Table 5.6Timetable for antenatal appointments for women with diabetes

Routine antenatal care (NICE antenatal care guideline)9Additional/different care for women with diabetes
First appointment (booking)
  • give information, with an opportunity to discuss issues and ask questions; offer verbal information supported by written information (on topics such as diet and lifestyle considerations, pregnancy care services available, maternity benefits and sufficient information to enable informed decision making about screening tests)
  • identify women who may need additional care and plan pattern of care for the pregnancy
  • check blood group and RhD status
  • offer screening for haemoglobinopathies, anaemia, red-cell alloantibodies, hepatitis B virus, HIV, rubella susceptibility and syphilis
  • offer screening for asymptomatic bacteriuria
  • offering screening for Down’s syndrome
  • offer early ultrasound scan for gestational age assessment
  • offer ultrasound screening for structural anomalies (18–20 weeks)
  • measure BMI, blood pressure and test urine for proteinuria.At the first (and possibly second) appointment, for women who choose to have screening, the following tests should be arranged:
  • blood tests (for checking blood group and RhD status and screening for haemogloinopathies, anaemia, red-cell alloantibodies, hepatitis B virus, HIV, rubella susceptibility and syphilis) ideally before 10 weeks
  • urine tests (to check for proteinuria and screen for asymptomatic bacteriuria)
  • ultrasound scan to determine gestational age using:

    crown–rump measurement if performed at 10 weeks 0 days to 13 weeks 6 days

    head circumference if crown–rump length is above 84 millimetres

  • Down’s syndrome screening using:

    nuchal translucency at 11 weeks 0 days to 13 weeks 6 days

    serum screening at 15 weeks 0 days to 20 weeks 0 days.

