L Owens

ATLANTIC DIP: The Impact of Obesity on Pregnancy Outcome in Glucose-Tolerant Women

OBJECTIVE A prospective study of the impact of obesity on pregnancy outcome in glucose-tolerant women. RESEARCH DESIGN AND METHODS The Irish Atlantic Diabetes in Pregnancy network advocates universal screening for gestational diabetes. Women with normoglycemia and a recorded booking BMI were included. Maternal and infant outcomes correlated with booking BMI are reported. RESULTS A total of 2,329 women fulfilled the criteria. Caesarean deliveries increased in overweight (OW) (odds ratio 1.57 [95% CI 1.24–1.98]) and obese (OB) (2.65 [2.03–3.46]) women. Hypertensive disorders increased in OW (2.30 [1.55–3.40]) and OB (3.29 [2.14–5.05]) women. Reported miscarriages increased in OB (1.4 [1.11–1.77]) women. Mean birth weight was 3.46 kg in normal BMI (NBMI), 3.54 kg in OW, and 3.62 kg in OB (P < 0.01) mothers. Macrosomia occurred in 15.5, 21.4, and 27.8% of babies of NBMI, OW, and OB mothers, respectively (P < 0.01). Shoulder dystocia occur in 4% (>4 kg) compared with 0.2% (<4 kg) babies (P < 0.01). Congenital malformation risk increased for OB (2.47 [1.09–5.60]) women. CONCLUSIONS OW and OB glucose-tolerant women have greater adverse pregnancy outcomes.

Applying Current Screening Tools for Gestational Diabetes Mellitus to a European Population—Is it Time for Change?

OBJECTIVE The optimal screening regimen for gestational diabetes mellitus (GDM) remains controversial. Risk factors used in selective screening guidelines vary. Given that universal screening is not currently adopted in our European population, we aimed to evaluate which selective screening strategies were most applicable. RESEARCH DESIGN AND METHODS Between 2007 and 2009, 5,500 women were universally screened for GDM, and a GDM prevalence of 12.4% using International Association of Diabetes in Pregnancy Study Groups (IADPSG) criteria was established. We retrospectively applied selective screening guidelines to this cohort. RESULTS When we applied National Institute for Health and Clinical Excellence (NICE), Irish, and American Diabetes Association (ADA) guidelines, 54% (2,576), 58% (2,801), and 76% (3,656) of women, respectively, had at least one risk factor for GDM and would have undergone testing. However, when NICE, Irish, and ADA guidelines were applied, 20% (120), 16% (101), and 5% (31) of women, respectively, had no risk factor and would have gone undiagnosed. Using a BMI ≥30 kg/m2 for screening has a specificity of 81% with moderate sensitivity at 48%. Reducing the BMI to ≥25 kg/m2 (ADA) increases the sensitivity to 80% with a specificity of 44%. Women with no risk factors diagnosed with GDM on universal screening had more adverse pregnancy outcomes than those with normal glucose tolerance. CONCLUSIONS This analysis provides a strong argument for universal screening. However, if selective screening were adopted, the ADA guidelines would result in the highest rate of diagnosis and the lowest number of missed cases.

ATLANTIC DIP: Closing the Loop A change in clinical practice can improve outcomes for women with pregestational diabetes

OBJECTIVE Prospective evaluation of pregnancy outcomes in women with pregestational diabetes over 6 years. RESEARCH DESIGN AND METHODS The ATLANTIC Diabetes in Pregnancy group provides care for women with diabetes throughout pregnancy. In 2007, the group identified that women were poorly prepared for pregnancy and outcomes were suboptimal. A change in practice occurred, offering women specialist-led, hub-and-spoke evidence-based care. We now compare outcomes from 2005 to 2007 with those from 2008 to 2010. RESULTS There was an increase in the numbers attending preconception care (28–52%, P = 0.01). Glycemic control before and throughout pregnancy improved. There was an overall increase in live births (74–92%, P < 0.001) and decrease in perinatal mortality rate (6.2–0.65%, P < 0.001). There was a decrease in large-for-gestational-age babies in mothers with type 1 diabetes mellitus (30–26%, P = 0.02). Elective caesarean section rates increased, while emergency section rates decreased. CONCLUSIONS Changing the process of clinical care delivery can improve outcomes in women with pregestational diabetes.

