Medical conditions and diabetes in pregnancy

#Background

This section aims to cover medical conditions and diabetes in pregnancy. At present only medical conditions in pregnancy is included.
Recommendations, practice points and resources and tools have been developed for diabetes in pregnancy, however publication of these is pending the official release of the new Te Whatu Ora ‘Testing for, diagnosing and managing gestational diabetes (diabetes of pregnancy) Te whakamātau, te tautohu me te whakahaere i te mate huka hapūtanga’ Clinical Practice Guideline’. Publication is expected later in 2025.

Wāhine/people with medical conditions prior to pregnancy have a higher chance of complications during their pregnancies including spontaneous preterm birth and/or provider initiated preterm birth. Provider initiated preterm birth may be recommended due to exacerbations of a medical condition or the impact it may have on pregnancy-related conditions for māmā/person and/or pēpi, such as early-onset preeclampsia or fetal growth restriction (FGR).

There are a wide variety, and degrees of severity, of medical conditions that may impact on pregnancy and the chance of preterm birth. Due to the diverse nature of medical conditions in pregnancy, Taonga Tuku Iho recommendations focus on the general principles for care. Recommendations for two of the most common conditions are made separately with diabetes in pregnancy considered in more detail below and hypertension covered in preeclampsia and other hypertensive disorders in pregnancy section of Taonga Tuku Iho.

Diabetes in pregnancy includes pre-existing diabetes (type 1, type 2 and rarer forms of diabetes) and gestational diabetes (when the diagnosis of diabetes is made during pregnancy). In Aotearoa, the rates of diabetes in pregnancy are not recorded at a national level and vary according to the data sources used.¹ There has been a large increase in rates of diabetes in pregnancy over the last few decades, reflecting change in the demographic and medical background of pregnant wāhine/people in Aotearoa, as well as screening and diagnostic thresholds. In an Auckland-wide cohort in 2009-2010, the rate of gestational diabetes was identified to be 6.2%.¹ Data from Te Toka Tumai Auckland in 2023, reports rates of all diabetes in pregnancy to be over 20%, with 17.3% having gestational diabetes and 2.5% entering pregnancy with type 2 diabetes.²

Wāhine/people with diabetes in pregnancy, especially with pre-existing disease and/or when poorly controlled, have a higher chance of preterm birth.^3-6 Rates of preterm birth have been reported to be as high as 40% for wāhine/people with type 1 diabetes and 22% for those with type 2 diabetes.⁴ This includes both spontaneous preterm birth (preterm labour and preterm prelabour rupture of membranes), as well as provider initiated preterm birth due to preeclampsia, FGR, antepartum haemorrhage and rarely for worsening organ damage (nephropathy, retinopathy, peripheral neuropathy and cardiovascular disease) for those with pre-existing diabetes. These adverse pregnancy outcomes, including the chance of preterm birth, have been shown to correlate with glycaemic control in wāhine/people with pre-existing diabetes.⁴ Hence there is a clear rationale to support appropriate screening, diagnosis and treatment of diabetes in pregnancy including to limit the impact of preterm birth on pregnancy outcomes. Provider initiated preterm birth should rarely be required or considered without additional clinical indications.

Taonga Tuku Iho focuses on aspects of diabetes in pregnancy care pertinent to preterm birth and limiting the impact of this for māmā/person and pēpi. It considers pre-existing diabetes and gestational diabetes separately. Preparation for preterm birth and the impact of corticosteroid treatment on glycaemic control and diabetes treatment is relevant to all with diabetes in pregnancy.

#Recommendations and Practice

Guideline Recommendations (pink boxes) and Good Practice (yellow boxes) are provided as recommendations of practice. Comprehensive clinical oversight of māmā/person and pēpi wellbeing is required, and this may influence how these recommendations of practice are used.

