Torbay antenatal clinic guidelines


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Torbay antenatal clinic guidelines

  1. 1. Title: DIABETES IN PREGNANCY Ref: 0485 Version: 4 Classification: Protocol Directorate: Obstetrics Due for Review: 15/10/12 Responsible Document Information for review: Dr R Dyer, Consultant Physician and Endocrinologist Ratified by: Miss Sudhakar, Clinical Lead for Obstetrics Paul Foster, Clinical Director of Pharmacy Applicability: All pregnant diabetic women PART 1: ANTENATAL CARE PART 2 : ANTENATAL INPATIENT MANAGEMENT/COMPLICATIONS PART 3: SCREENING FOR GESTATIONAL DIABETES MELLITUS (GDM) PART 4: LABOUR AND PUERPERIUM Appendix 1: Sliding scale Appendix 2: Care pathway for hand-held notes PART 1: ANTENATAL CARE Diabetes is the most common pre-existing medical disorder complicating pregnancy in the UK. Approximately 1 pregnant woman in 250 has pre-existing (type 1 or type 2) diabetes, and an increasing number of young people are being diagnosed with type 2 diabetes. The diabetic antenatal clinic is a multidisciplinary clinic for the management of pregnancy occurring in • Women with Type 1 diabetes • Women with Type 2 diabetes • Women found to have diabetes in pregnancy (gestational diabetes, GDM) • Women with Type 1 or Type 2 diabetes planning pregnancy can be seen at the end of the clinic or by the appropriate members of the team at other times. Organisation of Clinic Service. Antenatal care is the responsibility of one Obstetrician and one Diabetes Physician Weekly clinic (Thursday am) Present Dr Dyer, Consultant Diabetologist, and/or SpR in Diabetes Dietician Midwife with special responsibility for diabetes Miss Sudhakar, Consultant Obstetrician, and/or SpR in Obstetrics Diabetes Specialist Nurse. Advice available 9-5, ext 55525 Preconception • All women of childbearing potential should be given preconception advice. • All women with diabetes planning pregnancy should be prescribed folic acid 5mg daily preferably for 3 months before conception because of their increased risk of neural tube defects. • Rubella status should be checked and the opportunity taken to give general alcohol and smoking advice. • Attempts should be made to optimise glycaemic control prior to conception. • Target HbA1c as close to normal range as possible (<6.1%) but certainly <7% to reduce the risk of fetal abnormalities particularly cardiac and neural tube defects and miscarriage. • For women with Type 2 diabetes transfer to insulin therapy may be appropriate. • Assess diabetic complications, their likely impact on pregnancy and the effect of pregnancy on pre- existing complications. • Patients found to be pregnant should be seen at the next diabetic antenatal clinic or more urgently if clinically indicated. Collated by Clinical Effectiveness Diabetes in Pregnancy Page 1 of 15
  2. 2. Antenatal Management of Pregnancy in women with pre-existing diabetes (Type 1 or Type 2) Print protocol for woman’s blue notes Attach Appendix 2 care pathway to woman’s hand held notes Medical • Optimise glycaemic control as above. Patients are usually managed on basal bolus regimen – • Short acting insulin before meals intermediate long acting insulin before bed. • Individualised dietary advice. • Encourage consumption of low glycaemia index carbohydrate foods and reduce saturated fat. • Women with a body weight greater than 120% of the ideal require a lower energy intake to try to limit their weight gain during pregnancy • Advise on management of hypoglycaemia because tight diabetic control will almost certainly increase the frequency of mild hypoglycaemia (BM< 4.0 mmol/l) and can lead to a loss of warning symptoms for hypoglycaemia. Consequently will be at increased risk of a severe hypoglycaemic reaction (external help required to manage the episode), particularly prevalent in the first trimester. • Issue glucagon to selected high-risk women. • Direct access to Diabetic nurse specialist for advice during working hours (55525). • Out of hours: GP/A&E <20/40, Labour ward> 20/40. • For women with Type 2 diabetes transfer to insulin therapy. • Assessment of