When should I refer a patient with gestational diabetes to a specialist for further management?

For a patient diagnosed with gestational diabetes, you should refer them to a specialist for further management in the following circumstances:

• Upon Diagnosis: When a woman is diagnosed with gestational diabetes, offer a review with the joint diabetes and antenatal clinic within 1 week ¹. You should also inform their primary healthcare team ¹.
• Dietitian Referral: All women diagnosed with gestational diabetes should be referred to a dietitian ¹.
• Unmet Blood Glucose Targets: If blood glucose targets are not met with diet and exercise changes within 1 to 2 weeks, metformin should be offered ¹. If metformin is contraindicated or unacceptable, insulin should be offered ¹. If targets are still not met with diet, exercise, and metformin, insulin should be offered as well ¹. These medication adjustments are typically managed by the specialist team.
• High Fasting Plasma Glucose at Diagnosis: For women with a fasting plasma glucose level of 7.0 mmol/litre or above at diagnosis, immediate treatment with insulin (with or without metformin) and diet and exercise changes should be offered ¹.
• Moderate Fasting Plasma Glucose with Complications: For women with a fasting plasma glucose level between 6.0 and 6.9 mmol/litre and complications such as macrosomia or hydramnios, immediate treatment with insulin (with or without metformin) and diet and exercise changes should be considered ¹.
• Complex Insulin Management: For pregnant women on insulin therapy (who do not have type 1 diabetes) who experience problematic severe hypoglycaemia or unstable blood glucose levels despite optimisation efforts, real-time continuous glucose monitoring (rtCGM) may be considered, which requires specialist input from the joint diabetes and antenatal care team ¹.