Abstract
Adequacy of preconceptual counselling of diabetic women attending a joint diabetic antenatal clinic: an audit
Hak-Koon Tan MBBS MRCOG MMED (O&G), Chuen-Wen Tan MBBS, Chee-Hoe Chan MBBS, Yim-Leng Tham SRN SCM BHSN and Lay-Kok Tan MBBS MRCOG MMED (O&G)
Singapore General Hospital, Singapore
Introduction
The association between poor diabetic control and adverse obstetric outcomes including increased perinatal morbidity and mortality is well established. Preconceptual counselling of women with established diabetes mellitus is important in optimizing perinatal outcomes, by ensuring that conception occurs in conditions with good diabetic control and diabetic-related complications screened for and managed. In clinical practice the Haemoglobin A1C (HbA1c) taken at the first antenatal booking gives an indication of the degree of diabetic control. The aim of this study is to determine the mean booking antenatal HbA1c as an indicator of the adequacy of preconceptual counselling in a group of established diabetic pregnant women attending a joint diabetic antenatal clinic.
Methods
The records of all women attending the joint diabetic antenatal clinic in 2005 were retrospectively reviewed, and patients divided into those who were established diabetics (previously diagnosed and pre-existing diabetes) and those who were gestational diabetics (diabetic status diagnosed in pregnancy). The mean of the first HbA1c, recorded during the course of their antenatal care, was calculated and compared.
Results
There were a total of 140 women of which 23 were established diabetics (19.7%). The mean HbA1c was 7.5%, while that for the gestational diabetic group was 5.6% (P < 0.05). There was subsequent improvement in the diabetic control of established diabetic group, with the final recorded HbA1c having a mean of 6.4% (P < 0.05).
Conclusion
Receiving a multidisciplinary team approach improves diabetic control during pregnancy. Despite knowing themselves to have pre-existing diabetes and already receiving care prior to pregnancy, the mean booking antenatal HbA1c value of 7.5% of established diabetic women is unsatisfactory. There is an urgent need to improve preconceptual counselling services. This often overlooked aspect of management should be highlighted to primary health-care services, endocrinologists and gynaecologists looking after diabetic women of reproductive age.
Compliance with the postpartum OGTT: the weakest link in the holistic management of gestational diabetes mellitus?
Lay-Kok Tan MBBS MRCOG MMED (O&G), Chuen-Wen Tan MBBS, Chee-Hoe Chan MBBS, Yim-Leng Tham SRN SCM BHSN and Hak-Koon Tan MBBS MRCOG MMED (O&G)
Singapore General Hospital, Singapore
Introduction
Gestational diabetes mellitus is diagnosed on the basis of an oral glucose tolerance test (OGTT) performed during the course of pregnancy. A postpartum OGTT performed six weeks after delivery for gestational diabetics is necessary to identify those patients who might in fact be a previously undiagnosed pre-existing diabetes or have impaired glucose tolerance. This knowledge would be important for their continued long-term management as well as having implications for their future pregnancies. The aim of this study is to audit the compliance of gestational diabetics with following up with the postpartum OGTT, and the results of the postpartum OGTT.
Methods
Retrospective review of the records of all women who attended the joint diabetic antenatal clinic in 2005. Gestational diabetics were those whose diabetic condition was diagnosed during the pregnancy. Outcomes: attendance at postpartum OGTT, and if so, the result of the OGTT, with subsequent re-classification of the woman as diabetic, impaired glucose tolerance or normal.
Results
There were 140 women of which 117 were gestational diabetics (83.6%). All were given a six-week postpartum appointment for an OGTT. Only 60 women attended indicating a 48.7% default rate. Of the 60 who performed the postpartum OGTT, six (10%) were diagnosed with diabetes mellitus and 12 (20%) had impaired glucose intolerance.
Conclusion
The default rate for performing the postpartum OGTT is unacceptably high (almost one in two patients). That at least 30% of gestational diabetics will have at least impaired glucose tolerance or diabetes shows the importance of performing this test, with the true figure likely to be higher. Further measures including patient education should be put in place to improve compliance.
