contact in pregnancy in women with pre-existing diabetes.

1.3.4.3 Diabetic retinopathy should not be considered a contraindication to

rapid optimisation of glycaemic control in women who present with a

high HbA1c in early pregnancy. However women with severe

retinopathy should be closely monitored.

1.3.4.4 Women who have preproliferative diabetic retinopathy diagnosed during

pregnancy should have ophthalmological follow-up for at least 6 monthsfollowing the birth of the baby.

1.3.4.5 Diabetic retinopathy should not be considered a contraindication to

vaginal birth.


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1.3.5 Renal assessment during pregnancy

1.3.5.1 If renal assessment has not been undertaken in the preceding

12 months in women with pre-existing diabetes, it should be arranged at

the first contact in pregnancy. Do a serum creatinine and urine

diagnostic test for protein. If there is 1+ or more proteinuria, do a full 24-

hour urinary protein quantification test. If the serum creatinine isabnormal (120 micromol/litre or more) or if total protein excretion

exceeds 2 g/day, referral to a nephrologist should be considered.

Thromboprophylaxis should be considered for women with proteinuria

above 5 g/day (macroalbuminuria).

1.3.6 Screening for congenital malformations

1.3.6.1 Women with diabetes should be offered NT scanning at 12 weeks and a

fetal anomaly scan at 20 weeks.

1.3.7 Monitoring fetal growth and well-being

1.3.7.1 Pregnant women with diabetes should be offered Doppler tests of the

umbilical artery at 24 weeks (if microvascular disease or pre-existing

diabetes is present) as well as ultrasound monitoring of fetal growth and

amniotic fluid volume at 34 weeks and an estimated fetal weight and

morphometry at 38 weeks

1.3.7.2 Routine monitoring of fetal well-being before 38 weeks is not

recommended in pregnant women with diabetes, unless there is a risk

of intra-uterine growth restriction.

1.3.7.3 Women with diabetes and a risk of intra-uterine growth restriction

(microvascular disease and/or nephropathy) will require an

individualised approach to monitoring fetal growth and well-being.

1.3.8 Timetable of antenatal appointments

1.3.8.1 Women with diabetes who are pregnant should be offered immediate

contact with a special diabetic clinic (if near a tertiary center) or at leastrefer to a high risk clinic at a secondary hospital.

1.3.8.2 Women with diabetes should have contact with their diabetes care team

for assessment of glycaemic control every 2 weeks throughout

pregnancy.


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1.3.8.3 Antenatal appointments for women with diabetes should provide care

specifically for women with diabetes, in addition to the care provided

routinely for healthy pregnant women. Table 1 describes where care for

women with diabetes differs from routine antenatal care. At each

appointment women should be offered ongoing opportunities for

information and education.

1.3.9 Preterm labour in women with diabetes

1.3.9.1 Diabetes should not be considered a contraindication to antenatal

steroids for fetal lung maturation or to tocolysis.

1.3.9.2 Women with insulin-treated diabetes who are receiving steroids for fetal

lung maturation should be closely monitored and provided with

additional insulin as needed.

1.3.9.3 Betamimetic drugs should not be used for tocolysis in women

with diabetes.

1.4 Intrapartum care

1.4.1 Timing and mode of birth

1.4.1.1 Pregnant women with diabetes who have a normally grown fetus should

be offered elective birth through induction of labour, or by electivecaesarean section if indicated, after 38 completed weeks.

1.4.1.2 Diabetes should not in itself be considered a contraindication to

attempting vaginal birth after a previous caesarean section.

1.4.1.3 Pregnant women with diabetes who have an ultrasound-diagnosed

macrosomic fetus should be informed of the risks and benefits of

vaginal birth, induction of labour and caesarean section.

1.4.2 Analgesia and anaesthesia

1.4.2.1 Women with diabetes and co-morbidities such as morbid obesity or

autonomic neuropathy should be offered an anaesthetic assessment in

the third trimester of pregnancy.

1.4.2.2 If general anaesthesia is used for the birth in women with diabetes,

blood glucose should be monitored regularly (every 30 minutes) from


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induction of general anaesthesia until after the baby is born and the

woman is fully conscious.

1.4.3 Glycaemic control during labour and birth

1.4.3.1 During labour and birth, capillary blood glucose should be monitored on

an hourly basis in women with diabetes and maintained at between 4

and 7 mmol/litre.

