1. ANTENATAL CARE OF DIABETES IN PREGNANCY: AUDIT Rachael Read ST2 O&G Supervisor: Mr E Njiforfut Consultant

2. 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

3. 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

4. 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

5. GUIDELINES New NICE guidelines for management of Diabetes in pregnancy published Feb 2015 Replaced guidelines from March 2008

6. 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

7. DEMOGRAPHICS 50 patients  34 GDM (68%)  7 T1DM (14%)  9 T2DM (18%) 47 Singleton Pregnancies 3 DCDA Twins

8. BODY MASS INDEX Mean BMI 31.4 (20-50)

9. 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%

10. 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%

11. 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%

12. 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

13. 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 37 +0 weeks and 38 +6 weeks of pregnancy. Consider elective birth before 37 +0 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 40 +6 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 40 +6 weeks for women with gestational diabetes if there are maternal or fetal complications.

14. 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

15. 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