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Diabetes in pregnancy is associated with risks to the woman (for example, higher rates of miscarriage, pre-eclampsia, and preterm labour) and to the developing fetus and baby (for example, higher rates of congenital malformations, macrosomia, birth injury, and perinatal mortality).1 2 This article summarises the most recent guidance from the National Institute for Health and Clinical Excellence (NICE) on how to manage diabetes and its complications from preconception to the postnatal period.3
NICE recommendations are based on systematic reviews of best available evidence. When minimal evidence is available, recommendations are based on the guideline development group’s opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets.
Offer ongoing opportunities for information and education and provide the following care in addition to (or, where indicated, instead of) routine antenatal care.*
* Women with diabetes should also receive routine care according to the schedule of appointments in the NICE guideline on antenatal care for healthy pregnant women,5 including appointments at 25 weeks (for nulliparous women) and 34 weeks, but with the exception of the appointment for nulliparous women at 31 weeks
This guidance for care of women with diabetes and their families aims to empower them so that pregnancy and child birth are positive experiences. For example, uptake of preconception care is encouraged by using every contact with healthcare professionals (including the diabetes care team) to inform women of childbearing age about the benefits of preconception glycaemic control and every contact with the diabetes care team to document intentions about pregnancy and contraceptive use, and by also giving preconception care in a supportive environment, with the woman’s partner or other family members encouraged to attend. Other recommendations aim to prepare women for the additional time and effort required to manage diabetes during pregnancy and to provide maximal support for women who wish to breast feed.
To support implementation, NICE and the guideline development group have developed a version of the guidance (available at www.nice.org.uk/CG063PublicInfoEnglish) that can be given to women with pre-existing diabetes, women who are planning to become pregnant, and women’s partners or families.
About 650000 women give birth in England and Wales each year,6 and 2-5% of pregnancies involve women with diabetes.7 8Among pregnancies in which the woman has diabetes, about 87.5% involve gestational diabetes (which may or may not resolve after pregnancy), 7.5% involve type 1 diabetes, and 5% involve type 2 diabetes.3 The adverse outcomes associated with pregnancy complicated by diabetes together with the increasing prevalence of type 1 and type 2 diabetes (especially the increasing prevalence of type 2 diabetes in people of African, black Caribbean, South Asian, Middle Eastern, and Chinese family origin)7 highlight the need for effective clinical care to improve outcomes for women with diabetes and their babies.
This guidance builds on existing guidance for the routine care of type 1 and type 2 diabetes9 10 and for routine antenatal, intrapartum, and postnatal care.5 11 12 It emphasises aspects of maternity care that are additional or different for women with diabetes in pregnancy.
The guidance was developed by the National Collaborating Centre for Women’s and Children’s Health in accordance with NICE guideline development methods (see www.nice.org.uk/page.aspx?o=114219). The collaborating centre established a guideline development group consisting of healthcare professionals and patient and carer representatives, with experts in guideline methodology from the collaborating centre. The guideline development group identified and appraised clinical evidence and evaluated cost effectiveness of interventions where possible. Stakeholder organisations were invited to comment on a draft of the guideline that was subsequently revised to take account of comments received.
NICE has produced four different versions of the guideline: a full version containing all the evidence and the recommendations; a quick reference guide; a version known as the “NICE guideline” that lists the recommendations; and a version for patients and the public. All these versions are available from the NICE website (www.nice.org.uk/CG063). Future updates of the guidance will be produced as part of the NICE guideline development programme.13
This is one of a series of BMJ summaries of new guidelines, which are based on the best available evidence; they will highlight important recommendations for clinical practice, especially where uncertainty or controversy exists.
The members of the guideline development group are Dominique Acolet (until October 2007), clinical director (perinatal epidemiology), Confidential Enquiry into Maternal and Child Health (CEMACH), London; Lynne Carney, patient representative, Wrockwardine; Anne Dornhorst, consultant physician and honorary senior lecturer in metabolic medicine, Hammersmith Hospital, London; Robert Fraser, reader in obstetrics and gynaecology, University of Sheffield; Roger Gadsby, general practitioner, Nuneaton, and senior lecturer in primary care, University of Warwick; Jane Hawdon (from October 2007), consultant neonatologist, University College Hospitals London NHS Foundation Trust; Richard Holt, reader of endocrinology and metabolism, University of Southampton; Ann Parker, diabetes advisory midwife, Royal Shrewsbury Hospital; Nickey Tomkins, advanced nurse practitioner in diabetes and diabetes specialist midwife, Medway Primary Care Trust; Stephen Walkinshaw, consultant in maternal and fetal medicine, Liverpool Women’s Hospital; Jackie Webb, diabetes specialist nurse manager, Heart of England NHS Foundation Trust, Birmingham; Saiyyidah Zaidi, patient representative, London; and the following (who work for the National Collaborating Centre for Women’s and Children’s Health (NCC-WCH)): Paula Broughton-Palmer, senior work programme coordinator, Michael Corkett, senior information specialist; Anthony Danso-Appiah, research fellow; Paul Jacklin, senior health economist; Lorelei Jones, former research fellow at NCC-WCH (now research fellow at London School of Hygiene and Tropical Medicine); Moira A Mugglestone, deputy director; Jeffrey Round, health economist; Anuradha Sekhri, research fellow.
Contributors: Moira A Mugglestone, Anuradha Sekhri, and Robert Fraser wrote the initial draft of the article using material produced collectively by the entire guideline development group. They also contributed to its revision and the final draft, having received feedback from every member of the group.
Funding: The National Collaborating Centre for Women’s and Children’s Health was commissioned and funded by the National Institute for Health and Clinical Excellence to write this summary.
Competing interests: LC has spoken at a meeting of the Confidential Enquiry into Maternal and Child Health (CEMACH). AD has received funding from pharmaceutical companies (for consultancy, conference expenses, lecture fees, and research); she is a former officer of the Royal College of Physicians and a former member of the Working Lives intercollegiate committee. RG has received funding from pharmaceutical companies (for advisory services, consultancy, conference expenses, and lecture fees); he is medical adviser to Warwick Diabetes Care at the University of Warwick, chairman of trustees of Pregnancy Sickness Support, and honorary treasurer of the Primary Care Diabetes Society. JH is chair of the neonatal working group for the CEMACH Diabetes in Pregnancy Enquiry, and an adviser and speaker for Baby Friendly Initiative, BLISS, and CEMACH. RH has received funding from pharmaceutical companies (for consultancy, conference expenses, lecture fees, research, and educational support); he is chair of the Professional Advisory Council of Diabetes UK. JW has received funding from pharmaceutical companies (for advisory services, conference expenses, lecture fees, educational support, and working on a helpline); she is a member of Diabetes UK and has participated in CEMACH meetings and attended a meeting of the Management of Diabetes Excellence group.
Provenance and peer review: Commissioned; not externally peer reviewed.