The feasibility and impact of implementing NICE guidance on diabetes control during delivery
DOI:
https://doi.org/10.15277/bjd.2017.137Keywords:
feasibility, impact, NICE, diabetes, deliveryAbstract
Aims: The aim of this study was to report on the practicality, feasibility and impact of implementing the National Institute for Health and Care Excellence (NICE) guidelines for the control of diabetes in women during labour and birth.Methods: We analysed case records of pregnant women with diabetes who delivered in the period between July 2014 and June 2015. The data were collected in relation to the availability of a plan in the notes, capillary blood glucose (CBG) monitoring, use of variable rate intravenous insulin infusion (VRIII), maintenance of CBG targets within 4–7 mmol/L, maternal hypoglycaemia during labour and neonatal hypoglycaemia.
Results: Fifty-one women with diabetes delivered during this period. Only 45% of women were monitored by complete hourly CBGs until delivery. 27.4% of women had CBG ≥7 mmol/L but only 17.6% were started on VRIII. The VRIII group had a 22.2% incidence of minor maternal hypoglycaemia. Neonatal hypoglycaemia occurred in 47% of the babies.
Conclusion: A CBG target of 4–7 mmol/L during labour and initiation of VRIII when levels are above this target in pregnant women with diabetes is difficult to achieve and is associated with some maternal hypoglycaemia. Repeat CBG measurements within half an hour and strict adherence to clear guidelines and protocols supported by more education and adequate staffing may improve results.
References
National Institute for Health and Clinical Excellence. Clinical practice guideline. Diabetes in pregnancy: management of diabetes and its complications from preconception to the postnatal period. February 2015. http://www.nice.org.uk/guidance/ng3 (accessed 2 Aug 2016).
HAPO Study Cooperative Research Group. Hyperglycemia and adverse pregnancy outcomes. N Engl J Med 2008;358:1991-2002. http://dx.doi.org/10.1056/NEJMoa0707943
Pedersen J. Weight and length at birth of infants of diabetic mothers. Acta Endocrinol 1954;16:330-42. https://doi.org/10.1530/acta.0.0160330
Desoye G, Nolan CJ. The fetal glucose steal: an underappreciated phenomenon in diabetic pregnancy. Diabetologia 2016;59:1089-94. http://dx.doi.org/10.1007/s00125-016-3931-6
Molsted-Pedersen L. Aspects of carbohydrate metabolism in newborn infants of diabetic mothers. I. Intravenous glucose tolerance tests (a) distribution and means of K values, and (b) correlation between K value and birth weight. Acta Endocrinol 1972;69:174-88.
Jovanovic L. Glucose and insulin requirements during labor and delivery: the case for normoglycemia in pregnancies complicated by diabetes. Endocr Pract 2004;10(Suppl 2):40-5. http://dx.doi.org/10.4158/EP.10.S2.40
Flores-le Roux JA, Sagarra E, Benaiges D, et al. A prospective evaluation of neonatal hypoglycaemia in infants of women with gestational diabetes mellitus. Diabetes Res Clin Pract 2012;97:217-22. http://dx.doi.org/10.1016/j.diabres.2012.03.011
Taylor R, Lee C, Kyne-Grzebalski D, et al. Clinical outcomes of pregnancy in women with type 1 diabetes. Obstet Gynecol 2002;99:537-41. https://doi.org/10.1097/00006250-200204000-00004
Modi A, Levy N, Hall GM. Controversies in the peripartum management of diabetes. Anaesthesia 2016;71:750-5. http://dx.doi.org/10.1111/anae.13487
National Institute for Health and Clinical Excellence. Clinical practice guideline Safe midewifery staffing for maternity settings. February 2015. Available at https://www.nice.org.uk/guidance/ng4/resources/safe-midwifery-staffing-for-maternity-settings-51040125637 (accessed 20 Nov 2016).
