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

Clinical care issues: pregnancy
However, there were a number of concerns about clinical care during pregnancy. Nearly half of women
in the enquiry did not have a retinal examination during the fi rst trimester and there were concerns about
failure to change insulin regimes to achieve good glycaemic control, and a non-responsive local strategy
of diabetes antenatal care. A tenth of women did not have any additional interventions to ensure good
glycaemic control during antenatal steroid administration. Fetal surveillance was suboptimal for nearly half
of babies with antenatal evidence of macrosomia, and this was associated with poor pregnancy outcome,
specifi cally fetal or neonatal death from 20 weeks gestation (see Chapter 6 and Appendices C, D and E).
It is disappointing that women who had a poor pregnancy outcome were more likely to have suboptimal
diabetes care after delivery and were less likely to receive contraceptive advice prior to discharge
from hospital. It is recognised that clinicians are likely to need to provide more intensive counselling to
women who have had a fetal loss, stillbirth or a baby born with a congenital anomaly, and discussion
about contraception in this situation can be diffi cult. However, it is important that diabetes care is not
compromised for these women, and discussion about future pregnancy preparation may help to minimise
the risk of adverse pregnancy outcome in the future.
Some quotes from the panel discussions
Suboptimal glycaemic control during pregnancy:
• 'HbA1C 10.7% - should have been put on insulin.'
• 'At 36 weeks HbA1c 8.6%. Insulin was changed to QDS at 28 weeks this should have
been sooner.'
• 'Fragmented Care, locum consultants. No notes from Diabetologist.'
Suboptimal glycaemic control during labour and delivery:
• 'Sliding scale not commenced until well established in labour and blood glucose high. Fixed
sliding scale that did not adequately maintain blood glucose at acceptable levels.'
• 'The pump became disconnected, the 3 way tap was turned off. No one noticed for some time
until her BMs went up considerably.'
Diabetes care (excluding glycaemic control):
• ‘Inadequate nephropathy monitoring - no regular urine testing, only 2 dipstick urine tests.
No retinal screening after 13 weeks.’
• ‘Lack of evidence of holistic care, seemed to be outside multidisciplinary service, no information
about diabetes nurse specialist, dietetic or community team’s input, no joint clinic.’
Antenatal fetal surveillance:
• ‘Noted increase in abdominal circumference with previous history of IUD and the next scan
is arranged for 4 weeks. There should have been increased surveillance.’
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