4








Standards of care for the mother

 
     
 

KEY FINDINGS

  • There is evidence of poor preparation for pregnancy in women with diabetes.
  • There is room for improvement in current standards of care during pregnancy.
 
 
 

4.1

 

Introduction

One of the aims of the diabetes project was to audit clinical standards of maternity and diabetes care for women with pre-gestational diabetes before, during and after pregnancy. A description of how these standards were derived is included in Chapter 1. The complete list of standards can be found in Appendix D.

It is important to note that assessment of clinical care had, of necessity, to be based on documentation in routine medical records. This meant that some standards could be evaluated only in part and this is detailed in the text where relevant. The results are based on the information provided on the 3808 pregnancies notified to CEMACH.

 
 

4.2

 

Standards of preconception care

 
 

4.2.1

 

Provision of preconception care

 

A preconception clinic should be run jointly by the adult diabetes service and the maternity service for women wishing to become pregnant.

[Diabetes NSF – illustrative service models;
www.publications.doh.gov.uk/nsf/diabetes/ch2/servicemodels/pregnancy.htm]

 

There was evidence that prepregnancy counselling was received by just over one-third (34.5%) of all women with pre-gestational diabetes (Table 4.1). Sixty-eight percent of these women received counselling at the adult diabetes clinic, 13% at a preconception clinic and 4% from the general practitioner. For 15% of women, the service providing counselling was not known.

Similarly, just over one-third (37.1%) of women overall were reported as having had a prepregnancy measurement of long-term glycaemic control in the 6 months prior to pregnancy (Table 4.1). The women with type 2 diabetes were significantly less likely to have had this prepregnancy test (P < 0.001).

These findings suggest that the majority of women with pre-gestational diabetes were not adequately prepared for pregnancy. In Table 4.1, this is reflected in early pregnancy glycaemic control in these women (see section 4.4.1). The majority of women who did receive prepregnancy counselling did not do so in a multidisciplinary clinic, as advised by the standards of care.

 
 

4.2.2

 

Folic acid supplementation

 

Women with diabetes have an increased risk of fetal neural tube defects and should be offered prepregnancy folic acid supplements, continuing up to 12 weeks of gestation.

[CEMACH Diabetes Multidisciplinary Resource Group – standard derived from SIGN Guideline No. 9]

 

Less than half (39.2%) of women were documented in the medical records to have taken folic acid before their last menstrual period (Table 4.2). This is comparable with the general maternity population, where the uptake of folic acid before pregnancy is known to be 50% at best in the UK.1 Uptake was markedly lower in women with type 2 diabetes compared with those with type 1 diabetes (P < 0.001) (Table 4.2).

Prepregnancy dietary advice by a health professional, duration of folic acid supplementation, the gestation at which it was discontinued and the dose taken, were not assessed in this study. However, women without diabetes who are at high risk of neural tube defects decrease this risk by the use of high-dose folic acid.2 Women with pre-gestational diabetes are also in a high-risk category for neural tube defects. Current national guidelines recommend a higher dose (usually 5 mg) of folic acid for women at high risk.3–5 Both women and general practitioners should be aware of the importance of commencing folic acid before pregnancy in women with diabetes.

 
 

4.3

 

Standards of antenatal care

 
 

4.3.1

 

Dating the pregnancy and assessing for congenital malformations

 

All women with diabetes should be referred promptly for a first-trimester ultrasound scan to enable accurate dating of the pregnancy. They should all be offered a detailed anomaly ultrasound scan between 18 and 22 weeks and serial ultrasound scans during the third trimester to monitor fetal growth.

[Diabetes NSF – Intervention details; www.publications.doh.gov.uk/nsf/diabetes/ch2/interventions/pregnancy.htm]

 

This standard is echoed by the National Institute for Clinical Excellence Antenatal Care guideline, which recommends that all pregnant women should be offered an ultrasound scan before 13 weeks of gestation to determine gestational age.6 This is particularly important for women with diabetes, where timely delivery is one of the main tenets of care.

