Skip to main content
  1. Right Decisions
  2. GGC - Clinical Guideline Platform
  3. Maternity
  4. Back
  5. Medical conditions in pregnancy - diabetes
  6. Diabetes, Guidelines for the Management of Diabetes Mellitus during Pregnancy and Diagnosis of Gestational Diabetes (1136)
Announcements and latest updates

Right Decision Service newsletter: April 2024

Welcome to the Right Decision Service (RDS) newsletter for April 2024. 

Issues with RDS and Umbraco access

Tactuum has been working hard to address the issues experienced during the last week. They have identified a series of three mitigation measures and put the first of these in place on Friday 3rd May.  If this does not resolve the problems, the second mitigation will be actioned, and then the third if necessary.

Please keep a lookout for any slowing down of the system or getting locked out. Please email myself, mbuchner@tactuum.com and onivarova@tactuum.com if you experience any problems, and also please raise an urgent support ticket via the Support Portal.

Thank you for your patience and understanding while we achieve a full resolution.

Promotion and communication resources

A rotating carousel presenting some of the key RDS tools and capabilities, and an editable slideset, are now available in the Resources for RDS providers section of the Learning and Support toolkit.

Redesign and improvements to RDS

The redesign of RDS Search and Browse is still on-track for delivery by mid-June 2024. We then plan to have a 3-week user acceptance testing phase before release to live. All editors and toolkit owners on this mailing list will be invited to participate in the UAT.

The archiving and version control functionality is also progressing well and we will advise on timescales for user acceptance testing shortly.

Tactuum is also progressing with the deep linking to individual toolkits within the mobile RDS app. There are several unknowns around the time and effort required for this work, which will only become clear as the work progresses. So we need to be careful to protect budget for this purpose.

New feature requests

These have all been compiled and effort estimated. Once the redesign work is complete, these will be prioritised in line with the remaining budget. We expect this to take place around late June.

Evaluation

Many thanks to those of you completed the value and impact survey we distributed in February. Here are some key findings from the 65 responses we received.

Figure 1: Impact of RDS on direct delivery of care

Key figures

  • 93% say that RDS has improved evidence-informed practice (high impact 62%; some impact 31%)
  • 91% report that RDS has improved consistency in practice (high impact 65%, some impact 26%)
  • 85% say that RDS has improved patient safety (high impact 59%, some impact 26%)
  • Although shared decision-making tools are only a recent addition to RDS, and only represent a small proportion of the current toolset, 85% of respondents still said that RDS had delivered impact in this area (53% high impact, 32% some impact.) 92% anticipate that RDS will deliver impact on shared decision-making in future and 85% believe it will improve delivery of personalised care in future.

Figure 2 shows RDS impact to date on delivery of health and care services

 

Key figures

These data show how RDS is already contributing to NHS reform priorities and supporting delivery of more sustainable care.

Saving time and money

  • RDS clearly has a strong impact on saving practitioner time, with 90% of respondents reporting that this is the case. 65% say it has a high impact; 25% say it has some impact on time-saving.
  • It supports devolved decision-making across the multi-professional team (85% of respondents)
  • 76% of respondents confirm that it saves money compared, for example, to investing in commercial apps (54% high impact; 22% some impact.)
  • 72% believe it has impacted already on saving money and reducing waste in the way services are delivered – e.g. reducing costs of referral management, prescribing, admissions.

Quality assurance and governance

  • RDS leads are clear that RDS has improved local governance of guidelines, with 87% confirming that this is the case. (62% high impact; 25% some impact.)

Service innovation and workforce development

  • RDS is a major driver for service innovation and improvement (83% of respondents) and has impacted significantly on workforce knowledge and skills (92% of respondents – 66% high impact; 26% some impact).

New toolkits

A few examples of toolkits published to live in the last month:

Toolkits in development

Some of the toolkits the RDS team is currently working on:

  • SARCS (Sexual Assault Response Coordination Service)
  • Staffing method framework – Care Inspectorate.
  • SIGN 171 - Diabetes in pregnancy
  • SIGN 158 – British Guideline on Management of Asthma. Selected sections will be incorporated into the RDS, and complemented by a new chronic asthma pathway being developed by SIGN, British Thoracic Society and NICE.
  • Clinical pathways from NHS Fife and NHS Lanarkshire

Please contact his.decisionsupport@nhs.scot if you would like to learn more about a toolkit. The RDS team will put you in touch with the relevant toolkit lead.

