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

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Clinical care issues: pregnancy Audit and research 5. Research should be carried out to investigate: • the most appropriate management strategy following antenatal evidence of macrosomia in babies of women with diabetes • how best to achieve optimal blood glucose control during pregnancy, labour and delivery. References 1. Miller E, Hare JW, Cloherty JP, Dunn PJ, Gleason RE, Soeldner JS, et al. Elevated maternal haemoglobin A1c in early pregnancy and major congenital anomalies in infants of diabetic mother. N Engl J Med, 1981.304:1331-4. 2. Mills JL, Simpson JL, Driscoll SG, Jovanovic-Peterson L, Van Allen M, Aarons JH, Metzger B, Bieber FR, Knopp RH, Holmes LB et al. Incidence of spontaneous abortion among normal women and insulin-dependent diabetic women whose pregnancies were identifi ed within 21 days of conception. N Engl J Med, 1988: 319:1617-1623. 3. Rey E, Attie C, Bonin A. The effects of fi rst-trimester diabetes control on the incidence of macrosomia. Am J Obstet Gynecol, 1999; 181, 202-6. 4. Taylor R, Lee C, Kyne-Grzebalski D, Marshall SM, Davison JM. Clinical outcomes of pregnancy in women with type 1 diabetes. Obstet Gynecol, 2002; 99, 537 – 41. 5. 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. 6. Recommendations for the management of pregnant women with diabetes (including gestational diabetes). Diabetes UK Care Recommendation. Updated June 2005. 7. National Service Framework for Diabetes (England) Standards. Department of Health. The Stationery Offi ce: London; 2001. 8. Sheth BP. Does pregnancy accelerate the rate of progression of diabetic retinopathy? Current Diabetes Reports, Aug 2002: 2(4):327-30. 9. Duckitt K, Harrington D. Risk factors for pre-eclampsia at antenatal booking: systematic review of controlled studies. BMJ, 12 Mar 2005: 330(7491):565. 10. Fischer MJ, Lehnerz SD, Hebert JR, Parikh CR. Kidney disease is an independent risk factor for adverse fetal and maternal outcomes in pregnancy. American Journal of Kidney Diseases. Mar 2004: 43(3):415-23. 11. Irfan S, Arain TM, Shaukat A, Shahid A. Effect of pregnancy on diabetic nephropathy and retinopathy. J Coll Physicians Surg Pak: Feb 2004: 14(2):75-8. Commentary Stephen Walkinshaw Chair, CEMACH Diabetes Professional Advisory Group Consultant Obstetrician, Liverpool Women’s Hospital, Liverpool Although there are many areas of good clinical practice during pregnancy for women with diabetes, this chapter has highlighted some aspects of diabetes and maternity care that are less impressive. 62
The panel enquiries, which are in essence a detailed peer review of clinical care, have identifi ed a number of underlying issues which may help multidisciplinary teams to work towards improving care and outcomes. It is surprising that barely half of women in the enquiry had optimal glycaemic control after the fi rst trimester. Some of the underlying issues included poor integration of care, failure to follow up women and failure to change insulin regimens to enable optimal glycaemic control. It should be feasible to address these issues within the organisation of multidisciplinary clinics without signifi cant additional resource. Similarly, improving the setting of blood glucose targets, retinal and renal screening and more senior involvement should be feasible within existing local frameworks of care, though maintaining continuous senior input at the clinic may be a challenge. Women with diabetes are a ‘captive’ group during labour and delivery, and it cannot be acceptable that a large number were considered to have suboptimal glycaemic control during this time, especially given the knowledge that the level of glycaemic control during labour infl uences the risk of neonatal hypoglycaemia. Panels noted delays in starting intravenous insulin, and inadequate dose regimens, which when taken together with panels’ concerns about local guidelines in Chapter 10, suggests that the organisation of diabetes care on the labour ward needs improvement. Multidisciplinary teams need to consider how they can continue the high level of antenatal specialist involvement through to the labour ward, and how they can provide clear written guidance and practical training for non-specialist staff. Suboptimal maternity care during pregnancy, which was present in half of women in the enquiry, was associated with a two to threefold increase in the risk of losing a baby after 20 weeks. For babies with evidence of macrosomia, suboptimal fetal surveillance was strongly associated with an increased risk of death after 20 weeks gestation. The main underlying issues identifi ed were poor antenatal fetal surveillance, poor management of maternal risks, and inappropriate decisions about mode and timing of delivery. Though there is a relatively small evidence base for fetal surveillance in diabetic pregnancy, most women with diabetes have regular ultrasound scans and some form of fetal well-being monitoring. There is, however, little point in any form of surveillance if no or inadequate action is taken in response to the results. It suggests that such surveillance is carried out ‘routinely’ in many cases without detailed consideration of the possible impact on the fetus, and perhaps echoes the panels’ comments about lack of senior input. Similarly, it may be that all women with diabetes are regarded as high risk without any stratifi cation within the group, leading to poor management of individual risks and a blanket policy on mode and timing of delivery. Obstetric and midwifery members of the multidisciplinary team need to consider what tests and interventions are actually needed, and what these mean to the individual pregnancy and not for diabetic pregnancy in general. The NICE guidelines on diabetes in pregnancy, currently under development, may give some direction to these discussions. From the panels’ comments on postnatal care, it does appear that the diabetes team is not as closely involved with the woman’s care after birth as before, even though 4 out of 5 women had a documented plan. Delivery of consistent quality in postnatal care is a problem outwith pregnancy in women with diabetes, and this diffi cult service issue will be a challenge to improve. 63
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 and 60: Some quotes from the panel discussi
Page 61 and 62: Apart from the explanation of pregn
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: • ‘No serial growth scans perfo
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
Page 114 and 115: 102 Appendix B: Diabetes enquiry pr
Page 124 and 125:
112 Appendix B: Diabetes enquiry pr
Page 126 and 127:
Page 128 and 129:
Page 130 and 131:
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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