Each recommendation of practice should be considered in consultation with wāhine/people and whanāu, including clear explanations to allow informed decision-making. Wāhine/people have the right to decline a recommendation of practice. In these circumstances, healthcare providers should follow their professional responsibilities for ongoing care. ^33,54-56

Medical conditions in pregnancy

Pre-existing and gestational diabetes

Recommendations, practice points and resources and tools have been developed for diabetes in pregnancy, however publication of these is pending the official release of the new Te Whatu Ora ‘Testing for, diagnosing and managing gestational diabetes (diabetes of pregnancy) Te whakamātau, te tautohu me te whakahaere i te mate huka hapūtanga’ Clinical Practice Guideline’. Publication is expected later in 2025.

#Auditable Standards

To be developed.

#Included guidelines

For medical conditions in pregnancy the search identified 21 guidelines that met criteria for high-quality and/or were recommended for use/use with modifications by the Review Panel. ^7-27

Six related to sepsis in pregnancy,^7-12 including three international/national guidelines of which only two were assessed to be high-quality in Rigour of Development (score >60%) and Overall Assessment (score >60%) and recommended for use,^8,12 and the third was recommended for use.¹¹ Two of these have been updated since the search and the newer versions have been reviewed to inform content.^28,29 Three guidelines were specific to COVID-19 infection, all were international.^13,15,16 One met high-quality in Rigour of Development (score >60%) and Overall Assessment (score >60%) and was recommended for use,¹⁵ one met criteria for Overall Assessment (score >60%) and was recommended for use,¹⁶ and the third did not meet high-quality criteria but was recommended for use.¹³ One national guideline was specific to Sickle Cell disease¹⁴ (high-quality in Rigour of Development [score >60%] and Overall Assessment [score >60%] and recommended for use). One guideline was specific to hypothyroidism in pregnancy (high-quality in Overall Assessment [score >60%] and recommended for use);¹⁷ this was updated in 2022, and the newer version was reviewed.³⁰ Six guidelines related to obesity.^18-23 One international guideline was assessed to be high-quality in Rigour of Development (score >60%) but not Overall Assessment (score >60%).¹⁹ The remainder were recommended for use by the Review Panel.^18,20-23 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists ‘Management of Obesity in Pregnancy’ Best Practice Statement was updated in 2022, the newer version of this guide was reviewed.³¹ Three guidelines were specific to obstetric cholestasis; one of these was national/international and assessed as high-quality in Rigour of Development (score >60%) and Overall Assessment (score >60%) and recommended for use.²⁶ This guideline was updated in 2022, and the newer version³² was reviewed to inform Taonga Tuku Iho. One guideline considered medical conditions in pregnancy more broadly and was specific to criteria for referral to obstetric services in Aotearoa,²⁷ and was recommended for use by the Review Panel; this was updated in 2023, and the newer version reviewed.³³

All identified international/national guidelines relevant to medical conditions in pregnancy (excluding hypertension and diabetes which are included elsewhere) were reviewed to consider recommendations. None of the guidelines were specific to preterm birth, and only a few made specific reference to the timing of birth due to the medical condition. Only the Royal College of Obstetricians and Gynaecologists ‘Intrahepatic cholestasis of pregnancy’ guideline³² provided a recommendation for provider-initiated preterm birth without additional indications. The Society of Obstetric Medicine of Australia and New Zealand ‘Position Statement for the Investigation and Management of Sepsis in Pregnancy’ identifies that in the setting of intrauterine sepsis, birth should always be considered regardless of gestation (including before the limits of survival <23 weeks).²⁸ The Royal College of Obstetricians and Gynaecologists ‘Identification and management of maternal sepsis during and following pregnancy’ guideline includes a recommendation to expedite birth in a critically ill pregnant wahine/person if it would be beneficial to the wahine/person and/or pēpi.²⁹

There are a wide variety of other medical conditions across all organs that may impact on pregnancy and the chance of preterm birth. However, the nature of our inclusion criteria and search terms did not identify them through the systematic search for subsequent quality and impact appraisal. Since the guideline search was undertaken, the Te Whatu Ora commissioned ‘Aotearoa New Zealand Guidelines for the Prevention, Diagnosis, and Management of Acute Rheumatic Fever and Rheumatic Heart Disease’³⁴ have been updated, and for the first time include a pregnancy chapter. This guideline has been reviewed and referred to.

