Provision of information

Sources of further information

Diabetes-specific sources

Association of British Clinical Diabetologists

The Association of British Clinical Diabetologists (ABCD) is the national organisation of consultant physicians and specialist registrars working in the UK who specialise in diabetes mellitus. It promotes awareness of and interest in diabetes and diabetes care both locally and nationally and provides information resources to support the delivery of high-quality care.

Sitting within ABCD, the Diabetes Technology Network UK is an organisation which supports UK healthcare professionals who are involved in the delivery of technologies that are designed to improve the lives of people living with diabetes. The Network has developed a series of educational modules on use of diabetes technology in pregnancy.

Joint British Diabetes Societies for Inpatient Care Group

The Joint British Diabetes Societies for Inpatient Care (JBDS-IP) group was created in 2008 to ‘deliver a set of diabetes inpatient guidelines and proposed standards of care within secondary care organisations’, with the overall aim of improving inpatient diabetes care through the development and use of high-quality evidence-based guidelines, and through better inpatient care pathways. The JBDS–IP group was created and supported by Diabetes UK, ABCD and the Diabetes Inpatient Specialist Nurse UK group, and works with NHS England, Trend (Training Research and Education for Nurses in Diabetes) Diabetes and with other professional organisations.

Diabetes Scotland/Diabetes UK

Helpline: 0141 212 8710, Monday to Friday, 9am–6pm

X (formerly Twitter): @DiabetesScot

Diabetes Scotland provides a wide range of information on diabetes including leaflets, fact sheets, details of support groups and advice on all aspects of diabetes. The Diabetes UK Learning Zone offers videos, quizzes and interactive tools for managing diabetes day-to-day, which are tailored for each individual.

Dietary advice for women with gestational diabetes

Juvenile Diabetes Research Foundation (JDRF)

Tel: 01224 248677 (Scotland), 07442 332872 (Central Scotland)

Email: scotland@jdrf.org.uk

Facebook: http://www.facebook.com/jdrf.scotland

JDRF drives research to cure, treat and prevent type 1 diabetes, accelerates access to type 1 diabetes treatment technologies and medicines and supports people living with type 1 diabetes. Through its international JDRF network, funding of UK researchers, advocacy work with the NHS and the support it provides to people with type 1 diabetes, JDRF pushes new boundaries and generates progress to prevent, treat and ultimately find cures for type 1 diabetes.

Insulin Dependent Diabetes Trust

Tel: 01604 622 837

X (formerly Twitter): @UK_diabetes

The Insulin Dependent Diabetes Trust is run by people living with diabetes to raise awareness of important issues for people with diabetes. It provides information in non-medical language.

Insulin Pump Awareness Group

X (formerly Twitter): @iPAG_Scot

The Insulin Pump Awareness Group was formed and run by a group of people who are either pump users, likely to use pumps in the future, or parents of children with type 1 diabetes.

My Diabetes My Way

X (formerly Twitter): @MyDiabetesMyWay

Gestational diabetes e-learning site

My Diabetes My Way is NHSScotland’s interactive diabetes website which helps to support people who have diabetes and their family and friends.

Other national sources

NHS 24

Tel: 111

NHS 24 is an online and out-of-hours phone service providing the Scottish people with access to health advice and information 24 hours a day, 365 days a year.

NHS Inform

Tel: 0800 224 488

This is the national health and care information service for Scotland. It includes information and links to resources and to support people with diabetes and health conditions that can develop during pregnancy.

Public Health Scotland

Challenging weight stigma learning hub

This online learning course describes what weight stigma means and the effects it can have. The course introduces approaches that address weight stigma and improve outcomes for individuals with higher weight and provides advice on how to have good conversations about higher weight and behaviour change. It is aimed at health and social care staff, and those working in communications, policy, leisure and third sector settings.

Breathing Space

Tel: 0800 83 85 87 (Monday to Thursday, 6pm to 2am, Friday to Monday, 6pm to 6am)

Breathing Space is a free and confidential phone and webchat service for anyone in Scotland over the age of 16 who may be feeling down or experiencing depression and need someone to talk to.

British Heart Foundation

Tel: 0300 330 3311

X (formerly Twitter): @TheBHF

The British Heart Foundation provides a telephone information service for people looking for information on health issues to do with the heart, as well as providing a range of information on its website.

Chest, Heart and Stroke Scotland

Tel: 0131 225 6963

X (formerly Twitter): @CHSScotland

Chest, Heart and Stroke Scotland aims to improve the quality of life of people affected by chest, heart and stroke illnesses by offering information, advice and support in the community. It produces leaflets on the links between diabetes, heart disease and stroke.

Citizens Advice Scotland

X (formerly Twitter): @CitAdviceScot

Citizens advice bureaux are local independent charities that provide free, confidential and impartial advice to people who need it.

