Provision of information

Women who already have diabetes before pregnancy

Prepregnancy planning

• Discuss pregnancy planning with women with diabetes of childbearing age at their annual review. Discussion of care with women of childbearing age should include issues that may arise before pregnancy, during pregnancy and after pregnancy. This should be discussed at the annual review but also when it is timely and appropriate for the individual.

• Advise women with diabetes who are preparing for pregnancy that information about preconception planning is available and that they will be offered access to a prepregnancy multidisciplinary clinic, and outline the benefits of multidisciplinary management. Signpost to online resources for further information.

• Reassure women who have an unplanned pregnancy that the multidisciplinary diabetes team is always available and advise them to contact the team as soon as possible to access support.

• Agree individualised HbA1c levels to aim for, taking into account BMI, smoking, hypertension and level of diabetic retinopathy.

• Explain to women with diabetes why pregnancy should be avoided if HbA1c >86 mmol/mol and support women to have access to reliable contraception.

• Discuss the need for referral to relevant specialties to address diabetes complications before pregnancy, including psychological issues, where possible.

Optimising individualised diabetes management

• Offer lifestyle advice, for example, on stopping smoking, vaping, alcohol and drug use, and healthy eating, weight management and exercise, in line with all pregnancies. Explain about how to access support from a registered dietitian.

• Explain that HbA1c will be measured at the booking appointment and may be monitored regularly during pregnancy.

• Suggest that women should aim for an HbA1c as low as possible, and (for those using CGM) time in pregnancy range (3.5–7.8 mmol/L) >70% without excess hypoglycaemia prior to pregnancy. Provide information on the risks of diabetes to both mother and fetus. Explain why a review of glycaemic levels is necessary.

• Review blood glucose monitoring methods. Discuss use of diabetes technologies, specifically whether CGM and/or an insulin pump may offer benefits for the individual. Discuss achievable blood glucose levels prior to and during pregnancy.

• Ensure that women using CGM and/or an insulin pump have alternative glucose monitoring and insulin delivery equipment (eg glucose meters measuring capillary blood and insulin pens) in case of device failure.

• Explain that routine diabetes measurements will continue to be collected during pregnancy and that the interval between measurement may be smaller than before pregnancy, for example blood pressure, retinal screening, foot screening.

• Address issues with particular significance to pregnancy including reduced wellbeing and mental health.

• Explain to women on insulin therapy prior to pregnancy that their insulin requirements will increase by up to 50% and adjustments will be supported by the diabetes multidisciplinary team. Encourage women to continue to adjust and self manage during pregnancy to optimise diabetes management.

Medication review

• Advise that folic acid 5 mg (available on prescription only) should be taken for three months prior to conception, or as soon as possible after pregnancy is confirmed, and until the end of week 12 of pregnancy.

• Review all medication and offer advice on which medications should be stopped (eg ACE inhibitors and statins), the reasons behind stopping and what the alternatives are. Provide contact telephone numbers.

• Ensure that only insulin and/or metformin are prescribed to manage blood glucose levels in women with diabetes during pregnancy.

Managing hypoglycaemia

• Revisit awareness, recognition and management of hypoglycaemia regularly during pregnancy.

• Ensure that the woman has the ability and equipment to test for hypoglycaemia and understands how to treat it appropriately.

• Ensure the availability of glucagon and education regarding administration.

• Ensure that the woman knows to contact the multidisciplinary team in case of severe hypoglycaemia (requiring third-party intervention) or if episodes are increasing in frequency.

• Explain to women that hypoglycaemia can increase in frequency in the first trimester, which can be exacerbated by a change in symptoms, morning sickness and insulin sensitivity. Review safety aspects in the context of home circumstances, occupation and driving.

Women who are being tested for or are diagnosed with diabetes in pregnancy or gestational diabetes

Medication review

• Advise that folic acid 5 mg (available on prescription only) should be taken until the end of week 12 of pregnancy.

• Review all medication and offer advice on which medications should be stopped (eg ACE inhibitors and statins), the reasons behind stopping and what the alternatives are. Provide contact telephone numbers.

• Ensure that only insulin and/or metformin are prescribed to manage blood glucose levels in women diagnosed with diabetes during pregnancy.

Optimising individualised diabetes management

• Advise that during pregnancy glucose levels are important and they will need to monitor their blood glucose more often.

• Offer a range of blood glucose monitoring methods and discuss use of diabetes technologies, specifically whether CGM and/or an insulin pump may offer benefits for the individual.

• Explain to women with diabetes in pregnancy that they should aim for:

o     fasting glucose level <5.5 mmol/L

o     one-hour postprandial glucose level <8 mmol/L, and

o     two-hour postprandial glucose level <7 mmol/L.

• Suggest to women diagnosed with T1DM or T2DM in pregnancy who are using CGM that they should aim to spend at least 70% time in pregnancy range (3.5–7.8 mmol/L).

• Explain that HbA1c may be monitored regularly during pregnancy.

• Explain that routine antenatal care for women with diabetes in pregnancy involves regular monitoring, for example blood pressure, retinal screening, foot screening.

• Address issues with particular significance to pregnancy including reduced wellbeing and mental health.

Diet, nutrition and lifestyle advice

• Offer lifestyle advice, for example, on stopping smoking, vaping, alcohol and drug use, and healthy eating, weight management and exercise, in line with all pregnancies. Explain about how to access support from a registered dietitian.

