Background
Methods
Basic information | ||
Title of guideline | Diabetes in pregnancy: Management of diabetes and its complications from preconception to the postnatal period | |
Development institute | NICE | |
Publication year | Published 2008, updated 2015 | |
Guideline type | Evidence-based guideline | |
Guideline methodology | Developed in accordance with the NICE guideline development process | |
Quality assessment of evidence and grading of strength of recommendations | GRADE system | |
Guideline Currency | Literature search date | 2014.6 |
Search strategy | A comprehensive literature search was performed | |
Methodological quality of guideline | ||
AGREE II scores | Domain 1. Scope and Purpose | 100% |
Domain 2. Stakeholder Involvement | 100% | |
Domain 3. Rigor of Development | 100% | |
Domain 4. Clarity of Presentation | 100% | |
Domain 5. Applicability | 100% | |
Domain 6. Editorial Independence | 100% | |
Overall assessment | ☑Recommend ☐Recommend with modifications ☐Would not recommend | |
Recommendation extraction and assessment | ||
Health questions | What are the target ranges for blood glucose in women with gestational diabetes during pregnancy? | |
Specific recommendation | Advice pregnant women with any form of diabetes to maintain their capillary plasma glucose below the following target levels, if these are achievable without causing problematic hypoglycaemia: 1) fasting: 5.3 mmol/L(#1) and 2) 1 h after meals: 7.8 mmol/L(#2) or 3) 2 h after meals: 6.4 mmol/L.(#3) | |
Strength of recommendation | ☑Strong ☐Week | |
Supporting evidence | (#1) 1 secondary analysis of RCT data, 1 RCT, very low (#2) 1 retrospective cohort study, very low (#3) 1 secondary analysis of RCT data, very low | |
Consistency appraisal | Search strategy and selection of evidence ☐1 ☐2 ☐3 ☐4 ☐5 ☐6 ☑7 | |
Evidence and interpretation ☐1 ☐2 ☐3 ☐4 ☐5 ☐6 ☑7 | ||
Interpretation and recommendation ☐1 ☐2 ☐3 ☐4 ☐5 ☐6 ☑7 |
Results
Characteristics of included guidelines
Guidelines | Country/region | Development institute | Publication year | Type | Main content | |
---|---|---|---|---|---|---|
1 | Gestational Diabetes (2016) Evidence-Based Nutrition Practice Guideline [11] | USA | A.N.D. | 2016 | Evidence-based | The focus of this guideline is on nutrition practice during the treatment of women with GDM. Topics include: ①Referral to an RDN; ②Nutrition Assessment; ③MNT; ④Calories; ⑤Macronutrients; ⑥Vitamins and Minerals; ⑦Meal and Snack Distribution; ⑧High-Intensity Sweeteners; ⑨Alcohol; ⑩Physical Activity; ⑪Nutrition Monitoring and Evaluation |
2 | Clinical Practice Guidelines: Diabetes and Pregnancy [12] | Canada | CDA | 2013 | Evidence-based | “Diabetes and Pregnancy” is one of chapters of the full guideline--“Clinical Practice Guidelines”, which contains Pregestational Diabetes and GDM. GDM topics include: ①Screening and diagnosis; ②Management (Lifestyle, Glycemic control, Monitoring, Pharmacological therapy, Intrapartum glucose management, Intrapartum insulin management, Postpartum care, Planning future pregnancies) |
3 | Diabetes and Pregnancy: An Endocrine Society Clinical Practice Guideline [13] | USA | Endocrine Society | 2013 | Evidence-based | The Guideline addresses important clinical issues in the contemporary management of women with Pregestational Diabetes and women with GDM during and after pregnancy. GDM: ①Testing and diagnosis; ②Management of elevated blood glucose; ③Glucose monitoring and glycemic targets; ④Nutrition therapy and weight gain targets; ⑤Blood glucose-lowering pharmacological therapy during pregnancy, Labor, delivery, lactation, and postpartum care. |
