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Diabetes in pregnancy

SIMPSON CENTRE FOR REPRODUCTIVE HEALTH
ROYAL INFIRMARY of EDINBURGH

Clinical Protocol
DIABETES IN PREGNANCY
Diabetes;
Management of GlycaemicControl in labour and in the antenatal period.

Document Information
Diabetes: management of glycaemic control.
Current clinical guideline for glycaemic control in women with diabetes in labour and in the antenatal period. MANAGEMENT OF PREGNANT WOMEN WITH DIABETES WHO ARE IN-
PATIENTS
Background
Management is different in different groups of women with diabetes.
Women with Type 1 Diabetes (previously termed insulin dependent diabetes mellitus or IDDM) have an absolute requirement for insulin and quickly become ketotic without insulin. An increasing number of women are being seen with Type 2 Diabetes, especially in ethnic minority groups. These women are not insulin dependent but will almost all be on insulin in pregnancy.
Women with Gestational Diabetes (GDM) have been diagnosed as having diabetes during pregnancy and will be treated either with diet or diet and insulin. Ketoacidosis is very unlikely in this group, but can be precipitated with betamethasone.
The Standard
The absolute requirement is that
• women are maintained with blood glucose between 4 and 8 mmol/l most of the • hypoglycaemia is avoided as much as possible• no woman develops ketoacidosis• the Diabetes and Obstetric teams are fully involved with the management These guidelines give guidance only. The patient will always require careful clinical assessment. Management may differ from the guidelines in individual cases; indeed management will be individualised as much as possible to suit the needs of the
individual woman.
In all women treated with intravenous fluids regular (at least daily) monitoring of U&Es and venous plasma glucose will be necessary and the addition of potassium to intravenous fluids will almost always be necessary. Intravenous insulin is most easily administered by syringe driver. Add 50 units of ACTRAPID to 50ml of NaCl 0.9% in a 50ml syringe (1 unit per 1 ml), label and ‘piggy back’ into cannula with other infusions.
Advice is available from the Department of Diabetes during the day and in the evening 7 days a week and these guidelines assume that all patients will be referred early so that appropriate advice may be given: CONTACT NUMBERS
Diabetes Registrar
Bleep #6800
The diabetes registrar is currently on call from 09.00-21.00weekdays and from 09.00-19.00 at the weekends. Outwith these times the SHO on call for Ward 207 should be contacted via switchboard. There is no diabetes on call rota at consultant level, but Dr Jaap and Dr Patrick will always be prepared to give advice if a available. If neither is available the on-call medical consultant can be contacted via Consultant Obstetricians:
MANAGEMENT STRATEGIES DURING ANTENATAL ADMISSION
Women with Type 1 and Type 2 diabetes admitted during pregnancy for whatever reason • check capillary blood glucose using a Capillary BG meter and test urine for • If urinary ketones are present (moderate or large) OR blood glucose > 15 mmol/l
inform diabetic registrar immediately and check venous plasma glucose and U
• If vomiting inform diabetic registrar immediately, check venous plasma glucose and U and Es and commence an i.v. infusion of N/Saline.
• Let diabetic registrar know of admission, they will see the patient and/ or advise regarding management and alterations from the protocol below.
• Inform on call obstetric senior registrar of admission. They will se the patient and inform the consultant obstetrician of admission If betamethasone is to be administered then see separate guideline on page 9
• Continue s/c insulin as usual and adjust doses as necessary• Check capillary blood glucose (BG) 4 times daily (pre-breakfast, before each • Target values are between 4 and 8 mmol/l most of the timeIf not able to eat normally • check BG 2 hourly initially – may be able to stretch to 4 hourly if stable• start iv dextrose 5% 500ml 4 hourly• start i.v. insulin by sliding scale (50 Units of Actrapid insulin in 50 ml of Normal Insulin infusion (Units actrapid/hour = ml/hour) 6 (test urine for ketones, call Dr, the sliding 0.5 (call Dr, the sliding scale may need revision) WOMEN WITH GESTATIONAL DIABETES ADMITTED DURING PREGNANCY
FOR WHATEVER REASON
• check capillary blood glucose using Capillary BG meter and test urine for ketones
• If urinary ketones are present (moderate or large) OR blood glucose > 15 mmol/l
inform diabetic registrar immediately, check venous plasma glucose and U and
Es and commence an i.v. infusion of N/Saline.
