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

Clinical care issues: pregnancy
Table 9.5
Management of glycaemic control during antenatal steroid administration in women with diabetes delivering before
34 weeks gestation
Management of glycaemic control with antenatal steroid
administration
No. of women receiving corticosteroids
n(%)
(N=56)
No change from prior management 6 (11)
Increased checking of blood glucose only 3 (5)
Subcutaneous insulin regime changed* 3 (5)
Intravenous insulin and dextrose infusion started* 38 (68)
Information not available 6 (11)
* Women who had a change in subcutaneous insulin regime or who started intravenous insulin and dextrose infusion, also had
increased checking of blood glucose.
9.7 Discussion of mode and timing of delivery
Women with pre-existing diabetes have high rates of obstetric intervention, with a 39% induction of labour
rate and a 67% caesarean section rate. 5 It is important that women should be involved in the decisionmaking
process regarding mode and timing of delivery.
9.7.1 Enquiry fi ndings
A discussion about mode and timing of delivery was documented in the medical records for 86% (329/384)
of women who delivered after 24+0 weeks gestation. The fi rst discussion occurred at a median of 35
weeks (range 5 - 40 weeks). A lack of discussion of mode and timing of delivery was associated with poor
pregnancy outcome (OR 4.0, 95% CI 1.2 - 12.7, 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 but not with fetal congenital anomaly. However, women who did not have
a documented discussion delivered at an earlier gestation than women who had evidence of a discussion
(median gestation at delivery 35 weeks versus 37 weeks), and there may therefore have been other factors
contributing to poor outcome.
9.8 Maternity care during pregnancy, labour and delivery
Women with pre-existing diabetes have an increased risk of fetal and maternal complications and it is
important that there is ongoing fetal and maternal surveillance throughout pregnancy, labour and delivery
to identify and manage any risks.
Enquiry panels assessed that maternity care during pregnancy was suboptimal for 51% of 430 women
(58% of 215 cases and 44% of 215 controls), and these women were more likely to have a poor pregnancy
outcome (OR 1.9, 95% CI 1.2 - 2.8, 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 but not with fetal congenital anomaly.
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