Clinical FeaturesEndocrine/MetabolicWomen’s Health

Diabetes in Pregnancy

Medical conditions can develop in pregnancy, such as Gestational Diabetes (GDM), or pregnancy may exacerbate pre-existing medical conditions such as PreGestational Diabetes (PGDM). Diabetes is the most common significant medical condition to affect pregnant women with up to 12% of pregnancies in Ireland affected by diabetes. This article aims to briefly outline diabetes in pregnancy and look at advances in the management of diabetes in pregnancy.

Pre-Gestational Diabetes

Pre-Gestational Diabetes Mellitus, Type 1 Diabetes Mellitus (T1DM) and Type 2 Diabetes Mellitus (T2DM) occurs in 1-2% of all pregnancies, with rates of new diabetes diagnosis rising in women of child bearing age. PGDM confers significantly greater risk for both the mother and developing fetus but by providing comprehensive Multidisciplinary Team (MDT) care this can help reduce adverse outcomes. Rates of pre-eclampsia, macrosomia, caesarean section, congenital malformation and perinatal mortality are well established to be increased in this group compared to women without glucose abnormalities. We also see greater evidence of vascular disease e.g. nephropathy, retinopathy and hypertension in this cohort of women which further increases the risks of pregnancy complications.

The number of women presenting with T2DM in pregnancy is increasing in line with a worldwide upward trend in obesity and T2DM now accounts for 30% of women with PGDM in pregnancy. Women with T2DM are more likely to be living with obesity, hypertension and taking pharmacological agents that are contraindicated in pregnancy. Pre-conceptual care is of significant importance in this group to optimise diabetes management and pharmacological management of any pre-existing co-morbidities prior to achieving pregnancy.

Women with PGDM fall within the specialist care pathway within the National Maternity Strategy and require specialist care, booked from early pregnancy, often earlier than the traditional 12 week booking visit. The MDT is comprised of obstetrics, endocrinology, specialist midwifery, dietitians, lactation consultants, ultra-sonographers and ophthalmologists. Women require frequent review in the specialist diabetes clinic, often every 3-4 weeks, in comparison with standard antenatal combined care. The complexity of care required for women with PGDM due to complications and complexity of disease is demanding.

The advent of diabetes healthcare technology has provided both women and healthcare professionals with information to allow for accurate and contemporaneous dosing of insulin on a background of dynamic hormone changes and insulin resistance. Diabetes technology describes devices that are used by women with diabetes to help achieve glycaemic control and improve quality of life. Frequently used devices include Continuous Glucose Monitoring Sensors (CGMs), Continuous Subcutaneous Insulin Pumps (more recently closed loop hybrid systems) and smart insulin pens.

The current NICE guidelines recommends that all pregnant women with PGDM are offered CGMs and upcoming guidance will suggest that all women attempting to achieve pregnancy are offered closed loop hybrid insulin pumps. Insulin pump therapy has demonstrated effectiveness in lowering HbA1c prior to and during pregnancy and can be beneficial in cases of impaired hypoglycaemic awareness. The National Maternity Hospital provides a comprehensive service for women using Continuous Subcutaneous Insulin Pump Therapy (CSII) and continuous glucose monitoring (sensor) technology. The provision of this service requires expert training and continuous professional development to keep up to date with the multiple technology advances being made in diabetes care internationally. Current figures show that over 50% of women with T1DM attending The National Maternity Hospital are now using insulin pumps and even higher rates of CGMs are observed. Although the numbers of women with PGDM in the service are small compared to the GDM cohort they are under the care of the service from 6 weeks’ gestation and require weekly MDT input.

Gestational Diabetes

Gestational Diabetes (GDM) is diabetes with first onset or recognition during pregnancy. Maternal insulin resistance increases during pregnancy to ensure sufficient nutrition to the developing fetus and may result in impaired insulin action. GDM is a dynamic condition of variable severity and the most current Irish data suggests a prevalence of 12.4% of all pregnancies are affected by GDM. Women are often screened based on identified risk factors and some centres have implemented universal screening for all pregnant women. The increase in GDM prevalence is in line with global upward trends in obesity, advanced maternal age and a decrease in physical activity levels. GDM is one of the most common medical conditions to be diagnosed in pregnancy and results in an increased likelihood of pre-eclampsia, birth injury and caesarean section. Offspring of women with GDM are more likely to have a higher birth weight, neonatal hyperinsulinemia, birth trauma and intrauterine death. Lifestyle modification, a combination of medical nutritional therapy and physical activity are the cornerstone of treatment for GDM. These services are often delivered by specialist midwifery, dietitians and endocrinology and are shown to be highly effective in managing GDM. Whilst a yearly increase in gestational diabetes is expected, the numbers of women controlled with conservative measures i.e. lifestyle intervention remains constant in The National Maternity Hospital (~75%) however a proportion of this cohort will require pharmacological treatment.

The midwifery led team changed the care pathway for women diagnosed with gestational diabetes in The National Maternity Hospital. Our virtual care pathway means that following the initial diagnosis of GDM, women are educated via a live webinar in the comfort of their own surroundings with a specialist midwife and dietitian. Each woman is then followed up with virtual telehealth clinic appointments using the “Attend Anywhere” platform, the frequency of which is tailored to each woman’s gestation and needs.

The diabetes midwifery team sourced a blood glucose monitor, which is bluetooth enabled and syncs to an app that autopopulates to a patient master list. Consequently, for every virtual appointment, each woman’s synched information is readily available. This, in conjunction with the electronic health record, facilitates a comprehensive midwifery led consultation. Our colleagues from the Department of Clinical Nutrition and Dietetics also participate in the virtual “Attend Anywhere” clinic. This allows women access to both specialist midwives and specialist dietetics during the same appointment. It addition, this care pathway allows for immediate escalation to the advanced midwife practitioner to review for pharmacological treatment requirement. If insulin therapy is indicated, each woman receives same day education on insulin administration and safety via this virtual platform, enabling immediate commencement of insulin therapy.

From there, women can be referred to Endocrinology and Obstetric care within the diabetes in pregnancy specialist clinic if required. With the twinning of “Attend Anywhere” and the new remote glucose monitoring, the midwifery team aim to deliver evidence-based care on a more personal and easily accessible level to transform the service for women and enhance access to services.

At present we are at the write up stage of a research study to evaluate maternal and neonatal outcomes following the implementation of the virtual pathway of care. This aims to examine the use of assistive healthcare technology i.e. Attend Anywhere and bluetooth enabled healthcare technology. We are also evaluating maternal and pregnancy outcomes including interval to treatment, rates of pharmacological treatment, mode of delivery and induction rates. In addition, relevant neonatal outcomes will be evaluated including birth weight, NICU admission rates and neonatal hypoglycaemia rates. This study is the first of its type and size in Ireland that will examine real clinical outcomes for virtual care pathways and we are hopeful it will provide data to support the safe and widespread use of virtual care pathways to improve access to healthcare.

Written by Ciara Coveney, Registered Advanced Midwife Practitioner, Diabetes in Pregnancy at The National Maternity Hospital

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