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

of women after the fi rst trimester up to labour and delivery). This improved during labour and delivery,
with 79% of the 384 women delivering after 24 weeks having a target range documented.
When a target range was present during pregnancy, there was evidence that this had been communicated
to the woman for only 48% of the 232 women in the fi rst trimester and 51% of the 239 women after the
fi rst trimester.
9.4 Diabetes care - monitoring for diabetes complications
In addition to achieving good glycaemic control during pregnancy, women with diabetes also need ongoing
monitoring and treatment for diabetes complications. There may be development of new retinopathy
or deterioration of pre-existing retinopathy during pregnancy, 8 and women should have a full retinal
assessment during the fi rst trimester, 7 with prompt referral to an ophthalmologist if an abnormality is found.
Women with diabetes nephropathy are at increased risk of hypertensive disease of pregnancy, adverse
fetal outcomes, and progressive deterioration of renal disease. 9-11 Enquiry panels were not provided with
an explicit standard of monitoring for nephropathy, but were provided with the guidance that appropriate
monitoring included testing for microalbuminuria (incipient nephropathy), protein dipstick testing of urine
or serum creatinine.
9.4.1 Enquiry fi ndings
Just over half of women (59%, 258/441), had a retinal assessment documented during the fi rst trimester
or at the fi rst booking visit. Only 55% of these 258 assessments were recorded to have been done through
dilated pupils; for 40% of women, details about the retinal assessment procedure were not documented.
Seventy eight percent (343/441) of women were monitored for signs of nephropathy. Lack of monitoring
for nephropathy was associated with poor pregnancy outcome (OR 1.9, 95% CI 1.1 - 3.3, adjusted for
maternal age and deprivation, see Chapter 6). However, in the additional case-control analysis (see
Appendices C, D and E), lack of monitoring for nephropathy was associated only with fetal congenital
anomaly and not with fetal or neonatal death after 20 weeks gestation, and is therefore unlikely to have
been causative for poor pregnancy outcome. Nephropathy itself was not associated with poor pregnancy
outcome.
Enquiry panels assessed that 60% (264/440) of women (72% of 204 cases and 58% of 204 controls)
had suboptimal diabetes care (care other than glycaemic control management) during pregnancy. These
women were more likely to have a poor pregnancy outcome (OR 1.7, 95% CI 1.1 - 2.6, adjusted for
maternal age and deprivation, see Chapter 6). Additional case-control analysis (see Appendices C, D
and E) showed an association with fetal or neonatal death from 20 weeks gestation and not with fetal
congenital anomaly.
9.4.2 Panel comments on suboptimal diabetes care in pregnancy
Panels made 432 comments for 264 women about suboptimal diabetes care in pregnancy, with the
majority of these being concerns about suboptimal clinical practice (table 9.3).
53