1.4.3.2 Women with type 1 diabetes should be considered for an intravenous

dextrose and insulin infusion from the onset of established labour.

1.4.3.3 An intravenous dextrose and insulin infusion is recommended during

labour and birth for women with diabetes whose blood glucose is not

maintained at between 4 and 7 mmol/litre. Check urine hourly for

ketones.

1.5 Neonatal care

1.5.1 Initial assessment and criteria for admission to intensive or special care

1.5.1.1 Women with diabetes should be advised to give birth in hospitals where

advanced neonatal resuscitation skills are available 24 hours a day

(secondary or tertiary hospitals).

1.5.1.2 Babies of women with diabetes should be kept with their mothers unless

there is a clinical complication or there are abnormal clinical signs thatwarrant admission for intensive or special care.

1.5.1.3 Blood glucose testing should be carried out routinely in babies of

women with diabetes according to the provincial protocol for the

management of a baby of a diabetic mother. Blood tests for

polycythaemia, hyperbilirubinaemia, hypocalcaemia and

hypomagnesaemia should be carried out for babies with clinical signs.

1.5.1.4 Babies of women with diabetes should have an echocardiogram

performed if they show clinical signs associated with congenital heart

disease or cardiomyopathy, including heart murmur. The timing of the

examination will depend on the clinical circumstances.

1.5.1.5 Babies of women with diabetes should not be transferred to community

care until they are at least 24 hours old, and not before healthcare


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professionals are satisfied that the babies are maintaining blood glucose

levels and are feeding well.

1.5.2 Prevention and assessment of neonatal hypoglycaemia

1.5.2.1 All maternity units should have a written policy for the prevention,

detection and management of hypoglycaemia in babies of women with

diabetes.

1.5.2.2 Babies of women with diabetes who present with clinical signs of

hypoglycaemia should have their blood glucose tested and be treated

with intravenous dextrose as soon as possible.

1.6 Postnatal care

1.6.1 Breastfeeding and effects on glycaemic control

1.6.1.1 Women with insulin-treated pre-existing diabetes should return to pre-

pregnancy doses after birth and monitor their blood glucose levels

carefully to establish that the dose remains appropriate.

1.6.1.2 Women with insulin-treated pre-existing diabetes should be informed

that they are at increased risk of hypoglycaemia in the postnatal period,

especially when breastfeeding, and they should be advised to have a

meal or snack available before or during feeds.

1.6.1.3 Women who have been diagnosed with gestational diabetes shoulddiscontinue hypoglycaemic treatment immediately after birth.

1.6.1.4 Women with pre-existing type 2 diabetes who are breastfeeding can

resume or continue to take metformin and/or glibenclamide immediately

following birth but other oral hypoglycaemic agents should be avoided

while breastfeeding.

1.6.1.5 Women with diabetes who are breastfeeding should continue to avoid

any drugs for the treatment of diabetes complications that were

discontinued for safety reasons in the pre-conception period.

1.6.2 Information and follow-up after birth

1.6.2.1 Women with pre-existing diabetes should be referred back to their

routine diabetes care arrangements.


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1.6.2.2 Women who were diagnosed with gestational diabetes should have

their blood glucose tested to exclude persisting hyperglycaemia before

they are transferred to community care.

1.6.2.3 Women who were diagnosed with gestational diabetes should be

reminded of the symptoms of hyperglycaemia.

1.6.2.4 Women who were diagnosed with gestational diabetes should be

offered lifestyle advice (including weight control, diet and exercise) and

offered a glucose profile (as described on page 26) at the 6-week

postnatal check-up and annually thereafter.

1.6.2.5 Women who were diagnosed with gestational diabetes (including those

with ongoing impaired glucose regulation) should be informed about the

risks of gestational diabetes in future pregnancies and they should be

offered screening (OGTT or fasting plasma glucose) for diabetes when

planning future pregnancies.

1.6.2.6 Women who were diagnosed with gestational diabetes (including those

with ongoing impaired glucose regulation) should be offered early self-

monitoring of blood glucose or an OGTT in future pregnancies. A

subsequent OGTT should be offered if the test results in early

pregnancy are normal (see recommendation 1.2.2.4).

1.6.2.7 Women with diabetes should be reminded of the importance ofcontraception and the need for pre-conception care when planning

future pregnancies.

Further reading

1. Rowan JA, Hague WM, Gao W, Battin MR, Moore PM. Metformin versus Insulin for

the treatment of gestational diabetes. N Engl J Med 2008; 358: 2003-2015.

