Ante Natal Admission
Situation
This guideline describes the management of pregnant women who have diabetes who are admitted to the ante natal ward.
Background
- Women with type 1 diabetes have an absolute requirement for insulin and will quickly become ketotic without insulin
- Ketones can cause foetal death at any stage of pregnancy
- Women with type 2 diabetes and gestational diabetes (GDM) may require insulin therapy during pregnancy
- Diabetic Ketoacidosis (DKA) is normally associated with Type 1 diabetes, but it can occur in Type 2 or women with GDM and may be precipitated by illness, prolonged fast, alcohol or the use of steroids.
Assessment
Antenatal Admission – Immediate Management - On Presentation and Within the FIrst Hour
- Check capillary blood glucose (BG) level with ward BG meter and test urine/blood for ketones
- If urinary ketones are present, BG level is > 10 m.mol/L and/or the women is unwell, complaining of abdominal pain or vomiting check blood ketone level with ward blood ketone meter
- If blood ketones are > 0.6 m.mol/L, BG is > 10 m.mol/L, if the women is vomiting and/or complaining of abdominal pain check venous plasma glucose, U+E’s and venous bicarbonate, (refer to on going management below)
- If Diabetic ketoacidosis (DKA)* has been diagnosed use DKA protocol www.diabetes-healthnet.ac.uk
The definition of DKA is: uncontrolled diabetes with:-
- Elevated blood ketones ≥ 3 m.mols/L, or urinary ketones ≥ +++
- Metabolic acidosis; bicarbonate ≤ 18 m.mols/L or pH < 7.3 on venous blood
- Hyperglycaemia
- NB Euglycaemic ketoacidosis can occur – Bicarbonate 18-24 m.mols/L may imply “incipient” DKA, if in any doubt, treat as DKA
- If BG level < 10 m.mol/L, blood ketones < 0.6 m.mol/L, if the woman is vomiting, commence I.V infusion 0.9% Normal Saline (NaCl), 100 ml and continue SC insulin or other diabetes medication.
- Check other bloods (FBC, cultures etc)
- Fluid balance chart
- If the women is treated with insulin this must be prescribed on THB(MR)040 insulin prescription and monitoring diabetes record
- Inform diabetes team of admission
Recommendations
On Going Management
- BG levels should be monitored at least 4 times per day (pre meals and before bed), using ward BG meter
- Target blood glucose (BG) levels are 4-6 m.mol/L pre meals
- BG levels must be entered intoTHBMR040 insulin prescription and monitoring diabetes record
- Insulin doses administered by either the women herself or by Midwifery staff must be recorded on the THB(MR)040 insulin prescription and monitoring diabetes record
- If BG level < 10 m.mol/L, blood ketones < 0.6 m.mol/L,monitor BG level and blood ketone level 2 hourly until patient is ketone free
- If blood ketone levels are > 0.6 m.mol/L and/or BG> 12 m.mol/L transfer patient to Labour Suite Observation Area and commence IV insulin, (see intravenous insulin management guideline)
Use of Steroids in Pregnancy for Women with Diabetes
Situation
- Women with diabetes who are at risk of a pre-term delivery are advised regarding the use of corticosteroids
Background
- Administration of steroids has a beneficial effect on the foetal lungs to reduce risk and/or severity of respiratory distress syndrome
- Steroids can precipitate hyperglycaemia in women with diabetes during pregnancy
Assessment
- Monitor BG levels pre meals and before bed
Recommendations
- Admit to Antenatal ward
- Inform diabetes team of admission
- I.M Betamethasone is administered in 2 doses of 12 mg, 12 hours apart
- IM Dexamethasone is administered in 4 doses of 6 mg 6 hours apart
- For patients on subcutaneous insulin increase all insulin doses by 50% 6 to8 hours after the first dose of steroids
- Maintain this increase until 12 hours after the second dose of Betamethasone or the forth dose of Dexamethasone then revert back to usual insulin doses
- if BG levels are >10 m.mol/L, check for blood ketones
- If BG level > 12 m.mol/L and/or the patient has blood ketones > 0.6 m.mol/L transfer the women to Labour Suite Observation Area, commence IV insulin, (see intravenous insulin management guideline)
Management of Diabetes during Labour
Situation
Background
- The aim is to maintain normoglycaemia throughout labour. If BG levels are elevated, insulin secretion by the foetal pancreas may result in neonatal hypoglycaemia
- Try to maintain all women on their usual regime for as long as possible
Assessment
- Monitor BG levels hourly during labour
Recommendations
- if BG levels are >8 m.mol/L commence IV insulin, (see intravenous insulin management guideline)
Situation
Background
- The aim is to maintain normoglycaemia throughout labour
- If BG levels are elevated, insulin secretion by the foetal pancreas may result in neonatal hypoglycaemia
- Try to maintain all women on their usual regime for as long as possible
Assessment
- Assessment and administration of prostaglandin for cervical ripening as per protocol
