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NHS Royal Cornwall Hospitals NHS Trust
Diabetes Mellitus (pre-existing) in Pregnancy Clinical Guideline V3.0 March 2026
1. Aim/Purpose of this Guideline
1.1. To provide guidance to Midwives, Obstetricians, and the Joint Obstetric/Diabetes Team on the management of a pregnant woman with Type 1 and Type 2 Diabetes Mellitus (DM).
1.2. This guideline makes recommendations for women and people who are pregnant. For simplicity of language the guideline uses the term women throughout, but this should be taken to also include people who do not identify as women, but who are pregnant, in labour and in the postnatal period. When discussing with a person who does not identify as a woman, please ask them their preferred pronouns and then ensure this is clearly documented in their notes to inform all health care professionals.
1.3. This version supersedes any previous versions of this document.
Data Protection Act 2018 (UK General Data Protection Regulation – GDPR) Legislation.
The Trust has a duty under the Data Protection Act 2018 and UK General Data Protection Regulations 2016/679 to ensure that there is a valid legal basis to process personal and sensitive data. The legal basis for processing must be identified and documented before the processing begins. In many cases we may need consent; this must be explicit, informed, and documented. We cannot rely on opt out, it must be opt in.
Data Protection Act 2018 and UK General Data Protection Regulations 2016/679 is applicable to all staff; this includes those working as contractors and providers of services.
For more information about your obligations under the Data Protection Act 2018 and UK General Data Protection Regulations 2016/679 please see the Information Use Framework Policy or contact the Information Governance Team.
Royal Cornwall Hospital Trust rch-tr.infogov@nhs.net
2. The Guidance
2.1. The Multidisciplinary Team
2.1.1. All women with Diabetes (either Type 1 or Type 2) should book with their own Community Midwife who will continue to see the woman in the normal way throughout pregnancy.
2.1.2. In addition to this they will also have contact with the Diabetes Specialist Midwife and Diabetes Specialist Nurse and will be seen in the Joint Diabetic Antenatal Clinic (ANC) which is run by the Diabetes Consultant/Endocrinologist and the designated Obstetrician. The multidisciplinary team also includes the services of a Dietician.
2.1.3. All diabetic women should be referred without delay, by their midwife to the Joint Diabetic ANC by ringing the Diabetes Specialist Midwife. This clinic is held on a Wednesday morning at the Diabetes and Endocrine Centre on site.
Diabetes Mellitus (pre-existing) in Pregnancy Clinical Guideline V3.0
| Appointment | Care for Women with Diabetes during Pregnancy |
|---|---|
| First appointment (ideally by 10 weeks) | Information, advice, and support given in relation to optimising glycaemic control. Information and advice given about how diabetes will affect the pregnancy, birth, and early parenting.\nThe extent of diabetes-related complications including renal function* will be established and medications will be reviewed and changed if needed.\nRetinal screening will be arranged (if has not recently been done)**.\nWomen will be advised about the schedule of ultrasound scans The next scan should be booked at each scan appointment. |
| Approx 16 weeks | Retinal assessment** |
| 20 weeks | Detailed scan which includes four-chamber view of the fetal heart and outflow tracts. |
| 24 weeks | Ultrasound scan to monitor fetal growth and amniotic fluid volume (LV). |
| 28 weeks | Ultrasound scan to monitor fetal growth and amniotic fluid volume (LV).\nRetinal assessment** |
| 32 weeks | Ultrasound scan to monitor fetal growth and LV. |
| 36 weeks | Ultrasound scan to monitor fetal growth and LV Information and advice given about: • Timing, mode, and management of birth. Induction of labour information sheets given to women to take away and read. • Changes to blood glucose lowering therapy during and after birth. • Care of the baby after birth. • Initiation of breastfeeding and the effect of breastfeeding on glycaemic control. • Contraception and follow-up. |
| 37+0 weeks to 38+6 weeks | Offer induction of labour / caesarean section. If patient chooses to await spontaneous labour, then advised to monitor Fetal movements (FM) on a daily basis and to report any decrease. |
| 39 weeks | Advise induction of labour / caesarean section. If declined, review by senior obstetrician for individualised care plan. |
| *If serum creatinine is abnormal or if urine protein creatinine ratio (UPCR) exceeds 30mg/mmol, referral to a nephrologist should be considered. Thromboprophylaxis should be considered for women with significant proteinuria.\n **If significant retinopathy found then monthly retinal assessments will be organised ± /-referral to ophthalmology. | |
2.2. Timetable of Ante Natal Appointments
The following outlines the care that all women will receive in the Joint Diabetic ANC.
