Diabetes in pregnancy: management from preconception to the postnatal period

Provide information, advice and support, to empower women to have a positive experience of pregnancy and to reduce the risks of adverse pregnancy outcomes for mother and baby. [2008]

Explain to women with diabetes who are planning a pregnancy that:

• if they have good blood glucose control before conception and throughout their pregnancy, this will reduce the risk of miscarriage, congenital malformation, stillbirth and neonatal death but

• the risks can be reduced but not eliminated. [2008]

When women with diabetes are planning a pregnancy, provide them and their families with information about how diabetes affects pregnancy and how pregnancy affects diabetes. The information should cover:

• the role of diet, body weight and exercise

• the risks of hypoglycaemia and impaired awareness of hypoglycaemia during pregnancy

• how nausea and vomiting in pregnancy can affect blood glucose control

• the increased risk of having a baby who is large for gestational age, which increases the likelihood of birth trauma, induction of labour, and instrumental and caesarean section deliveries

• the need for diabetic retinopathy assessment before and during pregnancy

• the need for diabetic nephropathy assessment before pregnancy

• the importance of maternal blood glucose control during labour and birth, and the need for early feeding of the baby, in order to reduce the risk of neonatal hypoglycaemia

• the possibility of that the baby may have health problems in the first 28 days, and may need admitting to a neonatal unit

• the risk of the baby developing obesity, diabetes and/or other health problems in later life. [2008]

Emphasise the importance of planning for pregnancy, as part of diabetes education from adolescence for women with diabetes. [2008, amended 2015]

Explain to women with diabetes that their choice of contraception should be based on their own preferences and any risk factors (covered in the Faculty of Sexual and Reproductive Healthcare UK medical eligibility criteria for contraceptive use). [2015]

Advise women with diabetes that they can use oral contraceptives. [2015]

Advise women with diabetes who are planning to become pregnant:

• that the risks associated with diabetes in pregnancy will increase the longer they have had diabetes

• to use contraception until they have good blood glucose control (assessed by HbA1c levels – see recommendation 1.1.18)

• that blood glucose targets, glucose monitoring, medicines for treating diabetes (including insulin regimens) and medicines for complications of diabetes will need to be reviewed before and during pregnancy

• that extra time and effort is needed to manage diabetes during pregnancy, and that more frequent contact is needed with healthcare professionals. [2015]

For women with diabetes who are planning a pregnancy, provide information about the local arrangements for support, including emergency contact numbers. [2015]

Offer individualised dietary advice to women with diabetes who are planning a pregnancy. [2008]

For women with diabetes who are planning a pregnancy and who have a body mass index (BMI) above 27 kg/m², offer advice on how to lose weight, in line with the NICE guideline on identifying, assessing and managing obesity. See the NICE guideline on BMI for guidance on using variations on the BMI cut-off, based on the risk for different ethnic groups. [2008]

Advise women with diabetes who are planning a pregnancy to take folic acid (5 mg/day) until 12 weeks of gestation to reduce the risk of having a baby with a neural tube defect. [2008]

Offer up to monthly measurement of HbA1c levels for women with diabetes who are planning a pregnancy. [2008, amended 2020]

Offer blood glucose meters for self-monitoring to women with diabetes who are planning a pregnancy. [2008]

If a woman with diabetes who is planning a pregnancy needs to intensify blood glucose‑lowering therapy, advise her to monitor her blood glucose more often, to include fasting levels and a mixture of pre‑meal and post‑meal levels. [2008]

Offer blood ketone testing strips and a meter to women with type 1 diabetes who are planning a pregnancy, and advise them to test for ketonaemia if they become hyperglycaemic or unwell. [2015]

Agree individualised targets for self‑monitoring of blood glucose with women who have diabetes and are planning a pregnancy, taking into account the risk of hypoglycaemia. [2008]

Advise women with type 1 diabetes who are planning a pregnancy to aim for the normal capillary plasma glucose target ranges:

• a fasting plasma glucose level of 5 mmol/litre to 7 mmol/litre on waking and

• a plasma glucose level of 4 mmol/litre to 7 mmol/litre before meals at other times of the day.
  