For diabetes in pregnancy, the ** ** search identified 17 guidelines that met criteria for high-quality and/or were recommended for use or use with modifications by the Review Panel.^35-51 Two guidelines were assessed to be high-quality in Rigour of Development (score >60%) and Overall Assessment (score >60%) and recommended for use.^35,36 Three guidelines were assessed to be high-quality in Overall Assessment (score >60%), but not in Rigour of Development (score >60).^37-39 The remaining 12 guidelines were recommended for use with or without modifications.^40-51

One guideline was national,³⁵ four guidelines were international/bi-national (Aotearoa and Australia),^36,38-40 and 12 were district-specific.^37,41-51 Four guidelines were specific to pre-existing diabetes (type 1 and type 2),^42,43,47,49 four were specific to gestational diabetes,^35,36,39,48 and the rest covered all types of diabetes in pregnancy. Since the search was undertaken the ‘Diabetes and Pregnancy: An Endocrine Society Clinical Practice Guideline’³⁸ has been retired (2022) without a replacement; it was not reviewed further. The Manatū Hauora 2014 ‘Diabetes in Pregnancy Guide’³⁵ was replaced by the Te Whatu Ora 2025 ‘Testing for, diagnosing and managing gestational diabetes (diabetes of pregnancy) Te whakamātau, te tautohu me te whakahaere i te mate huka hapūtanga’ Clinical Practice Guideline’,⁵² and the newer version was used to inform Taonga Tuku Iho.

Recommendations for diabetes in pregnancy made here are broad and aimed at high-quality pregnancy care specific to diabetes and limiting the impact of preterm birth for māmā/person and pēpi who experience diabetes in pregnancy.

For those with type 1, type 2 and rarer forms of diabetes prior to pregnancy (pre-existing diabetes), recommendations were established using the Australasian Diabetes in Pregnancy Society (ADIPS) 2020 ‘Guideline for pre-existing diabetes and pregnancy’.⁴⁰ This bi-national (Aotearoa and Australia) guideline is described as a consensus-based guideline developed with a multidisciplinary writing team of experts in diabetes in pregnancy. It did not aim to meet the Australian National Health and Medical Research Council standard for guidelines, and rating quality of evidence or strength of each recommendation was considered out of scope. However, it received stakeholder review and feedback from 14 professional organisations.

For gestational diabetes, recommendations were established using the Te Whatu Ora 2025 ‘Testing for, diagnosing and managing gestational diabetes (diabetes of pregnancy) Te whakamātau, te tautohu me te whakahaere i te mate huka hapūtanga’ Clinical Practice Guideline’.⁵² This guideline supersedes the 2014 ‘Diabetes in Pregnancy Guide’³⁵. It was commissioned and funded by Health New Zealand Te Whatu Ora and developed by the Maternity Guidelines Review Steering Group. The Group interpreted literature and clinical guidance to update recommendations specifically for Aotearoa and the model of maternity care, with acknowledgement of national and international differences of opinion on testing for, diagnosing and managing gestational diabetes.

Recommendations on preparing for preterm birth for wāhine/people with diabetes in pregnancy are taken from the appropriate sections of Taonga Tuku Iho and modified for diabetes specific issues.

All other guidelines identified by the Review Panel for use or use with modifications were reviewed and checked for consistency with the recommendations made for both gestational and pre-existing diabetes.

#Impact on equity

The vision of the Carosika Collaborative is ‘Equity in preterm birth outcomes will be achieved in Aotearoa by lowering preterm birth rates and optimising preterm birth care; Taonga Tuku Iho is a major tool to support this. Equity has been prioritised throughout the development process of Taonga Tuku Iho and will drive its implementation and measurement of impact.

During the identification, evaluation and selection of the clinical practice guidelines that inform Taonga Tuku Iho, the Review Panel considered the potential impact on equity of recommendations within each guideline⁵³ and these are summarised here.