Delivery outcomes of established diabetic and gestational diabetic women attending a joint diabetic pregnancy clinic
Lay-Kok Tan MBBS MRCOG MMED (O&G), Chuen-Wen Tan MBBS, Chee-Hoe Chan MBBS, Yim-Leng Tham SRN SCM BHSN, Su-Chi Lim MBBS MRCP FAMS and Hak-Koon Tan MBBS MRCOG MMED (O&G)
Singapore General Hospital, Singapore
Introduction
Given the well-established association between poor diabetic control and increased perinatal morbidity and mortality, such pregnancies are best managed in a multidisciplinary clinic with an obstetrician and endocrinologist jointly in attendance. The aim of this study is to determine and compare the delivery outcomes of diabetic women (both established and gestational) in terms.
Patients and methods
Retrospective review of all women who attended the Joint Diabetic Pregnancy Clinic at the Singapore General Hospital. Delivery outcomes of labour induction rate, mean gestational age at delivery, mean birth weight, instrumental delivery rate and caesarean section rate were collected. The women were either established diabetics or gestational diabetics (GDM), based on the results of an oral glucose tolerance test (OGTT) performed at 28 weeks or earlier based on the clinical criteria and risk factors. Based on the availability of a postpartum OGTT, GDM women were re-classified as established diabetics, impaired glucose intolerance (IGT) or true GDM.
Results
There were a total of 140 women of whom 23 were known established diabetics (16.4%), leaving 117 classified as GDM as their diabetic status was only diagnosed during pregnancy. The mean gestational age of delivery was 36 and 39 weeks for established diabetics and GDM, respectively, with birth weights of 2840 and 3158 g, respectively. The induction rate was 18.2% and 20.5%, the caesarean section rate was 52.2% and 35% for established diabetics and GDM, respectively. The instrumental delivery rate was 8.7% and 7.9% for these two groups, respectively. The subgroup analysis will be presented separately.
Conclusion
The results will be discussed. Diabetic mothers should be counselled that with joint diabetic antenatal care, the mean gestational age of delivery is almost term for established diabetics and term for GDM. There is a one in five chance that their labour will be induced, as well as a higher risk of requiring a caesarean delivery compared with non-diabetic mothers, with established diabetics having a risk of one in two.
Diabetes in pregnancy: the Corniche experience
Bashir Salih MD, V M Rennie and Nageena Mahmoud MD FRCP
Corniche Hospital, Abu Dhabi, UAE
The experiment
Corniche Hospital is a major maternity hospital in the UAE with an annual delivery rate of 10,000–12,000 per year. Over 9% of the women attending the hospital have been identified as having diabetes in pregnancy. Ninety-two percent of these women have gestational diabetes of which 72% are treated with diet and 28% require insulin. In view of the large proportion of women being seen with diabetes and the potential perinatal morbidity associated with this condition, a separate clinic was set up for looking after women with diabetes requiring insulin in pregnancy in 1997.
This clinic is called the Combined Diabetic Clinic and is manned by an Obstetrician, an Obstetric Physician, Diabetes Educator and Dietician who look after these women as a multidisciplinary team.
Out of the patients attending Corniche Hospital Diabetes Clinic, 61% had pre-existing diabetes, of which 55% had type 2 and 6% had type 1 diabetes. Thirty-nine percent of the women were detected to have gestational diabetes.
The neonatal intensive care unit (NICU) statistics at Corniche have highlighted the fact that babies born to mothers whose diabetes is controlled by diet alone have a greater morbidity than the insulin-controlled group.
The UAE has one of the highest prevalence of diabetes in the world and universal screening should be used to detect gestational diabetes. More work is required to elucidate how women with diabetes – regardless of type – can be best enabled to improve the outcomes of their pregnancy. This applies in particular to preconception care.
Perception of risk of development of T2DM and unrecognized diabetes following a GDM pregnancy
Janine Malcolm, Margaret L Lawson, Stasia Hadjannakis, Isabelle Gaboury and Erin J Keely MD FRCPC
University of Ottawa, Canada
Objectives
Women with a history of gestational diabetes (GDM) have a high chance of developing type 2 diabetes mellitus (T2DM) following the index pregnancy. However, little is known of women's perception of this risk. Objectives were to (1) to determine women's perception of risk of future development of T2DM following a GDM pregnancy; (2) to describe the prevalence of undetected dysglcaemia and the prevalence of risk factors associated with T2DM in a Canadian population.
