Clinical Practice Guideline Diabetes in Pregnancy ... · mother such as retinopathy3 and...

Clinical Practice Guideline Diabetes in Pregnancy Department Obstetrics and Gynaecology

PROMPT doc no: 28849721 Version: 2.0

First created: 09/07/2015 of 14 Last reviewed:

Version changed: 15/05/2017 UNCONTROLLED WHEN DOWNLOADED

Next review: 01/03/2018

Purpose Pregnancy is associated with changes to insulin sensitivity which can lead to elevated maternal blood glucose levels (BGLs). When elevated BGLs are first diagnosed during pregnancy the mother has gestational diabetes mellitus (GDM). Also, if the mother has pre-existing diabetes (Type 1 or Type 2) the increase in maternal insulin resistance during pregnancy further increases BGLs and requires major increases in diabetes treatment. Elevated blood glucose levels in the mother cause foetal blood glucose levels to increase due to transplacental glucose transport. The resultant increase in foetal BGLs causes the foetus to overproduce insulin. The fetal hyperglycaemia and the resulting hyperinsulinaemia is thought to increase the risk of pre-eclampsia, foetal macrosomia, neonatal hypoglycaemia, hyperbilirubinaemia and respiratory distress syndrome. The incidence of these complications in the foetus can be decreased by treating the mother to ensure maternal BGLs are maintained in the near-normal range throughout pregnancy and labour. Pre-existing diabetes (Type 1 or Type 2 Diabetes) in pregnancy is also associated with other risks to the mother and developing foetus. Foetal risks include stillbirth, congenital malformations, macrosomia and birth injury, perinatal mortality, and postnatal adaptation problems such as hypoglycaemia3. Miscarriage, pre-eclampsia, and pre-term labour are more common with pre-existing diabetes. Pre-existing complications of diabetes in the mother such as retinopathy3 and nephropathy can worsen during pregnancy. Maternal and fetal outcomes in patients with pre-existing diabetes depend heavily on pre-pregnancy counseling and strict glycaemic control during pregnancy. Poor glycaemic control during labour is associated with neonatal hypoglycaemia due to the stimulation of fetal insulin release by maternal hyperglycemia 3,4. Maintenance of maternal BGLs in the normal range during labour decreases the risk of neonatal hypoglycaemia. Scope To provide information and guidance for staff on the antenatal, labour and postnatal management of patients with diabetes in pregnancy. This includes Gestational Diabetes and pre-existing Type 1 and Type 2 diabetes in pregnancy. Responsibilities Employer Peninsula Health acts to minimize risk by supporting adherence to Guidelines, occupational health and safety obligations and duty of care to staff and consumers through a comprehensive clinical governance system which includes the provision of and education in relation to evidence based Guidelines. Departmental The Executive supports Department Heads in the monitoring and evaluation of Guidelines. Providing the necessary infrastructure and resource to facilitate compliance with Guidelines and assisting the Department Heads to facilitate education and enforce compliance with Guidelines.






Department Head/Manager Department Heads/ Managers monitor compliance with Guideline via agreed evaluation methods and associated KPIs. Ensure all staff have easy access to relevant Guidelines and are kept informed of any updates or changes to Guidelines related to their employment and scope of practice. Facilitate education as appropriate in relation to the Guideline. Employee All employees must be familiar with and comply with Guidelines relevant to their employment and scope of practice. Guideline AIM To maintain BGL between 4 - 7mmol/L to help achieve optimal maternal and neonatal outcomes. On admission all histories should be reviewed for the plan of diabetes management. This policy will be divided into the following sections for easier practitioner reference.