A total of 2630 of 3586 women (73.3%) with an ongoing pregnancy at 13 weeks of gestation had a first-trimester dating scan. The reasons given for no first-trimester scan being performed (699 women) are shown in Table 4.3. The single largest contributing factor was units reporting a first trimester scan when in fact it had been performed after 13 weeks of gestation (median 14+3 weeks of gestation; interquartile range 13+3, 16+4). Early telephone referral from the general practitioner to a named contact within the specialist antenatal diabetes team may be useful to improve this aspect of care. An additional 163 women had a scan but the gestation was unknown with a not-known outcome in a further 94 women.

Units were asked if an anomaly scan was performed after 16 weeks of gestation: 3435 of 3552 women (96.7%) with an ongoing pregnancy had a detailed anomaly scan performed after this time, with no difference between women with type 1 and type 2 diabetes. A total of 117 women did not have an anomaly scan. Reasons for no anomaly scan were provided for 58 women. These included: anomaly scan performed before 16 weeks (17 women), late booking for antenatal care (nine women) and maternal choice (six women). A further 59 women had no documented reason for no having an anomaly scan.

 
 

4.3.2

 

Prophylactic antenatal steroids

 

If delivery is indicated before 34 weeks, administration of corticosteroids should be considered to prevent neonatal respiratory distress syndrome.

[Diabetes NSF – Intervention details; www.publications.doh.gov.uk/nsf/diabetes/ch2/interventions/pregnancy.htm]

 

A total of 328 of 3474 women (9.4%) with a continuing pregnancy at 24 weeks of gestation delivered before 34 weeks of gestation. Thirty-five of these pregnancies resulted in a stillbirth. Of the remaining women, nearly three-quarters (70.3%) received a full course of antenatal steroid therapy (Table 4.4). The commonest reason for non-administration was delivery before the full course could be given. It was not possible to assess whether this was due to delays in administration, quick, spontaneous, preterm labour or expedited delivery for maternal or fetal reasons (Table 4.5). In a small group of women, diabetes was seen as a contraindication to administration of antenatal steroids. This is not the case, although careful surveillance and adjustment of insulin regimens during this time is vital.

 
 

4.4

 

Standards of antenatal care of diabetes

 
 

4.4.1

 

Glycaemic control

 

Women should be encouraged and supported to monitor their blood glucose levels regularly and to adjust their insulin dosage, in order to maintain their blood glucose levels within the normal (non-diabetic) range. The aim should be for the woman to maintain her HbA1c below 7.0%.

[Diabetes NSF – Intervention details; www.publications.doh.gov.uk/nsf/diabetes/ch2/interventions/pregnancy.htm]

 

The information for this standard is evaluated in greater detail in Chapter 5. Less than one-third (28%) of women who had a glycosated haemoglobin (HbA1c measurement before pregnancy had a value of less than 7%. This proportion increased to 38% in the first trimester and at least 65% from 18 weeks onwards (Chapter 5). This reflects the poor level of preparation for pregnancy seen with regard to preconception care and folic acid supplementation.

 
 

4.4.2

 

Provision of glucagon kit

 

Hypoglycaemia should be discussed and glucagon made available with clear instructions on its use.

[CEMACH Diabetes Multidisciplinary Resource Group – standard derived from SIGN Guideline No. 9]

 

Just over one-quarter (26.5%) of all women with diabetes did not have a glucagon kit in the current pregnancy (Table 4.6). The reason for this was unclear in half of circumstances. Otherwise, ‘not hospital policy’ and ‘considered unnecessary by health professionals’ were cited most frequently and, in 5% of cases, women themselves declined the offer of a kit (Table 4.7). However, women with pre-gestational diabetes may develop ‘hypoglycaemia unawareness’ during pregnancy,7 and fatalities from hypoglycaemia have been documented in past reports into maternal deaths.8,9

More women with type 2 diabetes (33.8%) did not receive a glucagon kit than women with type 1 diabetes (18.8%) (P < 0.001) (Table 4.6). The majority of women with type 2 diabetes will require to be changed on to insulin before or during pregnancy and many women with type 2 diabetes may be more vulnerable to hypoglycaemia because of specific cultural practices (e.g. fasting during religious festivals). It is important that the risks of hypoglycaemia are communicated to all women. Interpreting services should be used if required.