2.2.1. Timetable of antenatal appointments and additional information regarding diabetes in pregnancy care is included in the Diabetes is Pregnancy supplementary or the booklets added to green handheld notes.
In addition to this they will require their normal antenatal care by their community midwife.
Women will be given appointments for the Joint Diabetic antenatal clinic at a frequency that will be determined by their diabetic control and their individual needs.
2.2.2. Women with type 1 DM will be offered the use of hybrid closed loop therapy (HCL) for the duration of their pregnancy. They will need to maintain a supply of insulin pens, needles, bloods glucose meter and test strips in the event of technology failure or illness. Those with Type 2 DM on multiple daily injections will be offered a continuous glucose sensor for the duration of their pregnancy (CGM). Women with Type 2 DM Women managing on diet/exercise alone or treated with oral therapy, or single dose intermediate or long-acting insulin should test fasting and 1 hour after meals.
2.2.3. Advise pregnant women with any form of diabetes to maintain CBG below the following targets:
- Fasting and pre- meals <5.3 mmol.
- Post prandial target – 1 hour of - <7.8 mmol or 2 hour of <6.4 mmol.
2.2.4. Women with Type 1 DM are offered blood ketone testing strips and advised to test for ketonaemia and to seek urgent medical advice if they become hyperglycaemic or unwell. They will all be advised of the risks of hypoglycaemia and the potential for unawareness of this in pregnancy. All diabetic women with Type 1 DM are given glucagon and instructed on how to use it, along with information on sick day rules.
2.2.5. If the woman is planning to breastfeed antenatal expressing will be recommended from 36 weeks' gestation.
2.2.6. The care of women with Type 1 or Type 2 Diabetes and retinopathy which requires treatment during pregnancy and/or renal impairment (CKD 2 and PCR>30 OR CKD 3 or more) should be planned with the regional maternal medicine centre in Bristol. This may be by ongoing Multi-disciplinary Team discussions throughout the pregnancy in collaboration with RCHT Maternal medicine consultant at the Southwest Maternal Medicine network meeting.
2.2.7. All women with Type 1 and 2 DM should have an HbA1c taken in the 1st trimester of pregnancy and repeated in the 3rd trimester, ideally this should take place when attending clinic at the 28/40 appointment.
2.3. Women with Type 1 or 2 DM requiring steroids
2.3.8. TYPE 1 DM
2.3.8.1. Women with diabetes who are at risk of pre-term delivery should receive Dexamethasone or Betamethasone (as per Preterm Birth, Optimisation and Delivery Clinical Guideline). If steroids are required, women with Type 1 DM should be considered for admission to Wheal Rose. VRIII (variable rate intravenous insulin infusion) may be required to avoid rapid deterioration in CBG levels. See VRIII policy for use in pregnancy and labour in Appendix 5.
2.3.8.2. With a planned admission an individual plan will be made by the endocrinologist or diabetes team. Should this not be possible then all doses of insulin should be increased by 20%. Women who have a continuous subcutaneous insulin infusion (CSII) or hybrid closed loop therapy (HCL) should aim to continue to use with additional insulin adjustments. Follow Insulin Pump Therapy (Continuous Subcutaneous Insulin Infusion (CSII)) for Adults during Admission Clinical Guideline.
2.3.8.3. With an unplanned admission, most women are able to administer extra doses of rapid acting insulin according to CBG levels therefore liaise with the woman when deciding appropriate action to an elevated CBG reading.
In the absence of CGM/Libre, monitor capillary blood glucose (CBG) levels every hour if ≥ 12mmol/L then measure again after one hour. If still ≥ 12mmol, check blood ketone levels. If blood ketone levels ≥ 0.6 but < 1.5mmol/L consider commencing VRII or a bolus of rapid acting insulin (after discussion with the woman).
