Louise Carmody

ATLANTIC DIP: Pregnancy Outcome for Women With Pregestational Diabetes Along the Irish Atlantic Seaboard

OBJECTIVE Prospective evaluation of pregnancy outcomes in pregestational diabetes along the Atlantic seaboard 2006–2007. RESEARCH DESIGN AND METHODS The Atlantic Diabetes in Pregnancy group, representing five antenatal centers in a wide geographical location, was established in 2005. All women with diabetes for >6 months before the index pregnancy were included. Results were collected electronically via the DIAMOND Diabetes Information System. Pregnancy outcome was compared with background rates. RESULTS There were 104 singleton pregnancies. The stillbirth rate (25/1,000) was 5 times, perinatal mortality rate (25/1,000) 3.5 times, and congenital malformation rate (24/1,000) 2 times that of the background population. A total of 28% of women received prepregnancy care, 43% received prepregnancy folic acid, and 51% achieved an A1C ≤7% at first antenatal visit. CONCLUSIONS Women are not well prepared for pregnancy, and outcomes are suboptimal. A regional prepregnancy care program and centralized glucose management are urgently needed.

ATLANTIC DIP: simplifying the follow-up of women with previous gestational diabetes

OBJECTIVE Previous gestational diabetes (GDM) is associated with a significant lifetime risk of type 2 diabetes. In this study, we assessed the performance of HbA1c and fasting plasma glucose (FPG) measurements against that of 75 g oral glucose tolerance testing (OGTT) for the follow-up screening of women with previous GDM. METHODS Two hundred and sixty-six women with previous GDM underwent the follow-up testing (mean of 2.6 years (s.d. 1.0) post-index pregnancy) using HbA1c (100%), and 75 g OGTT (89%) or FPG (11%). American Diabetes Association (ADA) criteria for abnormal glucose tolerance were used. DESIGN, COHORT STUDY, AND RESULTS The ADA HbA1c high-risk cut-off of 39 mmol/mol yielded sensitivity of 45% (95% CI 32, 59), specificity of 84% (95% CI 78, 88), negative predictive value (NPV) of 87% (95% CI 82, 91) and positive predictive value (PPV) of 39% (95% CI 27, 52) for detecting abnormal glucose tolerance. ADA high-risk criterion for FPG of 5.6 mmol/l showed sensitivity of 80% (95% CI 66, 89), specificity of 100% (95% CI 98, 100), NPV of 96% (95% CI 92, 98) and PPV of 100% (95% CI 91, 100). Combining HbA1c ≥39 mmol/mol with FPG ≥5.6 mmol/l yielded sensitivity of 90% (95% CI 78, 96), specificity of 84% (95% CI 78, 88), NPV of 97% (95% CI 94, 99) and PPV of 56% (95% CI 45, 66). CONCLUSIONS Combining test cut-offs of 5.6 mmol/l and HbA1c 39 mmol/mol identifies 90% of women with abnormal glucose tolerance post-GDM (mean 2.6 years (s.d.1.0) post-index pregnancy). Applying this follow-up strategy will reduce the number of OGTT tests required by 70%, will be more convenient for women and their practitioners, and is likely to lead to increased uptake of long-term retesting by these women whose risk for type 2 diabetes is substantially increased.

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.

Treatment With Diet and Exercise for Women With Gestational Diabetes Mellitus Diagnosed Using IADPSG Criteria

CONTEXT Prevalence of gestational diabetes mellitus (GDM) and obesity continue to increase. OBJECTIVE This study aimed to ascertain whether diet and exercise is a successful intervention for women with GDM and whether a subset of these women have comparable outcomes to those with normal glucose tolerance (NGT). DESIGN, SETTING, AND PARTICIPANTS This was a retrospective cohort study of five antenatal centers along the Irish Atlantic seaboard of 567 women diagnosed with GDM and 2499 women with NGT during pregnancy. INTERVENTION Diet and exercise therapy on diagnosis of GDM were prescribed and multiple maternal and neonatal outcomes were examined. RESULTS Infants of women with GDM were more likely to be hypoglycemic (adjusted odds ratio [aOR], 7.25; 95% confidence interval [CI], 2.94-17.9) at birth. They were more likely to be admitted to the neonatal intensive care unit (aOR, 2.16; 95% CI, 1.60-2.91). Macrosomia and large-for-gestational-age rates were lower in the GDM group (aOR, 0.48; 95% CI, 0.37-0.64 and aOR, 0.61; 95% CI, 0.46-0.82, respectively). There was no increase in small for gestational age among offspring of women with GDM (aOR, 0.81; 95% CI, 0.49-1.34). Women with diet-treated GDM and body mass index (BMI) < 25 kg/m(2) had similar outcomes to those with NGT of the same BMI group. Obesity increased risk for poor pregnancy outcomes regardless of diabetes status. CONCLUSION Medical nutritional therapy and exercise for women with GDM may be successful in lowering rates of large for gestational age and macrosomia without increasing small-for-gestational-age rates. Women with GDM and a BMI less than 25 kg/m(2) had outcomes similar to those with NGT suggesting that these women could potentially be treated in a less resource intensive setting.

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.