Ten Years of Optimizing Outcomes for Women With Type 1 and Type 2 Diabetes in Pregnancy—The Atlantic DIP Experience

CONTEXT Pregnancy for women with type 1 or type 2 diabetes is a time of increased risk for both mother and baby. The Atlantic Diabetes in Pregnancy program provides coordinated, evidence-based care for women with diabetes in Ireland. Founded in 2005, the program now shares outcomes over its first decade in caring for pregnant women with diabetes. OBJECTIVE The objective was to assess improvements in clinical outcomes after the introduction of interventions. DESIGN, SETTING, PARTICIPANTS We retrospectively examined 445 pregnancies in women with type 1 and type 2 diabetes and compared them over two timepoints, 2005–2009 and 2010–2014. INTEVENTIONS Interventions introduced over that time include: provision of combined antenatal/diabetes clinics, prepregnancy care, electronic data management, local clinical care guidelines, professional and patient education materials, an app, and a web site. MAIN OUTCOMES Pregnancy outcomes were measured. RESULTS The introduction of the Atlantic Diabetes in Pregnancy program has been associated with a reduction in adverse neonatal outcomes. There has been a reduction in congenital malformations (5 to 1.8%; P = .04), stillbirths (2.3 vs 0.4%; P = .09), despite an upward trend in maternal age (mean age, 31.7 vs 33 years), obesity (29 vs 43%; body mass index >30 kg/m2), and excessive gestational weight gain (24 vs 38%; P = .002). These improvements in outcomes occur alongside an increase in attendance at prepregnancy care (23 to 49%; P < .001), use of folic acid (45 vs 71%; P < .001), and sustained improvement in glycemic control. CONCLUSIONS Changing the process of clinical care delivery and utilizing evidence-based interventions in a pragmatic clinical setting improves pregnancy outcomes for women with pregestational diabetes. We now need to target optimization of maternal body mass index before pregnancy and put a greater focus on gestational weight gain through education and monitoring.

Comparing type 1 and type 2 diabetes in pregnancy- similar conditions or is a separate approach required?

BackgroundPregnancy in women with type 1 (T1DM) or type 2 diabetes (T2DM) is associated with increased risk. These conditions are managed similarly during pregnancy, and compared directly in analyses, however they affect women of different age, body mass index and ethnicity.MethodsWe assess if differences exist in pregnancy outcomes between T1DM and T2DM by comparing them directly and with matched controls. We also analyze the effect of glycemic control on pregnancy outcomes and analyze predictive variables for poor outcome.ResultsWe include 323 women with diabetes and 660 glucose-tolerant controls. T2DM women had higher BMI, age and parity with a shorter duration of diabetes and better glycemic control. Preeclampsia occurred more in women with T1DM only. Rates of elective cesarean section were similar between groups but greater than in controls, emergency cesarean section was increased in women with type 1 diabetes. Maternal morbidity in T1DM was double that of matched controls but T2DM was similar to controls. Babies of mothers with diabetes were more likely to be delivered prematurely. Neonatal hypoglycemia occurred more in T1DM than T2DM and contributed to a higher rate of admission to neonatal intensive care for both groups. Adverse neonatal outcomes including stillbirths and congenital abnormalities were seen in both groups but were more common in T1DM pregnancies. HbA1C values at which these poor outcomes occurred differed between T1 and T2DM.ConclusionsPregnancy outcomes in T1DM and T2DM are different and occur at different levels of glycemia. This should be considered when planning and managing pregnancy and when counseling women.

Community change and resident needs: Designing a Participatory Action Research study in Metropolitan Boston

&NA; The health implications of urban development, particularly in rapidly changing, low‐income urban neighborhoods, are poorly understood. We describe the Healthy Neighborhoods Study (HNS), a Participatory Action Research study examining the relationship between neighborhood change and population health in nine Massachusetts neighborhoods. Baseline data from the HNS survey show that social factors, specifically income insecurity, food insecurity, social support, experiencing discrimination, expecting to move, connectedness to the neighborhood, and local housing construction that participants believed would improve their lives, identified by a network of 45 Resident Researchers exhibited robust associations with self‐rated and mental health. Resident‐derived insights into relationships between neighborhoods and health may provide a powerful mechanism for residents to drive change in their communities. HighlightsParticipatory Action Research helps clarify links between urban development & health.social risk factors exhibited robust associations with health.Resident‐derived insights can help drive change in communities.