For medical conditions in pregnancy the ** ** Review Panel guideline assessments identified that the recommendations in four^10,15,21,23 of the 21 guidelines meeting criteria for consideration of inclusion in this guide had potential to increase differences by equity factors, and 15^{7-12,15-18,22-26} had potential to reduce differences.

A lack of availability and access to some resources was noted with advantages in metropolitan areas. This included for on-site laboratory services, negative pressure rooms and intensive care units for the management of sepsis and COVID in pregnancy, and equipment to provide safe care for those with severe/extreme obesity e.g. bed weight capacity and hover mats. Clinician skills, knowledge and experience were also identified as resources which may not be available in all units including for the management of more complex obstetric cholestasis (knowledge) and surgical techniques in for those with severe obesity (experience).

Several Review Panel members noted that those with obesity in pregnancy may face a number of challenges in accessing care in an equitable way including clinician judgement and cultural constraints which may impact on their engagement with care. It was also noted that primary care providers, midwives and obstetricians have limited ability to significantly impact on pregnancy health outcomes related to obesity. Many upstream contributors to obesity reflect socio-economic factors that are experienced inequitably by whānau across the country.

The availability of the Te Whatu Ora ‘Guidelines for Consultation with Obstetric and Related Medical Services (Referral Guidelines): Aratohu Aratohu Kimi Āwhina ki Te Ratonga Whakawhānau Pēpi, Ratonga Rata (Ngā Aratohu Tuku Atu)’³³ have potential to improve equity of access to obstetric and medical services throughout Aotearoa. However, members of the Review Panel identified the impact of midwifery shortages and high caseloads for practising midwives as an issue that may impact on their ability to refer all wāhine/people appropriately, as well as the impact on capacity of the hospital services to deliver the consultations and support transfers of care as recommended.

With regards to diabetes in pregnancy in Aotearoa some ethnicities experience more gestational diabetes than others but current national data is limited making it difficult to accurately report these differences.⁵² The prevalence of gestational diabetes also increases with increasing levels of socioeconomic deprivation.⁵²

Review Panel guideline assessments identified that the recommendations in three of the 17 diabetes guidelines meeting criteria for consideration of inclusion in this guide had potential to increase differences by equity factors,^37,40,49 and 12 had potential to reduce differences.^{37,39-46,48,49,51}

Themes identified by the Review Panel that may improve equity included recommendations for multidisciplinary teams skilled in the management of diabetes to be involved in care for all wāhine/people with diabetes in pregnancy. However, it was noted that not all hospitals or regions may have availability of, and access to, these teams including dieticians, obstetric physicians (especially for in-patient care) and specialised diabetes midwives and nurses, and hence may also increase inequity if not universally implemented.

Additional potential resource constraints that may limit equitable implementation of recommendations included access to oral glucose tolerance tests (OGTT) in rural areas, community ultrasound provision for additional fetal surveillance, funding subsidies for continuous glucose monitoring, funding and services to support recommended lifestyle changes, and access to in-patient care for optimisation of glycaemic control.

It was also noted that those with pre-existing diabetes or an increased chance of developing diabetes in pregnancy, are also those who may experience constraints in accessing early pregnancy care (and hence timely diabetes screening and care) with specific note made of this for Pacific, Māori and rural whānau. Review Panel members commented that lead maternity carer and primary care provider knowledge of risk factor assessment for diabetes in pregnancy may also be a limiting factor on equity of access to benefit from recommendations. Expectations that lead maternity carers take on a role and responsibility for some blood glucose monitoring in the community may significantly impact on care, in particular in more rural regions, as this is beyond their scope of practice and not remunerated appropriately.

It was highlighted that past national guideline recommendations³⁵ on thresholds for the screening and diagnosis of diabetes in pregnancy differ to those recommended in newer bi-national⁴⁰ and international bodies.³⁶ Consequently, to date different hospitals across Aotearoa use different thresholds which introduces systematic bias in who is diagnosed and treated for diabetes in pregnancy. One reviewer noted that the identified guidelines focus on downstream management of diabetes in pregnancy, and without additional consideration of the upstream determinants of health, any potential in addressing equity of care and outcomes will remain limited.

