1. Implementing NICE guidance
Diabetes in pregnancy
Implementing NICE guidance
This slide set was updated in March 2012 and includes details of NHS Evidence and the NICE Pathway. The NICE Guideline has not changed.
ABOUT THIS PRESENTATION:
This presentation has been written to help you raise awareness of the NICE clinical guideline on diabetes in pregnancy. The guideline is for healthcare professionals caring for women of reproductive age who have pre-existing diabetes or who develop diabetes during pregnancy, and their newborn babies in the primary, secondary and community care settings.
The guideline builds on existing clinical guidelines for routine care during the antenatal, intrapartum and postnatal periods. It focuses on areas where additional or different care should be offered to women with diabetes and their newborn babies.
The guideline is available in a number of formats. You can download these from
You can add your own organisation’s logo alongside the NICE logo. We have included notes for presenters broken down into ‘key points to raise’ for you to highlight these in your presentation and ‘additional information’ that you may want to draw on. Where necessary, the recommendation will be given in full.
DISCLAIMER
This slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself.
PROMOTING EQUALITY
Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties.
2nd edition – March 2012
NICE clinical guideline 63

2. Guideline review
Guideline issue date: 2008 First review : review recommendation The guideline should be updated. The consultation on the scope will take place in March/April The publication date for the updated guideline has not been confirmed.
NOTES FOR PRESENTERS:
This guideline was first issued in 2008 and was reviewed in 2011, in line with routine NICE practice.
Factors influencing the decision
From the evidence and intelligence identified through the process, it suggests that some areas of the guideline may need updating at this stage, particularly in relation to:
Screening and diagnosis of GDM (incorporating the results of the HAPO study)
Use of oral hypoglycemic agents during pregnancy
Continuous blood glucose monitoring during pregnancy
Consideration of multiple pregnancy as a risk factor for GDM
Areas mentioned by stakeholders may need to be considered during scoping.
Full details of the review may be found at

3. What this presentation covers
Background
Risks of diabetes in pregnancy
Key priorities for implementation
Costs and savings
Discussion
NHS Evidence and NICE Pathway
Find out more
NOTES FOR PRESENTERS:
In this presentation we will start by providing some background information about diabetes in pregnancy.
The NICE guideline contains nine key priorities for implementation, which you can find in the quick reference guide or by using the NICE pathways site (see slide 16).
The key priorities for implementation cover the following areas:
Pre-conception care
Antenatal care
Neonatal care
Postnatal care
Other areas covered within the guideline are intrapartum care and gestational diabetes.
Costs and savings that are likely to be incurred in implementing both this guideline and the Antenatal Care guideline are summarised, followed by a suggested list of questions to help prompt discussion. Information on how NICE pathways, NHS Evidence and how you can find out more about the support provided by NICE is given at the end of this presentation.

4. Background: prevalence
Number of pregnancies in England
Total singleton
pregnancies
600,200
Type 1 diabetes
0.3%
1,800
Type 2 diabetes
0.2%
1,200
Gestational diabetes
3.5%
20,400
Total diabetes in
pregnancy
23,400
NOTES FOR PRESENTERS:
Key points to raise:
This slide outlines the prevalence of diabetes in pregnancy and the breakdown between gestational diabetes, type 1 and type 2 diabetes.
The majority of cases of diabetes in pregnancy are due to gestational diabetes, which may or may not resolve after pregnancy.
Additional information:
The prevalence of type 1 and type 2 diabetes is increasing. In particular, type 2 diabetes is increasing in certain minority ethnic groups (including people of African, African-Caribbean, South Asian, Middle Eastern and Chinese family origin).
Diabetes in pregnancy is associated with risks to the woman and the developing fetus. The risks of having diabetes in pregnancy are outlined in the following slide.
Definitions
Women – This includes young women who have not yet transferred from paediatric to adult services. Care of young women in transition between paediatric and adult services should be planned and managed according to the best practice guidance described in ‘Transition: getting it right for young people’ (available from Adult and paediatric healthcare teams should work jointly to provide care for young women with diabetes.
Diabetes - is a disorder of carbohydrate metabolism that requires immediate changes in lifestyle. In its chronic forms, diabetes is associated with long-term vascular complications, including retinopathy, nephropathy, neuropathy and vascular disease.
Gestational diabetes - Carbohydrate intolerance of varying severity which is diagnosed in pregnancy and may or may not resolve after pregnancy.
Diabetes type 1 – There is an absolute deficiency of insulin production, due to autoimmune destruction of the insulin-producing beta cells in the islets of Langerhans in the pancreas.
Diabetes type 2 – There is a relative deficiency of insulin production, and/or the insulin produced is not effective (insulin resistance).