diabetic complications as early as possible in pregnancy. • Assessment of ischaemic heart disease risk should be undertaken in women with nephropathy and those with type 2 diabetes. • As soon as pregnancy is confirmed HbA1c, U&Es, and TSH should be performed. • HbA1c at time of confirmation of pregnancy and at least once in each trimester (more frequently if clinically indicated). • Urinalysis and blood pressure at each clinic visit. • Aim for pre-meal blood glucose of 5.5mmol/l and post prandial <7mmol/l (4-7 mmol/l) • Monitoring should be QDS and nocte, at least 2-3/week to daily. • Retinal screening in each trimester. Retinal photography is suggested in the first trimester unless performed within the last 6 months. Dilated fundoscopy is then acceptable later in pregnancy. • For patients with known diabetic nephropathy or patients with persistent proteinuria, 24 hour quantification of protein loss and creatinine clearance should be performed at least in each trimester or monthly if heavy or deteriorating. • Increased risk of VTE • Particularly increased risk of PET and IUGR. Consider low dose aspirin until 36 weeks. • Increased blood pressure surveillance is required for increased risk of PIH and PET. • Document pre-pregnancy insulin regime in hand held notes. Obstetric • Scans and obstetric review are appropriate at the following times. Before 12 weeks Diabetic visits, scan only if clinically indicated 12/40 Dating scan and Downs screening 20/40 Anomaly scan 22/40 Detailed cardiac. Miss Sudhakar 24/40 Growth and liquor volume. Only if high risk 28/40 Growth and LV 32/40 Growth and LV 34/40 Growth and LV 36/40 Growth and LV. Confirm and arrange delivery plan 38 /40 Growth and LV. Only if low risk with CTG Diabetes in Pregnancy Collated by Clinical Effectiveness Page 2 of 14
  3. 3. If growth scan results outside 3rd -97th centile or liquor volume abnormal more frequent scans and/or clinic visits may be appropriate • Fetal heart should be auscultated at every non-scan visit by the midwife. • Importance of awareness of fetal movements must be discussed with kick chart offered from 34 week or earlier if poor control. • Women should be seen weekly for BP, urinalysis and FH, with CMW visits in between the above clinic visits from 34 weeks. • Obstetric and neonatal risks of pregnancy and poor glycaemia control must be discussed and include: • Miscarriage, fetal malformations • Antenatal monitoring • Macrosomia, PET, IUD • Raised induction, instrumental delivery and caesarean section rates, • Monitoring in labour, shoulder dystocia. • Admission to SCBU, hypoglycaemia, breathing difficulties and jaundice. • High risk pregnancies in women with vascular complications should have Dopplers weekly and CTGs once or twice a week from at least 34 weeks. • Women with macrosomia (AC>97th centile) and polyhydramnios (AFI) should have weekly CTGs from 36 weeks. If associated with poor glycaemia control, from 34 weeks. • Discuss feeding plan, breast-feeding is recommended. Timing of Delivery • 39/40 for women with pre-existing diabetes (Type 1 or Type 2) if very good control with no macrosomia and no polyhydramnios. • Induction at 38/40 if suboptimal control, macrosomia or mild polyhydramnios. • Document and discuss risk of shoulder dystocia. • Delivery before 38/40 and by elective caesarean section may be appropriate on clinical grounds such as microvascular disease, poor control in association with polyhydramnios, macrosomia or sudden acceleration in growth, fetal growth restriction or reduction of insulin requirements in discussion with Miss Sudhakar and SCBU. • Please ensure that Special Care Baby Unit (SCBU) staff are aware of any planned early delivery prior to admission. • Any planned or premature delivery before 36 weeks should receive antenatal steroids, betamethasone 12mg IM x 2 doses, 24 hours apart and admission for glycaemia control and fetal monitoring. Collated by Clinical Effectiveness Diabetes in Pregnancy Page 3 of 15