2.3.8.4. If >12 mmol at any point and blood ketone levels ≥1.5 mmol/l commence Variable Rate Intravenous Insulin Infusion (VRIII) as there is an increased risk of diabetic ketoacidosis.
2.3.9. TYPE 2 DM
2.3.9.1. Women with Type 2 DM regardless of treatment can be managed as an outpatient, unless there are concerns from the diabetes team regarding pre-steroid diabetes control. If managed by diet and exercise and/or Metformin or insulin women should be advised to check CBG levels before and 1 hour after each meal and before bed.
2.3.9.2. If two consecutive readings are 12 mmol/l, 1 hour apart regardless of treatment they should be advised to contact Maternity and will be advised admission for management of
CBG levels.
2.3.9.3. All women should continue increased monitoring for a minimum 12 hours after the last dose of steroids.
2.3.10. Cautionary Notes
2.3.10.1. All diabetic women however treated should expect a rise in CBG levels. The rise may be apparent immediately or take several hours depending on the individual response. Rarely, no, or minimal effect is seen.
2.3.10.2. Women with Type 1 DM are particularly at risk of developing Diabetic Ketoacidosis (DKA).
2.3.10.3. Any type of diabetes, however treated where there is evidence of hyperglycaemia (as documented above) should be admitted for assessment.
2.3.10.4. Where possible seek advice from the diabetes team with the aim of avoiding VRIII.
2.3.10.5. If it is not possible to contact a member of the diabetes team and there is any doubt regarding blood glucose levels, then VRIII should be considered.
2.3.10.6. The impairment in glycaemic control associated with steroid use is likely to offset any benefits obtained for women having a planned caesarean birth between 37-39 weeks. A detailed discussion with the woman will occur detailing risks and benefits. This discussion will be documented by a senior obstetrician in the notes.
2.4. Inpatient Management of insulin treated diabetic women
2.4.1. Ensure Registered CHA2976: Registered Nurse Assessment for Patient Self-Administration of Insulin - GLP1 via a Pen Device (ideally completed by Diabetes Midwives) is filed in notes.
2.4.2. Individual sharps container should be given.
2.4.3. Insulin should be prescribed on EPMA and marked for self-administration ensuring standard hypoglycaemia and hyperglycaemia management is added.
2.4.4. Women can monitor their own CBG levels/use CGM or Libre sensor. and document on Diabetes Monitoring Chart (appendix 9). At least one CBG per day must be performed on the ward-based meter.
Unless:
Unwell, any episode of hypoglycaemia or hyperglycaemia (CBG<4 or ≥12mmol/l) then confirm reading on ward-based meter and take appropriate action.
Or
Are being managed with VRIII.
2.5. Diabetic Ketoacidosis (DKA)
2.5.1. Ketoacidosis should be excluded as a matter of urgency.
2.5.2. Women who are suspected or confirmed as having diabetic ketoacidosis should receive level 2 care.
2.5.3. Inform the endocrinologist and the Obstetric Consultant/ Obstetric Registrar on call of admission without delay. In this situation, it is appropriate to attempt to contact the Endocrinologist out of hours.
2.5.4. Senior Obstetrician to review the patient in person and arrange assessment of fetal wellbeing. The main risk is preterm labour and Intra Uterine Death (IUD). Discuss the obstetric management with the designated Obstetrician or call Consultant Obstetrician. If steroids are appropriate, then discuss the implications of this with the Endocrinologist.
2.6. Intrapartum care
See RCHT: Management of Type 1 and Type 2 diabetes in established labour. (Appendix 4).
See also RCHT: Management of Type 1 and Type 2 diabetes for elective caesarean section (Appendix 3).
See also RCHT: Women using CSII/HCL admitted in labour or for elective caesarean section. (Appendix 7).
2.7. Post Natal Care
See RCHT: Management of Type 1 and Type 2 diabetes post-delivery. (Appendix 6).
2.8. Breastfeeding
2.8.1. Whilst establishing breastfeeding, it is important to avoid hypoglycaemic episodes. Women with Type 1 DM should aim to keep glucose levels between 6-10 mmol/l in the initial post-natal period.