#Current research

The PRECeDe Trial is a randomised placebo-controlled trial of betamethasone in wāhine/people with diabetes undergoing planned caesarean section at 35⁺⁰ to 39⁺⁶ weeks gestation. This trial is specific to wāhine/people with diabetes (type 1, type 2 and gestational) as the risks of both benefit (neonatal respiratory morbidity) and harm (neonatal hypoglycaemia) are increased for pēpi born to wāhine/people with diabetes in pregnancy. It is funded by the Australian National Health and Medical Research Council and available at sites across Aotearoa and Australia. Wāhine/people with diabetes in pregnancy undergoing a planned caesarean section at late preterm gestations (35⁺⁰ to 36⁺⁶ weeks) are eligible. Sites participating in the trial should offer inclusion to all wāhine/people as the standard of care.

#Statement on rationale for any differing recommendations from the high-quality guidelines

Nil.

#References

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23. Northland District Health Board. Maternal Weight Gain and Body Mass Index (BMI) in Pregnancy. Whangarei: Northland District Health Board; 2021.

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27. Ministry of Health. Guidelines for Consultation with Obstetric and Related Medical Services (Referral Guidelines). Wellington: Ministry of Health; 2012. Available from: https://www.health.govt.nz/system/files/documents/publications/referral-glines-jan12.pdf.

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33. Te Whatu Ora - Health New Zealand. Guidelines for Consultation with Obstetric and Related Medical Services (Referral Guidelines). Wellington: Health New Zealand; 2023. Available from: https://www.tewhatuora.govt.nz/publications/guidelines-for-consultation-with-obstetric-and-related-medical-services-referral-guidelines/.

34. Anderson A, Mills C, Rentta N, Devlin G, Farrant B, Kando I, et al Aotearoa New Zealand Guidelines for the Prevention, Diagnosis, and Management of Acute Rheumatic Fever and Rheumatic Heart Disease: 2024 Update. Wellington: Health New Zealand; 2025. Available from: https://www.tewhatuora.govt.nz/for-health-professionals/clinical-guidance/diseases-and-conditions/rheumatic-fever-guidance/acute-rheumatic-fever-and-rheumatic-heart-disease-guidelines.

35. Manatū Haoura - Ministry of Health. Screening, Diagnosis and Management of Gestational Diabetes in New Zealand: A clinical practice guideline. Wellngton: Ministry of Health; 2014.

36. World Health Organisation. Diagnostic criteria and classification of hyperglycaemia first detected in pregnancy. Geneva: World Health Organisation; 2013. Available from: https://www.who.int/publications/i/item/WHO-NMH-MND-13.2.

37. Auckland District Health Board. Diabetes in Pregnancy. Auckland: Auckland District Health Board; 2019.

38. Blumer I, Hadar E, Hadden DR, Jovanovič L, Mestman JH, Murad MH, Yogev Y. Diabetes and Pregnancy: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2013;98(11):4227-49. DOI: 10.1210/jc.2013-2465.

39. Hod M, Kapur A, Sacks DA, Hadar E, Agarwal M, Di Renzo GC, et al. The International Federation of Gynecology and Obstetrics (FIGO) Initiative on gestational diabetes mellitus: A pragmatic guide for diagnosis, management, and care. Int J Gynaecol Obstet. 2015;131 S173-211. DOI: 10.1016/s0020-7292(15)30033-3.

40. Rudland VL, Price SAL, Hughes R, Barrett HL, Lagstrom J, Porter C, et al. ADIPS 2020 guideline for pre-existing diabetes and pregnancy. ANZJOG. 2020;60(6):E18-E52. DOI: 10.1111/ajo.13265.

41. Waikato District Health Board. Diabetes in Pregnancy. Hamilton: Waikato District Health Board; 2019.

42. Canterbury District Health Board. Diabetic Ketoacidosis (DKA) Management in Pregnancy. Christchurch: Canterbury District Health Board; 2017.