Quality audit of RDS toolkits

Thanks to all of you who have responded to the retrospective quality audit survey and to the follow up questions.  We still have some following up to do, and to work with owners of a further 23 toolkits to complete responses. An interim report is being presented to the HIS Quality and Performance Committee.

Implementation projects

Eight clinical services and two public library services are undertaking tests of change to implement the Being a partner in my care app. This app aims to support patients and the public to become active participants in Realistic Medicine. It has a strong focus on personalised, person-centred care and a library of shared decision aids, as well as simple explanations and videoclips to help the public to understand the aims of Realistic Medicine.  The tests of change will inform guidance and an implementation model around wider adoption and spread of the app.

With kind regards

Right Decision Service team

Healthcare Improvement Scotland

Diabetes, Guidelines for the Management of Diabetes Mellitus during Pregnancy and Diagnosis of Gestational Diabetes (1136)

Warning

Please report any inaccuracies or issues with this guideline using our online form

Women with Diabetes Before Pregnancy

INTRODUCTION

Type 1 diabetes in pregnancy is a high-risk state for both the woman and her fetus. Rates of miscarriage, perinatal loss and major congenital malformation are increased at least two to threefold.

Type 2 diabetes is becoming more common in this age group and management of pregnancies in people with type 2 diabetes should follow the same intensive program of metabolic, obstetric and neonatal supervision.

AIM

An optimal outcome may be obtained in diabetic pregnancy if excellent glycaemic control is achieved before and during pregnancy. Good pre-pregnancy planning is thus essential. Effective contraception, allowing a planned pregnancy, is therefore important.

CONTRACEPTION

Contraception should be discussed on an individual basis with all women of childbearing age with diabetes. In general, the contraceptive advice for a diabetic woman should follow that in the general population but with the following caveats:

  • The combined OCP should be avoided in women with complications or risk factors for vascular disease or over 35 years of Progesterone-only preparations may be suitable in these women.
  • Women using the intrauterine contraceptive device should be advised that they might be at increased risk of infection.

In women with complications or vascular risk a value judgement must be made which balances the risk of complications with the need to avoid pregnancy. The levonorgestrel releasing intrauterine device (e.g. Mirena coil) may be particularly suited as it is as effective as sterilisation and produces low circulating hormone levels.

PRE-PREGNANCY CARE

Infants whose mothers receive dedicated multidisciplinary pre-pregnancy counselling show significantly fewer major congenital malformations (approximating to the rate in non diabetic women) compared to infants of non-attendees. They also have fewer immediate problems and are kept in special care for shorter periods.

All women with diabetes who are planning a pregnancy should be seen at a Multidisciplinary Clinic involving a endocrinologist, obstetrician, diabetes nurse specialist, and dietician. They should be seen with their partners if possible and provided with written information.

  • Full medical, obstetric and gynaecological history.
  • Check thyroid function.
  • Review current medications.
  • STOP: ACE Inhibitors, A2 Blockers, Statins, Review anti diabetic medication and likely stop all but metformin and insulin. Women on other agents may need replacement with insulin. Contact the local Diabetes Secondary Clinic immediately as soon as pregnancy confirmed.
  • Prescribe Folic Acid 5mg daily for at least 1-month pre conception and for 1st trimester.
  • Screen for complications.
  • Advice on diet and weight reduction if relevant and strongly discourage smoking and refer to smoking cessation if appropriate
  • Educate on the importance of near normal glycaemia control.
  • Instruct partners to recognise and treat hypoglycaemia with glucagon if necessary.
  • Support improvements in glycaemic control including access to structured education where appropriate and consideration of optimal monitoring and insulin delivery.

Women who are well controlled and free from complications should take 1 month’s folic acid prior to stopping contraception and keep a record of periods. Others should spend additional time optimising control and having complications investigated and treated.

Women should perform a pregnancy test if there is a lapse of 5 weeks between periods and contact their Diabetes Specialist Nurse if positive.

ANTE-NATAL CARE

Care should be hospital based, from a multi-disciplinary team. Women generally attend every 2 to 4 weeks until 30 weeks and then every 1-2 weeks thereafter.