GDM – DIET CONTROLLED

GDM – INSULIN REQUIRING

TYPE 2 DIABETES - INSULIN REQUIRING

TYPE 1 DIABETES ANTENATAL CARE FOR DIABETES IN PREGNANCY ANTENATAL CARE – GESTATIONAL DIABETES The incidence rate for GDM in Australia is approximately 5% of all pregnancies, however there is an increased prevalence among Aboriginal and Torres Strait Islanders, Pacific Islanders, and women from the Indian subcontinent, East Asia and the Middle East 10 Risk of GDM is also elevated with BMI>30kg/m2, family history of diabetes, previous GDM or macrosomia 3. GESTATIONAL DIABETES DIAGNOSIS Routine Screening: All pregnant women should be offered an OGTT at 26 -28 weeks gestation. Earlier testing of those at higher risk of GDM is advised. Table 1. Criteria for Diagnosis of GDM and Diabetes Mellitus in Pregnancy with a 2 hours Pregnancy Oral GTT (from 1st January 2015)

Diagnosis Fasting plasma glucose (mmol/l)

1 hour glucose (mmol/l following 75g oral glucose load

2 hours glucose (mmol/l) following 75g oral glucose load

Normal < 5.1 <10.0 <8.5

GDM 5.1 – 6.9 ≥ 10.0 8.5 – 11.0

Diabetes Mellitus in Pregnancy

≥ 7.0 * ≥ 11.1

*There are no established criteria for the diagnosis of diabetes based on the 1 hour post load value.10






Higher risk for GDM Women with higher risk factors for GDM should be tested with a 75gm Oral Glucose Tolerance Test (OGTT) at first visit or around 12-14 weeks gestation.5 Higher risk factors include; foetal macrosomia, polycystic ovarian syndrome, strong family history, glycosuria, obesity and previous GDM.6 If result is normal the OGTT should be repeated 26-28 weeks gestation.1

ANTENATAL CARE GESTATIONAL DIABETES GDM Clinic

All women diagnosed with GDM referred to GDM clinic as soon as possible.

GDM Clinic consist of a team of heath care professionals (Endocrinologist, Endocrinology registrar, Diabetes Educators, Dietitian, )

Women are encouraged to take responsibility for making contact with the diabetes educators if they have 2 or more elevated BGL readings in a week.

Insulin therapy should be considered if BGL’s exceed target on two occasions in one week 5 It is not the usual practice in Australia to use oral hypoglycaemic agents in the treatment of GDM5 1

All women should have a plan of management discussed and documented from 36/40 regarding timing of birth and management of medication in labour

FREQUENCY OF VISITS - GDM

Frequency of visits to GDM clinic. Routinely fortnightly reviews – may be increased or decreased as required

Frequency of visits to MWC/OBS CLINIC / SMCP: o If not receiving insulin then routine antenatal care is assumed. The

following is the suggested regime: o 4/52 until 28 weeks, then 3/52 until 34 weeks, then 2 weekly until 38

weeks, then weekly until term

Once insulin is administered the following is the suggested regime O As above, then weekly from 34/40 gestation

TABLE OUTLINING ANTENATAL VISITS WITH GESTATIONAL DIABETES

GESTATION VISIT WITH LABORATORY TESTS FETAL ASSESSMENT

OTHER

0-12 weeks

GP

Obstetrician

confirm pregnancy

routine antenatal bloods

As per routine pregnancy

12-14 weeks Booking at hospital with midwife

OGTT for high risk of GDM

If normal repeat at 26/40

Ultrasound /blood test genetic abnormality screen

Referral to GDM Clinic if positive OGTT






18-20 weeks

Midwife / SMCP /OBS Review if requiring insulin

Anatomy U/S

24

Midwife / SMCP /OBS review

GTT 26-28 weeks for all routine women

routine care

28

OBS review

GDM Clinic as soon as diagnosed

FBE

antibody screen ± anti D

Iron Study

30

Midwife / SMCP /OBS +/-GDM Clinic

Review blood glucose control

32 OBS review

Growth Scan if needed

34

OBS review

+/-GDM Clinic

Discuss mode and timing of birth with obstetrician Review blood glucose control

36

OBS review

FBE

± anti D

GBS swab

offer U/S for fetal growth/ AFI if clinically indicated or baby > 80th percentile at 30/40 U/Sound


37

OBS review

+/-GDM Clinic

If complicating factors present

Consider delivery @38-39/40

If for planned Elective LUSCS -38/40


38

OBS review

+/-GDM Clinic

If for Planned C/S and good glycaemic control, book for






39/40 Review blood glucose control

39

OBS review

+/-GDM Clinic

CTG If good glycaemic control, on diet without Insulin, and no abnormal features, induce between 40-41 weeks.

