Diabetes in pregnancy: management of diabetes and its complications from preconception to the postnatal period (NG3)

Authors

  • Jonathan Webber University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
  • Mary Charlton University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
  • Nina Johns Birmingham Women’s Hospital NHS Foundation Trust, Birmingham, UK.

DOI:

https://doi.org/10.15277/bjdvd.2015.029

Abstract

In February 2015 the National Institute for Health and Care Excellence (NICE) published new guidance (NG3) on the management of diabetes in pregnancy. Care teams need to be aware of this guidance and implement its recommendations. These include preconception care with target HbA1c 48 mmol/mol. Women at risk of gestational diabetes mellitus (GDM) should have a 75 g oral glucose tolerance test (OGTT). Diagnostic criteria for GDM have changed to fasting glucose of 5.6 mmol/L or above or 2 hour glucose of 7.8 mmol/L or above.

Glycaemic targets in all diabetic pregnancies have changed to fasting glucose below 5.3 mmol/L (4–5.2 mmol/L if on insulin) and 1 hour postprandial glucose below 7.8 mmol/L if these can be achieved safely. Continuous glucose monitoring and insulin pump therapy should not be used routinely but can be used if glycaemic control is problematic. Capillary ketone testing should be routine for women with type 1 diabetes when hyperglycaemic and for all women with diabetes including, GDM when acutely unwell.

More flexibility is offered around recommended delivery timing: 37+0 weeks to 38+6 weeks for women with types 1 and 2 diabetes; prior to 40+6 in GDM (and earlier if complications arise). Postnatal testing following GSM should be by fasting glucose (not OGTT) at 6–13 weeks post partum. Testing later than this can use HbA1c.

Introducing these changes will have resource implications, including a likely increase in the number of women diagnosed with GDM.

Author Biography

Jonathan Webber, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.



References

National Institute for Health and Care Excellence. Diabetes in pregnancy: Management of diabetes and its complications from preconception to the postnatal period. NG3, Feb 2015. Available at https://www.nice.org.uk/guidance/ng3.

National Institute for Health and Care Excellence. Diabetes in pregnancy: Management of diabetes and its complications from pre-conception to the postnatal period. CG63, March 2008. Obsolete: no longer available online.

Confidential Enquiry into Maternal and Child Health. Pregnancy in women with type 1 and type 2 diabetes in 2002-03, England, Wales and Northern Ireland. CEMACH: London; 2005. Available at http://www. hqip.org.uk/assets/NCAPOP-Library/CMACE-Reports/29.-2005-Pregnancy-in-women-with-type-1-and-type-2-diabetes-2002-2003.pdf.

Crowther CA, Hiller JE, Moss JR, McPhee AJ, Jeffries WS, Robinson JS, for the Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS) Trial Group. Effect of treatment of gestational diabetes mellitus on pregnancy outcomes. N Engl J Med 2005;352:2477-86. http://dx.doi.org/10.1056/NEJMoa042973

International Association of Diabetes and Pregnancy Study Groups. Recommendations on the diagnosis and classification of hyperglycemia in pregnancy. Diabetes Care 2010;33:676-82. http://dx.doi.org/10.2337/dc09-1848

WHO 2013 Diagnostic Criteria and Classification of Hyperglycaemia First Detected in Pregnancy. Available at http://apps.who.int/iris/bitstream/10665/85975/1/WHO_NMH_MND_13.2_eng.pdf accessed 1.7.2015

Seely EW, Zera C. Gestational Diabetes Mellitus. BMJ Best Practice. http://bestpractice.bmj.com/best-practice/monograph/665/diagnosis/criteria.html as updated Mar 04, 2015

American Diabetes Association. Classification and diagnosis of diabetes. Diabetes Care 2015;38(Supplement 1):S8-S16. http://dx.doi.org/10.2337/dc15-S005)

Rowan JA, Hague WM, Gao W, Battin MR, Moore MP for the MiG Trial Investigators. Metformin versus insulin for the treatment of gestational diabetes. N Engl J Med 2008;358:2003-15. http://dx.doi.org/10.1056/NEJMoa0707193

Murphy J. Unpublished data from internal audit. Birmingham Women’s Hospital 2014

O'Connor C, O'Shea PM, Owens LA, et al. Trimester-specific reference intervals for haemoglobin A1c (HbA1c) in pregnancy. Clin Chem Lab Med 2011;50:905-09. http://dx.doi.org/10.1515/CCLM.2011.397

National Institute for Health and Care Excellence. Preventing type 2 diabetes: risk identification and interventions for individuals at high risk. PH38, July 2012. Available at https://www.nice.org.uk/guidance/ph38.

Downloads

Published

2015-09-01

Issue

Section

Editorials

Most read articles by the same author(s)