  4. 4. PART 2 : ANTENATAL INPATIENT MANAGEMENT/COMPLICATIONS See Diabetes care (ref 0243) and Medical Management of Poorly Controlled Diabetes / Prevention of DKA (ref 0021) In pregnancy a high degree of self-management and monitoring is required. It is appropriate for women to self-manage while in hospital. However, they may require assistance and guidance, particularly as insulin requirement may decrease with inactivity (hyperglycaemia). It is the responsibility of midwives caring for the pregnant mother to assist the mother and to inform the diabetes team (55525) /obstetrician of the admission even if unrelated to diabetes. Daily CTG. Intercurrent Illness/Diabetic ketoacidosis • Hyperglycaemia (BM>12), diabetic ketoacidosis and dehydration can occur with with intercurrent illness such as infection due to the stress response releasing glucose from glycogen stores. In pregnancy normoglycaemic ketoacidosis may be more common. • Admit to hospital if unable to take food or drink for >24 hours. • Contact diabetic team/medical team urgently • Never stop or reduce insulin during illness even if not eating. • May require more insulin. • Symptoms: thirsty, urinary frequency/polyuria, weakness • Signs: smell of acetone, tachypnoea • Urgently assess for urinary ketones • 2++ are significant if hyperglycaemic, • 4++++ are significant at any glucose level. • Use catheter specimen if unable to pass urine on admission. • Obtain iv access and test for urea, electrolytes and bicarbonate (acidosis if <20). • Treat with rehydration, Initially 1 litre normal saline + 20mmol KCl/8 hours (80mls/hr) and usual insulin and glucose sliding scale (appendix 1) and ref 0021. • Associated with a high risk of fetal loss. Continuous CTG. • May be more appropriate to manage on a medical ward/HDU • Cessation of glucose infusion may be required if blood glucose remains>15mmols (in conjunction with Medical advice only). • Urea and electrolytes should be checked after 4 hours and regularly thereafter to guide potassium replacement (risk of hypokalaemia with large doses of insulin). Steroid Treatment Intensive monitoring of diabetes is required during steroid treatment in preparation for premature delivery below 36 weeks. Steroids cause a variable rise on blood glucose, which can cause decompensation of diabetes and may cause fetal difficulties if delivery occurs soon after. All women with diabetes and GDM, whether on insulin or diet controlled, receiving steroids should be admitted for BM and fetal monitoring. • Inform Diabetes team of admission. • Check blood glucose pre and 2 hours post prandial , nocte then every 4 hours overnight or 4 hourly if not eating properly or unwell, for 24 hours after administration of each dose of betamethasone. • Day 0: Increase usual evening long-acting insulin dose by 20% on the first day of steroids. • Day 1, increase insulin by 40%, 40% and 20% at each meal and 10% at evening dose. • Or if mother is on mixed insulin bd increase usual insulin doses by approximately 30%. • e.g. , for Novomix 30 insulin, 20 unitsbd, the dose should be increased to 26 units bd. • If delivery is immediately after steroid course, fall in insulin requirements post-partum may be slower than expected. If delivery is delayed, increased insulin dosage should be maintained for 2-3 days after steroid course, with additional 8 units short acting insulin if capillary glucose > 8 mmol/l. The patient may give extra doses of short acting insulin to control blood glucose if she is confident to do so, or on the advice of the diabetes team. Diabetes in Pregnancy Collated by Clinical Effectiveness Page 4 of 14
  5. 5. • Women with abnormal glucose tolerance, of varying degrees, managed with diet alone, may require insulin during steroid administration. • Suggested regime if BMs > 8mmols/l : 8u,8u,8u actrapid then 10u insulatard at night. • If blood glucose still rises > 10 mmol/l when not in labour sliding scale insulin should be commenced according to labour ward protocol. • If labour imminent have lower threshold for proceeding to sliding scale ie BM > 8 mmol/l. • Urinalysis for ketonuria when hyperglycaemic (2++). Check all urine samples thereafter until no ketones. • But 4++++ ketonuria is significant at any glucose