Recommendations
For all women on insulin
- Day prior to Induction
- Normal subcutaneous insulin regime
Morning of Induction
- Women with diabetes should have priority for transfer to labour suite for induction of labour
If not in labour and not having significant uterine activity
- Give breakfast and normal insulin dose
- Transfer to Labour Suite, commence IV insulin, (see intravenous insulin management guideline), just prior to induction of labour
If in Labour or having significant uterine activity
- Omit breakfast and subcutaneous insulin
- Transfer to Labour Suite, commence IV insulin, (see intravenous insulin management guideline)
If the women goes into spontaneous labour during the night
- Transfer to Labour Suite, commence IV insulin, (see intravenous insulin management guideline)
For Women wih Type 2 diabetes or Gestational Diabetes controlled by oral medication
-
Stop oral medication at start of labour
-
Monitor BG levels hourly during labour, if >8 m.mols/L commence IV insulin, (see intravenous insulin management guideline)
For Women with Gestational Diabetes controlled by diet only
- Treat as a women without diabetes during induction/labour
- Monitor BG levels 2 hourly during labour, >8 m.mol/L commence IV insulin, (see intravenous insulin management guideline)
Management of Diabetes during the Postnatal Period
Situation
Background
- Women with type 1 or type 2 diabetes may require adjustment of their treatment regimen
Assessment
- For women with type 1 and type 2 diabetes monitor BG levels pre meals and before bed
Recommendations
Women with type 1 Diabetes
- Convert back to pre pregnancy subcutaneous insulin when clinically stable and eating
- Discuss transfer to subcutaneous insulin with diabetes team if required
- Stop IV insulin no less than 30 minutes after subcutaneous mealtime insulin
- BG levels should be monitored at least 4 times per day (pre meals and before bed), using ward BG meter
- BG levels must be entered intoTHBMR040 insulin prescription and monitoring diabetes record
- Insulin doses administered by either the patient herself or by Midwifery staff must be recorded on the THB(MR)040 insulin prescription and monitoring diabetes record
- Target BG levels 6-8 m.mols/L pre meals/bed
- Organise postnatal appointment at Ninewells/PRI combined Obstetric/Diabetes Clinic
Women with type 2 Diabetes.
- Convert back to pre pregnancy subcutaneous insulin and or oral medication when clinically stable and eating if required
- Discuss transfer to subcutaneous insulin and or oral medication with diabetes team
- Stop IV fluids and IV insulin no less than 30 minutes after subcutaneous mealtime insulin
- BG levels should be monitored at least 4 times per day (pre meals and before bed), using ward BG meter
- BG levels must be entered intoTHBMR040 insulin prescription and monitoring diabetes record
- Insulin doses administered by either the patient herself or by Midwifery staff must be recorded on the THB(MR)040 insulin prescription and monitoring diabetes record
- Target BG levels 6-8 m.mols/L pre meals/bed
- Organise postnatal appointment at Ninewells/PRI combined Obstetric/Diabetes Clinic
All Women with Gestational Diabetes
- Stop IV insulin if commenced during labour after birth
- Do not recommence oral medication
- Stop BG monitoring unless advised otherwise
- Normal diet
- Repeat Glucose Tolerance Test (GTT) required post partum
- Postnatal appointment required at Ninewells/PRI combined Obstetric/Diabetes Clinic for results of GTT
Breast Feeding Advice
- For women on insulin breast-feeding often requires insulin dose reduction
- It is advisable to reduce pre-pregnancy insulin doses by 20% initially
- Some oral hypoglycaemic medications (e.g. gliclazide) are contra indicated for women who are breastfeeding
- When breast feeding women may need up to an extra 50g of carbohydrate per day
- Some women may need to consume carbohydrate whilst breast-feeding in order to prevent hypoglycaemia
Remember: Baby should be managed according to the neonatal guidelines for infants at risk of hypoglycaemia
Management of Diabetes during Labour, Birth and Postnatal Period for Women using Insulin Pump Therapy (CSII)
Situation
Guidelines for women with Type 1 Diabetes using CSII (Continuous Subcutaneous Insulin Infusion)
Background
If diabetes control is stable and either the women and or their partner are able to manage the insulin pump during labour normal labour should be allowed
Assessment
- Monitor BG levels hourly, aim for blood glucose values of 4 – 8 mmol/L during labour
- Monitor blood ketone levels if blood glucose levels are >10 m.mols/L
Reccomendations
Women are advised to: -
- Ensure that the pump has new batteries, full reservoir, new infusion set and a spare set of each.
- Insert a new infusion set just below the lower rib near their back.