Driver and Vehicle Licensing Agency (DVLA)

X (formerly Twitter): @DVLAgovuk

The DVLA is an executive agency of the UK Government Department for Transport. It is responsible for issuing driving licenses and vehicle registration certificates, and also recording driver endorsements, disqualifications and medical conditions. People who use insulin for >3 months to control their diabetes are required to inform DVLA.

Checklist for provision of information

This section gives examples of the information patients/carers may find helpful at the key stages of the patient journey. The term woman/women has been used throughout this document to refer to women and birthing people who are pregnant or who recently gave birth. For the purpose of this toolkit, the term woman/women includes girls. It also includes people whose gender identity does not correspond with their birth sex or who may have a non-binary identity. The checklist was designed by members of the guideline development group based on their experience and their understanding of the evidence base. The checklist is neither exhaustive nor exclusive.

Women who already have diabetes before pregnancy

Prepregnancy planning

Discuss pregnancy planning with women with diabetes of childbearing age at their annual review. Discussion of care with women of childbearing age should include issues that may arise before pregnancy, during pregnancy and after pregnancy. This should be discussed at the annual review but also when it is timely and appropriate for the individual.
Advise women with diabetes who are preparing for pregnancy that information about preconception planning is available and that they will be offered access to a prepregnancy multidisciplinary clinic, and outline the benefits of multidisciplinary management. Signpost to online resources for further information.
Reassure women who have an unplanned pregnancy that the multidisciplinary diabetes team is always available and advise them to contact the team as soon as possible to access support.
Agree individualised HbA1c levels to aim for, taking into account BMI, smoking, hypertension and level of diabetic retinopathy.
Explain to women with diabetes why pregnancy should be avoided if HbA1c >86 mmol/mol and support women to have access to reliable contraception.
Discuss the need for referral to relevant specialties to address diabetes complications before pregnancy, including psychological issues, where possible.

Optimising individualised diabetes management

Offer lifestyle advice, for example, on stopping smoking, vaping, alcohol and drug use, and healthy eating, weight management and exercise, in line with all pregnancies. Explain about how to access support from a registered dietitian.
Explain that HbA1c will be measured at the booking appointment and may be monitored regularly during pregnancy.
Suggest that women should aim for an HbA1c as low as possible, and (for those using CGM) time in pregnancy range (3.5–7.8 mmol/L) >70% without excess hypoglycaemia prior to pregnancy. Provide information on the risks of diabetes to both mother and fetus. Explain why a review of glycaemic levels is necessary.
Review blood glucose monitoring methods. Discuss use of diabetes technologies, specifically whether CGM and/or an insulin pump may offer benefits for the individual. Discuss achievable blood glucose levels prior to and during pregnancy.
Ensure that women using CGM and/or an insulin pump have alternative glucose monitoring and insulin delivery equipment (eg glucose meters measuring capillary blood and insulin pens) in case of device failure.
Explain that routine diabetes measurements will continue to be collected during pregnancy and that the interval between measurement may be smaller than before pregnancy, for example blood pressure, retinal screening, foot screening.
Address issues with particular significance to pregnancy including reduced wellbeing and mental health.
Explain to women on insulin therapy prior to pregnancy that their insulin requirements will increase by up to 50% and adjustments will be supported by the diabetes multidisciplinary team. Encourage women to continue to adjust and self manage during pregnancy to optimise diabetes management.

Medication review

Advise that folic acid 5 mg (available on prescription only) should be taken for three months prior to conception, or as soon as possible after pregnancy is confirmed, and until the end of week 12 of pregnancy.
Review all medication and offer advice on which medications should be stopped (eg ACE inhibitors and statins), the reasons behind stopping and what the alternatives are. Provide contact telephone numbers.
Ensure that only insulin and/or metformin are prescribed to manage blood glucose levels in women with diabetes during pregnancy.

Managing hypoglycaemia

Revisit awareness, recognition and management of hypoglycaemia regularly during pregnancy.
Ensure that the woman has the ability and equipment to test for hypoglycaemia and understands how to treat it appropriately.
Ensure the availability of glucagon and education regarding administration.
Ensure that the woman knows to contact the multidisciplinary team in case of severe hypoglycaemia (requiring third-party intervention) or if episodes are increasing in frequency.
Explain to women that hypoglycaemia can increase in frequency in the first trimester, which can be exacerbated by a change in symptoms, morning sickness and insulin sensitivity. Review safety aspects in the context of home circumstances, occupation and driving.

Women who are being tested for or are diagnosed with diabetes in pregnancy or gestational diabetes

Medication review

Advise that folic acid 5 mg (available on prescription only) should be taken until the end of week 12 of pregnancy.
Review all medication and offer advice on which medications should be stopped (eg ACE inhibitors and statins), the reasons behind stopping and what the alternatives are. Provide contact telephone numbers.
Ensure that only insulin and/or metformin are prescribed to manage blood glucose levels in women diagnosed with diabetes during pregnancy.