level. • Woman should be allowed to eat normally but s/c insulin omitted. • Daily CTG with increased frequency if hyperglycaemic (risk of acidosis during hyperglycaemia) • Continuous CTG if on sliding scale. • Seek advice about discontinuing sliding scale (Diabetic team/Miss Sudhakar). • The maximal hyperglycaemic effect is 12 hours post each dose but may last up to 24 hours. Management of Hypoglycaemia See hypoglycaemia in adults who have diabetes (ref 0269) • Definition: BM<3 mmol/l • Commonest in the first trimester and the first few days post-partum. • Symptoms: double vision, confusion/vagueness, mood swings, aggression, irritability, sweating, slurred speech, sleepy/dizzy, panic, nausea, hunger, tremor, pins and needles, headache, seizures and loss of consciousness • Signs: tachypnoea, tachycardia, cold/clammy skin. • Causes: reduced food, increased insulin, dehydration, alcohol, breast-feeding. Conscious Check BM 10g oral glucose e.g. 3 dextrose tablets, Hypostop gel, 50mls lucozade or 100mls soft drink Semi/Unconscious Call medical SHO on call/ crash call 2222 Recovery position to protect airway 1mg glucagon iv/im/sc. If no response after 10 minutes give 20-50ml iv glucose 50% via large bore cannula. Then follow up with food. Check blood glucose 30 minutes later If a diabetic is unconscious and cause in doubt give glucagon/glucose because hypoglycaemia is a greater risk than hyperglycaemia. Collated by Clinical Effectiveness Diabetes in Pregnancy Page 5 of 15
  6. 6. PART 3: SCREENING FOR GESTATIONAL DIABETES MELLITUS (GDM) It can be defined as a carbohydrate intolerance of variable severity with its onset/first recognition in pregnancy. It includes women with abnormal glucose tolerance that reverts to normal after delivery, those with undiagnosed type 1 or type 2 diabetes and rarely women with inherited (monogenic) diabetes. The new NICE guidelines recommend screening women from the following categories. High risk pregnancies Oral Glucose Tolerance Test (OGTT) will be performed at 28 weeks gestation in patients at high risk. • Obesity (BMI >30 kg/m2) • Strong family history of diabetes (first and second degree relatives) • Previous large for dates baby (>4.5 kg/9lb 9oz at term) • Fetal AC above 97th centile on scan • Polyhydramnios • History of polycystic ovarian syndrome • Member of ethnic group with high prevalence of diabetes (Most non-Caucasian groups, particularly South Asian, African-Caribbean, Chinese. If in doubt ask diabetes team) If OGTT is normal at 28 weeks it is only repeated if clinically indicated. GDM in previous pregnancy • See in diabetic ANC at time of dating scan or as soon as possible afterwards to plan care. • Insulin required previously: Blood glucose monitoring in place of OGTT as early as possible. • Previously diet controlled: • Perform OGTT at the earliest opportunity. • If normal early in pregnancy repeat OGTT at 28 weeks plus growth scan. • No further management and return to previous level of care if OGTT normal and non-macrosomic baby at 28 weeks. Note; repeated OGTT is only recommended for patients with previous GDM, not other risk groups Performance and interpretation of 75g modified OGTT OGTT’s can be performed in the ANC at Torbay on any day. It is essential that that the test is performed under standardised conditions (a) OGTT should be performed as soon after 9am as possible. Women should be fasted for at least 10 hours and should avoid alcohol and cigarettes the night before the test. Water only should be taken on the morning of the test. Women should not smoke and should sit quietly for the duration of the test as exercise affects the results. (b) Blood is taken for fasting blood glucose. 75g glucose dissolved in 250ml water (can be flavoured with sugar free squash as required) is taken orally over 5- 10 minutes. Timing of the test starts at time of start of ingestion. Blood glucose taken at 2 hours after ingestion. Women with fasting glucose >5.5 mmol/l or 2 hour glucose >7.8mmol/l should be referred to the diabetic antenatal clinic. If in doubt about the need for referral discuss with Diabetic team/midwife. Low risk GDM 2 hour glucose 7.8 – 8.5 mmol/l High risk GDM 2 hour glucose > 8.6 mmol/l Diabetes in Pregnancy Collated by Clinical Effectiveness Page 6 of 14
