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

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A comparison of type 1 and type 2 diabetes Table 11.8 Differences in maternity care during the antenatal period between women with type 1 and type 2 diabetes Women with type 1 diabetes n/N (%) Women with type 2 diabetes n/N (%) p-value Assessment of suboptimal fetal monitoring (with antenatal evidence 2/11 (18) 1/11 (9) 0.53 of growth restricted baby) Assessment of suboptimal fetal monitoring (with antenatal evidence 19/32 (59) 16/45 (36) 0.68 of big baby > 90th centile) No discussion of mode and timing of delivery 5/164 (3) 4/122 (3) 0.91 No administration of corticosteroids 9/28 (32) 8/24 (33) 0.93 Assessment of suboptimal maternity care during the antenatal period 76/177 (43) 70/131 (53) 0.07 Assessment of suboptimal maternity care during labour and delivery 59/178 (33) 56/131 (43) 0.08 Table 11.9 Differences in diabetes care (excluding glycaemic control) during pregnancy between women with type 1 and type 2 diabetes Women with type 1 diabetes n/N (%) Women with type 2 diabetes n/N (%) p-value No retinal assessment 33/148 (22) 42/117 (36) 0.02 No referral to ophthalmologist (if retinopathy present) 20/43 (47) 5/9 (56) 0.62 No monitoring for nephropathy 24/169 (14) 21/128 (16) 0.6 No test of renal function (if nephropathy present) 3/12 (25) 3/6 (50) 0.29 Assessment of suboptimal diabetes care during pregnancy 96/169 (57) 49/120 (41) 0.28 11.8 Postnatal care Women with type 2 diabetes were less likely to receive postnatal contraceptive advice than women with type 1 diabetes (table 11.10). This may have been due partly to language diffi culties and also perceived differences in cultural attitudes to contraception. All women with pre-existing diabetes should receive advice about contraception soon after delivery in order to prevent future unplanned pregnancies, and it should be agreed locally as to which professionals are best placed to provide this advice in the puerperium. 78
Table 11.10 Differences in postnatal care between women with type 1 and type 2 diabetes Women with type 1 diabetes n/N (%) Women with type 2 diabetes n/N (%) p-value No postnatal contraceptive advice 21/137 (15) 31/105 (30) 0.008 No written plan for post-delivery diabetes management 20/156 (13) 15/115 (13) 0.95 Assessment of suboptimal postnatal diabetes care 93/177 (53) 59/127 (46) 0.3 11.9 Conclusions The comparison of women with type 1 and type 2 diabetes has shown some differences in clinical characteristics (Body Mass Index, retinopathy and frequency and severity of hypoglycaemia in pregnancy) which are to be expected from the difference in disease profi les between the two groups of women. It is concerning that women with type 2 diabetes were less likely than women with type 1 diabetes to have a retinal assessment in the fi rst trimester (or at booking if later), especially since retinopathy was a new fi nding in fi ve out of the nine women with type 2 diabetes who had retinopathy in pregnancy. This may refl ect a perception by health professionals that type 2 diabetes is less likely to cause complications than type 1 diabetes, and highlights the importance of early and regular retinal assessment for all women with pre-existing diabetes. Before pregnancy, women with type 2 diabetes were less likely than women with type 1 diabetes to have a retinal assessment or test for albuminuria in the 12 months before pregnancy. Women with type 2 diabetes are more likely to be managed in primary care, and this fi nding may therefore refl ect a lack of awareness by primary care professionals of the importance of screening for diabetes complications in women with type 2 diabetes. There may also be diffi culties in accessing investigations such as retinal photographs that are usually provided in the secondary care setting. Women with type 2 diabetes were less likely to receive postnatal contraceptive advice. It is recognised that health professionals may fi nd it diffi cult to provide contraceptive advice to women from different cultural backgrounds due to language diffi culties and perceived cultural sensitivities. However, this is a vital aspect of post-delivery counselling, and every effort should be made by health professionals to help women with diabetes, including those with type 2 diabetes, to prepare adequately for future pregnancies. 79
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
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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
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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 and 74: • ‘No serial growth scans perfo
Page 75 and 76: The panel enquiries, which are in e
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: enquiry related to a 12 month prior
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 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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