2. HAPO Study Cooperative Research Group. Hyperglycemia and Adverse Pregnancy

Outcomes. N Engl J Med 2008; 358: 1991-2002

3. Diabetes in pregnancy: management of diabetes and its complications from

preconception to the postnatal period. RCOG press March 2008.

4. Diagnosis and treatment of diabetic ketoacidosis. Van Zyl DG, SA Fam Pract 2008;

50: 35-39


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PROTOCOLS FOR THE SCREENING, DIAGNOSIS AND MANAGEMENT OF DIABETES

MELLITUS IN PREGNANCY

A. Gestational diabetes

Gestational Diabetes Mellitus (GDM) is glucose intolerance with onset or firstrecognition during pregnancy. It therefore includes mothers who have Impaired Glucose

Tolerance (IGT) or Diabetes diagnosed during the index pregnancy. The diabetes need not

disappear after pregnancy and many mothers probably had unrecognised IGT or even

Diabetes prior to the pregnancy.

Screening for diabetes at the antenatal clinic:

Do a urine test for glucose with each antenatal visit:

o If 1+ glucose or more on diagnostic strips: do a random blood glucose test

In addition, the following patients must be screened [with a glucose profile or,

preferably, with a 75g Oral Glucose Tolerance Test (OGTT)]; preferably before the

visit at 28 weeks at a doctors clinic even if the urinary diagnostic strips remain

negative for glucose:

o Previous gestational diabetes (do OGTT already with booking)

o Unexplained intra-uterine death in a previous pregnancy

o Previous macrosomic baby > 4.5 kg

o Body Mass Index at booking >40 kg/m2

o Maternal age >40 years

o Family history of diabetes (first-degree relative with diabetes)

o Family origin with a high prevalence of diabetes (Asiatic)

o Acanthosis nigricans

o Polycystic ovarian syndrome

These patients are at high risk for diabetes. Most of them would have been referred to a

doctors clinic in any case, as they do not qualify for BANC.

Interpretation of a random glucose test (BANC/MOU care):


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Interpretation of a fasting blood glucose (glucose profile) (BANC/MOU care) -do not

eat or drink anything after 22h00 the previous night (except for water) Test blood glucose

before breakfast (patient must bring her breakfast to the clinic)

5.5 or 2 hour value 7.8 mmol/l

How to do a glucose profile at the clinic:

NPO from midnight (only water allowed)

Patient brings own breakfast to clinic

Test fasting blood glucose level

Eat breakfast, repeat blood glucose test 2 hours later

Control

AIM for a fasting value of 3.5 - 5.5 mmol/l and a 2-hour post-prandial level of

below 7mmol/l. HbA1c should ideally be performed every 4 weeks to monitor

glycaemic control with the aim of maintaining this value below 6.1%.

Management of gestational diabetes at the high risk clinic:

Do thorough medical examination: look for complications of diabetes and for signs of

long-standing diabetes.

Do a baseline serum urea and creatinine determination.

Start on 7600 kJ diet and refer to dietician for advice. All diabetic pregnant patients

must do moderate exercise for 30 minutes each day.

Clinical judgement should be exercised when moving from lifestyle to medical

interventions. Certain women can be given 2 weeks to assess the impact of lifestyle

interventions. Correct dietary advice and compliance can lower serum glucose levels

significantly. However early progression to oral agents or insulin may sometimes be

necessary.


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Start on oral anti-diabetic drugs: Metformin (first choice) 500mg twice a day; increase

if needed to 850mg three times a day. Alternative choice Daonil (glybenclamide)

2.5-5 mg twice daily. Follow up in two weeks with a glucose profile. The available

evidence (poor quality but all we have) does not support combining oral agents in

pregnancy.

If there is poor control at follow up, admit the patient to hospital for better control.

While continuing with the oral medication, perform a 24 hour blood sugar monitoring

profile for additional insulin requirement (determine glucose values half an hour

before each main meal and 2 hours after the meal). Then add insulin to control blood

sugar. The following is suggested:

Begin an insulin regimen with Protophane (GREEN) [Humulin N] only. Start at

a dose of 0.2u/kg. If the calculated dose comes to more than 20 units, start

with 20 units. It is generally a good idea to start 2 units lower than the

calculated dose if the dose is less than 20 units and the patient has not been

on insulin before. Protophane should be administered 30 minutes before

bedtime and the patient should have a snack just before going to sleep.

