Background:
Peripartum management of women with diabetes in pregnancy is fraught with multiple variables that can impact maternal and foetal/neonatal outcomes. Acknowledging the importance and complexity of this phase, peripartum management plans are recommended to guide glycaemic management. The statewide Perinatal Practice Guideline (SA PPG) provides a framework for peripartum glycemic management. Further, individualised management of glycemia in consultation with an Endocrinologist or Obstetric Physician is advised for women who have required pharmacological treatment for GDM during pregnancy. A continuous improvement project undertaken within the health network highlighted the considerable variability in healthcare professionals’ perception of peripartum management of women with diabetes in pregnancy.
Aim: To ascertain current peripartum processes within the Sothern Adelaide Local health network, to assess how they align with the existing guidelines that are standard of care and to measure maternal and foetal outcomes in women with diabetes in pregnancy.
Methods: Data was systematically extracted from EMR using a standardized template for 30 women with gestational diabetes in pregnancy who presented consecutively in 2023. The data was classified depending on whether the women had GDM managed with medical nutrition therapy alone, GDM treated with metformin alone, GDM requiring <20 or > 20 units total daily dose of insulin. The records were assessed for documentation of a peripartum plan, protocol deviation and the frequency of maternal and fetal complications in each GDM category.
Results: Documented peripartum plans were noted to be in place only in 40% of the women with GDM. Peripartum planning was more evident in women with higher risk forms of GDM. Protocol deviations were assessed in both groups of women with and without documented peripartum plans and further analysed for their criticality and justification depending on the clinical context. Significant protocol deviations were noted especially in women without peripartum plans in place. These included critical omission of neonatal blood glucose testing as per protocol and omission of maternal postpartum blood glucose check despite being admitted in hospital. Women with GDM managed on MNT alone, while being the cohort with the least documented peripartum plan in place, were noted to be at significant risk of fetal and maternal complications.
Conclusion: Peripartum management of glycemia in women with diabetes in pregnancy continues to remain challenging with significant concerns regarding the impact on maternal and neonatal outcomes. This pilot study shines a light on the challenges in translating evidence based good practice into routine clinical decision making and will provide a springboard to explore system changes and clinical decision support tools to support healthcare professionals in optimizing glycemic management in the peripartum period.