5. Risks of diabetes in pregnancy
Pre-existing diabetes
Gestational
miscarriage
neonatal hypoglycaemia
congenital malformation
perinatal death
stillbirth
neonatal death
fetal macrosomia
birth trauma (to mother and baby)
induction of labour or caesarean section
transient neonatal morbidity
obesity and/or diabetes developing later
in the baby’s life
NOTES FOR PRESENTERS:
Key points to raise:
It is important to give advice to women on how to reduce the risks of diabetes in pregnancy with good glycaemic control.

6. Key priorities for implementation
Pre-conception care
Antenatal care
Neonatal care
Postnatal care
NOTES FOR PRESENTERS:
Key points to raise:
The NICE guideline contains 101 recommendations about how care can be improved, but the experts who wrote the guideline have chosen key recommendations that they think will have the greatest impact on care and are the most important priorities for implementation. They are divided into four areas of key priority and within these there are nine recommendations that we will consider in turn.

7. Pre-conception care: 1
Inform women with diabetes who are planning to become pregnant that establishing good glycaemic control before conception and continuing this throughout pregnancy will reduce the risk of miscarriage, congenital malformation, stillbirth and neonatal death.
It is important to explain that risks can be reduced but not eliminated.
NOTES FOR PRESENTERS:
Recommendation in full: shown on slide
Additional information:
In order to help women achieve good glycaemic control, the NICE guideline gives further information in the pre-conception care recommendations [ sections – ] including:
diet, body weight and exercise [section 1.1.4]
target ranges for blood glucose in the pre-conception period [section 1.1.4]
monitoring blood glucose and ketones in the pre-conception period [section 1.1.5]
the safety of medications for diabetes before and during pregnancy [section 1.1.6].

8. Pre-conception care: 2
The importance of avoiding unplanned pregnancy should be an essential component of diabetes education from adolescence for women with diabetes.
Offer pre-conception care and advice to women with diabetes who are planning to become pregnant before discontinuing contraception.
NOTES FOR PRESENTERS:
Key points to raise:
Starting from adolescence:
healthcare professionals should give information about the benefits of pre-conception glycaemic control at each contact
the diabetes care team should record the woman's intentions regarding pregnancy and contraceptive use at each contact
the importance of avoiding unplanned pregnancy should be an essential component of diabetes education
give pre-conception care in a supportive environment and encourage the woman’s partner or a family member to attend
this should build on previous care given in routine appointments with healthcare professionals, including the diabetes care team
Recommendations and in full: shown on slide
Additional information:
Give advice and information on:
the risks of diabetes in pregnancy and how to reduce them with good glycaemic control
diet, body weight and exercise, including weight loss for women with a body mass index (BMI) over 27 kg/m2
hypoglycaemia and hypoglycaemia unawareness
pregnancy-related nausea/vomiting and glycaemic control
retinal and renal assessment
when to stop contraception
taking folic acid supplements (5 mg/day) from pre-conception until 12 weeks of gestation
review of, and possible changes to, medication, glycaemic targets and self-monitoring routine
frequency of appointments and local support, including emergency telephone numbers.
The pre-conception care recommendations for women with diabetes are given in sections1.1.1−1.1.11,

9. Antenatal care: 1
If it is safely achievable, women with diabetes should aim to keep fasting blood glucose between 3.5 and 5.9 mmol/litre and 1-hour postprandial blood glucose below 7.8 mmol/litre during pregnancy.
Advise women with insulin-treated diabetes of the risks of hypoglycaemia and hypoglycaemia unawareness in pregnancy, particularly in the first trimester.
NOTES FOR PRESENTERS:
Key points to raise:
NICE has also developed a clinical guideline on antenatal care ( which has related recommendations on the care that all pregnant women should routinely receive.
Recommendations and in full: shown on slide
Additional information:
Additional care for women taking insulin
Offer:
concentrated oral glucose solution to all women taking insulin
glucagon to women with type 1 diabetes
insulin pump therapy if glycaemic control using multiple injections is not adequate and the woman experiences significant disabling hypoglycaemia.
Advise:
women to test blood glucose before going to bed at night
on the risks of hypoglycaemia and hypoglycaemia unawareness, especially in the first trimester
women and their partners or family members on the use of oral glucose solutions and glucagon for hypoglycaemia.
The antenatal care recommendations for women with diabetes in pregnancy are given in section 1.3