2.8.2. Post-delivery, women should be prescribed their pre pregnancy insulin doses.
2.8.3. If breastfeeding, may require a reduction in insulin dose by a further 25%.
2.8.4. Carbohydrate requirements of the mother may increase.
2.8.5. The mother should be encouraged to have a carbohydrate snack or meal before or during each episode of breastfeeding and before bedtime.
2.8.6. If hypoglycaemia occurs treat the hypo (as per management of RCHT hypoglycaemia guideline), reduce the dose of insulin and ensure snacks are being taken.
2.8.7. If breastfeeding is suddenly stopped, the dose of insulin will need to be increased.
2.9. Documentation
At first contact with the Diabetes Specialist Midwife the RCHT Joint Diabetes Antenatal Clinic Record of Pregnancy care booklet will be commenced.
3. Monitoring compliance and effectiveness
| Information Category | Detail of process and methodology for monitoring compliance |
|---|---|
| Element to be monitored | The audit will take into account record keeping by obstetric, anaesthetic and paediatric doctors, midwives, nurse, students and maternity support workers. The results will be inputted onto an excel spread sheet. The audit will be registered with the Trust’s audit department. |
| Lead | Diabetes Specialist Midwife. |
| Tool | Did the woman have initial contact with the diabetes specialist midwife? Was the woman seen in the Joint Obstetric/Endocrinologist Diabetic ANC? If required was a referral made to a Dietician and/or a Diabetes Specialist Nurse? |
| Frequency | 10 sets of all health records of women who have delivered with a diagnosis of pre-existing diabetes will be audited over the lifetime of the guideline. |
| Reporting arrangements | A formal report of the results will be received annually at the maternity Patient Safety Meeting and clinical audit forum, as per the audit plan. During the process of the audit if compliance is below 75% or other deficiencies identified, this will be highlighted at the next maternity Patient Safety Meeting and clinical audit forum and an action plan agreed. |
| Acting on recommendations and Lead(s) | Any deficiencies identified on the annual report will be discussed at the maternity Patient Safety Meeting and clinical audit forum and an action plan developed. Action leads will be identified and a time frame for the action to be completed by. The action plan will be monitored by the maternity Patient Safety Meeting and clinical audit forum until all actions complete. |
| Information Category | Detail of process and methodology for monitoring compliance |
|---|---|
| Change in practice and lessons to be shared | Required changes to practice will be identified and actioned within a time frame agreed on the action plan. A lead member of the forum will be identified to take each change forward where appropriate. The results of the audits will be distributed to all staff through the Patient Safety newsletter/audit forum as per the action plan. |
4. Equality and Diversity
4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the Equality Diversity And Inclusion Policy or the Equality and Diversity website.
4.2. Equality Impact Assessment
The Initial Equality Impact Assessment Screening Form is at Appendix 2.
Appendix 1. Governance Information
| Information Category | Detailed Information |
|---|---|
| Document Title: | Diabetes Mellitus (pre-existing) in Pregnancy Clinical Guideline V3.0. |
| This document replaces (exact title of previous version): | Diabetes Mellitus (pre-existing) in Pregnancy Clinical Guideline V2.3. |
| Date Issued/Approved: | March 2026 |
| Date Valid From: | March 2026 |
| Date Valid To: | March 2029 |
| Directorate/Department responsible (author/owner): | Helen Probert , Diabetes Specialist Midwife. Alison Parker, Diabetes Specialist Nurse. |
| Contact details: | 01872 253199. |
| Brief summary of contents: | To provide guidance to Midwives, Obstetricians and the Joint Obstetric/Diabetology Team on the management of a pregnant woman with Type 1 or Type 2 Diabetes. |
| Suggested Keywords: | Diabetes, pregnancy, Type 1 and Type 2, Metformin, breast, feeding. |
| Target Audience: | RCHT: Yes CFT: No CIOS ICB: No |
| Executive Director responsible for Policy: | Chief Medical Officer |
| Approval route for consultation and ratification: | Maternity Guidelines Group |
| Manager confirming approval processes: | Caroline Chappell |
| Name of Governance Lead confirming consultation and ratification: | Michael Cross |