  For more information, see the section on blood glucose targets in the NICE guideline on type 1 diabetes in adults. [2015]

Advise women with diabetes who are planning a pregnancy to aim to keep their HbA1c level below 48 mmol/mol (6.5%), if this is achievable without causing problematic hypoglycaemia. [2015]

Reassure women that any reduction in HbA1c level towards the target is likely to reduce the risk of congenital malformations in the baby. [2015]

Strongly advise women with diabetes whose HbA1c level is above 86 mmol/mol (10%) not to get pregnant until their HbA1c level is lower, because of the associated risks (see recommendation 1.1.2). [2015]

Women with diabetes may be advised to use metformin as an adjunct or alternative to insulin in the preconception period and during pregnancy, when the likely benefits from improved blood glucose control outweigh the potential for harm. Stop all other oral blood glucose‑lowering agents before pregnancy, and use insulin instead. [2008]

Be aware that the available evidence on rapid‑acting insulin analogues (aspart and lispro) does not show an adverse effect on the pregnancy or the health of baby. [2008]

Use isophane insulin (also known as NPH insulin) as the first choice for long‑acting insulin during pregnancy. Consider continuing treatment with long‑acting insulin analogues (insulin detemir or insulin glargine) for women with diabetes who have established good blood glucose control before pregnancy.

Note that this is an off-label use of long-acting insulin analogues. See NICE's information on prescribing medicines. [2008, amended 2015]

Stop angiotensin‑converting enzyme inhibitors and angiotensin‑II receptor antagonists before conception, or as soon as pregnancy is confirmed. Use alternative antihypertensive agents that are suitable for pregnant women. [2008]

Stop statins before pregnancy, or as soon as pregnancy is confirmed. [2008]

From adolescence onwards, at every contact with women with diabetes:

• healthcare professionals (including the diabetes care team) should explain the benefits of preconception blood glucose control

• the diabetes care team should record the plans women have for pregnancy and conception. [2008]

Provide preconception care for women with diabetes in a supportive environment, and encourage partners or other family members to attend. [2008, amended 2015]

As early as possible, offer a structured education programme to women with diabetes who are planning a pregnancy (if they have not already attended one). For more guidance, see the education and information section in the NICE guideline on type 1 diabetes in adults, and the patient education section in the NICE guideline on type 2 diabetes in adults. [2008]

Offer preconception care and advice before stopping contraception for women with diabetes who are planning a pregnancy. [2008]

For women with diabetes who are seeking preconception care, offer a retinal assessment at their first appointment (unless they have had a retinal assessment in the last 6 months). [2008, amended 2020]

Advise women with diabetes who are planning a pregnancy to defer rapid optimisation of blood glucose control until after they have had retinal assessment and treatment. [2008]

Offer women with diabetes a renal assessment (including a measure of albuminuria) before stopping contraception. [2008, amended 2015]

Consider referring women with diabetes to a nephrologist before stopping contraception if:

• serum creatinine is 120 micromol/litre or more or

• the urinary albumin:creatinine ratio is greater than 30 mg/mmol or

• the estimated glomerular filtration rate (eGFR) is less than 45 ml/minute/1.73 m². [2008, amended 2015]

Explain to women with gestational diabetes:

• the implications (both short and long term) of the diagnosis for her and her baby (including UK government advice on driving with diabetes)

• that good blood glucose control throughout pregnancy will reduce the risk of fetal macrosomia, trauma during birth (for her and her baby), induction of labour and/or caesarean section, neonatal hypoglycaemia, and perinatal death

• that treatment includes changes in diet and exercise, and could involve medicines. [2015]

Teach women with gestational diabetes how to self‑monitor their blood glucose. [2015]

Use the same capillary plasma glucose target levels for women with gestational diabetes as for women with pre‑existing diabetes (see recommendations 1.3.5 and 1.3.6). [2015]

