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

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A description of women and babies in the enquiry References 1. Confi dential Enquiry into Maternal and Child Health. Pregnancy in women with type 1 and type 2 diabetes in 2002-03, England, Wales and Northern Ireland. CEMACH: London; 2005. 2. EUROCAT Report 8: Surveillance of Congenital Anomalies in Europe 1980-1999. European Registration of Congenital Anomalies. University of Ulster: Belfast; 2002. 3. Macintosh MCM, Fleming KM, Bailey JA, Doyle P, Modder J, Acolet D, et al. Perinatal mortality and congenital anomalies in babies of women with type 1 or type 2 diabetes in England, Wales and Northern Ireland: population based study. BMJ 2006; 333:177. 4. Confi dential Enquiry into Stillbirths and Deaths in Infancy. 4th Annual Report 1 January – 31 December 1995. Maternal and Child Health Research Consortium: London; 1997. 5. Confi dential Enquiry into Maternal and Child Health. Stillbirth, Neonatal and Post-neonatal Mortality 2000 – 2003, England, Wales and Northern Ireland. CEMACH: London; 2005. 6. Jaffe R. In Wigglesworth JS, Singer DB eds. The pancreas. Textbook of Fetal and Perinatal Pathology. Blackwell: Massacussetts: 900-932. 24
6. Factors associated with poor pregnancy outcome in women with type 1 and type 2 diabetes 6.1 Introduction Women with type 1 and type 2 diabetes continue to have an increased risk of adverse pregnancy outcomes, including miscarriage, fetal congenital anomaly and perinatal death. 1-4 A case-control approach was utilised within the enquiry module to examine the association of demographic and clinical characteristics, social and lifestyle factors and clinical care with poor pregnancy outcome. 6.2 Methodology Poor pregnancy outcome was defi ned as a singleton baby with a major congenital anomaly who delivered at any gestation and/or a baby who died from 20 weeks gestation up to 28 days after delivery. There were 222 cases that met the defi nition of poor pregnancy outcome. These comprised: • Sixty one singleton babies with a major congenital anomaly who died at any gestation during pregnancy and up to 28 days after delivery. This included terminations of pregnancy for fetal congenital anomaly. • Ninety fi ve singleton babies without a major congenital anomaly who died from 20 weeks gestation up to 28 days after delivery. • Sixty six babies with a major congenital anomaly who survived to 28 days after delivery. There were 220 controls (singleton babies without a major congenital anomaly who survived to day 28 after delivery). Odds ratios and associated 95% confi dence intervals were calculated to examine each factor identifi ed by panels and its association with adverse outcomes. Odds ratios are also displayed adjusting for maternal age and deprivation, where appropriate, to allow for the potential confounding by these factors. 6.2.1 Additional analyses In addition to the primary analysis (section 6.2), associations of different factors with outcome were also analysed using three separate case defi nitions: • All major fetal congenital anomalies • All deaths from 20 weeks gestation up to 28 days after delivery • Deaths from 20 weeks gestation up to 28 days after delivery, excluding major fetal congenital anomalies. The results of these analyses can be found in Appendices C, D and E. In most cases the direction of association was the same regardless of the case defi nition used. Any notable differences are highlighted throughout the text. 6.3 Results Associations of factors with poor pregnancy outcome are presented below. Each group of factors is discussed in more detail in the relevant chapter in this report. 25
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
Page 11 and 12: Foreword This third and fi nal repo
Page 13 and 14: 1. Introduction This is the fi nal
Page 15 and 16: 2. Key fi ndings of the CEMACH Diab
Page 17 and 18: Suboptimal fetal surveillance of ba
Page 19 and 20: 3. Summary of recommendations This
Page 21 and 22: 2. Patient pathways of care includi
Page 23 and 24: the pregnancies meeting this defi n
Page 25 and 26: 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
Page 31 and 32: Table 5.1 Characteristics of women
Page 33 and 34: Table 5.4 Characteristics of women
Page 35: was no information available to pan
Page 39 and 40: Table 6.2 Association of clinical c
Page 41 and 42: Table 6.5 Association of specifi c
Page 43 and 44: Table 6.8 Association of postnatal
Page 45 and 46: folic acid before pregnancy (19% of
Page 47 and 48: Table 7.2 Panel comments on social
Page 49 and 50: 7.5 Conclusions One of the key fi n
Page 51 and 52: 11.Dex S, Heather J (eds). Millenni
Page 53 and 54: 8. Clinical care issues: preconcept
Page 55 and 56: chance of induction of labour was r
Page 57 and 58: 8.6.1 Enquiry fi ndings Just over h
Page 59 and 60: Some quotes from the panel discussi
Page 61 and 62: Apart from the explanation of pregn
Page 63 and 64: was associated with poor pregnancy
Page 65 and 66: of women after the fi rst trimester
Page 67 and 68: 9.5.1 Panel comments on suboptimal
Page 69 and 70: During labour and delivery, the maj
Page 71 and 72: Just 52% of 383 women (38% of 164 c
Page 73 and 74: • ‘No serial growth scans perfo
Page 75 and 76: The panel enquiries, which are in e
Page 77 and 78: 10.3.1 Enquiry fi ndings Seventy fi
Page 79 and 80: 10.6 Communication Effective commun
Page 81 and 82: Some quotes from the panel discussi
Page 83 and 84: working between primary and seconda
Page 85 and 86: 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
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Table 11.10 Differences in postnata
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Type 1 and type 2 diabetes have tra
Page 95 and 96:
Panels were chaired by the panel ch
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In 57% (24/42) of cases, a junior d
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Infant formula given as fi rst feed
Page 101 and 102:
2.1 hours in babies remaining with
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12.7.1 Panel comments on suboptimal
Page 105 and 106:
The concerns described here probabl
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External commentary Patricia Hamilt
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informed and motivated to manage th
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100 Appendix A: Pre-pregnancy care
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102 Appendix B: Diabetes enquiry pr
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Page 120 and 121:
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Page 128 and 129:
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Page 132 and 133:
Appendix C Association between demo
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Appendix C Association of preconcep
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Appendix C Association of postnatal
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Appendix D Association of social an
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Appendix D Association of diabetes
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Appendix E Association between demo
Page 144 and 145:
Appendix E Association between prec
Page 146 and 147:
Appendix E Association between post
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Appendix F - CEMACH advisory groups
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Appendix F - CEMACH advisory groups
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