• Offer dietary advice individually or in group settings depending on the needs of the woman.

• Offer advice on weight management at all opportunities.

• Be aware of increased risks of disordered eating. Sensitively enquire if the woman has a current or past history of an eating disorder and be aware of potential barriers to disclosure.

• Review individual physical activity levels and encourage women to achieve at least 150 minutes of moderate physical activity per week during pregnancy.

• Highlight the importance of wellbeing and offer psychological support through perinatal or diabetes services, depending on locality.

• Provide access to online education and information on diet, exercise, mental health and wellbeing.

Retinal screening

• Explain to women who are diagnosed with T1DM or T2DM during pregnancy that they will be offered retinal screening at least three times during pregnancy:

o     during the first trimester, as soon as possible after confirmation of pregnancy

o     during the second trimester at approximately 24 weeks gestation

o     during the third trimester at approximately 36 weeks gestation.

• Explain to women with GDM that they are not routinely invited for retinal screening but   that they may be reviewed by local retinal screening service if they have a high HbA1c level measured at the booking appointment or in early pregnancy.

• Explain what screening involves and what treatment to expect if retinopathy is found.

Managing hypoglycaemia

• Revisit recognition and management of hypoglycaemia regularly during pregnancy.

• Ensure that the woman has the ability and equipment to test for hypoglycaemia and understands how to treat it appropriately.

• Ensure the availability of glucagon and education regarding administration.

• Ensure that the woman knows to contact the multidisciplinary team in case of severe hypoglycaemia (requiring third-party intervention) or if episodes are increasing in frequency.

Driving

• Signpost the guidance from the DVLA for people with diabetes. Ensure that women who use insulin for over 3 months inform the DVLA.

All women with diabetes during pregnancy

Antenatal care and discussing pregnancy risks

• Discuss the local services providing diabetes and antenatal care, explaining the need for more frequent appointments during pregnancy, including additional scans. Explain who will be involved and who to contact for support.

• Using person-centred communication skills, sensitively highlight risks relating to congenital malformation, miscarriage, stillbirth and abnormal growth of the baby (small or large for gestational age). Explain the evidence supporting these risks and help the woman to weigh up and evaluate her choices without implying blame or negatively impacting her experience of pregnancy.

The role of the multidisciplinary team

• Explain that different professionals will be involved in care for the woman before, during and after her pregnancy.

• Explain that care will be provided by a community midwifery team and a specialist multidisciplinary team which, may include consultant obstetricians, consultant diabetologists, specialist and general midwives, diabetes specialist nurses, dietitians and insulin pump teams.

• Explain that the community and specialist teams will review and contact the woman throughout pregnancy to monitor and support her and her baby.

Sick day rules for pregnancy

• Offer advice about sick day rules and planning for periods of illness (including minor ailments) which may cause hyperglycaemia. This may include:

o     appropriate use of insulin or glucose-lowering medication

o     appropriate dietary alterations to maintain normal glucose levels

o     how often to measure blood glucose levels and when to check for ketones (when blood glucose level is ≥10 mmol/L or during illness in women with T1DM)

o     when and how to contact the diabetes team.

Planning delivery

• Discuss the timing and mode of birth during antenatal appointments as early as possible in the pregnancy and confirm birth plans with the woman in the third trimester.

• Discuss and make a plan for their diabetes during labour, delivery and the postnatal period, including options for pain relief and use of an insulin pump or sliding scale, as appropriate. Discuss dose changes or plans to stop insulin after delivery.

• Involve women who live in island or rural locations, who may need to travel to another hospital to have their baby, in discussions on transfer planning, the locality teams and timelines.

• Offer women sensitive, individualised breastfeeding support and contraception choice.

Postnatal care

• Discuss the following issues with women after delivery:

o     explain that if they used insulin before pregnancy that their basal insulin dose may reduce by 50% after delivery and the diabetes team will help them to return to their preconception regimen.

o     stopping glucose-lowering medications if they had GDM.

o     support (and medication review, if required) for breastfeeding. Ensure that women with diabetes do not transition to glucose-lowering therapies other than metformin and/or insulin while breastfeeding.

o     diabetes follow up and ongoing support for women with T1DM and T2DM. Book a return review appointment within the diabetes team. If returning to primary care, it is essential to signpost to support for future pregnancies.

o     contraception. Advise women of availability of contraception in postnatal wards. Otherwise provide information leaflets on contraception and advise a review with her GP or local family planning services.

o     review provision and plan for CGM according to individual need and service availability.

Gestational diabetes

• Explain to women diagnosed with GDM that due to the high risk of future T2DM it is important to have postnatal screening, annual review of glycaemic status and access to services to prevent and reduce the future risk of diabetes.

• Using shared decision making involving the woman, a registered dietitian and the multidisciplinary diabetes team, provide referral to a weight management programme, as required, as part of the A Healthier Future: type 2 diabetes prevention, early detection and intervention framework. Discuss with women the options available, including in-person or online sessions.

• Discuss future pregnancy planning and the importance of reviewing glycaemic control and avoiding T2DM prior to pregnancy (see prepregnancy advice).

• Explain to women who had received a diagnosis of GDM that they will receive an early screening for T2DM during subsequent pregnancies and will enter a ‘Gestational Diabetes Pathway’, which may include early booking and placement on a local specialist pathway (with community midwife, specialist service and dietetic input).