Tailor blood glucose‑lowering therapy to the blood glucose profile and personal preferences of the woman with gestational diabetes. [2015]

When women are diagnosed with gestational diabetes, offer advice about changes in diet and exercise. [2015]

Advise women with gestational diabetes to eat a healthy diet during pregnancy, and to switch from high to low glycaemic index food. [2015]

Refer all women with gestational diabetes to a dietitian. [2015]

Advise women with gestational diabetes to exercise regularly (for example, walking for 30 minutes after a meal). [2015]

For women with gestational diabetes who have a fasting plasma glucose level below 7 mmol/litre at diagnosis, offer a trial of diet and exercise changes. [2015]

If blood glucose targets are not met with diet and exercise changes within 1 to 2 weeks, offer metformin. [2015]

If metformin is contraindicated or unacceptable to the woman, offer insulin. [2015]

If blood glucose targets are not met with diet and exercise changes plus metformin, offer insulin as well. [2015]

For women with gestational diabetes who have a fasting plasma glucose level of 7.0 mmol/litre or above at diagnosis, offer:

• immediate treatment with insulin, with or without metformin and

• diet and exercise changes. [2015]

For women with gestational diabetes who have a fasting plasma glucose level of between 6.0 and 6.9 mmol/litre and complications such as macrosomia or hydramnios, consider:

• immediate treatment with insulin, with or without metformin and

• diet and exercise changes. [2015]

Advise pregnant women with type 1 diabetes to test their fasting, pre‑meal, 1‑hour post‑meal and bedtime blood glucose levels daily. [2015]

Advise pregnant women with type 2 diabetes or gestational diabetes who are on a multiple daily insulin injection regimen to test their fasting, pre‑meal, 1‑hour post‑meal and bedtime blood glucose levels daily. [2015]

Advise pregnant women with type 2 diabetes or gestational diabetes to test their fasting and 1‑hour post‑meal blood glucose levels daily if they are:

• managing their diabetes with diet and exercise changes alone or

• taking oral therapy (with or without diet and exercise changes) or single‑dose intermediate‑acting or long‑acting insulin. [2015]

Agree individualised targets for self‑monitoring of blood glucose with pregnant women with diabetes, taking into account the risk of hypoglycaemia. [2008]

Advise pregnant women with any form of diabetes to maintain their capillary plasma glucose below the following target levels, if these are achievable without causing problematic hypoglycaemia:

• fasting: 5.3 mmol/litre
  
  and

• 1 hour after meals: 7.8 mmol/litre or

• 2 hours after meals: 6.4 mmol/litre. [2015]

Advise pregnant women with diabetes who are taking insulin to maintain their capillary plasma glucose level above 4 mmol/litre. [2015, amended 2020]

Measure HbA1c levels at the booking appointment for all pregnant women with pre‑existing diabetes, to determine the level of risk for the pregnancy. [2015]

Consider measuring HbA1c levels in the second and third trimesters of pregnancy for women with pre‑existing diabetes, to assess the level of risk for the pregnancy. [2015]

Be aware that the level of risk for the pregnancy for women with pre‑existing diabetes increases with an HbA1c level above 48 mmol/mol (6.5%). [2015]

Measure HbA1c levels when women are diagnosed with gestational diabetes, to identify women who may have pre‑existing type 2 diabetes. [2015]

Do not routinely use HbA1c levels to assess a woman's blood glucose control in the second and third trimesters of pregnancy. [2008]

After pregnant women with pre‑existing diabetes have had their first antenatal clinic appointment:

• offer retinal assessment by digital imaging with mydriasis using tropicamide (unless they have had a retinal assessment in the last 3 months)

• if they have diabetic retinopathy, offer an additional retinal assessment at 16 to 20 weeks

• offer another retinal assessment at 28 weeks. [2008, amended 2015]

Diabetic retinopathy should not be considered a contraindication to rapid optimisation of blood glucose control in women who present with a high HbA1c in early pregnancy. [2008]

Diabetic retinopathy should not be considered a contraindication to vaginal birth. [2008]

