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  6. Diabetes, Steroids (Glucocorticoids) for Fetal Lung Maturation in Pregnancy (363)
Important: please update your RDS app to version 4.7.3 Details with newsletter below.

Please update your RDS app to v4.7.3

We asked you in January to update to v4.7.2.  After the deployment planned for 27th February, this new update will be needed to ensure that you are able to download RDS toolkits even when the RDS website is not available. We will wait until as many users as possible have downloaded the new version before switching off the old system for app downloads and moving entirely to the new approach.

To check your current RDS version, click on the three dots bottom right of the RDS app screen. This takes you to a “More” page where you will see the version number. 

To update to the latest release:

 On iPhones – go to the Apple store, click on your profile icon top right, scroll down to see the apps waiting to be updated and update the RDS app.

On Android phones – these can vary, but try going to the Google Play store, click on your profile icon top right, click on “Manage apps and device”, select and update the RDS app.

Right Decision Service newsletter: February 2025

Welcome to the February 2025 update from the RDS team

1.     Next release of RDS

 

A new release of RDS is planned (subject to outcomes of current testing) for week beginning 24th February. This will deliver:

 

  • Fixes to mitigate the recurring glitches with the RDS admin area and the occasional brief user interface outages which have arisen following implementation of the new distributed technology infrastructure in December 2024.

 

  • Capability to embed content from Google calendar, Google Maps, Daily Motion, Twitter feeds, Microsoft Stream into RDS pages.

 

  • Capability to include simple multiplication in RDS calculators.

 

The release will also incorporate a number of small fixes, including:

  • Exporting of form within Medicines Sick Day Guidance in polypharmacy toolkit
  • Links to redundant content appearing in search in some RDS toolkits
  • Inclusion of accordion headers alongside accordion text in search result snippets.
  • Feedback form on mobile app.
  • Internal links on mobile app version of benzo tapering tool

 

We will let you know when the date and time for the new release are confirmed.

 

2.     New RDS developments

There is now the capability to publish toolkits on the web with left hand side navigation rather than tiles on the homepage. To use this feature, turn on the “Toggle navigation panel” option at the top of the Page settings menu at toolkit homepage level – see below. Please note that publication to downloadable mobile app for this type of navigation is still under development.

The Benzodiazepine tapering tool (https://rightdecisions.scot.nhs.uk/benzotapering) is now available as part of the RDS toolkit for the national benzodiazepine prescribing guidance developed by the Scottish Government Effective Prescribing team. The tool uses this national guidance developed with a wide-ranging multidisciplinary group. This should be used in combination with professional judgement and an understanding of the needs of the individual patient.

3.     Archiving and version control and new RDS Search and Browse interface

Due to the intensive work Tactuum has had to undertake on the new technology infrastructure has pushed back the delivery dates again and some new requirements have come out of the recent user acceptance testing. It now looks likely to be an April release for the search and browse interface. The archiving and version control functionality may be released earlier. We’ll keep you posted.

4.     Statistics

At the end of January, Olivia completed the generation of the latest set of usage statistics for all RDS toolkits. If you would like a copy of the stats for your toolkit, please contact Olivia.graham@nhs.scot .

 

5.     Review of content past its review date

We have now generated reports of all RDS toolkit content that has exceeded its review date by 6 months or more. We will be in touch later this month with toolkit owners and editors to agree the plan for updating or withdrawing out of date content.

 

6.     Toolkits in development

Some important toolkits in development by the RDS team include:

  • National CVD prevention pathways – due for release end of March 2025.
  • National respiratory pathways, optimal cancer diagnostic pathways and cancer prehabilitation pathways from the Centre for Sustainable Delivery. We will shortly start work on the national cancer referral pathways, first version due for release via RDS around end of June 2025.
  • HIS Quality of Care Review toolkit – currently in final stages of quality assurance.

 

The RDS team and other information scientists in HIS have also been producing evidence summaries for the Scottish Government Realistic Medicine team, to inform development of national guidance around Procedures of Limited Clinical Value. This guidance will in due course be translated into an RDS toolkit.

 

7. Training sessions for new editors (also serve as refresher sessions for existing editors) will take place on the following dates:

  • Friday 28th February 12-1 pm
  • Tuesday 11th March 4-5 pm

 

To book a place, please contact Olivia.graham@nhs.scot, providing your name, organisation, job role, and level of experience with RDS editing (none, a little, moderate, extensive.)

 

To invite colleagues to sign up to receive this newsletter, please signpost them to the registration form  - also available in End-user and Provider sections of the RDS Learning and Support area.   If you have any questions about the content of this newsletter, please contact his.decisionsupport@nhs.scot  If you would prefer not to receive future newsletters, please email Olivia.graham@nhs.scot and ask to be removed from the circulation list.

With kind regards

 

Right Decision Service team

Healthcare Improvement Scotland

 

 

Diabetes, Steroids (Glucocorticoids) for Fetal Lung Maturation in Pregnancy (363)

Objectives

This guideline covers management of women with diabetes in pregnancy who require the use of antenatal glucocorticoids for fetal lung maturation.  It aims to improve care and ensures quicker and more accurate diagnosis for any adverse outcomes that may arise and specify the most effective treatment.

Scope

GGC Maternity staff

This guidance is written for the benefit of all staff involved in caring for pregnant women with diabetes- who have been administered with Steroids (glucocorticoids) for fetal lung maturation, this includes obstetricians, midwives and any other members of the maternity multi-disciplinary team. 

Audience

All midwives, obstetric staff and anyone else providing clinical care or guidance to women who have been administered with Steroids (glucocorticoids) for fetal lung maturation, should observe to the guidelines and ensure that local protocols and medical advice from specialist is sought.