Monitor the fasting glucose values and HbA1c. When the fasting morning

value remains high, Protophane (code GREEN) can be increased in a

stepwise fashion until fasting values are normal.

As a safety precaution monitor glucose level 4 hours after administration once

protophane has been initiated or dosages modified. If fasting values are normal but

HbA1cis raised there are post-prandial excursions. Determine glucose values half an

hour before each main meal and 2 hours after the main meal (three times a day) for

24-48 hours before any changes and then add Actrapid (YELLOW) [Humulin R] as

indicated below only once fasting values have been normalised.

Identify the meal with the largest post-prandial increase and begin with Actrapid 4

units (30 minutes prior to meal). Increase by 2 units until the post-prandial value is

within the target range. If necessary apply the same principle to other meals.

As soon as the profile is satisfactory and the patient can inject herself, she can be

discharged. Mark the antenatal card as level 3 (high risk).

Follow up at a high risk/diabetic clinic according to the schedule below.

Remember to offer home monitoring to any patient on insulin.

Review control with HbA1c 2-4 weeks after discharge along with home monitoring

values before and after meals.

Follow up of gestational diabetics at a high-risk clinic / diabetes clinic (refer to Table 1

of the guideline):


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2 weekly until 36 weeks.

Thereafter weekly until delivery.

Rural patients can be followed up at their own clinic in conjunction with a specialist

outreach program.

Perform detail ultrasound at 20 weeks including four-chamber view of the fetal heart

and outflow tracts. Perform ultrasound fetal evaluation and weight estimation at 36-38 weeks (weight

estimation clinically or with ultrasound, if available).

Perform glucose profile with each visit

Offer induction of labour at 38 weeks if certain gestation (preferable option). If

patient opts to continue with pregnancy, do weekly fetal surveillance until 41 weeks

and then induce. If gestation uncertain, perform amniocentesis and fetal lung

maturity tests.

Opt for elective caesarean section if the estimated fetal weight is >4 kgat term

and the baby has typical diabetic morphometry (AC >90thcentile, HC 50thcentile).

Management of gestational diabetes in labour

ALL DIABETIC PATIENTS MUST DELIVER IN A HOSPITAL WITH SPECIALIST

SUPERVISION AND 24-HOUR NEONATAL RESUSCITATION FACILITIES

Stop oral hypoglycaemic agents on the day of scheduled delivery or the night before

an elective induction or caesarean section.

Do hourly blood sugar values- aim for a value of between 4 and 7 mmol/l duringdelivery (if patient still eating meals).

If this can be achieved without additional insulin, monitoring blood sugar may be all

that is needed.

As soon as patient is nil per os, start a maintenance infusion of 10 units of short-

acting (Actrapid HM or Humulin R) insulin in 1 litre of 5% dextrose and administer

intravenously at 100ml/hour.

If hourly values not maintained between 4 and 7 mmol/l:

o If blood sugar levels rise >8mmol/l, place on a maintenance infusion of 12-14

units of short-acting (Actrapid HM or Humulin R) insulin in 1 litre of 5%

dextrose. Administer at 100 ml per hour. (Discard any previous infusions).

o If blood sugar level is


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The labour ward doctor must be present during delivery (danger of shoulder

impaction).

The doctor on call for pediatrics must be present at delivery (remind them in time).

Do not continue with oral anti-diabetic drugs after delivery

Follow up 6 weeks3 months after delivery to determine the long-term risk for

diabetes. Women who were diagnosed with gestational diabetes should be offeredlifestyle advice (including weight control, diet and exercise) and offered at least a

glucose profile (as described earlier) at the 6-week postnatal check and annually

thereafter.


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B. Pre-gestational (known) diabetes (non-insulin dependant)

Pregestational (Known) Diabetes Mellitus (PDM)

PDM mothers are usually older and overweight. They are insulin resistant, rather than

insulin depleted and therefore seldom go into diabetic ketoacidosis. They usually

need larger amounts of insulin to control their blood glucose values.

If it is safely achievable, women with diabetes who are planning to become pregnant

should aim to maintain their HbA1cbelow 6.1% and take folic acid 5mg daily.

Women with diabetes whose HbA1cis above 10% should be strongly advised to avoid

pregnancy.