Barrett HL, Morris J, McElduff A. Watchful waiting: a management protocol for maternal glycaemia in the peripartum period. Aust N Z J Obstet Gynaecol 2009;49:162-7. http://dx.doi.org/10.1111/j.1479-828X.2009.00969.x
Fresa R, Visalli N, Di Blasi V, et al. Experiences of continuous subcutaneous insulin infusion in pregnant women with type 1 diabetes during delivery from four Italian centers: a retrospective observational study. Diabetes Technol Ther 2013;15:328-34. http://dx.doi.org/10.1089/dia.2012.0260
Iafusco D, Stoppoloni F, Salvia G, et al. Use of real time continuous glucose monitoring and intravenous insulin in type 1 diabetic mothers to prevent respiratory distress and hypoglycaemia in infants. BMC Pregnancy Childbirth 2008;8:23. http://dx.doi.org/10.1186/1471-2393-8-23
Koh TH, Eyre JA, Aynsley-Green A. Neonatal hypoglycaemia: the controversy regarding definition. Arch Dis Child 1988;63:1386-8. https://doi.org/10.1136/adc.63.11.1386
Metzger BE, Persson B, Lowe LP, et al. Hyperglycemia and adverse pregnancy outcome study: neonatal glycemia. Pediatrics 2010;126:1545-52. http://dx.doi.org/10.1542/peds.2009-2257
Cornblath M, Reisner SH. Blood glucose in the neonate and its clinical significance. N Engl J Med 1965;273:378-81. https://doi.org/10.1056/NEJM196508122730707
Inder T. How low can I go? The impact of hypoglycemia on the immature brain. Pediatrics 2008;122:440-1. http://dx.doi.org/10.1542/peds.2008-1417
Cornblath M, Hawdon JM, Williams AF, et al. Controversies regarding definition of neonatal hypoglycemia: suggested operational thresholds. Pediatrics 2000;105:1141-5. https://doi.org/10.1542/peds.105.5.1141
Ryan EA, Al-Agha R. Glucose control during labor and delivery. Curr Diab Rep 2014;14:1-9. http://dx.doi.org/10.1007/s11892-013-0450-4
Agrawal RK, Lui K, Gupta JM. Neonatal hypoglycaemia in infants of diabetic mothers. J Paediatr Child Health 2000;36:354-6. https://doi.org/10.1046/j.1440-1754.2000.00512.x
West TE, Lowy C. Control of blood glucose during labour in diabetic women with combined glucose and low-dose insulin infusion. Br Med J 1977;1:1252-4. https://doi.org/10.1136/bmj.1.6071.1252
Kline GA, Edwards A. Antepartum and intra-partum insulin management of type 1 and type 2 diabetic women: Impact on clinically significant neonatal hypoglycemia. Diabetes Res Clin Pract 2007;77:223-30. http://dx.doi.org/10.1016/j.diabres.2006.10.024
Van Haltren K, Malhotra A. Characteristics of infants admitted with hypoglycemia to a neonatal unit. J Pediatr Endocrinol Metab 2013;26:525-9. http://dx.doi.org/10.1515/jpem-2013-0009
Henquin JC, Sempoux C, Marchandise J, et al. Congenital hyperinsulinism caused by hexokinase I expression or glucokinase-activating mutation in a subset of β-cells. Diabetes 2013;62:1689-96. http://dx.doi.org/10.2337/db12-1414
Hussain K, Aynsley-Green A. Hyperinsulinaemic hypoglycaemia in preterm neonates. Arch Dis Child Fetal Neonatal Ed 2004;89:F65–7. https://doi.org/10.1136/fn.89.1.F65
Feldberg D, Dicker D, Samuel N, et al. Intrapartum management of insulin‐dependent diabetes mellitus (IDDM) gestants. Acta Obstet Gynecol Scand 1988;67:333-8. https://doi.org/10.1111/j.1600-0412.1988.tb07810.x
Achong N, Duncan EL, McIntyre HD, Callaway L. Peripartum management of glycaemia in women with type 1 diabetes. Diabetes Care 2014;37:364-71. http://dx.doi.org/10.2337/dc13-1348
Lean ME, Pearson DW, Sutherland HW. Insulin management during labour and delivery in mothers with diabetes. Diabet Med 1990;7:162-4. https://doi.org/10.1111/j.1464-5491.1990.tb01352.x
Balsells M, Corcoy R, Adelantado JM, et al. Gestational diabetes mellitus: metabolic control during labour. Diabetes Nutr Metab 2000;13:257-62.
Rosenberg VA, Eglinton GS, Rauch ER, Skupski DW. Intrapartum maternal glycemic control in women with insulin requiring diabetes: a randomized clinical trial of rotating fluids versus insulin drip. Am J Obstet Gynecol 2006;195:1095-9. http://dx.doi.org/10.1016/j.ajog.2006.05.051
Njenga E, Lind T, Taylor R. Five year audit of peripartum blood glucose control in type 1 diabetic patients. Diabet Med 1992;9:567-70. https://doi.org/10.1111/j.1464-5491.1992.tb01840.x
Brown SC, Kyne-Grzebalski D, Mwangi B, Taylor R. Effect of management policy upon 120 type 1 diabetic pregnancies: policy decisions in practice. Diabet Med 1999;16:573-8. https://doi.org/10.1046/j.1464-5491.1999.00124.x
Published
Issue
Section
License
Publish & Transfer of Copyright Agreement
For the mutual benefit and protection of the Author and the Journal Owner/Publisher it is necessary that the Author provides formal written Consent to Publish and Transfer of Copyright before publication of the Work.