Study design
A 9–11-year follow-up study of women previously enrolled in a randomized controlled trial of tight versus minimal intervention for GDM. Women's perception of future risk of diabetes was determined by questionnaire. Fasting lipid profile, height and weight were performed on all participants. Oral glucose tolerance test were performed on all women with no prior history of T2DM.
Results
Eighty-nine of 299 (30%) of the original cohort were recruited. Seventy-seven women completed the questionnaire. Twenty-three of 30% felt their risk was no different than other women or did not know, 27 (35%) felt risk was increased a little, 27 (35%) felt risk was increased a lot. Twenty-five of 88 (28%) patients had diabetes (11 previously diagnosed and 14 diagnosed within the study). Of those newly diagnosed with T2DM, four of 29% were diagnosed by fasting glucose, six of 42% by two-hour glucose tolerance test (GTT) alone and four of 29% by both. Twenty-four women had impaired glucose tolerance. Of those with impaired glucose tolerance (IGT), 12 (57%) had a FBG < 5.6 mmol/L. Two were overweight, seven were obese, four had a family history of T2DM and all had a waist circumference of >88 cm in the high-risk perception group with newly diagnosed diabetes.
Conclusion
The perception of being at high risk for T2DM did not prevent women from having undetected T2DM. Many factors likely contribute to this, including the reliance on screening tests other than a two-hour GTT (i.e. fasting glucose) to detect diabetes. Further studies on effective public and health-care provider education and intervention are needed to identify this high-risk population.
Management of diabetes in pregnancy: fairview health system experience
Tanya Melnik MD
University of Minnesota Medical School, USA
Diabetes mellitus was documented in approximately 3.8% of pregnancies in the USA in 2005. Gestational diabetes accounted for the majority of the cases diagnosed in pregnancy (up to 90%), while type 1 and type 2 diabetes accounted for the remainder of the cases. Given the increase in incidence of diabetes in recent years, it has been estimated that about 1% of all pregnancies is complicated by pre-existing diabetes. Adverse obstetric outcomes, such as miscarriage, preterm labour, fetal macrosomia and increase in perinatal morbidity and birth injury, have been associated with maternal diabetes. The risk of the complications can be reduced by appropriate management of maternal blood glucose during pregnancy.
Clinical algorithms and protocols have been previously documented to improve care of diabetic patients in outpatient as well as inpatient care settings. Fairview Health Services is a large integrated health-care system in Minnesota providing inpatient as well as outpatient care through several hospitals as well as clinics. A quality improvement project in diabetes care during pregnancy was started in 2007 by the multidisciplinary panel of experts. Development of protocols for inpatient as well as outpatient care for pregnant women with diabetes, also collaborative practice agreement for the providers involved in care of such patients and initial stages of implementation of the algorithms for chronic disease management in pregnancy, will be discussed in the presentation.
A two-hour oral glucose tolerance test will identify more women with type 2 diabetes or impaired glucose tolerance than a fasting glucose when screening postpartum in gestational diabetics
Heather D Clark MD CM FRCPC MSc*†, Alan Karovitch MD MEd FRCPC*‡ and Erin J Keely MD FRCPC§
*University of Ottawa; †Ottawa Hospital-Civic Campus; ‡Ottawa Hospital-General Campus; §Ottawa Hospital-Riverside Campus, Ontario, Canada
The CDA 2003 Clinical Practice Guidelines recommends screening women with gestational diabetes (GDM) in the first six months postpartum for type 2 diabetes mellitus (T2DM) with a two-hour 75 g oral glucose tolerance test (two-hour GTT) as a fasting glucose may lead to an under-diagnosis of type 2 diabetes (Grade D consensus) and cannot identify women with impaired glucose tolerance (IGT). We performed a randomized controlled trial evaluating the effect of postal reminders on screening rates in women with GDM. All women from this cohort who completed a two-hour GTT were included. We determined the rates of impaired fasting glucose (IFG) and T2DM diagnosed by a fasting glucose and IGT, and T2DM diagnosed by a two-hour GTT. Of the 428 patients, 156 women completed a two-hour GTT. Twenty of 156 (12.8%) were diagnosed with IFG, 27 of 156 (17.3%) were diagnosed with IGT and four of 156 (2.6%) were diagnosed with both. Three of 156 (1.9%) women were diagnosed with T2DM by a fasting glucose and 8 of 156 (5.1%) were diagnosed based on the two-hour glucose result only. If a two-step testing strategy was utilized (i.e. only women with fasting glucose >5.6 mmol/L screened with two-hour GTT), 15 of 27 (56%) with IGT and three of 11 (27%) with T2DM would be missed.