  7. 7. Management of women with GDM - Red Risk Sticker Low risk Seen by midwife, healthy eating and lifestyle advice. USS: If macrosomia or polyhydramnios are present, transfer management to high risk group. Arrange capillary blood sugar (CBS) monitoring for one week for review by the diabetes specialist midwife. If all results are within the target range (fasting <5.5, 2hr < 7.0) see at 33/40 for one week further CBS monitoring and repeat growth scan at 36/40. If any results are above the targets or USS shows a big baby 7/or polyhydramnios transfer to the high risk clinic. Also transfer to high risk group if other adverse clinical indicators Manage according to other obstetric risk factors. If none, manage as low risk pregnancy and offer IOL from 41 weeks as per NICE guidelines. Post natal OGTT at 6 weeks. Write with results, only review in clinic if abnormal. High risk Diabetes specialist nurse or diabetes specialist midwife instruct in home blood glucose monitoring. Pre-meal capillary glucose >6 mmol/l or 2 hour post-prandial glucose >7 mmol/l (confirm with laboratory tests if borderline or doubt about validity) Consider insulin therapy if fetal macrosomia. Insulin treatment will depend upon size of baby, gestational age and other factors. USS assessment of fetal size and liquor volume as per pre-existing diabetic management. Delivery by 40 weeks if on insulin. Occasional post-prandial monitoring post delivery. Regular monitoring only if requested by diabetologist Post natal fasting blood sugar at 6 weeks. Review in clinic with results as necessary. Advise yearly glucose testing by GP Collated by Clinical Effectiveness Diabetes in Pregnancy Page 7 of 15
  8. 8. PART 4: LABOUR AND PUERPERIUM Assess and manage for thromboembolic risk (Ref 0428) Paediatrician is not required at delivery if diabetes well controlled at term. Any problems with control or management of diabetes should be referred to the diabetic team (ext 55525) during office hours or the on-call medical registrar out of hours. INDUCTION or EARLY LABOUR Gestational diabetes controlled with diet • Admission post prandial BM blood sugar • Routine observations only are required if BM <8 • If raised BM, perform regular post-partum BM monitoring and obtain medical advice as above. Insulin treated patients (pre-existing diabetes and gestational diabetes managed with insulin) • Inform diabetes team of admission (ext 55525) • Admission BM blood glucose. • Give normal insulin dose and usual food. • Still needs to take great care to avoid food and drinks that will cause a rise in blood glucose during induction or early labour. • Blood glucose should be recorded 2 hours post-prandially if GDM and before each meal as well if diabetic at least QDS and nocte or 4 hourly if not eating properly. • Blood glucose > 8mmol/l on admission or early in IOL, recheck 1 hour later. If still raised patients are generally advised to add an extra 2 units of their insulin to the next meals dose. • If remain raised obtain medical advice as above or transfer to labour ward and commence sliding scale insulin if labour/ARM/Syntocinon imminent or patient unwell or not eating. LABOUR Gestational diabetes controlled with diet • Once in established labour check blood glucose every 2 hours. If blood glucose above 8.0 mmol/l commence intravenous insulin and glucose (appendix 1). • Fetal heart rate monitoring should be by intermittent auscultation if no other obstetric complications and if blood glucose remains normal (<8.0mmols/l). • Continuous CTG fetal monitoring if sliding scale required. Insulin treated patients (pre-existing diabetes and gestational diabetes managed with insulin) • Inform obstetric registrar and SCBU. • Once in established labour commence insulin and glucose infusion (appendix 1). • Monitor blood glucose hourly and adjust insulin infusion rate according to sliding scale instructions. • Aim for blood glucose of 4-8mmol/l. • Tight control is required to prevent neonatal hypoglycaemia. • Continue all routine maternal observations. • Continuous CTG fetal monitoring for risk of acidosis • Clear fluids only. Consider NBM and Ranitidine if CS appears likely. • Beware shoulder dystocia particularly if macrosomia or delay in second stage. • Senior midwife and registrar to be available on labour ward. Diabetes in Pregnancy Collated by Clinical Effectiveness Page 8 of 14