TYPE 2 DIABETES

PRE NATAL CARE- TYPE 2 DIABETES9 Pre pregnancy counseling- review with endocrinologist, diabetes educator and dietitian. Recommend contraception until optimal glycaemic control (aim HbA1C 6-7%). Commence 5mg Folic Acid supplement one month prior to pregnancy and continue throughout first trimester. General Health Assessment including Rubella and Varicella test. Diabetes complications assessment (eyes, kidneys, nerves). Review of medications including diabetes tablets/insulin BP and lipid medication. Provide education regarding hypoglycaemia and sick days. ANTENATAL CARE- TYPE 2 DIABETES


FREQUENCY OF VISITS –TYPE 2 DIABETES

Frequency of visits to GDM clinic o As soon as pregnancy confirmed and then as needed o Routinely fortnightly reviews – may be increased or decreased as required

Frequency of visits to mid/obs as per table TYPE 1 DIABETES PRE NATAL CARE -TYPE 1 DIABETES9 Pre pregnancy counseling- review with Endocrinologist, diabetes educator and dietitian. Recommend contraception until optimal glycaemic control (aim HbA1C 6-7%) Commence 5mg Folic Acid supplement one month prior to pregnancy and continue throughout first trimester General Health Assessment including Rubella and Varicella test. Diabetes complications assessment (eyes, kidneys, nerves).Review of medications including diabetes tablets/insulin BP and lipid medication. Provide GlucaGen Script and education regarding hypoglycaemia, sick days and ketone testing






ANTENATAL CARE- TYPE 1 DIABETES

If Ketoacidosis is suspected during pregnancy -Immediate admission to level 2 critical care - ICU under combined obstetric and medical care as ketoacidosis is associated with foetal distress3, 11


Retinal assessment FREQUENCY OF VISITS –TYPE 1 DIABETES

Frequency of visits to GDM clinic- as soon as pregnancy confirmed and then as needed o Routinely fortnightly reviews – may be increased or decreased as required

Frequency of visits to mid/obs as per table TABLE OUTLINING SUBSEQUENT ANTENATAL VISTIS FOR TYPE 1 AND TYPE 2 DIABETES

GESTATION VISIT WITH LABORATORY TESTS FETAL ASSESSMENT

OTHER

0-12 weeks

GP

Obstetrician

Referral to GDM clinic for endocrinologist, dietitian and diabetes educator review

confirm pregnancy

routine antenatal bloods

HbA1c

U/S to confirm dates

12-20 weeks

Booking at hospital with midwife

U/S offering 4 chamber view of heart and outflow tracts

24

Midwife / SMCP routine care

28

OBS review FBE

antibody screen ± anti D

offer U/S for fetal growth/ AFI

31

Midwife SMCP

offer U/S for fetal growth/ AFI ( if on insulin or have poor control)

34

OBS review

HbA1c Weekly CTG commences

Discuss mode and timing of birth with obstetrician

35 OBS review

CTG






36

OBS review

FBE

± anti D

GBS swab

offer U/S for fetal growth/ AFI

CTG x 2 per week

Discuss mode and timing of birth with obstetrician

37

OBS review

CTG x 2 per week

38

OBS review

CTG x 2 per week if awaiting spontaneous labour

Offer IOL or LUSCS if indicated Commence expression of colostrum to assist in prevention of neonatal hypoglycaema

39

OBS review

CTG x 2 per week if awaiting spontaneous labour

40

OBS review

CTG x 2 week if awaiting spontaneous labour

GDM – DIET CONTROLLED

DEFINITION GESTATIONAL DIABETES MELLITUS (GDM) GDM is defined as any degree of glucose intolerance recognized, with the onset of or during pregnancy. The definition applies whether managed by diet or insulin and whether or not the condition persists after pregnancy. AIM To maintain BGL within targets below for optimal maternal and fetal outcomes:

Antenatal :Self blood glucose monitoring 4 times/day(fasting and 2hour post meals)

Minimum goals for self BGL - fasting <5.2 - 2hr post meal <7.0

During Labour: To maintain BGL between 4 – 7mmol/L. ANTENATAL CARE See attached chart – ANTENATAL CARE FOR DIABETES IN PREGNANCY If no abnormal features, induce between 40-41 weeks LABOUR – GDM - DIET CONTROLLED

Check BGLs 1 hourly






Aim to keep BGLs between 4 - 7mmol/L whilst in labour. This will decrease the risk of neonatal hypoglycemia

If BGL > 7.0 contact the endocrinology unit. An insulin infusion may be required

If insulin is required follow insulin infusion protocol and call endocrine unit to inform and obtain further orders.

