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

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Clinical care issues: preconception • Setting of glycaemic control targets and regular discussion of results of self-monitoring, to enable the woman to achieve control that is as near to normal as possible before conception • Discussion of diabetes pregnancy risks and expected management strategies • Clear documentation of care and counselling, ideally using a standard template. Audit and research 2. Preconception services should be audited to ensure that minimum standards are being met. References 1. National Service Framework for Diabetes (England) Standards. Department of Health. The Stationery Offi ce: London: 2001. 2. 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. 3. Macintosh M, Fleming K, Bailey J, 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, 22 Jul 2006: 333 (7560):177. 4. Pregnancy outcomes in the Diabetes Complications Trial. The Diabetes Control and Complications Trial Research Group. Am J Obstet Gynecol; 1996; 174: 1343-53. 5. Lumley J, Watson L, Watson M, Bower C. Cochrane Pregnancy and Childbirth Group. Periconceptional supplementation with folate and/or multivitamins for preventing neural tube defects. Cochrane Database of Systematic Reviews. 2006, 3. 6. Confi dential Enquiry into Maternal and Child Health. Survey of maternity services for women with type 1 and type 2 diabetes in 2002-03, England, Wales and Northern Ireland. CEMACH: London; 2005. Commentary Sue Roberts National Clinical Director for Diabetes Consultant Diabetes Physician, North Tyneside General Hospital This chapter paints a disturbing picture of a lack of diabetes preconception care services across England, Wales and Northern Ireland, and a lack of knowledge both on the part of healthcare professionals and women with diabetes, about the importance of preconception care. The evidence indicates that preconception care is vital in trying to ensure that both mothers and babies have as safe and healthy a pregnancy and birth as possible. The fi ndings in this report suggest that when there is suboptimal preconception care, pregnancy outcomes can be devastating for the mother-to-be and her baby. Adult diabetes services and primary care professionals are often in contact with women prior to pregnancy, and therefore have a real responsibility to provide relevant information and monitoring, both in the immediate pre-pregnancy period and as part of women’s routine care. In the current situation, many women are missing out on information and monitoring as part of their routine care on a year by year basis. 48
Apart from the explanation of pregnancy risks and the need to maintain good glycaemic control, some drugs which may be prescribed for women with type 2 diabetes, such as ACE inhibitors, are harmful in pregnancy. This emphasis on informing women of the risks and the preventive actions they can take, means that diabetes services for women of child bearing age should be planned in a slightly different way to other diabetes services. This is supported by the recently developed diabetes workforce competencies c that specifi cally address the needs of women of child bearing age with diabetes, as well as those actively seeking to become pregnant, and those who are already pregnant. The current absence of structured preconception care needs to be set within the context of the increasing number of women of child bearing age with diabetes – mainly type 2 diabetes. This rise has been fuelled by a number of factors, including the increasing obesity of the general population, changing ethnic demographics and reducing levels of exercise and fi tness. An additional factor is that women from ethnic minority groups with an increased risk of type 2 diabetes, tend to have larger families. The General Household Survey 1988-2001 d found that women of Bangladeshi origin tended on average to have families twice as large as the White population. The Diabetes National Service Framework (NSF) recommends that all diabetes services should be effectively planned, but it is clear that this is currently not the case for the majority of local services across the country, either for routine or preconception care. While pregnancy in women with diabetes used to be considered a specialist activity, there is now a critical need for services to be planned jointly in primary as well as secondary care in order to achieve integrated models of preconception and pregnancy care. This is an immense challenge, and diabetes networks have a crucial role in supporting this planning and commissioning process by enabling each of the stakeholders to identify needs and priorities. Although it may be diffi cult to accept, we must understand that pregnancy for women with diabetes will always be high risk. However, it is our responsibility to discover new ways of working with women that will reduce the risks and ensure the best possible outcomes, both for them and their babies. c Skills for Health, Diabetes Workforce Competencies, 2006. d Sources: Census 2001, Offi ce for National Statistics; General Register Offi ce for Scotland. 49
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 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: Some quotes from the panel discussi
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
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102 Appendix B: Diabetes enquiry pr
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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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Diabetes in pregnancy: are we providing the best care ... - HQIP

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