10. Antenatal care: 2
Admit pregnant women who are suspected of having diabetic ketoacidosis immediately for level 2 critical care where they can receive both medical and obstetric care.
Offer women with diabetes antenatal examination of the four-chamber view of the fetal heart and outflow tracts at 18–20 weeks.
NOTES FOR PRESENTERS:
Key points to raise:
The first recommendation is about ensuring that women are cared for by professionals with the appropriate skills. Level 2 critical care is defined as care for patients requiring detailed observation or intervention, including support for a single failing organ system or postoperative care and those 'stepping down' from higher levels of care.
Recommendations and in full: shown on slide
Related recommendations:
Women with type 1 diabetes who are pregnant should be offered ketone testing strips and advised to test for ketonuria or ketonaemia if they become hyperglycemic or unwell. [ ]
During pregnancy, women with type 1 diabetes who become unwell should have diabetic ketoacidosis excluded as a matter of urgency. [ ]
Women with diabetes should be offered antenatal examination of the four-chamber view of the fetal heart and outflow tracts at 18–20 weeks. [ ]
Pregnant women with diabetes should be offered ultrasound monitoring of fetal growth and amniotic fluid volume every 4 weeks from 28 to 36 weeks. [ ]
Routine monitoring of fetal well-being before 38 weeks is not recommended in pregnant women with diabetes, unless there is a risk of intrauterine growth restriction. [ ]
Women with diabetes and a risk of intrauterine growth restriction (macrovascular disease and/or nephropathy) will require an individualised approach to monitoring fetal growth and well-being. [ ]

11. Antenatal care: 3 At the booking appointment screen for risk factors
associated with gestational diabetes.
Offer testing for gestational diabetes if any
one risk factor identified.
NOTES FOR PRESENTERS
Key points to raise:
This is a key priority for implementation taken from the NICE antenatal care guideline in relation to screening for clinical conditions [NICE clinical guideline 63 available from ]
Recommendation in full:
Screening for gestational diabetes using risk factors is recommended in a healthy population. At the booking appointment, the following risk factors for gestational diabetes should be determined:
• body mass index above 30 kg/m2
• previous macrosomic baby weighing 4.5 kg or above
• previous gestational diabetes
• family history of diabetes (first-degree relative with diabetes)
• family origin with a high prevalence of diabetes: − South Asian (specifically women whose country of family origin is India, Pakistan or Bangladesh)
− black Caribbean
− Middle Eastern (specifically women whose country of family origin is Saudi Arabia, United Arab Emirates, Iraq, Jordan, Syria, Oman, Qatar, Kuwait, Lebanon or Egypt).
Women with any one of these risk factors should be offered testing for gestational diabetes (see recommendation ).
Related recommendations:
The 2-hour 75 g oral glucose tolerance test (OGTT) should be used to test for gestational diabetes and diagnosis made using the criteria defined by the World Health Organization*. Women who have had gestational diabetes in a previous pregnancy should be offered early self-monitoring of blood glucose or an OGTT at 16–18 weeks, and a further OGTT at 28 weeks if the results are normal. Women with any of the other risk factors for gestational diabetes (see recommendation ) should be offered an OGTT at 24–28 weeks. [ ]
* Fasting plasma venous glucose concentration greater than or equal to 7.0 mmol/litre or 2-hour plasma venous glucose concentration greater than or equal to 7.8 mmol/litre. World Health Organization Department of Noncommunicable Disease Surveillance (1999) Definition, diagnosis and classification of diabetes mellitus and its complications. Report of a WHO consultation. Part 1: diagnosis and classification of diabetes mellitus. Geneva: World Health Organization.

