All recommendations have been updated and reorganized to clarify management considerations for women with pregestational or gestational diabetes in the prepregnancy period, during pregnancy, and in the intrapartum and postpartum periods.
1.All women of reproductive age with type 1 or type 2 diabetes should receive advice on reliable birth control, the importance of glycemic control prior to pregnancy, the impact of BMI on pregnancy outcomes, the need for folic acid and the need to stop potentially embryopathic drugs prior to pregnancy [Grade D, Level 4 (1)]. 4.Women with type 2 diabetes who are planning a pregnancy should switch from noninsulin antihyperglycemic agents to insulin for glycemic control [Grade D, Consensus].
6.Women should be screened for chronic kidney disease prior to pregnancy (see Chronic Kidney Disease chapter, p.
9.Detemir [Grade C, Level 2 (24)] or glargine [Grade C, Level 3 (25)] may be used in women with pregestational diabetes as an alternative to NPH. 11.Women should receive adequate glucose during labour in order to meet their high-energy requirements [Grade D, Consensus]. 12.Women with pregestational diabetes should be carefully monitored postpartum as they have a high risk of hypoglycemia [Grade D, Consensus]. 15.All women should be encouraged to breastfeed since this may reduce offspring obesity, especially in the setting of maternal obesity [Grade C, Level 3 (28)]. 17.If there is a high risk of GDM based on multiple clinical factors, screening should be offered at any stage in the pregnancy [Grade D, Consensus]. 21.Receive nutrition counselling from a registered dietitian during pregnancy [Grade C, Level 3 (37)] and postpartum [Grade D, Consensus]. 22.If women with GDM do not achieve glycemic targets within 2 weeks from nutritional therapy alone, insulin therapy should be initiated [Grade D, Consensus]. 23.Insulin therapy in the form of multiple injections should be used [Grade A, Level 1 (20)]. 24.Rapid-acting bolus analogue insulin may be used over regular insulin for postprandial glucose control, although perinatal outcomes are similar [Grade B, Level 2 (38,39)]. 27.Women should receive adequate glucose during labour in order to meet their high-energy requirements [Grade D, Consensus]. 29.Women should be screened with a 75 g OGTT between 6 weeks and 6 months postpartum to detect prediabetes and diabetes [Grade D, Consensus]. NB: We use cookies to help personalise your web experience and comply with Irish healthcare law. This site contains information, news and advice for healthcare professionals.You have informed us that you are not a healthcare professional and therefore we are unable to provide you with access to this site. For decades, the diagnosis of diabetes was based on plasma glucose criteria — either the fasting plasma glucose (FPG) or the two-hour value in the 75g oral glucose tolerance test (OGTT). Since last year, the American Diabetes Association has recommended using the A1C test to diagnose diabetes, with a threshold of ?6.5 per cent. NICE recommends metformin as an option for first-line glucose-lowering therapy where blood glucose is inadequately controlled using lifestyle interventions alone. Metformin and the thiazolidinediones (TZDs such as pioglitazone) act on the liver to reduce hepatic glucose production. The glucagon-like peptide-1 (GLP-1) analogues, the inhibitors of dipeptidyl peptidase 4, (DPP-4 inhibitors) and the sulphonylureas are effective in the area of insulin secretion. There are two incretins, known as glucose-dependent insulinotropic peptide (GIP) and glucagon-like peptide-1 (GLP-1). Incretins are going to dominate the field of diabetes over the next five years, Prof O’Shea said. The active compound GLP-1 (7-36) is very quickly broken down by DPP-4 into the inactive compound GLP-1 (9-36).
Lowering A1C to below or around 7 per cent has been shown to reduce microvascular and neuropathic complications of diabetes and, if implemented soon after the diagnosis of diabetes, is associated with long-term reduction in macrovascular disease. The landmark UKPDS trial of type II diabetes observed a 16 per cent reduction in cardiovascular complications (combined fatal or nonfatal myocardial infarction [MI] and sudden death) in the intensive glycaemic control arm.
Aspirin therapy may be considered as a primary prevention strategy in those with type II diabetes who are at increased cardiovascular risk. Hypertension is a common comorbidity of diabetes, affecting the majority of patients, with prevalence depending on type of diabetes, age, obesity, and ethnicity. Patients with more severe hypertension (systolic blood pressure ?140 or diastolic blood pressure ?90mmHg) at diagnosis or follow-up should receive pharmacologic therapy in addition to lifestyle therapy.