POST NATAL CARE

  • Insulin requirements fall dramatically after delivery- reduce dose to pre-conception dose.
  • In breast feeding mothers reduce this further and encourage higher blood sugars than pregnancy.
  • Discuss contraception after delivery (usually prior to hospital discharge).
  • All women should be reviewed at the clinic in 6 weeks.

Gestational Diabetes

TESTING FOR GESTATIONAL DIABETES

Detection and management of gestational diabetes reduces birth weight and some maternal adverse outcomes such as pre-eclampsia. Dietary management is the key first step in management.   Risk factors for selection of women to offer OGTT are based on those in the SIGN and NICE guidelines – with the exception that BMI>= 35kg/m2 used (with the aim of reducing to 30kg/m2 as per those guidelines in time).  Diagnostic criteria are based on the SIGN guideline. 

  • Routine screening at first antenatal visit
    • At booking all women should be assessed for the presence of risk factors for gestational diabetes (see table 1).
    • All women with risk factors should have HbA1c measured.
    • In early pregnancy, levels of HbA1c≥48 mmol/mol, (or fasting glucose ≥7.0mmol/l , or random or two hour glucose after OGTT ≥11.1 mmol/l glucose) are diagnostic of diabetes and these women should be offered treatment pathways as per pre-existing diabetes.

  • Routine screening later in pregnancy
    • Women with previous GDM are also offered 75g OGTT at 14-16 weeks
    • All women with risk factors, including previous GDM (see table 1) should be offered a 75 g OGTT at 24-28 weeks unless already diagnosed or monitoring.

  • Non- routine screening if
    • glycosuria of 2+ or above on 1 occasion
    • glycosuria of 1+ or above on 2 or more occasions
    • Polyhydramnios
    • EFW ≥95th centile
  • Before 35 weeks- measure random glucose and HbA1c and offer 75gOGTT

  • after 35 weeks
    • Offer glucose monitoring for 2-3 days to exclude hyperglycaemia with Diabetes Specialist Midwife. Contact details for each hospital below

DIAGNOSIS

WHO 2013 criteria are used for 75 g OGTT:

  • fasting venous plasma glucose ≥5.1 mmol/l, OR
  • one hour value ≥10 mmol/l (if measured), OR
  • two hours after OGTT ≥8.5 mmol/l.

Table 1: Risk factors for gestational diabetes

BMI more than 35 kg/m² *
Previous macrosomic baby weighing 4.5 kg or more
Previous gestational diabetes
Family history of diabetes (first degree relative with diabetes)
Family origin with a high prevalence of diabetes:

  • South Asian (specifically women whose country of family origin is India, Pakistan or Bangladesh)
  • Black Caribbean
  • Middle Eastern (specifically women whose country of family origin is Saudi Arabia,
    United Arab Emirates, Iraq, Jordan, Syria, Oman, Qatar, Kuwait, Lebanon or Egypt).

*BMI more than 30kg/m2 in SIGN currently implemented locally as more than 35 kg/m2

MANAGEMENT

Women with gestational diabetes should have access to dietary advice from a dietician as well as consideration of treatment with metformin and/or insulin if needed - starting either with referral to the local multidisciplinary clinic or under a protocol agreed by that clinic.

Women with frank diabetes by non-pregnant criteria (fasting venous glucose ≥7 mmol/l, random or two hour ≥11.1 mmol/l) should be managed within a multidisciplinary clinic as they may have type 1 or type 2 diabetes and be at risk of pregnancy outcomes similar to those of women with pre-gestational diabetes.

FOLLOW-UP

Women who have had GDM are at an increased of type 2 diabetes in later life. 

All women should be offered HbA1c through their GP at 3-4 months.

Access to specialist weight management services is available and women can self refer using the GG&C website: Community Weight Management Service

Contact details

For OGTT : this is ordered through Badger

For Diabetes Specialist Midwife (eg concerns that BG monitoring raised,  request monitoring after 35 weeks):

PRMU:    ggc.dsm-prm@ggc.scot.nhs.uk

Clyde:    ggc.dsm-clyde@ggc.scot.nhs.uk 

QEUH:    ggc.dsm-qeuh@ggc.scot.uk

Editorial Information

Last reviewed: 28/02/2024

Next review date: 27/02/2029

Author(s): Robbie Lindsay (on behalf of Chris Smith, Rahat Maitland Abbie Swan, Jillian Smith, Nicola McLachlan).

Version: 1

Approved By: Maternity Clinical Governance Group

Document Id: 1136