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

9. Clinical care issues: pregnancy
Learning points
• Suboptimal glycaemic control during pregnancy was associated with poor pregnancy outcome.
The main clinical issues identifi ed were failure to change insulin regimes to achieve good
glycaemic control, and a non-responsive local strategy of diabetes antenatal care.
• Suboptimal maternity care and diabetes care (excluding glycaemic control) during pregnancy
was associated with poor pregnancy outcome. Underlying issues included suboptimal fetal and
maternal surveillance and suboptimal monitoring of diabetes complications.
• For babies with antenatal evidence of macrosomia, suboptimal antenatal fetal surveillance was
associated with poor pregnancy outcome, with the main issues being lack of timely follow up and
poor interpretation of ultrasound scans.
• Women who had a poor pregnancy outcome were more likely not to receive postnatal
contraceptive advice and more likely to have suboptimal postnatal diabetes care.
9.1 Introduction
During pregnancy, there are often rapid changes in glycaemic control due to increasing insulin resistance.
Suboptimal glycaemic control has been associated with fetal congenital anomaly, 1 an increased risk of
miscarriage 2 and fetal macrosomia; 3 and there may also be placental insufficiency (particularly associated
with nephropathy) resulting in fetal growth restriction. Women themselves may have complications
including hypoglycaemia, retinopathy, nephropathy, diabetic ketoacidosis and pre-eclampsia. Clinicians and
health services have an important role in building relationships with women before and during pregnancy,
empowering them to manage their diabetes, and providing effective maternal and fetal surveillance.
9.2 Glycaemic control during pregnancy, labour and delivery
Tight glycaemic control during pregnancy is one of the main principles of management for women with
pre-existing diabetes. During labour and delivery, good glycaemic control should be maintained to reduce
the risk of neonatal hypoglycaemia. 4
The 2005 CEMACH report 5 on pregnant women with pre-existing diabetes found that although
approximately three quarters of 2732 women had a glycosylated haemoglobin test (HbA1c) performed
during the fi rst trimester of pregnancy, just over a third of these women achieved an HbA1c value less
than 7%. This improved in the second and third trimesters, with two thirds of women with an HbA1c test
achieving a result less than 7%.
9.2.1 Enquiry fi ndings
Enquiry panels assessed that the majority of women in the enquiry had suboptimal glycaemic control
during pregnancy (84% of 204 cases and 61% of 192 controls in the fi rst trimester; 71% of 205 cases and
37% of 209 controls after the fi rst trimester). Suboptimal glycaemic control at any time during pregnancy
50