  9. 9. CAESAREAN SECTION Gestational diabetes controlled with diet – as for labour Admission BM Sliding scale insulin is not required for planned LSCS for women with GDM who are not treated with insulin (unless blood glucose on admission is greater than 8 mmol/l). Insulin treated patients Elective LSCS – Nil by mouth from midnight, omit morning insulin Emergency LSCS – commence intravenous insulin and glucose as early as possible GDM Sliding scale insulin is not required for women with GDM treated with insulin if admission blood glucose is 4 - 8 mmol/l and there is a clear instruction that insulin is to be discontinued immediately after delivery. If sub-optimal glycaemic control, admit to John Macpherson ward the night prior to LSCS with treatment plan to allow monitoring and stabilization of blood glucose. Commence sliding scale at 8 am on the morning of LSCS unless indicated earlier for stabilization of blood glucose. Pre-existing diabetes Sliding scale insulin will be required pre-LSCS regardless of BM to prevent both hypo- and hyperglycaemia. If reasonable control, admit to labour ward at 8am, perform BM and continue hourly. If sub-optimal control manage as above and defer delivery until BM 4-8 if feto-maternal condition allows. Plan LSCS for first on the morning list whenever possible to avoid risk of hypo or hyperglycaemia. Ensure that SCBU staff are aware of LSCS on admission. Pre-term delivery should have been discussed with SCBU when booked. Stillbirth 2 hourly BM monitoring. For sliding scale if BM>10. PUERPERIUM All asymptomatic term babies should remain with their mothers pending the post-feed lab glucose by 3 hours after delivery. See hypoglycemia in the neonate protocol (ref 0099). Breast-feeding is recommended. It reduces the insulin requirement. Extra carbohydrate is required, as snacks, particularly during the breast-feed. Gestational diabetes controlled by diet • Routine maternal and neonatal care. • No BM monitoring. • PN fasting blood sugar is arranged by the diabetes specialist midwife. Write with results, only review in clinic if abnormal. Gestational diabetes treated with insulin • Stop intravenous insulin and glucose after delivery if eating and drinking normally or permitted to eat (after LSCS). • Stop subcutaneous insulin used during pregnancy unless there is an indication to the contrary on shared care record. • Avoid iv glucose for rehydration • x 2 post-prandial BMs post delivery. • Regular monitoring only if requested by diabetologist. • If blood glucose remains above 7.0 mmol/l contact diabetes team (55525) • Post natal fasting blood sugar at 6 weeks. Collated by Clinical Effectiveness Diabetes in Pregnancy Page 9 of 15
  10. 10. • All results are reviewed by the diabetes team and follow up appointments made as required. Pre-existing diabetes (Type 1 or Type 2) • Halve the rate of insulin infusion immediately and continue sliding scale regimen until able to eat and drink reliably then stop infusions. Insulin requirements drop rapidly after delivery to pre-pregnancy levels. Blood glucose levels can fall even lower if the mother breastfeeds. • Start pre-pregnancy insulin doses and diabetic diet unless otherwise instructed. The sliding scale can be discontinued 30 minutes after s/c insulin and food. • Dose may need to be further reduced with breast-feeding. • Inform diabetic team (ext 55525). • In the post-operative period close monitoring of blood glucose is required, at least 4 hourly until diabetic review, by phone if straightforward. • Monitoring can be performed by the mother when well enough but is the responsibility of the midwife until then. Although the mother may be able to self-manage in these