Diabetes in pregnancy: are we providing the best care ... - HQIP

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Appendix D Association of social and lifestyle factors with fetal and neonatal death from 20 weeks gestation in babies of women with type 1 and type 2 diabetes Social and lifestyle factor Cases n/N (%) Controls n/N (%) Crude OR [95% CI] Adjusted OR a Unplanned pregnancy 40/88 (45) 55/144 (38) 1.4 [0.8, 2.3] 1.3 [0.7, 2.4] No contraceptive use in the 12 months before pregnancy 49/72 (68) 54/121 (45) 2.6 [1.4, 5.0] 2.5 [1.3, 4.8] No folic acid commenced prior to pregnancy 48/74 (65) 66/131 (50) 1.8 [1.0, 3.3] 2.0 [1.1, 3.7] Smoking 43/115 (37) 44/182 (24) 1.9 [0.1, 3.1] 2.1 [1.2, 3.6] Assessment of suboptimal approach of the woman to managing her diabetes before pregnancy 83/98 (85) 88/154 (57) 4.2 [2.1, 8.1] 4.7 [2.3, 9.3] Assessment of suboptimal approach of the woman to managing her diabetes during pregnancy a adjusted for maternal age and deprivation. 76/124 (61) 56/207 (27) 4.3 [2.6, 7.1] 3.9 [2.4, 6.5] Association of glycaemic control factors with fetal and neonatal death from 20 weeks gestation in babies of women with type 1 and type 2 diabetes Glycaemic control factor No test of glycaemic control before pregnancy No local targets set for glycaemic control Assessment of suboptimal preconception glycaemic control Assessment of suboptimal 1st trimester glycaemic control Assessment of suboptimal glycaemic control after 1st trimester Assessment of suboptimal blood glucose control during labour and delivery No intravenous insulin and dextrose during labour and/or delivery a adjusted for maternal age and deprivation. Cases n/N (%) Controls n/N (%) Crude OR [95% CI] Adjusted OR a 25/90 (28) 24/139 (17) 1.8 [1.0, 3.5] 1.8 [0.9, 3.4] 31/61 (51) 28/86 (33) 2.1 [1.1, 4.3] 2.1 [1.0, 4.4] 103/115 (90) 115/167 (69) 3.9 [1.9, 7.9] 4.3 [2.1, 8.7] 109/129 (85) 118/192 (61) 3.4 [1.9, 6.1] 3.4 [1.9, 6.1] 96/133 (72) 76/209 (37) 4.5 [2.7, 7.5] 5.0 [3.0, 8.4] 47/101 (47) 94/202 (47) 1.0 [0.6, 1.6] 1.1 [0.7, 1.8] 31/133 (26) 31/127 (14) 2.1 [1.2, 3.6] 2.0 [1.2, 3.6] 126
Association of preconception care factors in the 12 months prior to pregnancy with fetal and neonatal death from 20 weeks gestation in babies of women with type 1 and type 2 diabetes Preconception care factor Cases n/N (%) Controls n/N (%) Crude OR [95% CI] Adjusted OR a No contraceptive advice provided before pregnancy 18/51 (35) 19/83 (23) 1.8 [0.8, 4.0] 1.8 [0.8, 4.1] No discussion of the following specifi c diabetes issues: Alcohol 22/49 (45) 19/66 (29) 2.0 [0.9, 4.4] 2.2 [1.0, 5.2] Diet 13/65 (20) 12/100 (12) 1.8 [0.8, 4.4] 1.9 [0.8, 4.5] Poor glycaemic control 12/74 (16) 14/117 (12) 1.4 [0.6, 3.3] 1.3 [0.5, 3.0] Retinopathy 18/50 (36) 25/96 (26) 1.6 [0.8, 3.4] 1.5 [0.7, 3.3] Nephropathy 20/47 (43) 29/76 (38) 1.2 [0.6, 2.5] 1.0 [0.5, 2.3] Hypertension 19/46 (41) 23/75 (31) 1.6 [0.7, 3.5] 1.3 [0.6, 3.1] No discussion of the following pregnancy issues: Increased diabetes surveillance 9/81 (11) 7/124 (6) 2.1 [0.7, 5.9] 1.9 [0.6, 5.5] Increased pregnancy surveillance 9/73 (12) 8/124 (6) 2.0 [0.7, 5.6] 1.8 [0.6, 5.1] Increased risk of induction 13/51 (25) 14/110 (13) 2.4 [1.0, 5.5] 2.2 [0.9, 5.5] Possible caesarean section 14/62 (23) 11/110 (10) 2.6 [1.1, 6.3] 2.8 [1.1, 7.3] Fetal risks in diabetic pregnancy 12/63 (19) 7/114 (6) 3.6 [1.3, 9.9] 3.1 [1.0, 9.6] No dietetic review 36/84 (43) 42/135 (61) 1.7 [0.9, 2.9] 1.6 [0.9, 3.0] No assessment of the following diabetes complications in the 12 months prior to pregnancy: Baseline retinal examination 23/88 (26) 18/137 (13) 2.3 [1.2, 4.7] 2.4 [1.2, 5.1] Baseline test of renal function 19/79 (24) 15/133 (11) 2.5 [1.2, 5.3] 2.8 [1.2, 6.2] Assessment of albuminuria 28/70 (40) 30/109 (28) 1.8 [0.9, 3.3] 1.9 [1.0, 3.8] Assessment of suboptimal preconception care (excluding glycaemic control 71/84 (85) 80/134 (60) 3.7 [1.8, 7.5] 4.6 [2.2, 9.9] a adjusted for maternal age and deprivation. 127
Page 1 and 2:
Confidential Enquiry into Maternal
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Contents Acknowledgements .........
Page 5 and 6:
• Members of the CEMACH Diabetes
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Erb’s palsy Injury to the nerve r
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Neonatal unit A unit which provides
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Foreword This third and fi nal repo
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1. Introduction This is the fi nal
