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

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Appendix E Association between preconception care factors in the 12 months prior to pregnancy of fetal and neonatal deaths (excluding major fetal congenital anomaly) 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 12/36 (33) 19/83 (23) 1.7 [0.7, 4.0] 1.6 [0.7, 3.8] No discussion of the following specifi c diabetes issues: Alcohol 16/34 (47) 19/66 (29) 2.2 [0.9, 5.3] 2.7 [1.1, 6.9] Diet 10/47 (21) 12/100 (12) 2.0 [0.8, 5.0] 2.1 [0.8, 5.4] Poor glycaemic control 10/52 (19) 14/117 (12) 1.8 [0.7, 4.3] 1.6 [0.7, 4.0] Retinopathy 14/33 (42) 25/96 (26) 2.1 [0.9, 4.9] 2.0 [0.8, 4.7] Nephropathy 15/34 (44) 29/76 (38) 1.3 [0.6, 2.9] 1.2 [0.5, 2.8] Hypertension 15/32 (47) 23/75 (31) 2.0 [0.8, 4.7] 1.7 [0.7, 4.3] No discussion of the following pregnancy issues: Increased diabetes surveillance 8/62 (13) 7/124 (6) 2.5 [0.8, 7.3] 2.3 [0.8, 6.8] Increased pregnancy surveillance 8/55 (15) 8/124 (6) 2.5 [0.9, 7.0] 2.2 [0.8, 6.5] Increased risk of induction 11/40 (28) 14/110 (13) 2.6 [1.1, 6.5] 2.3 [0.9, 6.2] Possible caesarean section 13/46 (28) 11/110 (10) 3.6 [1.4, 8.9] 3.7 [1.4, 10.2] Fetal risks in diabetic pregnancy 10/46 (22) 7/114 (6) 4.3 [1.5, 12.4] 3.6 [1.1, 11.6] No dietetic review 22/60 (37) 42/135 (61) 1.3 [0.7, 2.4] 1.3 [0.6, 2.5] No assessment of the following diabetes complications in the 12 months prior to pregnancy: Baseline retinal examination 17/61 (28) 18/137 (13) 2.6 [1.2, 5.5] 2.6 [1.2, 5.9] Baseline test of renal function 14/58 (24) 15/133 (11) 2.5 [1.1, 5.7] 2.6 [1.1, 6.3] Assessment of albuminuria 19/54 (35) 30/109 (28) 1.4 [0.7, 2.9] 1.6 [0.8, 3.3] Assessment of suboptimal preconception care (excluding glycaemic control) 48/58 (83) 80/134 (60) 3.2 [1.5, 7.1] 4.0 [0.7, 9.4] a Adjusted for maternal age and deprivation. 132
Association between diabetes care factors of fetal and neonatal deaths (excluding major fetal congenital anomaly) from 20 weeks gestation in babies of women with type 1 and type 2 diabetes Diabetes care factor No referral to ophthalmologist (if retinopathy present) No monitoring for nephropathy No test of renal function (if nephropathy present) Assessment of suboptimal diabetes care during pregnancy a Adjusted for maternal age and deprivation. Cases n/N (%) Controls n/N (%) Crude OR [95% CI] Adjusted OR a 27/83 (33) 49/183 (27) 1.3 [0.8, 2.3] 1.2 [0.7, 2.2] 6/16 (38) 21/44 (48) 0.7 [0.2, 2.2] 0.6 [0.2, 2.3] 19/91 (21) 26/206 (13) 1.8 [1.0, 3.5] 1.8 [0.9, 3.5] 8/14 (58) 5/14 (36) 2.4 [0.5, 11.7] 2.9 [0.5, 15.8] 67/91 (74) 112/204 (55) 2.3 [1.3, 4.0] 2.2 [1.3, 3.9] Association between maternity care factors of fetal and neonatal deaths (excluding major fetal congenital anomaly) from 20 weeks gestation in babies of women with type 1 and type 2 diabetes Maternity care factor Assessment of suboptimal fetal monitoring (with antenatal evidence of growth restricted baby) Assessment of suboptimal fetal monitoring (with antenatal evidence of fetal size >90th centile) Cases n/N (%) Controls n/N (%) Crude OR [95% CI] Adjusted OR a 5/11 (45) 1/11 (9) 8.3 [0.6, 119.3] 5.2 [0.4, 62.8] 28/32 (88) 27/73 (37) 15.2 [3.9, 59.2] 17.7 [5.4, 57.6] No discussion of mode and timing of delivery 9/79 (12) 4/202 (2) 6.7 [1.9, 23.0] 5.9 [1.7, 20.7] No administration of antenatal corticosteroids b 2/7 (29) 12/33 (36) 0.7 [0.1, 4.3] 0.4 [0.0, 4.1] Assessment of suboptimal maternity care during the 68/90 (76) 95/215 (44) 3.9 [2.2, 7.0] 4.2 [2.3, 7.4] antenatal period Assessment of suboptimal maternity care during labour and delivery 34/88 (39) 72/213 (34) 1.2 [0.7, 2.1] 1.2 [0.7, 2.1] a Adjusted for maternal age and deprivation. b Analysis restricted to babies delivering from 24+0 to 35+6 weeks gestation and excluding antepartum stillbirths. 133
Page 1 and 2:
Confidential Enquiry into Maternal
Page 3 and 4:
Contents Acknowledgements .........
Page 5 and 6:
• Members of the CEMACH Diabetes
Page 7 and 8:
Erb’s palsy Injury to the nerve r
Page 9 and 10:
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
Page 19 and 20:
3. Summary of recommendations This
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2. Patient pathways of care includi
Page 23 and 24:
the pregnancies meeting this defi n
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in order to remove any identifi abl
Page 27 and 28:
When deriving odds ratios for any p
Page 29 and 30:
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
Page 43 and 44:
Table 6.8 Association of postnatal
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folic acid before pregnancy (19% of
Page 47 and 48:
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
Page 57 and 58:
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
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11.4 Preconception behaviour The CE
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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 138 and 139: Appendix D Association of social an
Page 140 and 141: Appendix D Association of diabetes
Page 142 and 143: Appendix E Association between demo
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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Diabetes in pregnancy: are we providing the best care ... - HQIP

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