The American Diabetes Association says that treatment should include an angiotensin converting enzyme (ACE) or an angiotensin II receptor blocker (ARB). Gastric reduction surgery, either gastric banding or procedures that involve bypassing, transposing or resecting sections of the small intestine — when part of a comprehensive team approach — can be an effective weight-loss treatment for severe obesity.
Bariatric surgery has been shown to lead to near or complete normalisation of glycaemia in between 55-95 per cent of patients with type II diabetes, depending on the surgical procedure. Patients with type II diabetes who have undergone bariatric surgery need life-long lifestyle support and medical monitoring.
Dr Velma Harkins of the Irish College of General Practitioners, the National Clinical Lead for Diabetes Prof Richard Firth and Dr John Devlin of the Department of Health published guidelines in regard to diagnosis, targets for clinical care and the interventions that are appropriate at each stage of the disease.


Metformin is contraindicated in those with renal impairment, those at risk of sudden deterioration of renal function and end-stage cardiac and hepatic failure.
DPP-4 inhibitors such as sitagliptin and vildagliptin are approved as add-on therapy to metformin. Do you agree that private hospitals should be paid via the NTPF to cut public hospital waiting lists?
Diabetic ketoacidosis is an acute metabolic and obstetric emergency that can jeopardize both mother and fetus.
Induction of labor before 40 week should be limited to those maternal or fetal complications that necessitate delivery before 40 weeks. Feel free to mail me or the webmaster Dr Lars Krag Moeller if you have suggestions or corrections that you believe could improve the manual. Women with pregestational diabetes who also have PCOS may continue metformin for ovulation induction [Grade D, Consensus]. S129) [Grade D, Level 4, for type 1 diabetes (17) ; Grade D, Consensus, for type 2 diabetes]. If the initial screening is performed before 24 weeks of gestation and is negative, rescreen between 24 and 28 weeks of gestation. Recommendations for weight gain during pregnancy should be based on pregravid BMI [Grade D, Consensus]. Use of oral agents in pregnancy is off-label and should be discussed with the patient [Grade D, Consensus].
Effectiveness of a regional prepregnancy care program in women with type 1 and type 2 diabetes: benefits beyond glycemic control.
Preconception care for diabetic women for improving maternal and fetal outcomes: a systematic review and meta-analysis.
Preconception care and the risk of congenital anomalies in the offspring of women with diabetes mellitus: a meta-analysis. Poor glycated hemoglobin control and adverse pregnancy outcomes in type 1 and type 2 diabetes mellitus: systematic review of observational studies. Glycemic control during early pregnancy and fetal malformations in women with type 1 diabetes mellitus.
Use of maternal GHb concentration to estimate the risk of congenital anomalies in the offspring of women with pre-pregnancy diabetes. Glycaemic control is associated with preeclampsia but not with pregnancy-induced hypertension in women with type 1 diabetes mellitus.
Strategies for reducing the frequency of preeclampsia in pregnancies with insulin-dependent diabetes mellitus. Effect of pregnancy on microvascular complications in the Diabetes Control and Complications Trial. Maternal exposure to angiotensin converting enzyme inhibitors in the first trimester and risk of malformations in offspring: a retrospective cohort study. Central nervous system and limb anomalies in case reports of first-trimester statin exposure. Microalbuminuria, preeclampsia, and preterm delivery in pregnancy women with type 1 diabetes: results from a nationwide Danish study. Improved pregnancy outcome in type 1 diabetic women with microalbuminuria or diabetic nephropathy: effect of intensified antihypertensive therapy? Twice daily versus four times daily insulin dose regimens for diabetes in pregnancy: randomised controlled trial. Maternal glycemic control and hypoglycemia in type 1 diabetic pregnancy: a randomized trial of insulin aspart versus human insulin in 322 pregnant women.
Glycemic control and perinatal outcomes of pregnancies complicated by type 1 diabetes: influence of continuous subcutaneous insulin and lispro insulin. A comparison of lispro and regular insulin for the management of type 1 and type 2 diabetes in pregnancy.
Maternal efficacy and safety outcomes in a randomized, controlled trial comparing insulin detemir with NPH insulin in 310 pregnant women with type 1 diabetes. Metformin therapy throughout pregnancy reduces the development of gestational diabetes in women with polycystic ovary syndrome. Breast-feeding and risk for childhood obesity: does maternal diabetes or obesity status matter? Fasting plasma glucose versus glucose challenge test: screening for gestational diabetes and cost effectiveness. Impact of increasing carbohydrate intolerance on maternal-fetal outcomes in 3637 women without gestational diabetes. Postprandial versus preprandial blood glucose monitoring in women with gestational diabetes mellitus requiring insulin therapy.