• If vomiting inform diabetic registrar immediately and check venous plasma • Let diabetic registrar know of admission, they will see the patient and/or advise regarding management and alterations from the protocol below.
If betamethasone is to be administered then see separate guideline (page 9)
• Continue s/c insulin as usual if on insulin• Check BG 4 times daily (pre-breakfast, before each main meal and pre-bed)• Target values are between 4 and 8 mmol/l most of the time If not able to eat normally contact Diabetes Registrar as previously detailed.
MANAGEMENT STRATEGIES DURING LABOUR AND DELIVERY
Pre-labour e.g. following cervical priming with prostaglandins
Try to maintain all women (Type 1, Type 2 and GDM) on their usual regimen for as long as possible with usual insulins and meals/snacks.
Test capillary blood glucose four times a day unless instructed otherwise.
In Labour
In women in labour maintaining good glucose control (blood glucose levels between 4 and 10 mmol/l) with s/c insulin may be possible throughout the labour, HOWEVER if the labour, is prolonged or the women vomits or is not keen to eat or unable to eat due to risk factors precluding eating in labour (risk of GA etc) then intravenous insulin will be necessary i.e. most patients will require i.v. insulin I.V. insulin using the sliding scale is necessary for Type 1 women if: • the blood glucose exceeds 10 mmol/l or if unable to eat, or vomiting, and not later than 6 hours after their last short acting insulin injection I.V. insulin using the sliding scale is necessary for Type 2 women or women with • the blood glucose exceeds 10 mmol/l during labour In women with elective Caesarean section then i.v. insulin infusion should start at
In women with emergency Caesarean section i.v. insulin infusion will begin
immediately decision is made to operate.
Intravenous fluids (N/Saline/5% Dextrose) will need to be co-administered After delivery
Insulin requirements fall immediately after delivery of the placenta thus all women will need less insulin and those with GDM will no longer need any insulin.
For those who have been maintained on s/c insulin during labour
• Write up pre-pregnancy doses having discussed these with the woman concerned. Refer to yellow sheet in case notes/ICP for post natal management For those who have been maintained on i.v. insulin during labour
• Reduce insulin infusion rate after third stage by 50% initially • Continue iv fluids as necessary• monitor BG 2 hourly initially• restart s/c insulin using pre-pregnancy doses when eating normally and OVERLAP with i.v. insulin infusion for AT LEAST 1 HOUR.
Remember insulin requirements fall dramatically after delivery of the placenta
and insulin doses will need to be reduced.
Women with gestational diabetes should require no insulin after delivery
GUIDELINE FOR ALL WOMEN WITH DIABETES IN PREGNANCY RECEIVING
BETAMETHASONE
Administration of betamethasone, while having beneficial effects on maturation of
fetal organs, in particular the lung, frequently precipitates ketoacidosis in women
with diabetes during pregnancy. This guideline applies to all women with Type 1
and Type 2 diabetes in pregnancy as well as all women known to have
gestational diabetes.
When betamethasone is to be administered: • Check baseline U&E’s, plasma glucose and urinary ketones• Inform Diabetes Registrar, Diabetes Consultant and Supervising Obstetric Consultant prior to administration of Betamethasone • The usual dose of s.c. insulin should be continued and i.v. insulin used to
supplement this to maintain blood glucose levels between 4 and 8 mmol/l
with no ketonuria or acidosis (serum bicarbonate should above 21 mmol/l
at all times).
• start insulin by sliding scale (50 Units of Actrapid insulin in 50 ml of Normal Saline Insulin infusion (Units actrapid/hour = ml/hour) 6 (test urine for ketones, call Dr the sliding scale off (call Dr, the sliding scale may need revision) • Check for urinary ketones at each void
• Venous plasma glucose and U and Es to be checked every 6 hours
• BM 2 hourly
• start iv dextrose 10% 500ml 4 hourly
If additional i.v. fluids are required then this should be Normal Saline.
The diabetes registrar will advise when infusions can be stopped (this is usually
24-48 hours after the betamethasone dose).
Protocol prepared by Dr Alan Patrick and Dr Claire Alexander. Sept 2005.
Ref No Repromed 006 Issue date November 2005 Review Date November 2006 Published by Labour suite management committee Level 1 2 3 4

Source: http://bigtomato.awardspace.com/diabetes/preg/simpsons_dm_in_preg_guideline.pdf

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