CTG required if poorly controlled GDM or fetal macrasomia.

Cease insulin infusion after delivery of placenta NO insulin will be required after delivery. IV fluids should be used with caution when using oxytocin or presence of pre-eclampsia due to risk of fluid overload.8 A patient requiring an induction of labour should continue usual meals. CAESAREAN SECTION - GDM DIET CONTROLLED Wherever possible, caesarian section should be booked as the 1st case on the morning theatre list. Check BGLs in the early morning prior to theatre and 2hrly until theatre. If BGL greater than 7mmol/L contact endocrinology unit as insulin therapy may be required POSTNATAL AND FOLLOW UP CARE – GDM - DIET CONTROLLED Most women with GDM revert to normoglycaemia at the time of birth

Monitor BGLs post-delivery for 24hrs (Pre-breakfast and 2hrs post-meals)

Diabetes educator review where they will be advised of subsequent risk of GDM and Type 2 diabetes

75gm GTT 6 weeks post partum

Review appointment booked for GDM clinic 8 weeks postpartum

1-2 yearly GTT if not pregnant

Early GTT next pregnancy – at first visit or 12-14 weeks gestation 5

NEONATAL CARE – GDM – DIET CONTROLLED

Infants of mothers with GDM managed with diet, born > 37 weeks and >2500 grams with out other complications may be cared for in Maternity Services

Follow Pathway for Neonates of GDM on Diet

GDM – INSULIN REQUIRING DEFINITION GESTATIONAL DIABETES MELLITUS (GDM) managed with insulin. See definition for GDM AIM To maintain BGL within targets below for optimal maternal and fetal outcomes:

Antenatal :Self blood glucose monitoring 4 times/day(fasting and 2hour post meals

Minimum goals for self BGL - fasting <5.2 - 2hr post meal <7.0

During Labour: To maintain BGL between 4 – 7mmol/L. ANTENATAL CARE - GDM INSULIN REQUIRING See attached chart – ANTENATAL CARE FOR DIABETES IN PREGNANCY






LABOUR- GDM INSULIN REQUIRING ON ADMISSION

Check Outpatient History for instructions from GDM Clinic See MR ……

If patient has taken insulin and presents in spontaneous labour shortly after, monitor BGL’s for hypoglycaemia.

If patient is admitted the evening prior to induction or caesarean section, they should receive their normal insulin dose in the evening and withhold the morning dose of insulin.

IOL: PROSTGLANDIN

Continue current Antenatal management until in established labour SPONTANEOUS LABOUR / IOL - SYNTOCINON / ARM

Withhold insulin in labour

Monitor BGLs 1hrly during induction/labour

Aim to keep BGL’s between 4 - 7mmol/L whilst in labour. This will decrease the risk of neonatal hypoglycemia

If BGL >or 7.0, contact the endocrinology unit. An insulin infusion may be required


Continuous CTG monitoring in labour.

Cease insulin infusion after delivery of placenta

NO insulin will be required after delivery. IV fluids should be used with caution when using oxytocin or presence of pre-eclampsia due to risk of fluid overload.8 CAESARIAN SECTION- GDM INSULIN REQUIRING

Wherever possible caesarian section should be booked for the 1st case on the morning theatre list.

Usual BGL times unless an insulin infusion is in-situ

If patient is admitted the evening prior to caesarean section, they should receive their normal insulin dose in the evening and withhold the morning dose of insulin.

Measure BGL o Early morning pre-operatively, 2hrly until theatre and in theatre, prior to

anaesthetic o If BGL’s are > 7.0 mmol/l, notify endocrinologist and anaesthetist for ongoing

management - insulin infusion may be required POSTNATAL AND FOLLOW UP CARE- GDM INSULIN REQUIRING Insulin requirements fall dramatically post partum. To avoid profound and prolonged hypoglycaemia, monitoring of blood glucose levels is required.