Screened with two-hour oral glucose tolerance test
GTT = glucose tolerance test
A case of gastric obstruction in a pregnant patient: a lap-band complication
Jeffrey S Zaidman MD*, Matthew Kozloff MD* and Rossana Moura MD†
*Rhode Island Hospital; †Women & Infants Hospital, USA
The use of a laparoscopically placed adjustable gastric band (Lap-band) is an increasingly popular method of weight loss. Care of the pregnant patient who has a Lap-Band requires knowledge of the device and its potential complications to promote proper prenatal nutrition and to ensure early recognition of complications.
Case report
A 28-year-old pregnant woman at 30 weeks four days gestation presented with an inability to tolerate food or drink. She had a remote history of an uneventful Lap-band placement for morbid obesity, with appropriate weight loss subsequently. The patient reported that her present symptoms were progressive over the course of the pregnancy and for two weeks prior to presentation any ingestion of solids or liquids would result in vomiting. She reported a 24 pound weight loss since becoming pregnant. Physical examination revealed a weight of 136 pounds, gravid uterus, mild epigastric tenderness and a palpable port site. An upper GI series revealed gastric obstruction at the level of the Lap-band, but deflation of the band failed to relieve the obstruction. A diagnosis of stoma obstruction secondary to band slippage was made. Laparoscopic removal of the Lap-band was performed and, postoperatively, the patient had complete resolution of symptoms and subsequent weight gain.
This case illustrates the potential for inappropriate weight gain or even complete food intolerance during pregnancy secondary to complications arising from an adjustable gastric band. Lap-band in pregnancy requires close coordination of care between obstetricians, bariatric surgeons and gastroenterologists to ensure appropriate management of the device and proper maternal nutrition.
Prepregnancy care for women with type 2 versus type 1 diabetes
Erin J Keely MD FRCPC*†, Janine Malcolm*‡, Heather D Clark MD CM FRCPC*‡, Alan Karovitch MD MEd FRCPC*§ and Edith Valcourt*§
*University of Ottawa; †Ottawa Hospital-Riverside Campus; ‡Ottawa Hospital-Civic Campus; §Ottawa Hospital-General Campus, Ontario Canada
Introduction
Type 2 diabetes (T2DM) is associated with poor obstetrical outcomes including increased congenital anomalies as is type 1 diabetes (T1DM). Preconception care with optimization of glucose control, identification of complications, substitution or discontinuation of medications best avoided in pregnancy and folic acid supplementation should be provided for all women with pregestational diabetes. However, in clinical practice this is rarely achieved. The goal of this study was to compare the preconception care of women with T1 and T2DM, and to identify barriers to optimization prior to pregnancy.
Methods
Women with T1 and T2DM were recruited from the special pregnancy unit at our tertiary centre during their antenatal visits. They were asked to complete a questionnaire and semi-structured interview. Demographic data, diabetes and medication history, prepregnancy folate use, pregnancy planning, information sources used and diabetes education information was collected.
Results
Women with T2DM (n = 35) were older (33 versus 30 years), heavier (body mass index 34 versus 27 kg/m2) and non-caucasian (31% versus 8%) compared with women with T1DM (n = 35). They were more likely to receive their care from a family physician (41% versus 20%), less likely to meet with the diabetes education team within one year prior to conceiving and did less glucose monitoring. There was no difference in preconception folic acid supplementation (70% versus 77%), gestational age at first visit to the clinic (11.4 versus 11.1 weeks) or first visit HbA1c (6.7% versus 6.9%). Only 32% of women with T2DM were on insulin prior to conception.
Conclusion
Women with T2DM were less likely to have been provided specialized services prior to pregnancy and were often not changed to insulin in anticipation of pregnancy. Public and professional education is needed to promote the importance of preconception care for women with T2DM.