First appointment (joint diabetes and antenatal clinic)
  • if the woman has been attending for preconception care and advice, continue to provide information, education and advice in relation to achieving optimal glycaemic control (including dietary advice)
  • if the woman has not attended for preconception care and advice give information, education and advice for the first time, take clinical history to establish extent of diabetes-related complications (including neuropathy and vascular disease), and review medications for diabetes and its complications
  • retinal assessment and renal assessment for women with pre-existing diabetes if these have not been undertaken in preceding 12 months
  • contact with the diabetes care team every 1–2 weeks throughout pregnancy for all women with diabetes and assessment of long-term glycaemic control using HbA1c (first trimester only).
16 weeks
The next appointment should be scheduled at 16 weeks to:
  • review, discuss and record the results of all screening tests undertaken; reassess planned pattern of care for the pregnancy and identify women who need additional care
  • investigate a haemoglobin level of less than 11 g/100 ml and consider iron supplementation if indicated
  • measure blood pressure and test urine for proteinuria
  • give information, with an opportunity to discuss issues and ask questions, including discussion of the routine anomaly scan; offer verbal information supported by antenatal classes and written information.
16 weeks
Retinal assessment for women with pre-existing diabetes if diabetic retinopathy was present at booking (16–20 weeks).
Early testing of glood glucose or OGTT for women with a history of gestational diabetes and/or ongoing IGT (18–20 weeks).
18–20 weeks
At 18–20 weeks, if the woman chooses, an ultrasound scan should be performed for the detection of structural anomalies. For a woman whose placenta is found to extend across the internal cervical os at this time, another scan at 36 weeks should be offered and the results of this scan reviewed at the 36 week appointment.
20 weeks
Ultrasound scan for detecting structural anomalies and anatomical examination of the four chamber view of the fetal heart plus outflow tracts.
25 weeks
At 25 weeks of gestation, another appointment should be scheduled for nulliparous women. At this appointment:
  • measure and plot symphysis–fundal height
  • measure blood pressure and test urine for proteinuria
  • give information, with an opportunity to discuss issues and ask questions; offer verbal information supported by antenatal classes and written information.
25 weeks
No additional or different care for women with diabetes.
28 weeks
The next appointment for all pregnant women should occur at 28 weeks. At this appointment:
  • offer a second screening for anaemia and atypical red-cell alloantibodies
  • investigate a haemoglobin level of less than 10.5 g/100 ml and consider iron supplementation, if indicated
  • offer anti-D to rhesus-negative women
  • measure blood pressure and test urine for proteinuria
  • measure and plot symphysis–fundal height
  • give information, with an opportunity to discuss issues and ask questions; offer verbal information supported by antenatal classes and written information
  • screening for gestational diabetes.
28 weeks
Start ultrasound monitoring of fetal growth and amniotic fluid volume
Retinal assessment for women with pre-existing diabetes if no diabetic retinopathy was present at the first antenatal clinic visit.
Women diagnosed with gestational diabetes as a result of routine antenatal screening enter the care pathway.
31 weeks
Nulliparous women should have an appointment scheduled at 31 weeks to:
  • measure blood pressure and test urine for proteinuria
  • measure and plot symphysis–fundal height
  • give information, with an opportunity to discuss issues and ask questions; offer verbal information supported by antenatal classes and written information
  • review, discuss and record the results of screening tests undertaken at 28 weeks; reassess planned pattern of care for the pregnancy and identify women who need additional care.
32 weeks (not 31 weeks)
Ultrasound monitoring of fetal growth and amniotic fluid volume.
All routine investigations normally scheduled for 31 weeks should also be conducted at 32 weeks.
34 weeks
At 34 weeks, all pregnant women should be seen in order to:
  • offer a second dose of anti-D to rhesus-negative women
  • measure blood pressure and test urine for proteinuria
  • measure and plot symphysis–fundal height
  • give information, with an opportunity to discuss issues and ask questions; offer verbal information supported by antenatal classes and written information
  • review, discuss and record the results of screening tests undertaken at 28 weeks; reassess planned pattern of care for the pregnancy and identify women who need additional care.
34 weeks
No additional or different care for women with diabetes
36 weeks
At 36 weeks, all pregnant women should be seen again to:
  • measure blood pressure and test urine for proteinuria
  • measure and plot symphysis–fundal height
  • check position of baby
  • for women whose babies are in the breech presentation, offer external cephalic version
  • review ultrasound scan report if placenta extended over the internal cervical os at previous scan
  • give information, with an opportunity to discuss issues and ask questions; offer verbal information supported by antenatal classes and written information.
36 weeks
Ultrasound monitoring of fetal growth and amniotic fluid volume.
Offer information and advice about timing, mode and management of labour and birth, including anaesthetic review/assessment.
Plan postnatal diabetes management, breastfeeding, management of the baby after birth and information about follow-up.
38 weeks
Another appointment at 38 weeks will allow for:
  • measurement of blood pressure and urine testing for proteinuria
  • measurement and plotting of symphysis–fundal height
  • information giving, including options for management of prolonged pregnancy, with an opportunity to discuss issues and ask questions; verbal information supported by antenatal classes and written information.
38 weeks
Induction of labour, or caesarean section if indicated, otherwise await spontaneous labour.
Monitoring of fetal wellbeing if baby not yet born.
39 weeks
Monitoring of fetal wellbeing if baby not yet born.
40 weeks
For nulliparous women, an appointment at 40 weeks should be scheduled to:
  • measure blood pressure and test urine for proteinuria
  • measure and plot symphysis–fundal height
  • give information, with an opportunity to discuss issues and ask questions; offer verbal information supported by antenatal classes and written information.
40 weeks
No additional or different care for women with diabetes.
Monitoring of fetal wellbeing if baby not yet born.
41 weeks
For women who have not given birth by 41 weeks:
  • a membrane sweep should be offereda
  • induction of labour should be offereda
  • blood pressure should be measured and urine tested for proteinuria
  • symphysis–fundal height should be measured and plotted
  • information should be given, with an opportunity to discuss issues and ask questions; verbal information supported by written information.
41 weeks
No additional or different care for women with diabetes.
Monitoring of fetal wellbeing if baby not yet born.
a

The NICE clinical guideline on induction of labour is being updated and is expected to be published in June 2008.

IGT = impaired glucose tolerance; OGTT = oral glucose tolerance test.

From: 5, Antenatal care

Cover of Diabetes in Pregnancy
Diabetes in Pregnancy: Management of Diabetes and Its Complications from Preconception to the Postnatal Period.
NICE Clinical Guidelines, No. 63.
National Collaborating Centre for Women's and Children's Health (UK).
London: RCOG Press; 2008 Mar.
Copyright © 2008, National Collaborating Centre for Women’s and Children’s Health.

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