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

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Factors associated with poor pregnancy outcome in women with type 1 and type 2 diabetes 6.3.4 Glycaemic control A test of glycaemic control before pregnancy, local glycaemic control targets, and panel assessments of glycaemic control before and during pregnancy, were examined in relation to poor pregnancy outcome (table 6.4). A lack of local glycaemic control targets, and suboptimal glycaemic control before and during pregnancy were associated with poor pregnancy outcome. These issues are discussed further in Chapters 7 and 8. Table 6.4 Association of factors related to glycaemic control before and during pregnancy in women with type 1 and type 2 diabetes, with poor pregnancy outcome Factor related to glycaemic control Cases n/N (%) Controls n/N (%) Crude OR [95% CI] Adjusted OR a [95% CI] No test of glycaemic control in the 12 months prior to pregnancy 36/139 (26) 24/139 (17) 1.7 [0.9, 3.0] 1.5 [0.8, 2.8] No local targets set for glycaemic control 44/90 (49) 28/86 (33) 2.0 [1.1, 3.7] 2.0 [1.0, 3.8] Assessment of suboptimal preconception glycaemic control 165/187 (88) 115/167 (69) 3.4 [1.9, 6.0] 3.9 [2.2, 7.0] Assessment of suboptimal 1st trimester glycaemic control 171/204 (84) 118/192 (61) 3.3 [2.0, 5.3] 3.4 [2.1, 5.7] Assessment of suboptimal glycaemic control after 1st trimester 146/205 (71) 76/209 (37) 4.3 [2.8, 6.7] 5.2 [3.3, 8.2] Assessment of suboptimal glycaemic control during labour and delivery 80/162 (49) 96/202 (48) 0.9 [0.6, 1.4] 1.0 [0.7, 1.6] No intravenous insulin and dextrose during labour and/or delivery 48/208 (23) 31/217 (14) 1.8 [1.1, 3.0] 1.8 [1.1, 3.0] a adjusted for maternal age and deprivation. 6.3.5 Preconception care in the 12 months prior to pregnancy Specifi c preconception care factors, based on the medical records held by adult diabetes services or general practitioners, were investigated for association with poor pregnancy outcome. The results are shown in table 6.5 and are discussed further in chapter 8. These fi ndings were dependent on documentation in the medical records, and poor documentation by health professionals of the care and advice given to women may have infl uenced the apparent association with poor pregnancy outcome. 28
Table 6.5 Association of specifi c preconception care factors in women with type 1 and type 2 diabetes with poor pregnancy outcome Preconception care factor Cases n/N (%) Controls n/N (%) Crude OR [95% CI] Adjusted OR a [95% CI] No contraceptive advice provided before pregnancy 28/85 (33) 19/83 (23) 1.7 [0.8, 3.3] 1.7 [0.8, 3.5] No discussion of the following specifi c diabetes issues: Alcohol intake 31/70 (44) 19/66 (29) 2.0 [1.0, 4.1] 2.5 [1.1, 5.4] Diet 20/103 (19) 12/100 (12) 1.8 [0.8, 3.9] 1.8 [0.8, 4.1] Poor glycaemic control 18/118 (15) 14/117 (12) 1.3 [0.6, 2.8] 1.2 [0.5, 2.5] Retinopathy 25/83 (30) 25/96 (26) 1.2 [0.6, 2.4] 1.1 [0.6, 2.3] Nephropathy 28/74 (38) 29/76 (38) 1.0 [0.5, 1.9] 0.8 [0.4, 1.7] Hypertension 27/71 (38) 23/75 (31) 1.4 [0.7, 2.8] 1.1 [0.5, 2.3] No discussion of the following pregnancy issues: Increased diabetes surveillance 13/123 (11) 7/124 (6) 2.0 [0.8, 5.2] 1.7 [0.6, 4.5] Increased pregnancy surveillance 13/117 (11) 8/124 (6) 1.8 [0.7, 4.6] 1.5 [0.6, 4.0] Increased risk of induction 21/83 (25) 14/110 (13) 2.3 [1.1, 5.0] 2.2 [1.0, 4.9] Possible caesarean section 20/95 (21) 11/110 (10) 2.4 [1.1, 5.4] 2.4 [1.0, 5.8] Fetal risks in diabetic pregnancy 17/98 (17) 7/114 (6) 3.2 [1.3, 8.2] 2.9 [1.1, 8.2] No dietetic review 46/129 (36) 42/135 (61) 1.2 [0.7, 2.1] 1.2 [0.7, 2.1] No assessment of the following diabetes complications in the 12 months prior to pregnancy: Baseline retinal examination 36/141 (26) 18/137 (13) 2.3 [1.2, 4.3] 2.3 [1.2, 4.5] Baseline test of renal function 26/130 (20) 15/133 (11) 2.0 [1.0, 3.9] 2.0 [0.9, 4.3] Assessment of albuminuria 41/116 (35) 30/109 (28) 1.4 [0.8, 2.6] 1.5 [0.8, 2.8] Assessment of suboptimal preconception care (excluding glycaemic control) 116/133 (87) 80/134 (60) 4.6 [2.4, 8.8] 5.2 [2.7, 10.1] a adjusted for maternal age and deprivation. 6.3.6 Diabetes care (excluding glycaemic control) Diabetes care in the enquiry referred to monitoring for diabetes complications, including retinal assessments and tests of renal function. Findings are shown in table 6.6 and are discussed further in Chapter 9. 29
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 and 36: was no information available to pan
Page 37 and 38: 6. Factors associated with poor pre
Page 39: Table 6.2 Association of clinical 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
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 116 and 117:
Page 118 and 119:
Page 120 and 121:
Page 122 and 123:
Page 124 and 125:
Page 126 and 127:
Page 128 and 129:
Page 130 and 131:
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 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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