12. Neonatal care
Keep babies of women with diabetes with their mothers unless there is a clinical complication
Admit the baby to a neonatal unit if he or she:
is hypoglycemic with abnormal signs
has respiratory distress or jaundice that requires monitoring or treatment
has signs of cardiac decompensation, neonatal encephalopathy or polycythaemia
needs intravenous fluids or tube feeding (unless adequate support is available on the postnatal ward)
is born before 34 weeks (or between 34 and 36 weeks if dictated clinically).
NOTES FOR PRESENTERS:
Key points to raise:
Babies should be admitted if they have any of the criteria described on the slide above, except if the baby needs tube feeding and adequate support is available on the postnatal ward.
Recommendation in full:
Babies of women with diabetes should be kept with their mothers unless there is a clinical complication or there are abnormal clinical signs that warrant admission for intensive or special care
Related recommendations:
Women with diabetes should be advised to give birth in hospitals where advanced neonatal resuscitation skills are available 24 hours a day.
[ ]
Babies of women with diabetes should be admitted to the neonatal unit if they have:
• hypoglycaemia associated with abnormal clinical signs
• respiratory distress
• signs of cardiac decompensation due to 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 dictated clinically by the initial assessment of the baby and feeding on the labour ward). [ ]
Additional information:
Preventing, detecting and managing neonatal hypoglycaemia:
All maternity units should have a written policy for the prevention, detection and management of hypoglycaemia in babies of women with diabetes. Advise:
women to feed their babies as soon as possible (within 30 minutes of birth) and then at frequent intervals (2–3 hours) until pre-feeding blood glucose levels are maintained at 2 mmol/litre or above.
Test:
for polycythaemia, hyperbilirubinaemia, hypocalcaemia and hypomagnesaemia if the baby has clinical signs
for heart abnormalities using an echocardiogram if the baby has clinical signs associated with congenital heart disease or cardiomyopathy.
Test the baby’s blood glucose levels:
2–4 hours after birth using a quality-assured method validated for neonatal use (ward-based glucose electrode or laboratory analysis)
if he or she has signs of hypoglycaemia.
Give:
intravenous dextrose as soon as possible if the baby has clinical signs of hypoglycaemia
tube feeding or intravenous dextrose if the baby has blood glucose levels below 2 mmol/litre on two consecutive readings despite maximal feeding support, has abnormal clinical signs or will not feed orally effectively.
The neonatal care recommendations for women with diabetes in pregnancy are given in section 1.5 of the NICE guideline.

13. Postnatal care
Offer women who were diagnosed with gestational diabetes:
lifestyle advice
a fasting plasma glucose
measurement
NOTES FOR PRESENTERS:
Key points to raise:
Lifestyle advice includes weight control, diet and exercise
A fasting plasma glucose measurement should be offered (but not an oral glucose tolerance test) at the 6-week postnatal check and annually thereafter.
For more information about routine postnatal care please refer to the NICE clinical guideline on postnatal care (
Recommendation in full:
Women who were diagnosed with gestational diabetes should be offered lifestyle advice (including weight control, diet and exercise) and offered a fasting plasma glucose measurement (but not an oral glucose tolerance test) at the 6-week postnatal check and annually thereafter.
Additional information:
Advise women with gestational diabetes:
to stop taking hypoglycaemic medication immediately after birth
on weight control, diet and exercise
on the symptoms of hyperglycaemia
on the risks of gestational diabetes in subsequent pregnancies and screening for diabetes when planning pregnancy.
The postnatal care recommendations for women with diabetes in pregnancy are given in 1.6 of the NICE guideline.