circumstances to a certain extent, she will need help. She may be very expert in management of her diabetes, but it is unlikely that she will have experience in these situations and is likely to need guidance about change in insulin doses. • The main risk to the mother is hypoglycaemia. • Target blood glucose 4 – 10 mmol/l. • Contact diabetic team if > 10mmol/l. • Poor blood glucose control soon after operative delivery may result in increased risk of wound infection and breakdown and thrombotic complications. • Refer to plan in notes or seek advice from diabetes team if type 2 diabetes and not on insulin prior to pregnancy. • Oral hypoglycaemics should not be used if breast-feeding so may require continued blood glucose monitoring or remain on insulin (reduce dose by 1/3). • Reassess and manage for thromboembolic risk. • For TED stockings. • Arrange appointment in Monday clinic with diabetes team for around 6 weeks post-natal. Diabetes in Pregnancy Collated by Clinical Effectiveness Page 10 of 14
  11. 11. Appendix 1 Intravenous Insulin and Glucose regimen Departments of Obstetrics and Diabetes Labour Ward Only Insulin Infusion Protocol • The aim of this guideline is to achieve excellent intrapartum glycaemic control to prevent hyperglycaemia or hypoglycaemia in mother and to prevent hypoglycaemia and other metabolic consequences for baby • Please note that this infusion protocol is different from sliding scale protocols in use on general wards and should not be used in other clinical areas Insulin prescription Record of syringes given 50 units human actrapid insulin made up to 50 ml Date Time Insulin NaCl Midwife’s with sodium chloride 0.9%, infused intravenously batch no batch signature via 50ml syringe driver. no Dr’s Signature Date Dr’s Name Bleep Fluid administration The fluid to be used with sliding scale should be prescribed on a fluid chart. Standard fluid is 500ml 10% Glucose with 10mmol/l KCl or 1 litre 10% glucose with 20mmol KCl via infusion pump at 125 ml/hr. Fluid and insulin should be given through the same venflon using a non-return Y connector. May need to fluid restrict to 80mls/hr if pre-eclamptic. Seek advice (Miss Sudhakar/ Diabetic team). Sliding scale Blood glucose should be recorded hourly and insulin infusion varied as set out below. Note that insulin requirement varies, sliding scale prescription may need to be altered. Seek advice if glucose not well controlled. Aim for BM between 4-7 mmols/l. Blood glucose (mmol/l) Insulin (ml/hr) Instructions Alternative 0-4 0 Inform Doctor. 0 Continue dextrose infusion. Recheck 1 hour. If >/4 change to alternative non-pregnant regime. See Diabetic patients who are NBM (ref 0023) 4.1 - 6 1 1 6.1 - 8 2 3 8.1-12 3 5 >12.1 5 Inform Doctor 6 >17 6 Inform Doctor urgently 8 and reassess Doctor’s signature Collated by Clinical Effectiveness Diabetes in Pregnancy Page 11 of 15
  12. 12. Labour Ward Only Insulin Infusion Protocol Name …………………………………… ………….. Do not use in other clinical areas. Number…………………………………….. ………. Date Time Blood Insulin Syringe Fluid type (and Fluid Midwife’s glucose U/hr volume additive) rate signature RGD 02.06 Diabetes in Pregnancy Collated by Clinical Effectiveness Page 12 of 14
  13. 13. Appendix 2 CARE PATHWAY: PRE-EXISTING DIABETES To be attached to woman’s hand held notes Pre-pregnancy medication Post-natal monitoring/ medication if different Pre-pregnancy s/c insulin Alternative Contraception ANTENATAL SCHEDULE Gestation Diabetic review at Obstetric/scan Midwifery Sign/date each visit First 1-2 weekly Booking bloods trimester HbA1c& TSH General health Retinal / renal assessment Folic acid 12/40 HbA1c. Dating scan BP, MSU monthly 16/40 Double test 20/40 Anomaly 24/40 Growth scan if high risk only 28/40 HbA1c, Growth scan and Downs screening Hb, Bld grp retinal assessment 32/40 Growth scan fortnightly 34/40 HbA1c, Growth scan (retinal assessment) Commence CTGs if very high risk 35/40 Only If high risk CTG if very high risk CMW if low risk BP/urinalysis/FH 36/40 Growth scan weekly Arrange elective delivery date Commence CTGs if high risk 37/40 Only If high risk CTG if high risk CMW Pre-birth visit if low risk BP/urinalysis/FH 38/40 Delivery Or Growth scan + CTG only if low risk 39/40 Delivery if low risk only Date admission for delivery Caesarean Induction : Beware Shoulder Dystocia Collated by Clinical Effectiveness Diabetes in Pregnancy Page 13 of 15