If insulin infusion was required, this should be ceased at delivery of placenta.

NO insulin will be required after delivery

BGLs should be monitored QID (pre breakfast and 2hrs post meals) for 48hours.

Contact endocrinology or if BGL over 10mmol

Diabetes educator review – where they will be advised of subsequent risk of GDM and type 2 diabetes

75gm GTT 6 weeks post partum and then yearly

Review appointment GDM clinic or GP 8 weeks postpartum

GTT at 12-14 weeks in next pregnancy.






NEONATAL CARE- GDM INSULIN REQUIRING Neonates born to mothers with gestational diabetes or diabetes mellitus are at increased risk of becoming hypoglycaemic. It is current practice at Peninsula Health that all infants born to mothers who have required insulin in their pregnancy should be admitted to SCN. Assessment on admission is required for incubator care or supplemental oxygen TYPE 2 DIABETES– INSULIN REQUIRING DEFINITION- TYPE 2 DIABETES. Characteristics of type 2 diabetes:

Less common than GDM in the pregnant population.

Diabetes diagnosed at any time prior to pregnancy.

Management of diabetes prior to pregnancy with diet or oral hypoglycaemic agents.

Some may have been insulin requiring prior to pregnancy but it is important to distinguish these women from those with Type 1 diabetes. See definition for Type 1 diabetes.

Type 2 diabetes is characterized by an insensitivity of target tissues to insulin, combined with an inadequate insulin response to hyperglycaemia. The pancreas still produces insulin, however it is not effectively utilized. Oral hypoglycaemic agents are not currently recommended for use in pregnancy. Insulin will be required to manage Type 2 diabetes in pregnancy. AIM To maintain BGL within targets below for optimal maternal and foetal outcomes:

Antenatal: Self BGL monitoring 4 times per day (fasting and 2hr (or1hr) post meals)1

Minimum goals for self BGL monitoring2: fasting 5.2, 1hr post meal <8.0, 2hr post-meal <7.0.

During Labour: To maintain BGL between 4 - 7mmol/L ANTENATAL CARE- TYPE 2 DIABETES See attached chart – ANTENATAL CARE FOR DIABETES IN PREGNANCY LABOUR- TYPE 2 DIABETES Poor glycaemic control during labour is associated neonatal hypoglycaemia3 Stimulation of fetal insulin release by maternal hyperglycemia during labor significantly increases the risk of early hypoglycemia in these infants4 PRE TERM LABOUR Use of corticosteroids for foetal lung maturity and ß-agonists in pre-term labour has been associated with hyperglycaemia11 ON ADMISSION

All women should have a plan of management discussed and documented from 36/40 regarding timing of birth and management of medication in labour See MR…..

Contact urgently and inform endocrine unit of admission (after hours notify on call endocrine consultant)

If patient is admitted the evening prior to induction or, they should receive their normal insulin dose in the evening and withhold the morning dose of insulin

IOL: PROSTGLANDIN

Continue current Antenatal management until in established labour SPONTANEOUS LABOUR / IOL : SYNTOCINON / ARM

Withhold insulin in labour






Monitor BGLs 1hrly during induction


Aim to keep BGL’s between 4 - 7mmol/L whilst in labour. This will decrease the risk of neonatal hypoglycemia



Fetal monitoring continuously in labour.

Cease insulin infusion after delivery of placenta

NO insulin will be required after delivery. IV fluids should be used with caution when using oxytocin or presence of pre-eclampsia due to risk of fluid overload.8 CAESARIAN SECTION - TYPE 2 DIABETES

Wherever possible caesarian section should be booked for the 1st case on the morning theatre list.

If patient is admitted the evening prior to caesarean section, they should receive their normal insulin dose in the evening and withhold the morning dose of insulin.

Usual BGL times unless an insulin infusion is in-situ

Measure BGL o Early morning pre operatively, and if theatre is delayed 1hrly until in theatre

and prior to anaesthetic o If BGLs are >7.0mmol/l, notify endocrinologist and anesthetist for ongoing

management- insulin infusion may be required. POSTNATAL AND FOLLOW UP CARE- TYPE 2 DIABETES Insulin requirements fall dramatically postpartum. To avoid profound and prolonged hypoglycaemia, monitoring of blood glucose levels is required.