14. Costs and savings per 100,000 population
Recommendations with significant resource impact (costs/savings )
Costs/savings
(£ in first year)
Screening for fetal anomalies
12,700
Screening for Down’s syndrome
6500
Screening and testing for gestational diabetes
2900
Treatment of gestational diabetes
1500
Avoidance of neonatal care for babies of women with diabetes
– 2300
Estimated net cost of implementation
21,300
NOTES FOR PRESENTERS:
Key points to raise:
This slide outlines the costs and saving per 100,000 population of implementing the NICE guideline on antenatal care and the NICE guideline on diabetes in pregnancy (published in March 2008 and available at The costs and savings related to these two guidelines are linked, because screening, diagnosing and treating gestational diabetes cross the guidelines but are likely to be carried out by the same provider, and so a combined costing tool has been produced.
The information on this slide has been extracted from the NICE costing report, which has been provided by NICE to support implementation of this guidance. It was developed after careful consideration of the available data and by working closely with the guideline developers and other people in the NHS. It is not NICE guidance. Assumptions used in this report are based on assessment of the national average and it is recognised that local practice or circumstances may differ from this. The costs published in this report are estimates only and are not to be taken as the Institute's view of desirable maximum or minimum figures.
ADAPTING THIS SLIDE FOR LOCAL USE:
Local factors such as incidence and baseline can vary considerably when compared with the national average. NICE has provided a costing template for you to calculate the financial impact locally. We encourage you to calculate the local impact by amending the local variations in the template such as incidence, baseline and uptake. You can then remove the national figures from the table and replace them with your local figures to present to your colleagues.
Benefits and savings for Diabetes in pregnancy:
Increased detection of fetal anomalies
Increased detection and treatment of gestational diabetes, leading to improved care for the mother and a reduction in complications during pregnancy and labour
Possible reduction in rates of caesarian section
Reduction in unnecessary admissions to neonatal care, which could also lead to an increase in breast feeding rates and associated benefits for these mothers and babies.
In addition, compliance with NICE guidance is one of the criteria indicating good risk reduction strategies, and in combination with meeting other criteria could lead to a discount on contributions to the NHS Litigation Authority schemes, including the clinical negligence scheme for trusts (CNST).
The estimated national annual changes in costs and savings arising from implementing the Antenatal Care and Diabetes in Pregnancy guidelines are £11.6 million in the first year, net of savings. It is recognised that implementation of the recommendations may take place over a number of years.
For further information please refer to the costing template and costing report for this guidance on the NICE website.
This slide also includes costs and savings for implementing the
NICE guidance on antenatal care
Costs correct at March 2008.
Costs not updated for 2nd edition

15. Discussion
How can we promote pre-conception services to support women with diabetes to plan for pregnancy?
How can we ensure women with risk factors for gestational diabetes are identified?
What more do we need to do to ensure appropriate referrals are made to joint diabetes and antenatal clinics?
What should we be doing to ensure that we are providing annual follow up of lifestyle advice and fasting blood glucose testing to women diagnosed with gestational diabetes?
NOTES FOR PRESENTERS:
These questions are suggestions that have been developed to help provide a prompt for a discussion at the end of your presentation – please edit and adapt these to suit your local situation.

16. Click here to go to NICE Pathways website
The NICE Diabetes in pregnancy Pathway covers.
Click here to go to NICE Pathways website
NOTES FOR PRESENTERS:
Key points to raise
If you are showing this presentation when connected to the internet, when you are in slide show you can click on the orange button to go straight to the NICE Pathways website.
NICE Pathways: guidance at your fingertips
Our new online tool provides quick and easy access, topic by topic, to the range of guidance from NICE, including quality standards, technology appraisals, clinical and public health guidance and NICE implementation tools. Simple to navigate, NICE Pathways allows you to explore in increasing detail NICE recommendations and advice, giving you confidence that you are up to date with everything we have recommended.
The NICE pathway can be found at

17. Click here to go to the NHS Evidence website
Visit NHS Evidence for the best available evidence on all aspects of diabetes.
To be added- the latest NHS evidence image
Click here to go to the NHS Evidence website
NOTES FOR PRESENTERS:
If you are showing this presentation and you are connected to the internet, in slide show you can click on the blue button to go straight to the NHS Evidence website topic page for Type 2 Diabetes, which includes diabetes in pregnancy.
For the home page go to

18. Find out more Visit www.nice.org.uk/CG63 for: other guideline formats
costing report and template
audit support
online educational tool
NOTES FOR PRESENTERS:
The guideline is available in a number of formats.
The quick reference guide – which summarises the guidance.
The NICE guideline – which includes all of the recommendations in full.
The full guideline – which includes all of the evidence and rationale.
‘Understanding NICE guidance’ – a version for patients and carers.
You can download these from the NICE website
NICE has developed tools to help organisations implement this guideline, which can be found on the NICE website.
Costing tools – a costing report gives the background to the national savings and costs associated with implementation, and a costing template allows you to estimate the local costs and savings involved.
Audit support – assists NHS trusts to determine how well they meet NICE recommendations.
Online educational tool – developed in conjunction with BMJ Learning. This interactive module uses interactive case histories to improve users knowledge of six NICE guidelines addressing complications in pregnancy from a GP perspective, of which Diabetes in Pregnancy is part. The tools are free to use and open to all. You will need to provide your address and a password to register with BMJ Learning.

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NOTES FOR PRESENTERS:
Additional information:
The final slide is not intended to be part of the presentation, it asks for feedback on whether this implementation tool meets your requirements and whether it will help you to put this NICE guidance into practice - your opinion would be appreciated.
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