National Pregnancy in Diabetes Audit Report 2020

Health Quality Improvement Partnership | October 2021 | National Pregnancy in Diabetes Audit Report 2021

The National Pregnancy in Diabetes Audit measures the quality of antenatal care and pregnancy outcomes for women with pre-gestational diabetes. HQIP has published its report for 2020.

Key findings from the audit report:

There are now more pregnancies in women with type 2 diabetes, than in women with type 1 diabetes (54 per cent of diabetes’ pregnancies, compared to 47 per cent in 2014).

Women with type 2 diabetes face additional healthcare inequalities and are frequently not prepared for pregnancy (reduced use of insulin and folic acid before pregnancy), and

Despite the additional challenges of supporting women with diabetes during the COVID-19 pandemic, pregnancy outcomes are comparable in 2019 and 2020.

Image source: HQIP The first mage shows a sonographer, ultrasound and an expectant couple. The second shows a pregnant women preparing a selection of healthy foods

The report makes three recommendations

  1. Dedicated pre-pregnancy co-ordinators focused on enhanced provision of contraception and support for pregnancy preparation are recommended to improve glycaemic management and 5mg folic acid supplementation before pregnancy, especially in women with type 1 and type 2 diabetes, living in the most deprived regions.
  2. We found fewer preterm births, large for gestational age (LGA) birthweight, neonatal care admissions and perinatal deaths in women with HbA1c less than 43mmol/mol from 24 weeks gestation, both in the current 2019-2020 and recent datasets*. NICE guidelines [NG3 Diabetes in pregnancy: management from preconception to the postnatal period], recommend use of continuous glucose monitoring (CGM) in type 1 diabetes. Data are now needed to evaluate whether Libre or CGM use will improve glucose levels, target HbA1c attainment and neonatal health outcomes in pregnant women with type 2 diabetes.
  3. Access to structured education, weight management and diabetes prevention programmes for women (Source: HQIP).

National Pregnancy in Diabetes (NPID) Audit Report 2020

Metformin for pregnancy and beyond: the pros and cons

Newman, C. & Dunne, F. P. | 2021| Metformin for pregnancy and beyond: the pros and cons | Diabetic Medicine | https://doi.org/10.1111/dme.14700

The authors of this review set out to review the benefits and potential pitfalls of metformin use in pregnancy. To this end they conducted a literature search of web-based databases (including PubMed, CENTRAL via the Cochrane Library and EMBASE) using identified search terms. They read the full texts of any relevant texts published in English and searched clinicaltrials.gov for relevant unpublished trials. The team included randomised controlled trials (RCTs), cluster RCTs, pilot and feasibility studies in our review. They excluded conference abstracts, case reports and case series. Observational data which were deemed to be of high quality were also considered. Additionally, the researchers searched bibliographies for all relevant publications to identify other studies.

In this paper they report their findings that metformin has many maternal advantages when taken during and after pregnancy, including reduced maternal GWG, PTD and insulin requirements, a reduction in operative delivery and possible reduction in hypertensive disorders and future type 2 diabetes. Some benefits are even greater for women with a BMI more than or equal to 30 kg/m2 (Source: Newman & Dunne, 2021).

Abstract

Context and Aim

Metformin has been used in pregnancy since the 1970s. It is cheap, widely available and is acceptable to women. Despite its increasing use, controversy remains surrounding its benefits and risks. Metformin effectively reduces hyperglycaemia for the mother during pregnancy and it reduces rates of macrosomia and neonatal hypoglycaemia. However, concern exists surrounding an increase in the rate of SGA births and obesity in childhood. We aim to review the evidence and expert opinion behind metformin in pregnancy through to the post-partum period.

Methods

We performed a literature review of relevant studies from online databases using a combination of keywords. We also searched the references of retrieved articles for pertinent studies.

Results

There is strong evidence that metformin is safe in early pregnancy with no risk of congenital malformations. If used throughout pregnancy, it is likely to lead to reduced maternal weight gain and reduced insulin dose in women with type 2 diabetes. In infants, metformin reduces hypoglycaemia and macrosomia but may increase the rate of infants born SGA. There is some evidence of an increased risk of obesity and altered fat distribution in offspring. Metformin appears well tolerated in pregnancy and is more acceptable to women than insulin therapy.

Conclusion

Due to increasing rates of maternal obesity, GDM and type 2 diabetes, metformin use in pregnancy is increasing. Overall, it appears safe and effective but further research is needed to examine mechanisms linking metformin to obesity reported during childhood in some follow-up studies.

  • Metformin has been used outside of pregnancy for decades and has multiple benefits in pregnancy including reduced weight gain and a potential decrease in pre-eclampsia (PET).
  • However, some clinicians have concerns regarding its use due to increased rates of small for gestational age (SGA) births and adiposity in infants exposed to metformin.
  • With the rising rates of obesity and gestational diabetes (GDM), cheap, acceptable and effective treatments for hyperglycaemia are needed.
  • This study follows the use of metformin from the pre-conception to the post-partum period and examines the evidence for and against its use.