Please report any inaccuracies or issues with this guideline using our online form

In all women with diabetes in pregnancy (gestational, type1 or type II) use of antenatal glucocorticoids will result in resistance to insulin, a need for increased insulin doses and potentially onset of ketoacidosis, unless diabetes is managed appropriately.  All women should be checking blood glucose levels regularly as per local management plans and be able to test for ketones at home.  Women on diet alone or metformin also require this monitoring and may require commencement of insulin.

Background

In all women with diabetes in pregnancy (gestational or pre-gestational) use of antenatal glucocorticoids will result in resistance to insulin, a need for increased insulin and potentially onset of ketoacidosis, unless diabetes is managed appropriately.  All women should be checking blood glucose regularly as per local management plans and be able to test for ketones at home when glucocorticoids used.  Women on diet alone or metformin also require this monitoring and may require commencement of insulin after glucocorticoids.

Women should be advised:

  1. Planned Steroids from Clinic;
  2. Planned admission;
  3. Emergency admission.

1. planned steroids from clinic with prospective increase in subcutaneous insulin

Prospective increase in insulin dose in women on insulin treatment for gestational, type1 or type2 diabetes

  • After glucocorticoids insulin dose will need to be increased
  • Medical staff may use the following algorithm to prescribe insulin depending on response on a day by day basis (i.e no more than 24hrs in advance) if the patient is on 4 times daily insulin.
  • For women using an insulin pump a similar increase in both basal and bolus doses will be planned with medical or nursing staff. Note that for women using a hybrid closed loop system the system will facilitate increased basal insulin but bolus ratios will need to be increased.

(Further adjustments in dose will be required depending on response)

Record baseline insulin dosage

Day

Betamethasone

Insulin dose (units)

1

12mg im

Doses 8-24 hours later on same day increased 10% (short acting) or 25% (long acting) over baseline

2

12 mg im

All doses increased by 40% over baseline

3

 

All doses increased by 40% over baseline

4

 

All doses increased by 20% over baseline

5

 

All doses increased by 10% over baseline

6 + 7

 

Reduce to baseline

 

For example: with betamethasone at 12 noon on day 1 & 2

 

Short acting (units)

(pre b’fast, lunch, tea)

long acting (units)

(bedtime/10pm)

Baseline

10, 10, 14

24

Day 1

10, 10, 14

30

Day 2

14, 14, 20

34

Day 3

14, 14, 20

34

Day 4

12, 12, 16

30

Day 5

12, 10, 16

26

Day 6&7

Back to baseline doses

 

2. Planned admission to hospital

Depending on local management plans this will usually involve admission at time, or 12-24 hours after, first glucocorticoids dose for monitoring of blood sugars, ketones and VRIII (Variable Rate Intravenous Insulin Infusion) as necessary.

3. Emergency admission to hospital

Post administration of Glucocorticoids, Capillary Blood Glucose monitoring should be commenced immediately, every 2hours with GGC equipment (do not use glucose readings from Freestyle Libre or continuous glucose monitoring (CGM) devices. 

Capillary Blood Glucose Targets:

Outside labour CBG target 4 - 10mmol/L
During active labour CBG target 5 - 8mmol/L

If CBG >10mmol/L OR urinary ketones >1+ OR blood ketones >0.6mmol/L consider VRIII (see VRIII chart)

VRIII (formerly Sliding Scale)

  1. Site IV cannula
  2. Using an insulin syringe, draw up 50 units of soluble insulin (Actrapid® or Humulin S®) and add 49.5ml of 0.9% sodium chloride in a 50ml luer-lock syringe. Prepared concentration is 1 unit/ml
  3. Secure a standard giving set to IV fluids (10mmol potassium chloride – 0.45% sodium chloride + 5% glucose + 0.15% potassium chloride) @100mls/hr
  4. Obtain CBG (and thereafter every hour)
  5. Commence both insulin pump with VRIII fluids at appropriate rate as below
  6. U&E’s should be obtained 4 hours post commencement of VRIII and thereafter 6-12hrs (appropriate fluids to be prescribed as per potassium levels, see fluid chart below)
  7. Women’s long-acting insulin should continue and if the women is well and remains eating, mealtime bolus of short-acting insulin should continue (unless advised otherwise) (premixed insulin should not be administered whilst on VRIII)

 

Capillary bloods

Glucose (CBG) mmol/l

Insulin Infusion Rate (units/hour)

 

Recommended initial rate

Alternative rate

<4
(see * below)

0 (if long acting insulin given)
0.5 (if long acting insulin not  given)

(only to be used by specialist medical staff)

4-7

1

 

7.1 – 9

2

 

9.1 – 11

3

 

11.1 – 14

4 (check ketones if Type1)

 

14.1 – 17

5 (check ketones if Type1)

 

17.1 – 20

6 (check ketones if Type1)

 

>20

Seek senior medical advice (check ketones

 

*CBG <4.0 mmol/L: Treat as per Acute Hypo glycaemia Guideline (switch off VRIII)

 

Fluid chart

Plasma potassium

Prescribe a VRIII IV infusion bag with:

Examples of 500ml pre-prepared infusion bags

<3.5mmol/L

20mmol potassium chloride

0.45% sodium chloride + 5% glucose + 0.3% potassium chloride

3.5 – 5mmol/L

10mmol potassium chloride

0.45% sodium chloride + 5% glucose + 0.15% potassium chloride

5 mmol/L
or women is anuric

Zero potassium

0.45% sodium chloride + 5% glucose +

 

Editorial Information

Last reviewed: 28/08/2024

Next review date: 28/08/2027

Author(s): Robbie Lindsay.

Version: 4

Approved By: Maternity Clinical Governance Group

Document Id: 363