Optimising individualised diabetes management

Advise that during pregnancy glucose levels are important and they will need to monitor their blood glucose more often.
Offer a range of blood glucose monitoring methods and discuss use of diabetes technologies, specifically whether CGM and/or an insulin pump may offer benefits for the individual.
Explain to women with diabetes in pregnancy that they should aim for:
- fasting glucose level <5.5 mmol/L
- one-hour postprandial glucose level <8 mmol/L, and
- two-hour postprandial glucose level <7 mmol/L.
Suggest to women diagnosed with T1DM or T2DM in pregnancy who are using CGM that they should aim to spend at least 70% time in pregnancy range (3.5–7.8 mmol/L).
Explain that HbA1c may be monitored regularly during pregnancy.
Explain that routine antenatal care for women with diabetes in pregnancy involves regular monitoring, for example blood pressure, retinal screening, foot screening.
Address issues with particular significance to pregnancy including reduced wellbeing and mental health.

Diet, nutrition and lifestyle advice

Offer lifestyle advice, for example, on stopping smoking, vaping, alcohol and drug use, and healthy eating, weight management and exercise, in line with all pregnancies. Explain about how to access support from a registered dietitian.
Offer dietary advice individually or in group settings depending on the needs of the woman.
Offer advice on weight management at all opportunities.
Be aware of increased risks of disordered eating. Sensitively enquire if the woman has a current or past history of an eating disorder and be aware of potential barriers to disclosure.
Review individual physical activity levels and encourage women to achieve at least 150 minutes of moderate physical activity per week during pregnancy.
Highlight the importance of wellbeing and offer psychological support through perinatal or diabetes services, depending on locality.
Provide access to online education and information on diet, exercise, mental health and wellbeing.

Retinal screening

Explain to women who are diagnosed with T1DM or T2DM during pregnancy that they will be offered retinal screening at least three times during pregnancy:
- during the first trimester, as soon as possible after confirmation of pregnancy
- during the second trimester at approximately 24 weeks gestation
- during the third trimester at approximately 36 weeks gestation.
Explain to women with GDM that they are not routinely invited for retinal screening but that they may be reviewed by local retinal screening service if they have a high HbA1c level measured at the booking appointment or in early pregnancy.
Explain what screening involves and what treatment to expect if retinopathy is found.

Managing hypoglycaemia

Revisit recognition and management of hypoglycaemia regularly during pregnancy.
Ensure that the woman has the ability and equipment to test for hypoglycaemia and understands how to treat it appropriately.
Ensure the availability of glucagon and education regarding administration.
Ensure that the woman knows to contact the multidisciplinary team in case of severe hypoglycaemia (requiring third-party intervention) or if episodes are increasing in frequency.

Driving

Signpost the guidance from the DVLA for people with diabetes. Ensure that women who use insulin for over 3 months inform the DVLA.

All women with diabetes during pregnancy

Antenatal care and discussing pregnancy risks

Discuss the local services providing diabetes and antenatal care, explaining the need for more frequent appointments during pregnancy, including additional scans. Explain who will be involved and who to contact for support.
Using person-centred communication skills, sensitively highlight risks relating to congenital malformation, miscarriage, stillbirth and abnormal growth of the baby (small or large for gestational age). Explain the evidence supporting these risks and help the woman to weigh up and evaluate her choices without implying blame or negatively impacting her experience of pregnancy.

The role of the multidisciplinary team

Explain that different professionals will be involved in care for the woman before, during and after her pregnancy.
Explain that care will be provided by a community midwifery team and a specialist multidisciplinary team which, may include consultant obstetricians, consultant diabetologists, specialist and general midwives, diabetes specialist nurses, dietitians and insulin pump teams.
Explain that the community and specialist teams will review and contact the woman throughout pregnancy to monitor and support her and her baby.

Sick day rules for pregnancy

Offer advice about sick day rules and planning for periods of illness (including minor ailments) which may cause hyperglycaemia. This may include:
- appropriate use of insulin or glucose-lowering medication
- appropriate dietary alterations to maintain normal glucose levels
- how often to measure blood glucose levels and when to check for ketones (when blood glucose level is ≥10 mmol/L or during illness in women with T1DM)
- when and how to contact the diabetes team.

Planning delivery

Discuss the timing and mode of birth during antenatal appointments as early as possible in the pregnancy and confirm birth plans with the woman in the third trimester.
Discuss and make a plan for their diabetes during labour, delivery and the postnatal period, including options for pain relief and use of an insulin pump or sliding scale, as appropriate. Discuss dose changes or plans to stop insulin after delivery.
Involve women who live in island or rural locations, who may need to travel to another hospital to have their baby, in discussions on transfer planning, the locality teams and timelines.

Offer women sensitive, individualised breastfeeding support and contraception choice.