DIABETES AND THE USE OF INSULIN IN PREGNANCY

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(Date of issue: September 2017, Version: 1)

This is a UKTIS monograph for use by health care professionals. For case-specific advice please contact UKTIS on 0344 892 0909. To report an exposure please download and complete a pregnancy reporting form. Please encourage all women to complete an online reporting form.

A corresponding patient information leaflet on Treatment of diabetes in pregnancy is available at www.medicinesinpregnancy.org.

Summary

Diabetes mellitus is a group of conditions characterised by high levels of blood glucose. Type 1 diabetes results from failure to produce insulin (a hormone produced by the pancreas to regulate carbohydrate and fat metabolism) necessitating administration of exogenous insulin which may be derived from human, porcine or recombinant sources and administered via subcutaneous injection or continuous subcutaneous infusion. In type 2 diabetes, insulin is produced but cannot be utilised by the body. Lifestyle changes (including diet and exercise) are the first-line treatment for type 2 diabetes, although oral hypoglycaemic agents and insulin may be necessary. Gestational diabetes occurs during pregnancy and usually resolves spontaneously after delivery. Treatment of gestational diabetes is the same as for type 2 diabetes.

Whereas maternal pregestational diabetes is associated with an increased risk of congenital malformations (typically CNS, cardiovascular, urogenitary, musculoskeletal and gastrointestinal), studies have not demonstrated an increased malformation rate in infants born to women who develop gestational diabetes. Both conditions are, however, associated with increased risks of large for gestational age infants and fetal macrosomia which are in turn associated with delivery complications (such as shoulder dystocia) and increased perinatal mortality. Good maternal glycaemic control during fetal organogenesis is vital to reduce teratogenicity, but should be balanced against the risk of hypoglycaemic episodes which are associated with significant maternal and fetal risks. Some studies have estimated that the risk of congenital malformations with untreated or poorly controlled pregestational diabetes is up to 10-fold higher than the background risk, while the risk for intrauterine death is five times higher, and neonatal death three times higher.

Increasing maternal hyperglycaemia is directly correlated with both maternal and fetal adverse outcomes, therefore glycaemic control during pregnancy is of particular importance. However, even with good glycaemic control, infants of diabetic mothers remain at increased risk of congenital malformation. The risks of uncontrolled or poorly controlled diabetes should ideally be discussed with the patient prior to conception, along with maternal diet and exercise regimes. Women with poorly controlled diabetes and glycosylated haemoglobin (HbA1c) above 10% should be strongly advised to improve diabetic control prior to conception in light of the associated increased risk of congenital malformations in the fetus and other adverse pregnancy outcomes. Preconception and antenatal high dose folic acid (5mg/day) is advised for all women with pregestational diabetes. Insulin does not cross the placenta and has not been associated with fetal teratogenesis. NICE guidance at the time of writing recommends that oral blood glucose lowering agents other than metformin are discontinued before pregnancy and insulin substituted. 

Management of diabetes in pregnancy is complex. Readers are advised to refer directly to NICE guidance. NICE recommend that women with pre-existing diabetes are seen by members of the joint diabetes and antenatal care team within one week of their pregnancy being confirmed. The importance of preconception education and care cannot be emphasised enough.
                     
This document is regularly reviewed and updated. Only use full UKTIS monographs downloaded directly from TOXBASE.org to be sure you are using the most up-to-date version. The summaries of these monographs are openly available on UKTIS.org.

This is a summary of the full UKTIS monograph for health care professionals and should not be used in isolation. The full UKTIS monograph and access to any hyperlinked related documents is available to health care professionals at www.toxbase.org.

If you have a patient with exposure to a drug or chemical and require assistance in making a patient-specific risk assessment, please telephone UKTIS on 0344 892 0909 to discuss the case with a teratology specialist.

If you would like to report a pregnancy to UKTIS please click here to download our pregnancy reporting form. Please encourage all women to complete an online reporting form.

Disclaimer: Every effort has been made to ensure that this monograph was accurate and up-to-date at the time of writing, however it cannot cover every eventuality and the information providers cannot be held responsible for any adverse outcomes of the measures recommended. The final decision regarding which treatment is used for an individual patient remains the clinical responsibility of the prescriber. This material may be freely reproduced for education and not for profit purposes within the UK National Health Service, however no linking to this website or reproduction by or for commercial organisations is permitted without the express written permission of this service. This document is regularly reviewed and updated. Only use UKTIS monographs downloaded directly from TOXBASE.org or UKTIS.org to ensure you are using the most up-to-date version.