Obesity, the emerging challenge to maternity care
Nageena Mahmood MD MRCP, Rashida Abbas MD MRCOG, Bashir Salih MD and Natalie Bennett
Corniche Hospital, Abu Dhabi, UAE
Background
The Corniche Hospital is the largest maternity hospital in the UAE, with an annual delivery rate of up to 12,000. The International Task Force on Obesity report in 2007 stated that 74% of UAE women are obese. This far exceeds the incidence within the USA, thus propelling obesity to the forefront of medical concerns.
Objective
To study the prevalence of obesity and subsequent maternal and perinatal morbidity from antenatal booking through to delivery.
Study design
A prospective, non-interventional pilot study of all patients registered for antenatal booking over a one-month period.
Results
Five hundred and sixty-three patients registered for antenatal booking over a four-week period. The prepregnancy body mass index (BMI) was calculated for each woman. Four hundred and twenty of these women delivered in Corniche and their data was analysed postnatally. Of these, 67.6% patients had a BMI of ≥25, 35.4% had a BMI ≥ 30 and 4.5% had a BMI ≥ 40. The main maternal morbidity was diabetes (which affects 14% of our hospital population), with 55% of diabetics having a BMI ≥ 30. This was followed by hypertension (3.11%). Osteoarthritis was noted in two patients both with a BMI ≥ 45 (0.47%). Higher caesarean section rate was noted, but not prematurity in those with a BMI ≥ 30.
Conclusion
Obesity is a new epidemic in the UAE. The researchers have commenced a large-scale study in response to these findings. A total of 10,000 women will be targeted to address such issues as optimal weight gain in pregnancy, the role of dietary intervention and optimal GTT timing in those with a BMI ≥ 30.
Exercise in obese pregnant women: a randomized study to assess feasibility
Leonie K Callaway FRACP PhD*, H David McIntyre FRACP†, Paul Colditz MD PhD‡, Nuala Byrne PhD§, Katie Foxcroft RN** and Briony O'Connor**
*University of Queensland, Royal Brisbane and Women's Hospital; †University of Queensland, Mater Mothers Hospital; ‡University of Queensland, Centre for Clinical Research; §Queensland University of Technology; **Royal Brisbane and Women's Hospital, Brisbane, Australia
Background
Obesity is arguably the leading reason for a high-risk pregnancy. Obese pregnant women are more likely to develop gestational diabetes and hypertensive disorders of pregnancy. Exercise improves insulin sensitivity and lowers blood pressure, and so it could be a valuable therapy in helping to prevent pregnancy complications in obese pregnant women.
Objectives
To assess the feasibility of a highly supported, individualized exercise programme in obese pregnant women.
Methods
Fifty obese women were recruited early in pregnancy and randomized to either a highly supported, individualized exercise intervention or usual activity. Women in the intervention arm met with a physiotherapist/exercise physiologist, and had a detailed assessment of their preferences for physical activity and potential barriers to physical activity. A personalized programme was developed, targetting 1500 kCal of physical activity per week (equivalent to 30 minutes of physical activity on most days of the week). Women could choose from a menu of options including, pregnancy aqua-aerobics, pregnancy fitness classes, swimming, commercial fitness programmes, walking, playing with their children, dancing and many other options. Women were provided with free memberships and passes to access these options, and extensive support. Programmes were reviewed at least second weekly. Physical activity was measured in both intervention and control women using the validated Physical Activity Questionnaire and accelerometers.
Results
At 28 weeks, women in the intervention arm showed a mean of 1213 kCal (standard deviation [SD] 931) exercise per week compared with 710 kCal (SD 873) for the control group (P = 0.03). However, there was no statistically significant difference in the overall physical activity of the two groups. On objective measure with the accelerometer, there was no difference in physical activity in either group at any point during pregnancy.
Discussion
Despite the intensive efforts to assist women to exercise in this study, there was no objective evidence that an exercise programme of this type succeeded in providing women with a ‘dose’ of exercise. There was an interesting difference between the results of the validated pregnancy physical activity questionnaire and objective accelerometer measurements. This highly supported, individualized exercise intervention is not a feasible way of increasing exercise in obese pregnant women.