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December 22, 2014

Quick guide to antenatal care for women with pre-existing type 1 or type 2 diabetes

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Antenatal Care (Types 1 & 2 diabetes)  by trimester
1st Trimester
  • Book as soon as pregnancy is confirmed in combined diabetes/obstetric clinic for diabetes and obstetric assessment
  • Review foetal risk/maternal benefit ratio of present medication, and commence/continue folic acid 5mg daily. Type 2: Commence insulin as necessary
  • Refer to dietitian for initial review
  • Perform baseline laboratory tests – FBC, U&E, Creatinine, HbA1c, Fructosamine, TFTs, blood type, antibody screen and viral studies as per local protocol.
  • Perform retinal assessment
  • Perform ultrasound scan at 7-10weeks to confirm viability and to assign dates
  • Encourage frequent contact by telephone and/or clinic visits to monitor glycaemic control
  • Hospitalise if glycaemic control sub-optimal
  • Assess self care ability and educate as necessary
2nd Trimester
  • Maintain frequent clinic visits
  • Maintain regular telephone contact between clinic reviews for glycaemic review and insulin dose adjustment
  • Perform ultrasound scan for foetal anomalies at 18-20weeks
  • Arrange retinal assessment
  • Observe for maternal complications; PET, PIH, worsening of diabetes complications
  • Dietitian review
3rd Trimester
  • Perform a minimum of two ultrasound scans for foetal growth evaluation
  • Continue frequent visits as recommended by specialists
  • Observe for macrosomia, polyhydramnios
  • Advise woman to monitor foetal movements and report concerns immediately
  • Arrange anaesthetic review in the presence of medical complications Arrange retinal assessment
  • Provide information on proposed mode and timing of delivery
  • Dietitian review

Key messages

  • Women with pre-existing diabetes who are contemplating pregnancy should be educated on the possible teratogenic effect of diabetes on pregnancy and on the need for tight glycaemic control prior to conception.
  • The risk of hypoglycaemia and hypoglycaemic unawareness in pregnancy should be explained to all women on insulin treatment.
  • Confirm pregnancy as early as possible and ideally, commence care with a multi-disciplinary team that includes a consultant endocrinologist or a physician experienced in diabetes care in pregnancy, consultant obstetrician, diabetes nurse/midwife specialist and senior dietitian in a dedicated combined Obstetric-Endocrine clinic.
  • Visits will usually occur every 2-3 weeks, with variations depending on stage of pregnancy and glycaemic control.
  • Measure blood pressure, body weight and urinalysis at each visit as the risk of hypertensive disorders increases when pregnancy is complicated by diabetes.
  • Severe, unexplained or frequent episodes of hypoglycaemia can occur as a result of many factors which include; defective counter-regulation, hypoglycaemia unawareness, as well as administration errors in insulin dose, dietary intake or physical activity expenditure.
  • For women with type 2 diabetes, non teratogenic oral hypoglycaemic agents may be continued until insulin is commenced to avoid hyperglycaemia which is a known teratogen.
  • Women admitted with diabetic ketoacidosis (DKA) should be managed in a high dependency area of care.
  • Women with Type 2 diabetes admitted with Hyperosmolar Non-Ketotic Syndrome (HONK) should be managed in a high dependency area of care.
  • Delivery should take place in a hospital with full obstetric, anaesthetic and neonatal intensive care facilities and with an experienced paediatrician available for delivery.
  • Neonates should be nursed at the mother’s bedside unless admission to intensive care is necessary.
  • Early blood glucose testing in the well baby at term should be avoided.