  14. 14. Monitoring compliance of this guideline In order to monitor compliance with this guideline, the guideline will be monitored as follows. • Minimum Requirements • Evidenced • CNST standard a. the involvement of the multidisciplinary team • Diabetes notes • 3.9 including the obstetrician, midwife, diabetes physician, diabetes specialist nurse and dietician in the provision of care b. the timetable of antenatal appointments • Pregnancy notes • 3.9 c. the requirement to document an individual • Diabetes notes • 3.9 management plan in the health records that covers the pregnancy and postnatal period up to six weeks d. targets for glycaemic control • Diabetes notes • 3.9 e. advising women with type 1 diabetes of the risks of • Diabetes notes • 3.9 hypoglycaemia and hypoglycaemia unawareness in pregnancy f. offering antenatal ultrasound examination of the four • Pregnancy notes • 3.9 chamber view of the fetal heart and outflow tracts at 20 weeks g. how women who are suspected of having diabetic • Medical / • 3.9 ketoacidosis are admitted immediately to a high pregnancy notes dependency unit where they can receive both medical and obstetric care Frequency Ongoing Undertaken by Audit midwife Dissemination of Results Directorate Audit meeting Recommendations/Action Plans Implementation of the recommendations and action plan will be monitored by the Clinical Effectiveness Department. Any barriers to implementation will be risk assessed and added to the local risk register. Any changes will be highlighted to the midwifery staff via team leaders and to the medical staff via the education lead. Diabetes in Pregnancy Collated by Clinical Effectiveness Page 14 of 14
  15. 15. Protocols & Guidelines – Document Information This is a controlled document. It should not be altered in any way without the express permission of the author or their representative. On receipt of a new version, please destroy all previous versions. Ref: 0485 Title: Diabetes in Pregnancy Date of Issue: 15 October 2009 Next Review Date: 15 October 2012 Version: 4 Author: Dr R Dyer, Consultant Physician and Endocrinologist Index: Obstetrics Classification: Protocol Applicability: All pregnant diabetic women Evidence based: Yes American Diabetes Association Clinical Practice Recommendations 2002. Diabetes Care January 2002 NSF Diabetes: Standards: Diabetes and Pregnancy 2002. References: SIGN Guidelines for management of diabetes in pregnancy 2001. CEMACH Maternity services in 2002 for women with type 1 and type 2 diabetes. CEMACH Pregnancy in women with type 1 and type 2 diabetes in 2002-2003. Produced following audit: Yes Audited: This is a new protocol developed as a result of audit Approval Route: See ratification Date Approved: Approved By: Miss Sudhakar, Clinical Lead for Obstetrics Paul Foster, Clinical Director of Pharmacy Links or overlaps with other policies: 0243, Diabetes Care, 0021, Medical Management of Poorly Controlled Diabetes/Prevention of DKA, 0269, Hypoglycaemia in adults who have diabetes, 0428, Thrombo Prophylaxis including assessment and treatment, 0099, Hypoglycaemia in the Neonate All SDHCF Trust strategies, policies and procedure documents. RATIFICATION: PUBLICATION HISTORY: Issue Date Status Authorised 1 July 2002 New R Dyer, Consultant Physician and Endocrinologist 2 November 2002 Revised R Dyer, Consultant Physician and Endocrinologist 2 27 October 2005 Date Change R Dyer, Consultant Physician and Endocrinologist 2 4 November 2005 Date Change R Dyer, Consultant Physician and Endocrinologist 3 9 March 2006 Revised G Pandher, Clinical Lead for Obstetrics, Paul Foster, Clinical Director of Pharmacy 4 15 October 2009 Revised Miss Sudhakar, Clinical Lead for Obstetrics, Paul Foster, Clinical Director of Pharmacy Collated by Clinical Effectiveness Diabetes in Pregnancy Page 15 of 15