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2. Key fi ndings of the CEMACH Diab
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Suboptimal fetal surveillance of ba
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3. Summary of recommendations This
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2. Patient pathways of care includi
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the pregnancies meeting this defi n
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in order to remove any identifi abl
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When deriving odds ratios for any p
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Associations are reported in Chapte
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Table 5.1 Characteristics of women
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Table 5.4 Characteristics of women
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was no information available to pan
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6. Factors associated with poor pre
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Table 6.2 Association of clinical c
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Table 6.5 Association of specifi c
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Table 6.8 Association of postnatal
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folic acid before pregnancy (19% of
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Table 7.2 Panel comments on social
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7.5 Conclusions One of the key fi n
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11.Dex S, Heather J (eds). Millenni
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8. Clinical care issues: preconcept
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chance of induction of labour was r
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8.6.1 Enquiry fi ndings Just over h
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Some quotes from the panel discussi
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Apart from the explanation of pregn
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was associated with poor pregnancy
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of women after the fi rst trimester
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9.5.1 Panel comments on suboptimal
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During labour and delivery, the maj
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Just 52% of 383 women (38% of 164 c
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• ‘No serial growth scans perfo
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The panel enquiries, which are in e
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10.3.1 Enquiry fi ndings Seventy fi
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10.6 Communication Effective commun
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Some quotes from the panel discussi
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working between primary and seconda
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we therefore selected 7.2% of pregn
Page 87 and 88: 11.4 Preconception behaviour The CE
Page 89 and 90: enquiry related to a 12 month prior
Page 91 and 92: Table 11.10 Differences in postnata
Page 93 and 94: Type 1 and type 2 diabetes have tra
Page 95 and 96: Panels were chaired by the panel ch
Page 97 and 98: In 57% (24/42) of cases, a junior d
Page 99 and 100: Infant formula given as fi rst feed
Page 101 and 102: 2.1 hours in babies remaining with
Page 103 and 104: 12.7.1 Panel comments on suboptimal
Page 105 and 106: The concerns described here probabl
Page 107 and 108: External commentary Patricia Hamilt
Page 109 and 110: informed and motivated to manage th
Page 112 and 113: 100 Appendix A: Pre-pregnancy care
Page 114 and 115: 102 Appendix B: Diabetes enquiry pr
Page 132 and 133: Appendix C Association between demo
Page 134 and 135: Appendix C Association of preconcep
Page 136 and 137: Appendix C Association of postnatal
Page 140 and 141: Appendix D Association of diabetes
Page 142 and 143: Appendix E Association between demo
Page 144 and 145: Appendix E Association between prec
Page 146 and 147: Appendix E Association between post
Page 148 and 149: Appendix F - CEMACH advisory groups
Page 150: Appendix F - CEMACH advisory groups
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