Arrange a renal assessment at first contact during the pregnancy for women with pre‑existing diabetes, if they have not had 1 in the last 3 months. [2008, amended 2015]

Consider referring pregnant women with diabetes to a nephrologist if:

• their serum creatinine is 120 micromol/litre or more or

• the urinary albumin:creatinine ratio is greater than 30 mg/mmol or

• total protein excretion exceeds 0.5 g/day. [2008, amended 2015]

Do not use eGFR to measure kidney function in pregnant women. [2008, amended 2015]

Consider thromboprophylaxis for pregnant women with nephrotic range proteinuria above 5 g/day (albumin:creatinine ratio greater than 220 mg/mmol). [2008, amended 2015]

For guidance on using antiplatelet agents to reduce the risk of pre‑eclampsia in pregnant women with diabetes, see the section on antiplatelet agents in the NICE guideline on hypertension in pregnancy. [2015]

Offer women with diabetes an ultrasound scan at 20 weeks to detect fetal structural abnormalities, including examination of the fetal heart (4 chambers, outflow tracts and 3 vessels). [2008, amended 2015]

Offer pregnant women with diabetes ultrasound monitoring of fetal growth and amniotic fluid volume every 4 weeks from 28 to 36 weeks. [2008]

Routine monitoring of fetal wellbeing before 38 weeks is not recommended in pregnant women with diabetes, unless there is a risk of fetal growth restriction. This includes methods such as fetal umbilical artery doppler recording, fetal heart rate recording and biophysical profile testing. [2008, amended 2015]

Provide an individualised approach to monitoring fetal growth and wellbeing for women with diabetes and a risk of fetal growth restriction (macrovascular disease or nephropathy). [2008, amended 2015]

Offer immediate contact with a joint diabetes and antenatal clinic to pregnant women with diabetes. [2008]

Joint diabetes and antenatal clinics should be in contact with women with diabetes every 1 to 2 weeks throughout pregnancy, for blood glucose control assessment. [2008, amended 2015]

At antenatal appointments, provide care specifically for women with diabetes, in addition to routine care for healthy pregnant women (see the NICE guideline on antenatal care). Table 1 describes how care for women with diabetes differs from routine antenatal care. [2008, amended 2015]

At each appointment, offer pregnant women with diabetes ongoing opportunities for information and education. [2008, amended 2015]

Diabetes should not be considered a contraindication to tocolysis or to antenatal steroids for fetal lung maturation. [2008]

For women with insulin‑treated diabetes who are taking steroids for fetal lung maturation, give additional insulin according to an agreed protocol and monitor the woman closely. [2008, amended 2015]

Do not use betamimetic medicines for tocolysis in women with diabetes. [2008]

Discuss the timing and mode of birth with pregnant women with diabetes during antenatal appointments, especially during the third trimester. [2015]

Advise pregnant women with type 1 or type 2 diabetes and no other complications to have an elective birth by induced labour or (if indicated) caesarean section, between 37 weeks and 38 weeks plus 6 days of pregnancy. [2015]

Consider elective birth before 37 weeks for women with type 1 or type 2 diabetes who have metabolic or other maternal or fetal complications. [2015]

Advise women with gestational diabetes to give birth no later than 40 weeks plus 6 days. Offer elective birth by induced labour or (if indicated) by caesarean section to women who have not given birth by this time. [2015]

Consider elective birth before 40 weeks plus 6 days for women with gestational diabetes who have maternal or fetal complications. [2015]

Diabetes should not be considered a contraindication to vaginal birth after a previous caesarean section. [2008]

For pregnant women with diabetes who have an ultrasound‑diagnosed macrosomic fetus, explain the risks and benefits of vaginal birth, induction of labour and caesarean section. [2008]

For women with diabetes and comorbidities such as obesity or autonomic neuropathy, offer an anaesthetic assessment in the third trimester of pregnancy. [2008]

