ANTENATAL CARE OF DIABETES IN PREGNANCY: AUDIT Rachael Read ST2 O&G Supervisor: Mr E Njiforfut Consultant
WHAT IS DIABETES? Gestational Diabetes (NICE): Diagnosed with 2 ‑ hour 75 g oral glucose tolerance test Fasting plasma glucose level of 5.6 mmol/L or above, or 2-hour plasma glucose level of 7.8 mmol/L or above Type 1 Diabetes Autoimmune disease Insulin producing ß cells of pancreas destroyed UK prevalence 1 in 700 – 1000 children ~10% diabetics Type 2 Diabetes Metabolic disease Combination of insulin resistance and relative lack of insulin ~90% diabetics
BACKGROUND 5% of pregnant ladies will have pre-existing or gestational diabetes mellitus 87.5% Gestational Diabetes 7.5% Type II Diabetes 5% Type 1 Diabetes Prevalence Type 1 & 2 DM increasing in recent years Gestational DM also on the up
WHY DO WE WORRY ABOUT IT? Risks to mum: Miscarriage Pre-eclampsia T2DM Trauma at birth Worsening nephropathy (T1DM) Rapidly worsening diabetic retinopathy Risks to baby: Stillbirth Congenial malformations (7%) e.g. Spina bifida, Heart problems, Oral clefts, GI tract defects, Kidney defects, Limb deficiencies Macrosomia Perinatal mortality Postnatal problems e.g. Hypoglycaemia Shoulder dystocia Birth Injury Preterm delivery
GUIDELINES New NICE guidelines for management of Diabetes in pregnancy published Feb 2015 Replaced guidelines from March 2008
AUDIT 50 case notes of patients who gave birth between Feb 2014-Feb 2015 Pre-existing and gestational DM included Audit of antenatal care of these ladies against 2008 guidance Demographic and outcome information included
DEMOGRAPHICS 50 patients 34 GDM (68%) 7 T1DM (14%) 9 T2DM (18%) 47 Singleton Pregnancies 3 DCDA Twins
BODY MASS INDEX Mean BMI 31.4 (20-50)
AUDIT RESULTS Offer immediate referral to a joint diabetes and antenatal clinic 100% Offer retinal assessment to patients with pre-existing DM as soon as possible after the first contact in pregnancy if it has not been performed in the past 12 months (3 months, 2015) Yes: 75 % Not documented: 25%
RENAL ASSESSMENT Offer renal assessment at the first contact in pregnancy if it has not been performed in the past 12 months (3 months, 2015) At first contact: 88% During pregnancy: 12%
ULTRASOUND GROWTH SCANS Offer pregnant women with diabetes ultrasound monitoring of fetal growth and amniotic fluid volume every 4 weeks from 28 to 36 weeks Yes 84 % Yes after diagnosis: 6% 2 scans: 10% Offer antenatal examination of the four-chamber view of the fetal heart and outflow tracts at 18–20 weeks: 100%
GESTATION AT DELIVERY Offer induction of labour, or caesarean section if indicated, after 38 weeks if the baby has grown normally. 33 weeks: 2 x preterm labour 36 weeks: 2 x twins, 1 x T1DM
NEW GUIDELINES 2015 Advise pregnant women with type 1 or type 2 diabetes and no other complications to have an elective birth by induction of labour, or by elective caesarean section if indicated, between weeks and weeks of pregnancy. Consider elective birth before weeks for women with type 1 or type 2 diabetes if there are metabolic or any other maternal or fetal complications. Advise women with gestational diabetes to give birth no later than weeks, and offer elective birth (by induction of labour, or by caesarean section if indicated) to women who have not given birth by this time. Consider elective birth before weeks for women with gestational diabetes if there are maternal or fetal complications.
CONCLUSIONS Overall standard of care for diabetic patients was very good With MDT care risks to mum and baby are well managed Compliance to NICE guidelines very good Most patients had regular ultrasound, renal and ophthalmology appointments although not always exactly in line with NICE guidelines There will be some fundamental changes in antenatal care for these patients in line with new NICE guidelines
RECOMMENDATIONS Education of juniors 2 people running diabetic clinic to minimise variations Step by step guides for basic investigations and management in diabetic clinic to streamline care Re-audit