Recommendations for nutrition best practice in the management of gestational diabetes mellitus.


Maternal metabolic control and perinatal outcome in women with gestational diabetes treated with regular or lispro insulin: comparison with non-diabetic pregnant women. Comparison of an insulin analog, insulin aspart, and regular human insulin with no insulin in gestational diabetes mellitus. Prospective observational study to establish predictors of glyburide success in women with gestational diabetes mellitus.
Comparative placental transport of oral hypoglycemic agents in humans: a model of human placental drug transfer.
Comparison of glyburide and insulin for the management of gestational diabetes in a large managed care organization.
Effects of early breastfeeding on neonatal glucose levels of term infants born to women with gestational diabetes. Association of breast-feeding and early childhood overweight in children from mothers with gestational diabetes mellitus. Lactation intensity and postpartum maternal glucose tolerance and insulin resistance in women with recent GDM: the SWIFT cohort. However, self blood-glucose monitoring (SBGM) is the single most expensive aspect of diabetes care to the State.
It is no longer necessary to measure glucose to make a diagnosis of diabetes, Prof O’Shea said. Incretins, such as exenatide (Byetta) and liraglutide (Victoza) may be given in type II diabetes.
After 10 years of follow-up, the UKPDS showed that for participants originally randomised to intensive glycaemic control — compared with those randomised to conventional glycaemic control — there were long-term reductions in MI (15 per cent with sulfonylurea or insulin as initial pharmacotherapy and 33 per cent with metformin as initial pharmacotherapy). There is an argument in diabetes about whether blood pressure management, rather than glycaemic management, should be pre-eminent. Multiple drug therapy (two or more agents at maximal doses) is generally required to achieve blood-pressure targets.
In this trial, 73 per cent of surgically-treated patients achieved ‘remission’ of their diabetes, compared with 13 per cent of those treated medically. Long-acting, once-daily sulphonylureas may be useful where concordance with therapy is a suspected problem.
Begin one liter of 0.9 percent NaCl over one hour and draw arterial blood gases, complete blood count with differential, urinalysis, serum glucose, BUN, electrolytes, chemistry profile and creatinine levels STAT. Begin one liter of 0.9 percent NaCl over one hour and draw arterial blood gases, complete blood count with differential, urinalysis, serum glucose, BUN, electrolytes, chemistry profile, and creatinine levels STAT.
Women with microalbuminuria or overt nephropathy are at increased risk for development of hypertension and preeclampsia [Grade A, Level 1 (17,18)] and should be followed closely for these conditions [Grade D, Consensus]. All of these agents are used and they all confer a benefit to the A1c — and to cardiovascular and microvascular profiles. There were also reductions in all-cause mortality (13 per cent and 27 per cent respectively). In type II diabetes, hypertension usually coexists with other cardiometabolic risk factors.
The UKPDS study proved that if blood pressure could be controlled, patients did much better. This is especially the case if the diabetes or associated co-morbidities are difficult to control with lifestyle and pharmacologic therapy. Am J Med 2009) of studies of bariatric surgery involving 3,188 patients with diabetes reported that 78 per cent had remission of diabetes (normalisation of blood glucose levels in the absence of medications) and that the remission rates were sustained in studies that had follow-up exceeding two years.
The Expert Advisory Group in Diabetes in its 2007 report recognised the need for a new model of care for people with type II diabetes.
Doctors encourage this and need to steer away from it, said Prof Donal O’Shea, Consultant Endocrinologist at St Vincent’s Hospital. The DPP-IV inhibitors include Januvia (sitagliptin), Onglyza (saxagliptin) and Eucreas — a combination of vildagliptin and metformin. As is the case with microvascular complications, it may be that glycaemic control plays a greater role before macrovascular disease is well developed. Remission rates tend to be lower with procedures that only constrict the stomach, and higher with those that bypass portions of the small intestine. This integration across primary, secondary and tertiary care requires agreed clinical guidelines. However, compounds have been developed that activate the GLP-1 receptor with a view to improving insulin secretion. Additionally, there is a suggestion that intestinal bypass procedures may have glycaemic effects that are independent of their effects on weight, perhaps involving incretins.



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