KEY PRIORITIES FOR IMPLEMENTATION
- Offer pre-conception care and advice before contraception is discontinued.
- Advise that good glycaemic control before conception and throughout pregnancy will reduce the risk of miscarriage, congenital malformation, stillbirth and neonatal death.
- Aim for an HbA1c <6.1 per cent.
- Aim for fasting blood glucose of 3.5—5.9mmol/L and 1-hour postprandial blood glucose <7.8mmol/L
- Advise insulin-treated women of risks of hypoglycaemia and hypoglycaemia unawareness in pregnancy, particularly in the first trimester.
- Admit women with suspected diabetic ketoacidosis immediately for level 2 critical care.
- Offer antenatal examination of the four-chamber view of the foetal heart and outflow tracts at 18—20 weeks.
- Keep babies with their mothers unless intensive or special care is warranted.
- Offer lifestyle advice to women diagnosed with gestational diabetes plus a fasting plasma glucose
measurement at the six-week postnatal check, then annually thereafter.
- Oral hypoglycaemics (except for metformin), ACE inhibitors, angiotensin II antagonists and statins should
be stopped before or as soon as pregnancy is confirmed; consider insulin and alternative antihypertensives.
- Metformin* may be used before and during pregnancy, as well as or instead of insulin.
- Rapid-acting insulin analogues are safe to use in pregnancy and have advantages over soluble human
insulin during pregnancy.
- Isophane (NPH) insulin is specified as the first choice long-acting insulin during pregnancy.
A detailed schedule of antenatal care is included in the guidance, together with a neonatal care plan and post-partum advice for women with all types of diabetes.
* Metformin does not have UK marketing authorisation specifically for pregnant and breastfeeding women at the time of publication (March 2008). Informed consent should be obtained and documented.
The full guideline is available at www.nice.org.uk