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A well-rounded approach

1 April, 2010

A well-rounded approach

Middlesex University’s head of midwifery, child health and primary care Chris Bewley explains why dealing with women with diabetes in its different forms involves care before, during and after pregnancy.

Midwives magazine: April/May 2010 

Middlesex University’s head of midwifery, child health and primary care Chris Bewley explains why dealing with women with diabetes in its different forms involves care before, during and after pregnancy.

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Diabetes affects between 2% to 5% of pregnancies in England and Wales, with rates rising (NICE, 2008). Women with pre-existing (pregestational) diabetes are at greater risk of miscarriage, pre-term labour and pre-eclampsia. Additionally, the complications of diabetes, such as diabetic retinopathy, renal disorders and neuropathy can be adversely affected by pregnancy. Stillbirth, congenital malformations, macrosomia, birth injury, and perinatal mortality are higher in babies of women who have pregestational diabetes. Their babies may experience other problems after birth, such as neonatal hypoglycaemia. Some women may develop diabetes during pregnancy (gestational diabetes mellitus or GDM) and their babies are at risk of macrosomia, birth injury, perinatal death, hypoglycaemia and the development of diabetes in later life (CEMACH, 2005, 2007; NICE, 2008).

Diabetes illustration

Type I or insulin-dependent diabetes mellitus (IDD)
✲ More common in younger people
✲ Genetic, autoimmune disorder, which destroys beta cells in islets of Langerhans, resulting in almost complete lack of insulin
✲ If untreated will lead to metabolic acidosis, coma and death.

Characterised by:

✲ Hyperglycaemia
✲ Polyuria
✲ Ketosis
✲ Weight loss.

Treated by:
✲ Insulin injections.

Type II or non-insulin-dependent diabetes mellitus (NIDD)
✲ Onset is usually over 40, but it is increasingly affecting the young. It may be confused with maturity onset diabetes of the young (MODY)
✲ Cells become resistant to insulin.
More common in:
✲ Overweight people
✲ Black and minority ethnic groups
✲ Areas of deprivation.

Characterised by:
✲ Similar symptoms to those associated with Type I, but the condition is often asymptomatic.

Treated by:
✲ Lifestyle changes such as weight loss, diet and exercise
✲ Oral hypoglycaemic drugs such as metformin, or glibenclamide, possibly in conjunction with subcutaneous exenatide (Byetta), which is unsuitable for use during pregnancy or when breastfeeding.

Women with pregestational diabetes – Type I or II – require specialised care before, during and after pregnancy.

Particular risks are:
✲ Unstable control of diabetes
✲ Women with Type II or MODY may need insulin
✲ Induction of labour
✲ Preterm labour and delivery
✲ Instrumental delivery
✲ Caesarean section.

And for their babies:
✲ Congenital abnormality including neural tube defects and cardiac anomalies
✲ Preterm delivery
✲ Macrosomia
✲ Respiratory distress
✲ Hypoglycaemia
✲ Higher rate of perinatal mortality.

Sub-optimal maternal glycaemic control is associated with poor pregnancy outcome, therefore women with pregestational diabetes need good pre-conception care as well as:
✲ Diet and lifestyle advice
✲ Higher dose folic acid (5mg per day before conception and up to the 12th week of pregnancy (Department of Health, 2001))
✲ Assessment and management of diabetes-related complications such as hypertension, retinopathy, renal problems
✲ Good glycaemic control with self-monitoring and regulation of insulin, avoiding hypo- or hyperglycaemia. Targets may be between 3.5-5.9mmol/l fasting, up to 7.8mmol/l post eating
✲ Monitoring of HbA1C (glycosylated haemoglobin) to determine effectiveness of glycaemic
control over the previous one to three months.

All of the above, except for folic acid, should continue throughout pregnancy, along with:
✲ Strategies for managing hypoglycaemia such as regular meals/snacks
✲ Advice about carrying and using glucagon to counter hypoglycaemia
✲ Fetal surveillance for signs of macrosomia
✲ Specialist scan for fetal cardiac and other anomalies.
Gestational diabetes mellitus (GDM)
Some women develop diabetes during pregnancy, and this is known as GDM. Women with GDM and their babies are at risk of:
✲ Fetal macrosomia
✲ Instrumental delivery, birth trauma to mother and/or baby
✲ Perinatal death
✲ Neonatal hypoglycaemia
✲ Obesity and/or diabetes developing later in the baby.