4 | Global Guideline on Pregnancy and Diabetes [14] | International | IDF | 2009 | Evidence-based | The guideline is for pregnant women with known diabetes or GDM, and topics include: ①Pre-conception glycaemic control; ②Testing for GDM; ③Management during pregnancy (Monitoring glucose levels, Lifestyle management, Insulin use during pregnancy, Oral glucose-lowering agents in pregnancy); ④Management after pregnancy (Breastfeeding, Follow-up of GDM, Prevention of type 2 diabetes in women who developed GDM). |
5 | Screening, Diagnosis and Management of Gestational Diabetes in New Zealand: A clinical practice guideline [15] | New Zealand | NZGG | 2014 | Evidence-based | This guideline covers: ①Early screening of women for probable undiagnosed diabetes; ②Screening, diagnosis and management of women with GDM; ③Follow-up of women with GDM to detect type 2 diabetes after birth. |
6 | Queensland Clinical Guideline: Gestational diabetes mellitus [16] | Queensland | Department of Health | 2015 | Evidence-based | This guideline includes recommendations about: ①Risk Assessment of GDM; ②Antenatal Care (Maternal and Fetal surveillance, Psychosocial support, Self-monitoring, Medical nutrition therapy, Physical activity); ③Pharmacological therapy; ④Birthing Care; ⑤Postpartum care. |
7 | Management of diabetes: A national clinical guideline [17] | Scotland | SIGN | 2013 | Evidence-based | This guideline provides recommendations based on current evidence for best practice in the management of diabetes. “Management of diabetes in pregnancy” is one of updated chapters, which only contains a few recommendations about pre-pregnancy care, nutritional management, optimization of glycemic control, complication during pregnancy, fetal assessment, gestational diabetes, delivery, postnatal care. |
8 | Initiative on gestational diabetes mellitus: A pragmatic guide for diagnosis, management, and care [18] | International | FIGO | 2015 | Evidence-based | To address the issue of GDM, FIGO recommends the following: ①Public health focus; ②Universal testing; ③Criteria for diagnosis; ④Diagnosis of GDM; ⑤Management of GDM; ⑥Lifestyle management; ⑦Pharmacological management; ⑧Postpartum follow-up and linkage to care. |
9 | Consensus Evidence-based Guidelines for Management of Gestational Diabetes Mellitus in India [19] | India | API | 2014 | Evidence-based | The guideline presents an overview of following consensus: ①Screening for GDM; ②Diagnostic criteria for GDM; ③Blood glucose targets and monitoring; ④Oral anti-diabetic drugs; ⑤Insulin therapy; ⑥Continuous subcutaneous insulin infusion. |
10 | Standards of medical care in diabetes −2018 [20] | USA | ADA | 2018 | Evidence-based | It is a general Standards of Medical Care in Diabetes. “Management of Diabetes in Pregnancy” is a chapter of this guideline, which include following relevant recommendations: ①Preconception counseling; ②Glycemic targets in pregnancy; ③Management of GDM; ④Pregnancy and drug consideration |
11 | Diabetes in pregnancy: management from preconception to the postnatal period [21] | England | NICE, NCC-WCH | 2015 | Evidence-based | The guideline focus on Management of diabetes and its complications from preconception to the postnatal period: ①Preconception planning and care; ②Gestational diabetes; ③Antenatal care for women with diabetes; ④Intrapartum care; ⑤Postnatal care. |
12 | Gestational Diabetes Mellitus (GDM) – Diagnosis, Treatment and Follow-Up. Guideline of the DDG and DGGG [29] | Germany | DDG, DGGG | 2018 | Evidence-based | This guideline focus on: ①Screening and diagnosis; ②Treatment (First medical consultation after GDM diagnosis; Physical activity; Dietary counselling; Recommended weight gain; Blood glucose monitoring; Insulin therapy; Oral antidiabetic drugs and GLP-1 analogues); ③Obstetric care; ④Postpartum care. |