REFER ANY KNOWN TYPE 2 PREGNANT DIABETIC TO THE NEAREST HIGH RISK

CLINIC DIRECTLY AFTER BOOKING. DO NOT STOP ANY ORAL ANTI-DIABETIC

DRUGS BEFORE REFERRAL.

Management at high risk clinic

Search for the complete medical records on the management of her disease to date.

Do a thorough medical examination: look for complications of diabetes and for signs

of long-standing diabetes.

Start on 7600 kJ diet and refer to a dietician for advice. All diabetic pregnant patients

must do moderate excercise for 30 minutes each day.

Do renal assessment: serum creatinine and urine diagnostic strips.

o If serum creatinine >120 micromol/litre, refer to a nephrologist.

o If 1+ or more proteinuria on diagnostic strips- do a full 24 hour urine protein

determination. If total protein excretion >2g/24 hours, refer to a nephrologist.

Refer to ophthalmology for retinal check-up if long-standing type 2 diabetes and no

assessment in the past year.

How to do a glucose profile at the clinic:

NPO from midnight (only water allowed).

Patient brings own breakfast to clinic.

Test fasting blood glucose level.

Eat breakfast, repeat blood glucose test 2 hours later.


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Control


below 7mmol/l. HbA1cshould be performed every 4 weeks to monitor glycaemic


Pharmacological management of type 2 pregnant diabetics at the high risk clinic:

Stop all anti-diabetic drugs and replace with: metformin 500mg twice a day; increase

if needed to 850mg three times per day. Follow up in two weeks with a glucose

profile.

If there is poor control at follow up, admit the patient to hospital for better control.

While continuing with the oral medication, perform a 24 hour blood sugar monitoring

profile for additional insulin requirement (determine glucose values half an hour

before each main meal and 2 hours after the meal). Then add insulin to control blood

sugar. The following is suggested:

Begin an insulin regimen with Protophane (GREEN) [Humulin N] only. Start at

a dose of 0.2u/kg. If the calculated dose comes to more than 20 units, start

with 20 units. It is generally a good idea to start 2 units lower than the

calculated dose if the dose is less than 20 units and the patient has not been

on insulin before. Protophane should be administered 30 minutes before

bedtime and the patient should have a snack just before going to sleep.

Monitor the fasting glucose values and HbA1c. When the fasting morning

value remains high, Protophane (code GREEN) can be increased in a

stepwise fashion until fasting values are normal.

As a safety precaution monitor glucose level 4 hours after administration once

Protophane has been initiated or dosages modified. If fasting values are normal but

HbA1cis raised there are post-prandial excursions. Determine glucose values half an

hour before each main meal and 2 hours after the main meal (three times a day) for

24-48 hours before any changes and then add Actrapid (YELLOW) [Actrapid HM or

Humulin R] as indicated below only once fasting values have been normalised.

Identify the meal with the largest post-prandial increase and begin with Actrapid 4

units (30 minutes prior to meal). Increase by 2 units until the post-prandial value is

within the target range. If necessary apply the same principle to other meals.

As soon as the profile is satisfactory and the patient can inject herself, she can be


Follow up at the high risk/diabetic clinic according to the schedule below.


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Remember to offer home monitoring to any patient on insulin.

Review control with HbA1c 2-4 weeks after discharge along with home monitoring

values before and after meals.

Follow up of controlled type 2 diabetics at the high risk clinic:

2 weekly until 36 weeks Thereafter weekly until delivery.

Rural patients are followed up at their own clinic in conjunction with the outreach

specialist program.

Perform NT scan at 11-13 weeks if available and detail ultrasound at 20 weeks

including four-chamber view of the fetal heart and outflow tracts.

Perform a Doppler test of the umbilical artery at 24 weeks.

Perform ultrasound fetal evaluation and weight estimation at 36-38 weeks (weight





and then induce. If gestation uncertain, perform amniocentesis and fetal lung maturity

tests.

Opt for elective caesarean section if estimated fetal weight is >4 kgat term and

the baby has a typical diabetic morphometry (AC >90thcentile, HC 50thcentile).

Management of type 2 diabetes in labour


SUPERVISION AND 24-HOUR NEONATAL RESUSCITATION FACILITIES

If the client is only on oral anti-diabetic drugs, manage the same as for GDM (protocol

A)

If she is using insulin, put up a maintenance infusion of 10 units of short-acting

(Actrapid HM or Humulin R) insulin in 1 litre of 5% dextrose and administer

intravenously at 100ml/hour.