A Prepregnancy Care Program for Women With Diabetes: Effective and Cost Saving

CONTEXT Only a minority of women with diabetes attend prepregnancy care service and the economic effects of providing this service are unclear. OBJECTIVE The objective of the study was to design, put into practice, and evaluate a regional prepregnancy care program for women with types 1 and 2 diabetes. DESIGN This was a prospective cohort and cost-analysis study. SETTING The study was conducted at antenatal centers along the Irish Atlantic Seaboard. PARTICIPANTS Four hundred fourteen women with type 1 or 2 diabetes participated in the study. INTERVENTIONS The intervention for the study was a newly developed prepregnancy care program. MAIN OUTCOME MEASURES The program was assessed for its effect on the risk of adverse pregnancy outcomes. The difference between program delivery cost and the excess cost of treating adverse outcomes in nonattendees was evaluated. RESULTS In total, 149 (36%) attended: this increased from 19% to 50% after increased recruitment measures in 2010. Attendees were more likely to take preconception folic acid (97.3% vs 57.7%, P < .001) and less likely to smoke (8.7% vs 16.6%, P = .03) or take potentially teratogenic medications at conception (0.7 vs 6.0, P = .008). Attendees had lower glycated hemoglobin levels throughout pregnancy (first trimester glycated hemoglobin 6.8% vs 7.7%, P < .001; third trimester glycated hemoglobin 6.1% vs 6.5%, P = .001), and their offspring had lower rates of serious adverse outcomes (2.4% vs 10.5%, P = .007). The adjusted difference in complication costs between those who received prepregnancy care vs usual antenatal care only is €2578.00. The average cost of prepregnancy care delivery is €449.00 per pregnancy. CONCLUSIONS This regional prepregnancy care program is clinically effective. The cost of program delivery is less than the excess cost of managing adverse pregnancy outcomes.

Abnormal glucose tolerance post-gestational diabetes mellitus as defined by the International Association of Diabetes and Pregnancy Study Groups criteria

OBJECTIVE An increase in gestational diabetes mellitus (GDM) prevalence has been demonstrated across many countries with adoption of the International Association of the Diabetes and Pregnancy Study Groups (IADPSG) diagnostic criteria. Here, we determine the cumulative incidence of abnormal glucose tolerance among women with previous GDM, and identify clinical risk factors predicting this. DESIGN Two hundred and seventy women with previous IADPSG-defined GDM were prospectively followed up for 5years (mean 2.6) post-index pregnancy, and compared with 388 women with normal glucose tolerance (NGT) in pregnancy. METHODS Cumulative incidence of abnormal glucose tolerance (using American Diabetes Association criteria for impaired fasting glucose, impaired glucose tolerance and diabetes) was determined using the Kaplan-Meier method of survival analysis. Cox regression models were constructed to test for factors predicting abnormal glucose tolerance. RESULTS Twenty-six percent of women with previous GDM had abnormal glucose tolerance vs 4% with NGT, with the log-rank test demonstrating significantly different survival curves (P<0.001). Women meeting IADPSG, but not the World Health Organization (WHO) 1999 criteria, had a lower cumulative incidence than women meeting both sets of criteria, both in the early post-partum period (4.2% vs 21.7%, P<0.001) and at longer-term follow-up (13.7% vs 32.6%, P<0.001). Predictive factors were glucose levels on the pregnancy oral glucose tolerance test, family history of diabetes, gestational week at testing, and BMI at follow-up. CONCLUSIONS The proportion of women developing abnormal glucose tolerance remains high among those with IADPSG-defined GDM. This demonstrates the need for continued close follow-up, although the optimal frequency and method needs further study.

Diabetic retinopathy in pregnancy: a population-based study of women with pregestational diabetes.

The aim of this observational study was to evaluate screening and progression of diabetic retinopathy during pregnancy in women with pregestational diabetes attending five antenatal centres along the Irish Atlantic seaboard. An adequate frequency of screening was defined as at least two retinal evaluations in separate trimesters. Progression was defined as at least one stage of deterioration of diabetic retinopathy and/or development of diabetic macular edema on at least one eye. Women with pregestational diabetes who delivered after 22 gestational weeks (n = 307) were included. In total, 185 (60.3%) had an adequate number of retinal examinations. Attendance at prepregnancy care was associated with receiving adequate screening (odds ratio 6.23; CI 3.39–11.46 (P < 0.001)). Among those who received adequate evaluations (n = 185), 48 (25.9%) had retinopathy progression. Increasing booking systolic blood pressure (OR 1.03, CI 1.01–1.06, P = 0.02) and greater drop in HbA1c between first and third trimesters of pregnancy (OR 2.05, CI 1.09–3.87, P = 0.03) significantly increased the odds of progression. A significant proportion of women continue to demonstrate retinopathy progression during pregnancy. This study highlights the role of prepregnancy care and the importance of close monitoring during pregnancy and identifies those patients at the highest risk for retinopathy progression.

Postpartum glucose testing for women with gestational diabetes mellitus: Improving regional recall rates

Our aim was to evaluate attendance for postpartum glucose testing among women attending five antenatal centres with a diagnosis of GDM in the preceding pregnancy. A central, regional coordinator who made verbal and written contact with each individual facilitated a favourable recall rate of 75%.