13 | Guidelines for the Management of Gestational Diabetes Mellitus [22] | Hong Kong | HKCOG | 2016 | Expert Consensus | This is an Expert Consensus focus on:①Diagnostic criteria and classification; ②Screening for hyperglycemia in pregnancy; ③Early detection of GDM and screening for pre-GDM in the first trimester; ④Management for hyperglycemia first detected in pregnancy; ⑤Postnatal management. |
14 | Diagnosis and Management of diabetes in pregnancy: A clinical practice guideline (2014) [23] | China | CMA | 2014 | Expert Consensus | This is an Expert Consensus focus on:①Diagnosis of GDM and PGDM; ②surveillance during pregnancy; ③counseling and treatment; ④Timing and mode of delivery; ⑤Postnatal management. |
Comparison and summary of recommendations
Health questions | Description | Guideline | Recommendations (example) |
---|---|---|---|
Diagnosis of GDM | |||
Risk factors | Factors that make pregnant women more likely to get GDM and should be recognized | 2 evidence-based guidelines (NICE, CDA) 2 expert consensus (HKCOG, CMA) | Assess risk of gestational diabetes using risk factors in a healthy population. At the booking appointment, determine the following risk factors for gestational diabetes: ①BMI above 30 kg/m2; ② previous macrosomia baby weighing 4.5 kg or above; ③ previous gestational diabetes; ④ family history of diabetes (first-degree relative with diabetes); ⑤ minority ethnic family origin with a high prevalence of diabetes. |
Screening | Screening method to identify women who have GDM | 9 evidence-based guidelines (NICE, NZGG, SIGN, ADA, FIGO, NGC, CA, API, IDF) 2 expert consensus (HKCOG, CMA) | Use the 2-h 75 g oral glucose tolerance test (OGTT) to test for gestational diabetes in women with risk factors. Offer women with any of the other risk factors for gestational diabetes a 75 g 2-h OGTT at 24–28 weeks. |
Diagnostic criteria | Diagnostic criteria for GDM | 7 evidence-based guidelines (SIGN, ADA, FIGO, NGC, A.N.D., DDG Queensland) 2 expert consensus (HKCOG, CMA) | GDM should be diagnosed at any time in pregnancy if one or more of the following criteria are met following a 75 g glucose load: ① fasting PG 5.1–6.9 mmol/l; ② 1-h PG ≥ 10.0 mmol/l; ③ 2-h PG 8.5–11.0 mmol/l |
Prenatal Care | |||
Health education | Inform women with GDM relevant information | 7 evidence-based guidelines (NICE, NZGG, SIGN, ADA, FIGO, IDF, A.N.D.) 1 expert consensus (CMA) | Explain that:① in some women, gestational diabetes will respond to changes in diet and exercise; ② the majority of women will need oral blood glucose-lowering agents or insulin therapy if changes in diet and exercise do not control gestational diabetes effectively; ③ if gestational diabetes is not detected and controlled, there is a small increased risk of serious adverse birth complications such as shoulder dystocia; ④ a diagnosis of gestational diabetes will lead to increased monitoring, and may lead to increased interventions, during both pregnancy and labor. |
Medical nutrition therapy | Medical nutrition therapy (MNT) recommendations for management of GDM that assist in achieving and maintaining glycemia, and reducing the risk of adverse maternal and neonatal outcomes | 11 evidence-based guidelines (NICE, NZGG, SIGN, ADA, FIGO, NGC, CDA, API, IDF, Queensland, A.N.D.) 2 expert consensus (HKCOG, CMA) | In women with GDM, the registered dietitian nutritionist (RDN) should provide adequate amounts of macronutrients to support pregnancy, based on nutrition assessment, with guidance from the Dietary Reference Intakes (DRI). |