If hourly values not maintained between 4 and 7 mmol/l:

o If blood sugar levels rise >8mmol/l, replace the maintenance infusion with a

new infusion of 12-14 units of short-acting (Actrapid HM or Humulin R)


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insulin in 1 litre of 5% dextrose. Administer at 100 ml per hour. (Discard any

previous infusions).



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C. Pre-gestational (known) insulin-requiring diabetes

If it is safely achievable, women with insulin dependent (IDDM) diabetes who are

planning to become pregnant should aim to maintain their HbA1cbelow 6.1% and

take folic acid 5mg daily.

Women with diabetes whose HbA1c is above 10% should be strongly advised to

avoidpregnancy.

REFER ANY KNOWN TYPE 1 (INSULIN DEPENDENT) PREGNANT DIABETIC TO THE

NEAREST HIGH RISK CLINIC DIRECTLY AFTER BOOKING. DO NOT STOP INSULIN

BEFORE REFERRAL. IT IS PREFERABLE THAT THEY RECEIVE TERTIARY CARE.

Please note that there is currently no good evidence to begin with metformin in women with

Type 1 diabetes. The goal of such an approach would be to decrease the insulin

requirements (that will increase in pregnancy) and to address the insulin resistance of

pregnancy. It is not recommended.

Management at the clinic (usually admission will be required)

Most patients on insulin will already be using short acting insulin three times a day

with intermediate or long-acting insulin at night (basal bolus). If this is not the case butthere is good control, continue with the current regime, otherwise change to the basal

bolus approach, which is the ideal.

If a change of regimen is necessary admit to hospital. Calculate total daily insulin

requirement, then administer 50% as intermediate acting (Protophane / Humulin N)

30 min before bed time (with a maximum starting dose of 30U) and 50% as short

acting insulin (Actrapid / Humulin R) 30 minutes prior to each main meal (divide

evenly over the three meals).

While on the basal bolus regimen, determine glucose values half an hour before each

main meal and 2 hours after the main meal (three times a day) and at bedtime for 24-

48 hours before any changes.

Begin with the fasting glucose value. If this is still high increase the dose of

Protophane by 2-4U increments until within the target range.

Next compare pre- and post-prandial values. If there is an increase of >2mmol/l over

meals and the postprandial value is not within the target range, add 2U Actrapid to

existing dosage until within the target range.


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In Type I diabetics it is sometimes necessary to use Protophane twice daily as the

effect lasts only for 12-18 hours (shorter in pregnancy). Consider a second dose of

Protophane when pre-prandial values at lunch and supper remain high.

All patients with IDDM must do home monitoring of blood glucose. If she does not

have the necessary equipment, motivate for this before discharge.

All insulin dependent diabetics must carry glucagon and sweets with them at all times

with detailed instructions on their use in cases of hypoglycemia.

Search for the complete medical records on the previous management of the

patients disease.

Review the records of glycaemic control and HbA1c (ideally perform HbA1c on a

monthly basis).

Perform a thorough medical examination to look for complications of diabetes and for

signs of micro-vascular disease.

An ophthalmic examination should be done (fundoscopy).

Start on a 7600 kJ diet and refer to the dietician for advice. All diabetic pregnant

patients must do moderate exercise for 30 minutes each day.

Perform renal assessment: serum creatinine and urine diagnostic strips.

o If serum creatinine >120micromol/litre, refer to a nephrologist.

o If 1+ or more proteinuria on diagnostic strips- do a full 24 hour urine protein

determination as inpatient. If total protein excretion >2g/24 hours, refer to a

tertiary diabetic unit.

Refer to ophthalmology for retinal check-up if no assessment in the past year.

Control


below 7mmol/l. HbA1cshould be performed every 4 weeks to monitor glycaemic


As soon as the profile is satisfactory and the patient can inject herself, she may be


Follow up at a diabetic or high risk clinic according to the schedule below

Follow up of controlled type 1 diabetics at the high-risk clinic:

2 weekly until 36 weeks

Thereafter weekly until delivery.


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Rural patients can be followed up at their own clinic in conjunction with the specialist

outreach program, but must preferably stay with family or friends in a larger centre for

the duration of the pregnancy to attend the tertiary diabetic unit.

Perform NT scan at 11-13 weeks if available, and a detail ultrasound at 20 weeks

including four-chamber view of the fetal heart and outflow tracts.