Treated by:
✲ Lifestyle changes including diet
and exercise
✲ Weight loss for women with BMI over 27kg/m2
✲ Self-monitoring of blood glucose to maintain optimal levels
✲ Hypoglycaemic drugs if weight loss and diet do not achieve optimal glucose levels over a one to two week period
✲ Rapid acting insulin such as
aspart and lispro, or oral hypoglycaemics such as metformin or glibenclamide.

NICE guidelines (NICE, 2008) do not advise routine screening for GDM, unless the following are present:

✲ Family origin with a high prevalence of diabetes, for example, South Asian and Black Caribbean
✲ History of diabetes in a close relative
✲ Previous GDM
✲ Previous macrosomic baby
✲ Body mass index >30kg/m2.   

Based on the above, women with risk factors should be offered an oral glucose tolerance test using 75g glucose at 24-28 weeks.

Women who have had GDM should be offered the opportunity to monitor their own blood glucose from early in the pregnancy. Alternatively they should be offered a two-hour oral glucose tolerance test (OGTT) using 75g glucose at 16 to 18 weeks. If this is normal, a follow-up test should be offered at 28 weeks.

NICE (2008) guidelines advise against screening for GDM using tests for fasting blood glucose, random blood glucose, glucose challenge test or urinalysis for glucose.

Intrapartum care
✲ High-risk labour, therefore should be in a level 2 critical care unit with access to paediatric facilities
✲ Induction of labour or caesarean section if indicated
✲ Hourly blood glucose monitoring aiming for between 4 and 7mmol/l
✲ Insulin/IV dextrose as required
✲ Close monitoring due to high incidence of need for intervention.

Postnatal care
✲ Skin-to-skin contact or close maternal contact post delivery
✲ Mother and baby to stay together where there are no complications
✲ Breastfeeding within one hour of birth and ongoing support
✲ Avoid glucose testing of the baby too early.

Organisational issues

Clear recommendations are made from a number of sources (CEMACH, 2005; 2007; NICE, 2008) for the following to be set in place:
✲ Clear, detailed local guidelines for antenatal, intrapartum and postnatal care, including a plan for managing the baby post-delivery
✲ Care from a multidisciplinary team including consultant obstetrician, midwives, dietician, paediatrician
✲ Individualised care plans with targets, devised jointly by health professionals and women
✲ Retinal and renal screening schedules  
✲ Advice about preventing, recognising and managing hypoglycaemic episodes, including use of glucagon
✲ Clearly documented care pathways and record-keeping for preconception, antenatal, intrapartum and postnatal periods, using modified maternity notes
if necessary
✲ Plan for delivery
✲ Plan for postnatal and baby care. 


Confidential Enquiry into Maternal and Child Health. (2005) Pregnancy in women with type I and type II diabetes in 2002 to 2003: England, Wales and Northern Ireland. CEMACH: London.

Confidential Enquiry into Maternal and Child Health. (2007) Diabetes in pregnancy: are we providing the best care? Findings of a national enquiry: England, Wales and Northern Ireland. CEMACH: London.

Department of Health. (2001) National Service Framework for diabetes (England) standards. HMSO: London.

NICE. (2008) Diabetes in pregnancy: management of diabetes and its complications from pregnancy to the postnatal period. NICE: London.

Further reading

Bewley C. (2004) Medical disorders in pregnancy (chapter 46): In: Henderson C, Macdonald S. (Eds.). Mayes midwifery (14th edition). Elsevier: Edinburgh.

Billington M, Heptinstall T. (2007) Medical disorders and the critically ill woman: In: Billington M, Stevenson M. (Eds.). Critical care in childbearing for midwives. Blackwell Science: Oxford.

Diabetes UK. (2009) Pregnancy. See: www.diabetes.org.uk (accessed 1 September 2009).

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