Physical activity | Physical activity recommendations for management of GDM. | 6 evidence-based guidelines (NICE, ADA, FIGO, NGC, IDF, DDG) 2 expert consensus (HKCOG, CMA) | Advice regular exercise (such as walking for 30 min after a meal) to improve glycemic control. |
Pharmacological therapy | Pharmacological therapy for management of GDM, including insulin and oral hypoglycemic agents | 5 evidence-based guidelines (ADA, CDA, API, IDF, DDG) 1 expert consensus (CMA) | For women who are non-adherent to or who refuse insulin, glyburide or metformin may be used as alternative agents for glycemic control. |
Blood glucose monitoring | Effect blood glucose monitoring method in predicting adverse outcomes in women with GDM | 9 evidence-based guidelines (NICE, SIGN, ADA, FIGO, NGC, CDA, API, IDF, Queensland,) 2 expert consensus (HKCOG, CMA) | Self-monitoring of blood glucose is recommended for all pregnant women with diabetes, 3–4 times a day: • Fasting: once daily, following at least 8 h of overnight fasting • Postprandial: 2–3 times daily, 1 or 2 h after the onset of meals, rotating meals on different days of the week |
Target blood glucose values | Target ranges for blood glucose in women with GDM | 7 evidence-based guidelines (NICE, NZGG, ADA, FIGO, NGC, CDA, API) 2 expert consensus (HKCOG, CMA) | Targets for glucose control during pregnancy: • Fasting glucose < 5.3 mmol/L • 1-h postprandial < 7.8 mmol/L • 2-h postprandial < 6.7 mmol/L |
Ketone monitoring | Ketone monitoring and target ranges in pregnancy in women with GDM | 1 evidence-based guidelines (NICE) 1 expert consensus (CMA) | Test urgently for ketoaemia if a pregnant woman with any form of diabetes presents with hyperglyaemia or is unwell, to exclude diabetic ketoacidosis. |
HbA1c monitoring | HbA1c monitoring and target ranges in pregnancy in women with GDM | 2 evidence-based guidelines (NICE, IDF) 1 expert consensus (CMA) | Use HbA1c as an ancillary aid to self-monitoring. Aim for an HbA1c < 6.0%, or lower if safe and acceptable. |
Continuous glucose monitoring | continuous glucose monitoring recommendations during pregnancy | 3 evidence-based guidelines (NICE, NGC, API) 1 expert consensus (CMA) | Do not offer continuous glucose monitoring routinely to pregnant women with diabetes. |
Fetal monitoring | Screening for congenital malformations and monitoring fetal growth and wellbeing | 4 evidence-based guidelines (NICE, NZGG, SIGN, FIGO) 1 expert consensus (CMA) | Offer women with GDM an ultrasound scan at the time of diagnosis and at 36–37 weeks. Further ultrasound scans should be based on clinical indications. Treatment decisions should not be based solely on fetal ultrasound. |
Intrapartum Care | |||
Timing and mode of birth | Optimal timing and mode of birth in women with GDM | 4 evidence-based guidelines (NICE, NZGG, SIGN, FIGO) 1 expert consensus (CMA) | Discuss the timing and mode of birth with pregnant women with diabetes during antenatal appointments, especially during the third trimester. |
Glycemic control | Maintaining maternal blood glucose in target range during labor and birth to reduce the incidence of neonatal hypoglycemia and reduce fetal distress. | 6 evidence-based guidelines (NICE, SIGN, FIGO, NGC, CDA, API) 1 expert consensus (CMA) | Women should be closely monitored during labor and delivery, and maternal blood glucose levels should be kept between 4.0 and 7.0 mmol/L in order to minimize the risk of neonatal hypoglycemia. |
Neonatal Care | |||
Neonatal hypoglycemia | Prevention, assessment and treatment of neonatal hypoglycemia | 3 evidence-based guidelines (NICE, NZGG, SIGN) 1 expert consensus (CMA) | Measure the infant’s plasma glucose at 1–2 h of age, 4 h, and then 4-hourly, preferably before feeds, until there have been three consecutive readings > 2.6 mmol/L. |