If the woman has general anaesthesia for the birth, monitor blood glucose every 30 minutes from induction of general anaesthesia until after the baby is born and the woman is fully conscious. [2008]

Monitor capillary plasma glucose every hour during labour and birth for women with diabetes, and maintain it between 4 mmol/litre and 7 mmol/litre. [2008, amended 2015]

Consider intravenous dextrose and insulin infusion from the onset of established labour for women with type 1 diabetes. [2008]

Use intravenous dextrose and insulin infusion during labour and birth for women with diabetes whose capillary plasma glucose is not maintained between 4 mmol/litre and 7 mmol/litre. [2008, amended 2015]

Advise women with diabetes to give birth in hospitals where advanced neonatal resuscitation skills are available 24 hours a day. [2008]

Babies of women with diabetes should stay with their mothers, unless there are complications or abnormal clinical signs that mean the baby needs to be admitted to intensive or special care. [2008]

Carry out blood glucose testing routinely at 2 to 4 hours after birth in babies of women with diabetes. Carry out blood tests for babies with clinical signs of polycythaemia, hyperbilirubinaemia, hypocalcaemia or hypomagnesaemia. [2008]

Perform an echocardiogram for babies of women with diabetes if they show clinical signs associated with congenital heart disease or cardiomyopathy, including heart murmur. Base the timing of the examination on the clinical circumstances. [2008]

Admit babies of women with diabetes to the neonatal unit if they have:

• hypoglycaemia associated with abnormal clinical signs

• respiratory distress

• signs of cardiac decompensation from congenital heart disease or cardiomyopathy

• signs of neonatal encephalopathy

• signs of polycythaemia, and are likely to need partial exchange transfusion

• need for intravenous fluids

• need for tube feeding (unless adequate support is available on the postnatal ward)

• jaundice requiring intense phototherapy and frequent monitoring of bilirubinaemia

• been born before 34 weeks (or between 34 and 36 weeks, if the initial assessment of the baby and their feeding suggests this is clinically appropriate). [2008]

Do not transfer babies of women with diabetes to community care until:

• they are at least 24 hours old and

• you are satisfied that the baby is maintaining blood glucose levels and is feeding well. [2008]

All maternity units should have a written policy for preventing, detecting and managing hypoglycaemia in babies of women with diabetes. [2008]

Test the blood glucose of babies of women with diabetes using a quality‑assured method validated for neonatal use (ward‑based glucose electrode or laboratory analysis). [2008]

Women with diabetes should feed their babies:

• as soon as possible after birth (within 30 minutes) and then

• at frequent intervals (every 2 to 3 hours) until feeding maintains their pre‑feed capillary plasma glucose levels at a minimum of 2.0 mmol/litre. [2008, amended 2015]

Only use additional measures (such as tube feeding or intravenous dextrose) if:

• capillary plasma glucose values are below 2.0 mmol/litre on 2 consecutive readings despite maximal support for feeding or

• there are abnormal clinical signs or

• the baby will not effectively feed orally. [2008, amended 2015]

For babies with clinical signs of hypoglycaemia, test blood glucose levels and provide intravenous dextrose as soon as possible. [2008, amended 2015]

Women with insulin‑treated pre‑existing diabetes should reduce their insulin immediately after birth and monitor their blood glucose levels to find the appropriate dose. [2008]

Explain to women with insulin‑treated pre‑existing diabetes that they are at increased risk of hypoglycaemia in the postnatal period (especially when breastfeeding), and advise them to have a meal or snack available before or during feeds. [2008]

Women who have been diagnosed with gestational diabetes should stop blood glucose‑lowering therapy immediately after birth. [2008]

Women with pre‑existing type 2 diabetes who are breastfeeding can resume or continue metformin immediately after birth, but should avoid other oral blood glucose‑lowering therapy while breastfeeding.

Note that this is an off-label use of metformin. See NICE's information on prescribing medicines. [2008, amended 2020]

Women with diabetes who are breastfeeding should continue to avoid any medicines for their diabetes complications that were stopped for safety reasons when they started planning the pregnancy. [2008]