- Once in established labour, confirmed by midwifery or obstetric staff, basal rate to be reduced by 50%. There after the temporary basal feature can be used to increase or decrease the basal rate in 10% increments as required.
- For any dietary intake during labour it is advisable to reduce insulin to carbohydrate ratio by 50%. E.G. if Insulin:CHO ratio prior to labour was 1 unit of insulin for every 10g of carbohydrate use 1 unit for every 20g instead.
- Avoid using the extended bolus facility for any dietary intake. If calculated food bolus dose is greater than 5 units the bolus dose should be split. Administer one half immediately before eating and the other half after finishing food.
- Correction bolus doses may be given at 2 hourly intervals. Anticipate that 1 unit of insulin will reduce blood glucose by approximately 2.5 mmol/L.
- If blood glucose targets are not achieved and/or ketones are present >0.6 m.mol/L it is recommended that the insulin pump is disconnected and IV insulin commenced.
- For birth by caesarean section under general or spinal anaesthetic insulin pump to be discontinued and IV insulin commenced, (see intravenous insulin management guideline).
Following the use of IV insulin
- Once well enough to manage the pump restart using the guidelines detailed below.
- When changing back from intravenous insulin onto insulin pump, the insulin pump and IV insulin should run together for 1 hour before the intravenous infusion is discontinued.
Following Birth
- Stop any temporary basal rate function.
- Pre labour basal rate should be reduced by 50% or use pre pregnancy basal rate.
- Return to pre pregnancy CHO:Insulin ratios, if unknown use 1 unit of insulin for every 10g of carbohydrate. Bolus doses may now be extended in the usual manner.
- For any correction doses use pre-pregnancy ratio. If unknown assume that 1 unit will reduce BG by approximately 2.5 m.mol/L.
- BG levels should be monitored at least 4 times per day (pre meals and before bed), using ward BG meter.
- BG levels must be entered intoTHBMR040 insulin prescription and monitoring diabetes record.
- Insulin doses administered by either the women herself or by Midwifery staff must be recorded on the THB(MR)040 insulin prescription and monitoring diabetes record.
- Organise postnatal appointment at Ninewells/PRI combined Obstetric/Diabetes Clinic.
Breast Feeding Advice
- Breast-feeding often requires a further basal reduction.
- It is advisable to reduce basal rates by a further 20%.
- While breast feeding an extra 50g of carbohydrate per day maybe required.
- Some women need to consume carbohydrate whilst breast-feeding in order to prevent hypoglycaemia using a reduced insulin to carbohydrate ratio.
Additional Information
- Blood ketone monitoring is more reliable than urine ketone testing (1). Blood ketone testing provides information of the immediate situation. Urinary ketone testing provides retrospective information. This is the main reason blood ketone measurement is more useful as negative urine ketones do not necessarily mean that there is no ketosis. False negative urine results can also be obtained if urine dipsticks have been exposed to the air for some time.
- Measuring ketones in the blood is more effective than urine tests to assess the progress of management i.e. if the level of blood ketones is decreasing when extra insulin is given. A rise in blood ketone level indicates increased risk of DKA in patients with type 1 diabetes.
- Blood ketone meters and urine ketone sticks measure different ketone bodies. There are three ketone bodies in DKA - Beta hydroxybutyrate, acetoacetate, and acetone. Beta hydroxybutyrate is the more prevalent ketone in blood during DKA (about 78% of total ketones) and this is what is measured by blood ketone meters. Urine dipsticks measure acetoacetate. During treatment of DKA beta hydroxybutyrate is converted to acetoacetate and ketones will be evident in urinalysis as they are excreted in urine. (This may result in a paradoxical rise in urinary ketones initially, but does not mean treatment is inadequate, it is however important for healthcare professionals to note that blood and urine testing are not strictly interchangeable). Ketones are partly transformed into acetone, which is stored in fat tissue. Acetone is slowly released to the blood and excreted via the urine and lungs (2).
- Some studies have suggested that foetal lung maturation is delayed in infants of mothers with diabetes (3,4) while other studies report that Respiratory Distress Syndrome is uncommon in well-controlled mothers with diabetes at or beyond 37 weeks gestation (5,6,7).
- Hormonal changes during pregnancy and increased metabolic demands imposed by the foetus can increase the risk of DKA. If pregnant women with diabetes develop DKA there can be a 50%-90% risk of foetal mortality (8).
- One study has suggested that in 10% of cases of pregnancy complicated by DKA , glucose levels are not elevated at presentation, (euglycaemic DKA). This can occur in association with excessive vomiting and continued insulin administration (9).
Diabetes Team Contact Details
Ninewells: Consultant, Prof. Graham Leese, (bleep 4320) or on call Diabetes Consultant, 09.00-17.00 hrs via switchboard On call SPR, bleep 5416 Mrs Mary Robertson, Diabetes Specialist Nurse, Tel: ex 32293