The primary paper is available from the journal Diabetic Medicine

The impact of COVID-19 on the physical activity and sedentary behaviour levels of pregnant women with gestational diabetes #Covid19RftLks

Hillyard, M., Sinclair, M., Murphy, M., Casson, K. & Mulligan, C. | 2021 | The impact of COVID-19 on the physical activity and sedentary behaviour levels of pregnant women with gestational diabetes | PLoS ONE | 16 | 8 | e0254364. https://doi.org/10.1371/journal.pone.0254364

The authors’ objective was to understand how COVID-19 has affected the self-reported physical activity and sedentary behaviour levels of pregnant women with gestational diabetes mellitus (GDM). To this end they surveyed over 500 participants using an online survey to gauge levels of physical activity and sedentary behaviour in this population.

The COVID-19 pandemic has had a considerable impact on the activity levels of pregnant women with gestational diabetes and for the researchers of this study, highlights the need for targeted public health initiatives. In their paper they underline that the findings of their study will help policy makers and health service providers to understand how best to support pregnant women during subsequent waves of COVID-19 or future pandemics or situations requiring lockdown.

Abstract

Background

The aim of this study was to understand how physical activity and sedentary behaviour levels of pregnant women with gestational diabetes in the UK have been affected by COVID-19.

Methods

An online survey exploring physical activity and sedentary behaviour levels of pregnant women with gestational diabetes during COVID-19 was distributed through social media platforms. Women who had been pregnant during the COVID-19 outbreak and had gestational diabetes, were resident in the UK, were 18 years old or over and could understand written English were invited to take part.

Results

A total of 724 women accessed the survey, 553 of these met the eligibility criteria and took part in the survey. Sedentary time increased for 79 per cent of the women during the pandemic. Almost half of the women (47 per cent) were meeting the physical activity guidelines pre COVID-19 during their pregnancy, this dropped to 23 per cent during the COVID-19 pandemic. Fear of leaving the house due to COVID-19 was the most commonly reported reason for the decline. Significant associations were found between meeting the physical activity guidelines during COVID-19 and educational attainment, fitness equipment ownership and knowledge of how to exercise safely in pregnancy.

Conclusions and implications

These results show the impact of COVID-19 on physical activity and sedentary behaviour levels and highlight the need for targeted public health initiatives as the pandemic continues and for future lockdowns. Women with gestational diabetes need to know how it is safe and beneficial to them to engage in physical activity and ways to do this from their homes if fear of leaving the house due to COVID-19 is a barrier for them. Online physical activity classes provided by certified trainers in physical activity for pregnant women may help them remain active when face-to-face appointments are reduced and limited additional resources are available.

The impact of COVID-19 on the physical activity and sedentary behaviour levels of pregnant women with gestational diabetes [primary paper]

Balancing diabetes and pregnancy: the keys are shared decision-making and technology

Cochrane | 11 June 2021 | Balancing diabetes and pregnancy: the keys are shared decision-making and technology

This blog provides a patient-perspective Emma Doble, who lives with Type 1 Diabetes and gave birth for the first time in 2020, reflects on her pregnancy journey. She highlights the importance of technology and shared decision-making, and calls for better postnatal care for women with diabetes. 

The blog is available from Cochrane

Gestational diabetes and ethics

Winter, G. | Gestational Diabetes and Ethics| British Journal of Midwifery | Vol. 28, No. 4 | Published Online 2nd April 2020

With cases of gestational diabetes on the rise due to the increase in obesity rates, the author reveals the importance of screening and diagnosis. According to the National Institute for Health and Care Excellence around 700 000 women give birth in England and Wales annually; up to 5% of these women have either pre-existing diabetes or gestational diabetes mellitus; and the incidence of GDM is rising because of higher obesity rates in the general population and more pregnancies in older women.

Available with an NHS OpenAthens password at British Journal of Midwifery

Maternal diabetes during pregnancy and early onset of cardiovascular disease in offspring

Yu, Y., et al. |2019| Maternal diabetes during pregnancy and early onset of cardiovascular disease in offspring: population based cohort study with 40 years of follow-up| BMJ367 | doi: https://doi.org/10.1136/bmj.l6398

A recent study that analysed the association between maternal diabetes in pregnancy and early onset of cardiovascular disease (CVD) in the offspring, found that children of mums with diabetes, particularly those who mothers have CVD or diabetic complications, have higher rates of early onset CVD from childhood to early adulthood. 

The full paper is available to read in the BMJ 

Maternal diabetes during pregnancy and early onset of cardiovascular disease in offspring: population based cohort study with 40 years of follow-up

National Pregnancy in Diabetes Audit

National Pregnancy in Diabetes (NPID) audit report 2018 | The Healthcare Quality Improvement Partnership

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The National Pregnancy in Diabetes (NPID) audit measures the quality of antenatal care and pregnancy outcomes for women with pre-gestational diabetes.

This is the first year that a Quality Improvement Collaborative (QIC) has been incorporated into the NPID programme for 2018/19 with the aim of focusing on improvement activity.

