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

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.
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