If insulin infusion used cease insulin infusion after birth of placenta

No insulin after delivery.

QID BGL (pre breakfast and 2hrs post meals) notify endocrinology unit if BGL >10mmol

Endocrinology review to assess insulin or oral hypoglycaemic agent requirements

Diabetes Educator review – advise risk of hypoglycaemia post delivery and after breastfeeding

GDM clinic review 2-4 weeks

Ongoing follow-up at Diabetes clinic or private endocrinologist NEONATAL CARE- TYPE 2 DIABETES Neonates born to mothers with gestational diabetes or diabetes mellitus are at increased risk of becoming hypoglycaemic. It is current practice at Peninsula Health that all infants born to mothers who have required insulin in their pregnancy should be admitted to SCN. Assessment on admission is required for incubator care or supplemental oxygen. TYPE 1 DIABETES DEFINITION - TYPE 1 DIABETES Characteristics of type 1 diabetes:

Diabetes diagnosed at any time prior to pregnancy.






Patient required insulin soon after diagnosis of diabetes

May have had previous episodes of ketoacidosis. Type 1 diabetes is characterized by a cessation of the production and secretion of insulin in the pancreatic beta cells which is usually the result of an autoimmune disease. People with Type 1 diabetes require insulin to be administered everyday, even prior to pregnancy. Without sufficient insulin hyperglycaemia and ketoacidosis may occur. AIM To maintain BGL within targets below for optimal maternal and foetal outcomes: To avoid Ketoacidosis and minimize hypoglycaemia

Antenatal: Self BGL monitoring 4-8 times per day Minimum goals for self BGL monitoring: 2 Fasting 5.2, 1hr post meal <8.0, 2hr post meal < 7.0

During Labour: To maintain BGL between 4 - 7mmol/L ANTENATAL CARE- TYPE 1 DIABETES See attached chart – ANTENATAL CARE FOR DIABETES IN PREGNANCY LABOUR- TYPE 1 DIABETES Poor glycaemic control during labour is associated neonatal hypoglycaemia3 Stimulation of fetal insulin release by maternal hyperglycemia during labor significantly increases the risk of early hypoglycemia in these infants4

Patients who are on insulin pumps o Urgently contact Endocrine Unit o Patient may require cessation of insulin pump and need to commence

dextrose and insulin infusions PRE TERM LABOUR Use of corticosteroids for foetal lung maturity and ß-agonists in pre-term labour has been associated with hyperglycaemia and increased risk of ketoacidosis11 ON ADMISSION


Check Outpatient History for instructions from GDM Clinic

Contact urgently and inform Endocrine unit of admission (after hours notify on call endocrine consultant)

IOL / PROSTGLANDIN / SYNTOCINON / ARM

If patient is admitted the evening prior to induction or caesarean section, they should receive their normal insulin dose in the evening and commence an insulin infusion in the morning- contact endocrinology unit.

IN LABOUR

Insulin must not be withheld

Type 1 diabetes patients require glucose and insulin at all times

Hourly BGLs in labour

Patient will always require an insulin infusion (see attached guidelines)

Continuous fetal monitoring whilst in labour IV fluids should be used with caution when using oxytocin or presence of pre-eclampsia due to risk of fluid overload.8






CAESARIAN SECTION

Caesarian Section should be booked for the 1st case on the morning theatre list.

Administer usual insulin and meals the night before C/S until fasting commences

Usual BGL monitoring times unless an insulin infusion is in-situ

Morning of C/S – withhold usual insulin and commence infusions of dextrose and insulin

Measure BGLs o pre operatively and in theatre prior to anesthetic o If BGL s are >7.0 mmol/l, notify endocrinologist and anesthetist for ongoing

management

POSTNATAL AND FOLLOW UP CARE

Reduce insulin infusion to 20% at delivery. (e.g. if rate at 5 units/hr, reduce to 1 unit/hr)

All doses of insulin post delivery to be reduced to 20% of pregnancy dose. (e.g. if all insulin doses total up to 100 units per day, reduce to total of 20 units per day)