Some of the key findings include:

  • Overall 7 out of 8 women were not well prepared for pregnancy
  • There has been an increase in the rate of admissions with hypoglycaemia for women with type 1 diabetes
  • Almost one in two babies had complications related to maternal diabetes which is mostly the result of large for gestational age (LGA) babies
  • Admissions to neonatal units are more common than in the general population.

Full report: National Pregnancy in Diabetes (NPID) Audit Report 2018

See also: NHS Digital resources

High blood sugar levels and BMI linked to stillbirth in mothers with diabetes 

Mackin, S.T. et al | 2019|Factors associated with stillbirth in women with diabetes| Diabetologica | https://doi.org/10.1007/s00125-019-4943-9

Experts at the University of Glasgow analysed population-level data from Scotland during the period 1 April 1998 to the end of June 2016 to describe timing of stillbirths in women with diabetes and associated risk factors.

 

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They report that babies at extremes of weight centiles are at most risk. The authors of the study conclude that maternal blood glucose level and BMI are the main modifiable risk factors associated with stillbirth in our population of women with diabetes

Many stillbirths occur at term and could potentially be prevented by change in routine care and delivery policies (Source: Mackin, et al. 2019).

Abstract

Aims/hypothesis

Stillbirth risk is increased in pregnancy complicated by diabetes. Fear of stillbirth has major influence on obstetric management, particularly timing of delivery. We analysed population-level data from Scotland to describe timing of stillbirths in women with diabetes and associated risk factors.

 

Methods

A retrospective cohort of singleton deliveries to mothers with type 1 (n = 3778) and type 2 diabetes (n = 1614) from 1 April 1998 to 30 June 2016 was analysed using linked routine care datasets. Maternal and fetal characteristics, HbA1c data and delivery timing were compared between stillborn and liveborn groups.

 

Results

Stillbirth rates were 16.1  and 22.9  per 1000 births in women with type 1 (n = 61) and type 2 diabetes (n = 37), respectively. In women with type 1 diabetes, higher HbA1c before pregnancy and in later pregnancy  were associated with stillbirth, while in women with type 2 diabetes, higher maternal BMI  and pre-pregnancy HbA1c  were associated with stillbirth. Risk was highest in infants with birthweights more than 10th centile (sixfold higher born to women with type 1 diabetes [n = 5 stillbirths, 67 livebirths]; threefold higher for women with type 2 diabetes [n = 4 stillbirths, 78 livebirths]) compared with those in the 10th–90th centile (n = 20 stillbirths, 1685 livebirths). Risk was twofold higher in infants with birthweights more than 95th centile born to women with type 2 diabetes (n = 15 stillbirths, 402 livebirths). A high proportion of stillborn infants were male among mothers with type 2 diabetes (81.1% vs 50.5% livebirths, p = 0.0002). A third of stillbirths occurred at term, with highest rates in the 38th week among mothers with type 1 diabetes and in the 39th week for type 2 diabetes.

 

Conclusions/interpretation

Maternal blood glucose levels and BMI are important modifiable risk factors for stillbirth in diabetes. Babies at extremes of weight centiles are at most risk. Many stillbirths occur at term and could potentially be prevented by change in routine care and delivery policies.

 

Article available in full from Diabetologica 

See also:

University of Glasgow [news release]  High blood sugar levels and BMI linked to stillbirth in mothers with diabetes 

In the news:

Independent Diabetic women need more support after study into stillbirth risk, say experts 

AI app for gestational diabetes adopted by NHS

The NHS has adopted a software system to help manage gestational diabetes. The system from Sensyne Health comprises a smartphone application which connects to a wireless blood glucose monitor. 

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Glucose measurements, free-text commentary and requests for a call-back are transmitted directly to a dashboard for the multi-disciplinary team at the hospital in charge. The care team can also communicate directly with the patient via the system. The app has now completed a two-year clinical evaluation and is available for implementation across the NHS.

Full detail at Med Tech Innovation

Diabetes in pregnancy: management from preconception to the postnatal period

NICE | Diabetes in pregnancy: management from preconception to the postnatal period

A new surveillance report has been published by NICE.  This surveillance report looks at new evidence in relation to diabetes in pregnancy: management from preconception to the postnatal period.

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NICE will partially update the NICE guideline on diabetes in pregnancy (NG3). The update will focus on the role of continuous glucose monitoring for women with type 1 diabetes who are planning to become pregnant or already pregnant.

This is because there is new evidence on continuous glucose monitoring. In particular, the CONCEPTT trial has published which experts deem to be a landmark trial that provides the best available evidence for the foreseeable future. The CONCEPTT trial found improvements in a range of neonatal outcomes with continuous glucose monitoring plus standard care, compared with standard care alone, and advocates routine usage in pregnant women with type 1 diabetes. This could potentially alter recommendation 1.3.17, which currently advises do not offer continuous glucose monitoring routinely to pregnant women with diabetes.

Full details are at NICE