| Links to key external standards: | None |
| Related Documents: | • NICE (2021) Diabetes in pregnancy: Management from preconception to the postnatal period. |
| Information Category | Detailed Information |
|---|---|
| • JBDS-IP (May 2017) Management of glycaemic control in pregnant women with diabetes on obstetric wards and delivery units. • JBDS (Feb 2022) Inpatient care managing diabetes and hyperglycaemia during labour and birth. • JBDS (Feb 2023) Managing Diabetes hyperglycaemia during labour and birth. | |
| Training Need Identified? | No |
| Publication Location (refer to Policy on Policies – Approvals and Ratification): | Internet and Intranet |
| Document Library Folder/Sub Folder: | Clinical / Midwifery and Obstetrics |
Version Control Table
| Date | Version Number | Summary of Changes | Changes Made by |
|---|---|---|---|
| February 2018. | V1.0. | Amalgamation of Clinical guideline for the management of Type 1 and Type 2 diabetes in pregnancy V1.3 and Gestational Diabetes Mellitus and subsequent management of confirmed gestational diabetes mellitus (GDM) and selective screening-clinical guideline V1.5. Management of glycosuria after 34 weeks gestation. Management of diabetes following steroid administration. | Helen Probert, Diabetes Specialist Midwife. |
| February 2020. | V1.1. | New information regarding BMI calculation. | Helen Probert, Diabetes Specialist Midwife. |
| October 2022. | V2.0. | Separation of Management of Diabetes Mellitus (DM) in pregnancy clinical guideline to Diabetes Mellitus (pre-existing) clinical guideline V1.2 and Gestational Diabetes Mellitus (GDM) Clinical Guideline V1.0. | Helen Probert, Diabetes Specialist Midwife. |
| Date | Version Number | Summary of Changes | Changes Made by |
|---|---|---|---|
| January 2023. | V2.1. | Addition of Ketoacidosis table in appendix 7. | Tamara Thirlby, Patient Safety Midwife. |
| December 2023. | V2.2. | Addition of 2.2.2, 2.2.6 and 2.2.7. | Helen Probert, Diabetes Specialist Midwife. |
| June 2025. | V2.3. | Addition of hybrid closed loop, VRIII for use during pregnancy and labour, maternity glucose and ketone monitoring chart. | Alison Parker, Diabetes Specialist Nurse. |
| March 2026 | V3.0 | Full review – transposed to latest Trust template. | Helen Probert, Diabetes Specialist Midwife. Alison Parker, Diabetes Specialist Nurse. |
All or part of this document can be released under the Freedom of Information Act 2000.
All Policies, Strategies and Operating Procedures, including Business Plans, are to be kept for the lifetime of the organisation plus six years.
This document is only valid on the day of printing.
Controlled Document.
This document has been created following the Royal Cornwall Hospitals NHS Trust The Policy on Policies (Development and Management of Knowledge Procedural and Web Documents Policy). It should not be altered in any way without the express permission of the author or their Line Manager.
Appendix 2. Quality and Equality Impact Assessment (QEIA) Guidance Form
The QEIA process allows RCHT to monitor the impact of changes to its policies and services, ensuring that nobody is unduly disadvantaged.
For guidance, please contact the Equality, Diversity and Inclusion Team at rcht.inclusion@nhs.net
1. About the Policy / Service Change:
| Information Category | Detailed Information |
|---|---|
| Individual completing QEIA: (Name, Role, Email) | Helen Probert, Diabetes Specialist Midwife. 01872 253199 |
| Service Area: (Department, Care Group) | Obstetrics and Gynaecology |
| Name of document: | Diabetes Mellitus (pre-existing) in Pregnancy Clinical Guideline V3.0. |
| Type of document: (Policy, Strategy, Service Change) | Clinical Guideline |
| Policy / Service Change Objective(s): (What should it achieve, and for whom?) | To ensure pregnant woman with diabetes receive current evidence-based care. |
| Does this Policy / Service Change: (Select all that apply) | Eliminate Discrimination? Yes Advance Equal Opportunity? Yes Foster Good Relations? Yes |
| Which Groups are impacted by this policy? (Select all that apply) | Yes – Workforce. Yes – Patients. No – Visitors. No – System Partners. No – External Organisations. No – Contractors. |
2. About the impact:
For each characteristic, please indicate whether you think the impact will be positive, negative or unknown, and provide a brief explanation:
Note: Stating 'This document has no impact on this group' for all characteristics will result in the document not being approved.