If restarting insulin pump- rates and ratios to be reduced to 20% (contact Endocrinology unit)

Endocrinology review to assess insulin requirements

Ongoing insulin doses will NEED TO BE REDUCED to 20% of previous dose

DO NOT withhold insulin or glucose even if not eating

QID BGLs pre-meals – notify endocrinology if BGL>10 mmol/l

Diabetes Educator review to advise risk of hypoglycaemia post delivery and after breastfeeding

GDM clinic review in 2-4 weeks

Ongoing follow up at diabetes clinic or private endocrinologist NEONATAL CARE Neonates born to mothers with gestational diabetes or diabetes mellitus are at increased risk of becoming hypoglycaemic. It is current practice at Peninsula Health that all infants born to mothers who have required insulin in their pregnancy should be admitted to SCN. Assessment on admission is required for incubator care or supplemental oxygen ADDITIONAL INFORMATION FOR INSULIN INFUSION PREPARATION Prepare as per Insulin Infusion Order MR/013 (18b)

Prepare Dextrose infusion first o 10% dextrose should be commenced at a 12 hourly rate when BGL’s are

less that 15 mmol/l

INSULIN is a sticky protein and will adhere to plastic coating until it is fully coated, so it is essential to make up an initial solution of 10 units of (Actrapid insulin) in 10mls of normal saline and to prime the infusion line with all of this solution, prior to the commencement of the actual insulin infusion of 50units/50mls

To prepare insulin infusion draw up 50 mls of normal saline solution and add 50 units of Actrapid insulin to this. This will create a solution of 1unit/ml of insulin per solution

Connect both the insulin infusion and the dextrose infusion to the same cannulae via a Y-lumen connector. This ensure the patient receives both of the infusions and not one alone, in cases of extravasation of intravenous sites






The insulin infusion rate will be determined by the endocrinologist dependent on the patients BGLs

Follow hypoglycaemic treatment regime designated by endocrinologist for patient. Key Aligned Documents

Peninsula Health Policy – Hand Hygiene & Aseptic Technique

Nursing Clinical Practice Guideline - Blood Glucose Monitoring

Nursing Clinical Practice Guideline - Insulin Infusion

Paediatrics Clinical Practice Guideline - Blood glucose monitoring - Neonate References [1] IDF Clinical Guidelines Task Force 2009, Global Guideline on Pregnancy and Diabetes Brussells International Diabetes Federation. [2] Potter, C and Kicklighter S (2009) Infant of Diabetic Mother, Retrieved from emedicine.medscape.com [3] Nankervis A (2007) Gestational Diabetes. Diabetes Management Vol 19 June 2007 [4] Royal Women’s Hospital (2008) Clinical Practice Guideline- Diabetes Mellitus: Management of gestational diabetes [5] Royal Women’s Hospital, Melbourne. Clinical Practice Guidelines. December 4, 2008 retrieved from http://www.thewomens.org.au/diabetesMellitusManagmentofgestationalDiabetes. [6] Royal Womens Hospital, Melbourne. Clinical Practice Guideline Diabetes in pregnancy-management in labour. 22 April, 2008 [7] Diabetes Australia Vic, ADIPS Type 1 Diabetes Network(2002), Can I have a Healthy Baby?- Diabetes and Pregnancy, NDSS. [8] Barrett, H and McElduff A, How to Treat Gestational Diabetes, Australian Doctor, March 2010 p31-38 [9] kamalakannan,D et al (2002) Diabetic Ketoacidosis in Pregnancy, Postgrad Med Journal 79:454-457 [10] RANZCOG, diagnosis of gestational diabetes mellitus, 2014 http://www.ranzcog.edu.au/publications/statement/C-obs7.pdf [11] Royal West Sussex NHS Trust. England. 2009 Diabetic Pregnancy Guidelines

Document management Position

Document Coordinator: Clinical Director Women’s Health

Executive Sponsor: Chief Operating Officer Frankston Hospital

Approved by: Women’s Health Executive

Date created/revised in archived system: 03/2015

http://www.ranzcog.edu.au/publications/statement/C-obs7.pdf

Clinical Practice Guideline Diabetes in Pregnancy ... · mother such as retinopathy3 and...

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