Initial assessment | Neonatal assessment and criteria for admission to intensive or special care | 2 evidence-based guidelines (NICE, NGC) 1 expert consensus (CMA) | Carry out blood glucose testing routinely in babies of women with diabetes at 2–4 h after birth. Carry out blood tests for polycythemia, hyperbilirubinemia, hypocalcemia and hypomagnesemia for babies with clinical signs. |
Postpartum Care | |||
Blood glucose control | Including taking insulin, oral hypoglycemic agents to control blood glucose and using other medicines, as well as breastfeeding after birth | 6 evidence-based guidelines (NICE, NZGG, NGC, CDA, API, IDF) 2 expert consensus (HKCOG, CMA) | Women should be encouraged on breastfeeding. They can resume or continue to take metformin and glibenclamide immediately after birth as required, but should avoid other forms of oral hypoglycemic agents while breastfeeding. |
Information and follow-up | Education interventions after delivery | 8 evidence-based guidelines (NICE, NZGG, SIGN, ADA, FIGO, NGC, IDF, Queensland) 2 expert consensus (HKCOG, CMA) | Women diagnosed with hyperglycemia in pregnancy should be informed about the increased risk of future DM and hyperglycemia in future pregnancy and should be offered lifestyle advice including weight control, diet and exercise. |
Postnatal blood glucose testing | Accuracy and timing of postnatal blood glucose testing in women who had GDM | 8 evidence-based guidelines (NICE, NZGG, SIGN, ADA, NGC, CDA, IDF, DDG) 2 expert consensus (HKCOG, CMA) | Offer a postnatal test at 6–12 weeks to exclude DM, either OGTT or HbA1c (with or without fasting glucose). |
Diagnosis of GDM
Prenatal care
Guidelines | Recommendation |
---|---|
NICE, 2015 | ① Offer metformin to women with gestational diabetes if blood glucose targets are not met using changes in diet and exercise within 1–2 weeks; ② Offer insulin instead of metformin to women with gestational diabetes if metformin is contraindicated or unacceptable to the woman; ③ Consider glibenclamide for women with gestational diabetes: in whom blood glucose targets are not achieved with metformin but who decline insulin therapy or who cannot tolerate metformin. |
NZGG, 2014 | Where women who have gestational diabetes and poor glycaemic control (above treatment targets) in spite of dietary and lifestyle interventions, offer oral hypoglycaemics (metformin or glibenclamide) and/or insulin therapy. In deciding whether to use oral therapy or insulin, take account of the clinical assessment and advice, and the woman’s preferences and her ability to adhere to medication and self-monitoring. |
SIGN, 2013 | Metformin or glibenclamide may be considered as initial pharmacological, glucose-lowering treatment in women with gestational diabetes. |
ADA, 2018 | Insulin is the preferred medication or treating hyperglycemia in gestational diabetes mellitus as it does not cross the placenta to a measurable extent. Metformin and glyburide may be used, but both cross the placenta to the fetus, with metformin likely crossing to a greater extent than glyburide. All oral agents lack long-term safety data. |
FIGO, 2015 | ① Insulin, glyburide, and metformin are safe and effective therapies for GDM during the second and third trimesters, and may be initiated as first-line treatment after failing to achieve glucose control with lifestyle modification. Among OADs, metformin may be a better choice than glyburide; ② High resource: Insulin should be considered as the first-line treatment in women with GDM who are at high risk of failing on OAD therapy, including some of the following factors: • Diagnosis of diabetes < 20 weeks of gestation • Need for pharmacologic therapy > 30 weeks • Fasting plasma glucose levels > 110 mg/dL • 1-h postprandial glucose > 140 mg/dL • Pregnancy weight gain > 12 kg |