Characteristic Impact Explanation
Age Positive
Sex Positive
Gender Reassignment Positive
Race, Ethnicity, Culture Positive
Disability or Long-term Health Condition Positive
Religion or Belief Positive
Marriage and Civil Partnership Positive
Pregnancy and Maternity Positive
Sexual Orientation Positive
Armed Forces Community Positive
Low Income Households Positive
A consultation must take place with appropriate groups to clarify unknown impacts and recommend mitigation of negative impacts.
3. About the Consultation
| Information Category | Detailed Information |
|---|---|
| Which bodies have been consulted? (Not all will be required) | Yes Service Employees.No Employee Network Groups.No Union Representatives.No EDI Team.No Patient / Service Users.No Patient Advisory Group.Yes Patient Representatives.No Local / National Charities.No System Partners.No External Organisations.No Other. |
| Information Category | Detailed Information |
|---|---|
| Please list the individuals / groups who have been consulted: (Role, Organisation, Email. Avoid using individual names) | Maternity Guidelines Group |
| Consultation Outcomes: (Positive feedback, new negative impacts, recommendations) | Guideline agreed |
| What action will you now take? | Continue without Amendments |
| Provide Details: | Agreed |
| Do any negative impacts remain? | No |
| Explain rationale for proceeding with negative impacts: | None |
I am confident that this QEIA is an honest reflection of my efforts to comply with the Public Sector Equality Duty, and that all appropriate, necessary actions have been taken to mitigate any negative impacts as far as practicable.
Name: Helen Probert Role: Diabetes Specialist Midwife.
Appendix 3. Management of Type 1 and Type 2 Diabetes for Elective Caesarean Section
Appendix 4. Management of Type 1 and Type 2 diabetes in Established Labour
Appendix 5. Diabetic Monitoring and Variable Rate Intravenous Insulin Infusion Chart (VRIII)
Diabetic Monitoring and Variable Rate in Pregnancy
Appendix 6. Management of Type 1 and Type 2 Diabetes Post Delivery
Appendix 7. Women Using CSII/HCL Admitted in Labour or For Elective Caesarean Section
Diabetes Mellitus (pre-existing) in Pregnancy Clinical Guideline V3.0
Appendix 8. Guidance for Capillary Blood Ketone Testing in Pregnant Women at Risk of Diabetic Ketoacidosis (DKA)
When to measure blood ketone levels:
- All women with Type 1 DM who are admitted Unwell/Vomiting. (DKA less likely but not impossible with Type 2 DM, consider testing if 2+ or more urinary ketones).
- Blood ketone monitoring is NOT for the routine use of women with hyperemesis. Interpretation of Blood Ketones (B-OHB).
| \beta OHB mmol/L | Action |
|---|---|
| Below 0.6mmol/l | • Normal ketone levels – continue to test blood glucose levels as normal. • Treat for elevated glucose appropriately (discuss with the woman as she is likely to know how to manage this herself or if possible, refer to diabetes team). |
| 0.6 – 1.5mmol/l | • Doctor to review. • Ensure adequate fluid intake (if tolerating oral fluids advise at least 200mls water/sugar free fluids every hour). • Consider giving additional rapid acting insulin. • Retest blood glucose and ketones in 1 hour (blood ketones can rise by 1-2mmol/L per hour. |
| Over 1.5mmol/l | Risk of DKA Contact a doctor immediately. • Assess woman for signs of DKA urgently, check U and E's, bicarbonate and pH on venous blood gas analyser. • If confirmed DKA (Bicarbonate < 15.0mmol/L and or pH <7.3) follow Clinical guideline for the management of Diabetic Ketoacidosis (DKA) in adult. Admit for level 2 critical care. • If the pH and bicarbonate are normal the woman is likely to still require additional insulin and fluid replacement via VRIII (or additional subcutaneous doses on advice of diabetes team if possible). • Recheck blood glucose and ketone levels hourly (blood ketones level should fall by 0.5mmol/L per hour). |
*In pregnancy DKA can occur with a normal blood glucose level.
Appendix 9. Blood Glucose and Ketone Monitoring for Pregnant people with Diabetes CHA4998: Appendix 9 Blood Glucose and Ketone Monitoring for Pregnant people with diabetes