Perform a Doppler test of the umbilical artery at 24 weeks. Perform ultrasound fetal evaluation and weight estimation at 36-38 weeks (weight





and then induce. If gestation uncertain, perform amniocentesis and fetal lung maturity

tests.

Opt for elective caesarean section if estimated fetal weight is >4 kgat term and

the baby has a typical diabetic morphometry (AC >90thcentile, HC 50thcentile).

Management of type 1 diabetes in labour


SUPERVISION AND 24 HOUR NEONATAL RESUSCITATION FACILITIES

Put up a maintenance infusion of 10 units of short-acting insulin in 1 liter of 5%

Dextrose and administer intravenously at 100ml/hour as soon as patient is nil per os

Perform hourly glucose determination- must be maintained between 4 and 7 mmol/l If hourly values not maintained between 4 and 7 mmol/l:

o If blood sugar levels rise >8mmol/l, replace the maintenance infusion with a

new infusion of 12-14 units of short-acting (Actrapid HM or Humulin R)

insulin in 1 litre of 5% dextrose. Administer at 100 ml per hour. (Discard any

previous infusions).



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After the delivery the patient can be returned to the insulin doses used before

pregnancy. As insulin requirements will be much less directly after the delivery, the

patient should be monitored for hypoglycemia.


38/41


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MAKE SURE THAT THERE IS 5% DEXTROSE IN THE IV FLUIDS IF

HGT 3.0

mmol/l)


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Table 1 Specific antenatal care for women with diabetes

Appointment Care for women with diabetes during pregnancy

First appointment (jointdiabetes and antenatalclinic)

Offer information, advice and support in relation to optimising glycaemiccontrol.

Take a clinical history to establish the extent of diabetes-relatedcomplications.

Review medications for diabetes and its complications, review record ofglycaemic control and HbA1c. (consider performing HbA1c on a monthlybasis).

Offer retinal and/or renal assessment if these have not been undertaken inthe previous 12 months.

79 weeks Confirm viability of pregnancy and gestational age.

Booking appointment(ideally by 10 weeks)

Discuss information, education and advice about how diabetes will affect thepregnancy, birth and early parenting (such as breastfeeding and initial careof the baby).

12 weeks NT scan (pre-existing diabetes)

16 weeks Offer retinal assessment at 1620 weeks (or earlier if necessary) to womenwith pre-existing diabetes who showed signs of diabetic retinopathy at thefirst antenatal appointment.

20 weeks Offer fetal anomaly scan24 weeks Offer Doppler tests of the umbilical artery (if pre-existing diabetes)

34 weeks Offer ultrasound monitoring of fetal growth and amniotic fluid volume.

36 weeks Offer information and advice about:

timing, mode and management of birth

analgesia and anaesthesia

changes to hypoglycaemic therapy during and after birth

management of the baby after birth

initiation of breastfeeding and the effect of breastfeeding on glycaemiccontrol

contraception and follow-up.

38 weeks Do ultrasound fetal weight estimation and morphometry.Offer induction of labour, or caesarean section if indicated, at 38 weeksproviding the G.A. is certain (ultrasound at 22 weeks or before). Where G.A.is uncertain an amniocentesis and test for surfactant is indicated. Startregular tests of fetal well-being for women with diabetes who choose to awaitspontaneous labour. If the EFW of a baby is over 4000g and the baby has atypical diabetic morphometry (AC >90th centile, HC 50th centile) then anelective caesarean section should be offered to the mother.

39 weeks Offer tests for fetal well-being.



Note: The objective of this guideline is to offer induction of labour to women with diabetes mellitus at

38 weeks gestation. Further monitoring of the patient beyond 38 weeks applies where the offer of

induction is not accepted, where gestational age is uncertain, or where other circumstances exist.


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Table 2

Currently available insulin (provincial coding list)

insulin human soluble

biosynthetic (yeast)

100units/ml ACTRAPID HM

insulin human solublebiosynthetic (E-coli)

100units/ml HUMULIN R

insulin human soluble +isophane (yeast)

30% + 70%100units/ml

ACTRAPHANE HM

insulin human Soluble +isophane (E-coli)

30% + 70%100units/ml

HUMULIN 30/70

insulin human isophanebiosynthetic (yeast)

100units/ml PROTAPHANE HM

insulin human isophanebiosynthetic (E-coli)

100units/ml HUMULIN N

insulin human lispro 100units/ml HUMALOG

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Diabetes in Pregnancy Western Cape Guidelines

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