 
 

4.4.3

 

Detailed retinal assessment

 

A full retinal assessment should be undertaken in all women with pre-existing diabetes during the first trimester or at booking if this is later.

[Diabetes NSF – Intervention details; www.publications.doh.gov.uk/nsf/diabetes/ch2/interventions/pregnancy.htm]

 

Retinopathy may be exacerbated by pregnancy and assessment during the pregnancy is an essential aspect of care. A detailed retinal assessment was recorded at least once during pregnancy in 3039 of 3805 women (79.9%). This reflects the UK survey in 1994,10 where 81% of physicians reported carrying out retinal examinations during pregnancy, but falls short of the Scottish data, where 97% of pregnant women with type 1 diabetes had a detailed retinal assessment.11 All diabetes maternity services should have robust processes in place to ensure that all women with diabetes have at least one detailed retinal assessment during pregnancy.3

 
 

4.5

 

Standards of care for labour and delivery

 
 

4.5.1

 

Mode and timing of delivery

 

The mode and timing of delivery should be determined on an individual basis, aiming to realise a spontaneous vaginal delivery by no later than 40 weeks of gestation if possible.

[CEMACH Diabetes Multidisciplinary Resource Group – standard derived from SIGN Guideline No. 9]

 

Less than one-quarter (24.4%) of women achieved a spontaneous vaginal delivery (Table 4.8). This was due to a high caesarean section rate of 67.4% (elective section accounting for 29.8% and emergency section for 37.6% of this rate).

The reasons for induction of labour and caesarean section, and the timing of delivery, are explored in greater detail in Chapter 6.

Sixty-eight of 3474 women (2.0%) (33 of 2524 [1.3%] of women with type 1 diabetes and 35 of 950 [3.7%] of women with type 2 diabetes) delivered after 40 completed weeks of gestation.

 
 

4.5.2

 

Intrapartum fetal heart rate monitoring

 

Continuous electronic fetal heart monitoring should be offered to all women with diabetes during labour and fetal blood sampling should be available if indicated.

[Diabetes NSF – Intervention details; www.publications.doh.gov.uk/nsf/diabetes/ch2/interventions/pregnancy.htm]

 

Of the 1832 women in labour with an ongoing pregnancy at 24 weeks of gestation, 1711 (93.4%) had continuous electronic fetal heart monitoring (CEFM). The availability of fetal blood sampling was not assessed. For seven women, electronic fetal heart rate monitoring was offered but declined by the woman. Of the small group of babies (121) who did not have CEFM in labour the majority (116 of 121; 95.9%) were at least 28 weeks of gestation. While the value of continuous intrapartum fetal monitoring in prematurity and maternal diabetes has not been specifically investigated, current national practice recommendations are that CEFM should be used in any situation where there is a higher risk of fetal compromise.12

 
 

4.5.3

 

Use of intravenous dextrose and insulin

 

Intravenous dextrose and insulin should be administered during labour and delivery following an agreed multidisciplinary protocol.

[CEMACH Diabetes Multidisciplinary Resource Group – standard derived from SIGN Guideline No. 9]

 

The majority (86.3%) of women received an intravenous insulin and dextrose infusion during labour and delivery (Table 4.9). The small group who did not receive this when there was opportunity to do so comprised a disproportionate number of women with type 2 diabetes. It is difficult to comment on this, as there are a small number of women with type 2 diabetes who are managed by diet alone during pregnancy and this may have contributed to the results.

 
 

4.6

 

Conclusion

Preconception care

  • Nearly two-thirds of women did not have a record of prepregnancy counselling.
  • Only one-third of women had a recorded assessment of glycaemic control in the 6 months prior to pregnancy.
  • Less than two-fifths of all women were recorded as taking folic acid supplements before their last menstrual period.