43. Canterbury District Health Board. Type 2 Diabetes Mellitus (Insulin and/or Metformin) - Antenatal, Intrapartum and Postnatal Care. Christchurch: Canterbury District Health Board; 2020.

44. Counties Manukau District Health Board. Diabetes in Pregnancy - Antenatal Inpatient Management and Antenatal Insulin Infusion Procedure. Auckland: Counties Manukau District Health Board; 2016.

45. Counties Manukau District Health Board. Diabetes in Pregnancy – Antenatal Steroids and Antenatal Steroids Insulin Infusion Procedure. Auckland: Counties Manukau District Health Board; 2020.

46. Counties Manukau District Health Board. Diabetes in pregnancy (DIP) – Induction, Labour and Birth. Auckland: Counties Manukau District Health Board; 2021.

47. MidCentral District Health Board. Outpatient Antenatal Management of the Pregnant Woman with Pre-existing Diabetes. Palmerston North: MidCentral District Health Board; 2019.

48. Northland District Health Board. Diabetes; Screening, Diagnosis and Management of Gestational Diabetes Mellitus (GDM). Whangarei: Northland District Health Board; 2016.

49. Northland District Health Board. Pregnant Women with Type 1 Diabetes. Whangarei: Northland District Health Board; 2021.

50. Tairāwhiti District Health Board. Antenatal blood glucose monitoring. Gisborne: Tairāwhiti District Health Board; 2019.

51. Tairāwhiti District Health Board. Diabetes in Pregnancy - Intrapartum care. Gisborne: Tairāwhiti District Health Board; 2019.

52. Te Whatu Ora - Health New Zealand. Testing for, diagnosing and managing gestational diabetes (diabetes of pregnancy) Te whakamātau, te tautohu me te whakahaere i te mate huka hapūtanga2025. Available from: TBC.

53. Hunter B, Dawes L, Wadsworth M, Sadler L, Edmonds L, McAra-Couper J, Allen-Mokaraka T, Groom KM. An evaluation of the quality, suitability and impact on equity of clinical practice guidelines relevant to preterm birth for use in Aotearoa New Zealand. BMC Pregnancy and Childbirth. 2024;24(1):234. DOI: 10.1186/s12884-024-06415-0.

54. New Zealand College of Midwives. Consensus Statement: Informed Consent and Decision Making. 2016. Available from: https://www.midwife.org.nz/wp-content/uploads/2019/05/Informed-Consent-and-Decision-Making.pdf.

55. Medical Council of New Zealand. Good Medical Practice. 2021. Available from: https://www.mcnz.org.nz/assets/standards/b3ad8bfba4/Good-Medical-Practice.pdf.

56. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Consent and provision of information to patients in New Zealand regarding proposed treatment. 2019. Available from: https://ranzcog.edu.au/wp-content/uploads/Consent-Provision-Information-to-Patients-New-Zealand.pdf.

57. Te Whatu Ora - Health New Zealand. Diagnosis and Treatment of Hypertension and Pre-eclampsia in Pregnancy in Aotearoa New Zealand: Te Tautohu, Te Tumahu i te Toto Pōrutu me te Pēhanga Toto Kaha i te Hapūtanga ki Aotearoa: A clinical practice guideline. Wellington: Health New Zealand; 2022. Available from: https://www.tewhatuora.govt.nz/publications/diagnosis-and-treatment-of-hypertension-and-pre-eclampsia-in-pregnancy-in-aotearoa-new-zealand/.

58. Te Whatu Ora - Health New Zealand. Small for Gestational Age and Fetal Growth Restriction in Aotearoa New Zealand He Aratohu Ritenga Haumanu mō te Tōhuatanga Kōpiri me te Pakupaku Rawa. A clinical practice guideline. Wellngton: Health New Zealand; 2023. Available from: https://www.tewhatuora.govt.nz/publications/small-for-gestational-age-fetal-growth-restriction-guidelines/.