Endocrine Society, 2013 | ① We suggest that glyburide (glibenclamide) is a suitable alternative to insulin therapy for glycemic control in women with gestational diabetes who fail to achieve sufficient glycemic control after a 1-week trial of medical nutrition therapy and exercise except for those women with a diagnosis of gestational diabetes before 25 weeks gestation and for those women with fasting plasma glucose levels > 110 mg/dl (6.1 mmol/l), in which case insulin therapy is preferred; ② We suggest that metformin therapy be used for glycemic control only for those women with gestational diabetes who do not have satisfactory glycemic control despite medical nutrition therapy and who refuse or cannot use insulin or glyburide and are not in the first trimester. |
CDA, 2013 | ① If women with GDM do not achieve glycemic targets within 2 weeks from nutritional therapy alone, insulin therapy should be initiated; ② For women who are nonadherent to or who refuse insulin, glyburide or metformin may be used as alternative agents for glycemic control. Use of oral agents in pregnancy is off-label and should be discussed with the patient. |
API, 2014 | The use of OADs is currently not recommended for glycaemic management during pregnancy. |
IDF, 2009 | Insulin has been, and is likely to remain, the treatment of choice but there is now adequate evidence to consider the use of metformin and glibenclamide (glyburide) as treatment options for women who have been informed of the possible risks. Combination therapy has not been specifically studied. |
Queensland, 2015 | ① Metformin when compared to Insulin is effective at lowering blood glucose and is safe for pregnant women and their fetuses; ②I nsulin is safe to use in pregnancy. |
HKCOG, 2016 | ① Offer metformin if blood glucose targets are not met after diet and exercise therapy within 1–2 weeks; ② Offer addition of insulin to diet therapy, exercise and metformin if blood glucose targets are not met. ③ Consider glibenclamide for women in whom blood glucose targets are not achieved with metformin but who decline insulin therapy or who cannot tolerate metformin. |
CMA, 2014 | Insulin should be considered as the first-line treatment in women with GDM, and OADs is currently not recommended for glycaemic management during pregnancy. |
DDG, 2018 | ① The indication for insulin should first be considered within 1–2 weeks after the start of basic therapy (diet, exercise); ② For pregnant women with GDM and suspected severe insulin resistance and when individually indicated, use of metformin can be considered following explanation of the off-label use. |
Intrapartum care
Neonatal care
Postpartum care
Assessment of consistency
Guidelines | N | Mean (SD) | ||
---|---|---|---|---|
C1* | C2* | C3* | ||
NICE | 74 | 6.93 (0.34) | 6.96 (0.26) | 6.96 (0.26) |
NZGG | 38 | 6.55 (0.76) | 6.39 (0.82) | 6.53 (0.65) |
SIGN | 18 | 5.78 (1.11) | 6.00 (0.91) | 4.67 (0.59) |
ADA | 17 | 1.00 (0.00) | 2.65 (1.17) | 3.18 (1.24) |
FIGO | 40 | 1.20 (0.72) | 1.83 (1.65) | 3.45 (2.33) |
Endocrine Society | 25 | 5.04 (1.72) | 6.68 (1.25) | 5.88 (1.81) |
CDA | 17 | 3.53 (2.43) | 4.18 (2.40) | 3.88 (1.69) |
API | 22 | 5.45 (2.22) | 5.45 (2.22) | 5.04 (2.38) |
IDF | 13 | 1.00 (0.00) | 3.38 (2.29) | 2.77 (1.24) |
Queensland | 8 | 1.75 (0.71) | 3.88 (1.36) | 3.13 (1.25) |
HKCOG | 13 | 1.00 (0.00) | 1.23 (0.60) | 1.15 (0.55) |
A.N.D. | 15 | 6.00 (0.00) | 5.67 (0.49) | 5.93 (0.26) |
DDG | 21 | 1.05 (0.22) | 1.43 (0.75) | 2.24 (1.30) |
CMA | 40 | 1.00 (0.00) | 1.30 (0.72) | 1.15 (0.48) |
Total | 361 | 4.00 (2.74) | 4.43 (2.59) | 4.49 (2.42) |