These findings strongly suggest ineffective preconception targeting and fragmented service provision. Up to 40% of pregnancies in women with diabetes may be unplanned. Education about the importance of pregnancy preparation for all women with diabetes of reproductive age is an urgent need. Primary and secondary care services should aim to develop joint protocols based on national guidelines to ensure that all women with diabetes receive consistent preconception care of a high standard.

Care during pregnancy

  • Fifteen percent of women in this cohort had their first dating scan after 13 weeks of gestation.
  • One-fifth of women did not have a detailed retinal examination during pregnancy.
  • One-fifth of women with type 1 diabetes and one-third of women with type 2 diabetes did not have a glucagon kit during pregnancy.
  • Over one-quarter of women who delivered before 34 weeks of gestation did not receive a full course of antenatal steroids.

Women with diabetes are at high risk of complications during pregnancy. Early and prompt referral to secondary care series is essential. Maternity units need to ensure a strong multidisciplinary team and the availability of guidelines that are evidence-based and agree with national recommendations.

Care during labour and delivery

  • Only one-quarter of women achieved a spontaneous vaginal delivery.
  • The majority of women received an intravenous infusion of insulin and dextrose during labour and delivery.
  • The majority of babies had continuous electronic fetal monitoring in labour; only five (4.1%) babies who did not were less than 28 weeks of gestation.

The high caesarean section rate in diabetes is likely to be due, in part, to the conflict between achieving a vaginal delivery and concerns about adverse pregnancy outcome. This is discussed in Chapter 6.

 
     

References

  1. Ray JG, Singh G, Burrows RF. Evidence for suboptimal use of perinconceptional folic acid supplements globally. BJOG 2004;111:399–408.
  2. Lumley J, Watson L, Watson M, Bower C. Periconceptional supplementation with folate and/or multivitamins for preventing neural tube defects. Cochrane Database Syst Rev 2005;(3).
  3. Department of Health. National Service Framework for Diabetes (England) Standards. London: The Stationery Office; 2001 [www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4002951&chk=09Kkz1].
  4. Scottish Intercollegiate Guidelines Network. Management of Diabetes. SIGN Publication No. 55. Edinburgh: SIGN; 2001 [www.sign.ac.uk/guidelines/published/index.html#Diabetes].
  5. Diabetes UK care recommendations. Folic acid supplementation in pregnancy. June 2005 [www.diabetes.org.uk/infocentre/carerec/folic.htm].
  6. National Collaborating Centre for Women's and Children's Health. Antenatal Care: Routine Care for the Healthy Pregnant Woman. Clinical Guideline. London: RCOG Press; 2003.
  7. Evers IM, Ter Braak EWMT, de Valk HW, van der Schoot B, Janssen N, Visser GHA. Risk indicators predictive for severe hypoglycaemia during the first trimester of type 1 diabetic pregnancy. Diabetes Care 2002;25(3):554–9.
  8. Lewis G, Drife J, editors. Why Mothers Die 1997–1999. The fifth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. London: RCOG Press; 2001.
  9. Lewis G, editor. Why Mothers Die 2000–2002: The Sixth Report of the Confidential Enquiries into Maternal Death in the United Kingdom. London: RCOG Press; 2004.
  10. Jardine Brown C, Dawson A, Dodds R, Gamsu H, Gillmer M, Hall M, et al. Report of the Pregnancy and Neonatal Care Group. Diabetic Med 1996:13:S43–53.
  11. Penney GC, Pearson D. A national audit to monitor and promote the uptake of clinical guidelines on the management of diabetes in pregnancy. Br J Clin Governance 2000;5(1):28–34.
  12. Royal College of Obstetricians and Gynaecologists, Clinical Effectiveness Support Unit. The Use of Electronic Fetal Monitoring. Evidence-based Clinical Guideline Number 8. London: RCOG Press; 2001 [www.rcog.org.uk/index.asp?PageID=695].