A service evaluation of the impact of adoption of JBDS guidelines for the management of glucose during labour and birth in women with diabetes

Authors

  • Umesh Dashora Conquest Hospital, Hastings
  • Suhail Ahmed
  • Irene Bossman
  • Ko Ko Aung
  • Erwin Castro
  • Pariasamy Sathiskumar

DOI:

https://doi.org/10.15277/bjd.2021.287

Keywords:

JBDS, NICE, targets, diabetes, delivery, neonatal, hypoglycaemia, outcome

Abstract

Aims: The aim of this retrospective observational study was to report on the impact of adopting the Joint British Diabetes Society for Inpatients (JBDS-IP) guidelines on the achievement of targets recommended by the National Institute for Health and Care Excellence (NICE) and the maternal and neonatal outcomes.

Methods: We analysed case records of pregnant women with diabetes who delivered in the period between November 2017 and October 2018 from our data base ‘Euroking’ (Wellbeing Software Ltd, Mansfield). Data were collected in relation to the availability of a dedicated prescription chart in the notes, capillary blood glucose (CBG) monitoring, use of variable rate intravenous insulin infusion (VRIII), maintenance of CBG targets within 4.0–7.0 mmol/L, maternal hypoglycaemia during labour when on VRIII and neonatal hypoglycaemia.

Results: Sixty women with diabetes in our database delivered during this period. Thirty-six (60%) were monitored with hourly CBG monitoring and 30 (50%) achieved CBG levels within the NICE recommended target range. Only five women (8.3%) were started on VRIII. There was no maternal hypoglycaemia in the VRIII group. One baby (1.7%) developed mild neonatal hypoglycaemia.

Conclusion: Adoption of JBDS guidelines contributed to 60% of women with diabetes receiving complete CBG monitoring, of whom 70% achieved the NICE recommended target of 4.0–7.0 mmol/L during labour and birth. Repeat CBG measurements before starting VRIII, strict adherence to clear JBDS guidelines and protocols, daily review by the diabetes team during the working week and appropriate use of VRIII was associated with good maternal and neonatal outcomes.

Author Biography

Umesh Dashora, Conquest Hospital, Hastings

Senior consultant Department of diabetes and endocrfinology

References

National Institute for Health and Clinical Excellence. Clinical practice guideline. Diabetes in pregnancy: management of diabetes and its complications from preconception to the postnatal period. February 2015. Available at http://www.nice.org.uk/guidance/ng3 (accessed 6 October 2020)

Wahabi HA, Fayed A, Esmaeil S, et al. Systematic review and meta-analysis of the effectiveness of pre-pregnancy care for women with diabetes for improving maternal and perinatal outcomes. PloS One 2020 Aug 18;15(8):e0237571. https://doi.org/10.1371/journal.pone.0237571

HAPO Study Cooperative Research Group. Hyperglycemia and adverse pregnancy outcomes. N Engl J Med 2008;358:1991–2002. https://doi.org/10.1056/NEJMoa0707943

Pedersen J. Weight and length at birth of infants of diabetic mothers. Acta Endocrinol 1954;16:330–42. https://doi.org/10.1530/acta.0.0160330

Desoye G, Nolan CJ. The fetal glucose steal: an underappreciated phenomenon in diabetic pregnancy. Diabetologia 2016;59:1089–94. https://doi.org/10.1007/s00125-016-3931-6

Molsted-Pedersen L. Aspects of carbohydrate metabolism in newborn infants of diabetic mothers. I. Intravenous glucose tolerance tests (a) distribution and means of K values, and (b) correlation between K value and birth weight. Acta Endocrinol 1972;69:174–88.

Voormolen DN, de Wit L, Van Rijn BB, et al. Neonatal hypoglycemia following diet-controlled and insulin-treated gestational diabetes mellitus. Diabetes Care 2018;41:1385–90. https://doi.org/10.2337/dc18-0048

Shah R, Harding J, Brown J, McKinlay C. Neonatal glycaemia and neurodevelopmental outcomes: a systematic review and meta-analysis. Neonatology 2019;115:116–26. https://doi.org/10.1159/000492859

Jovanovic L. Glucose and insulin requirements during labor and delivery: the case for normoglycemia in pregnancies complicated by diabetes. Endocr Pract 2004;10(Suppl 2):40–5. https://doi.org/10.4158/EP.10.S2.40

Flores-le Roux JA, Sagarra E, Benaiges D, et al. A prospective evaluation of neonatal hypoglycaemia in infants of women with gestational diabetes mellitus. Diabetes Res Clin Pract 2012;97:217–22. https://doi.org/10.1016/j.diabres.2012.03.011

Taylor R, Lee C, Kyne-Grzebalski D, Marshall SM, Davison JM. Clinical outcomes of pregnancy in women with type 1 diabetes. Obstet Gynecol 2002;99:537–4. https://doi.org/10.1016/s0029-7844(01)01790-2

Modi A, Levy N, Hall GM. Controversies in the peripartum management of diabetes. Anaesthesia 2016;71:750–5. https://doi.org/10.1111/anae.13487

Yamamoto JM, Donovan LE, Mohammad K, Wood SL. Severe neonatal hypoglycaemia and intrapartum glycaemic control in pregnancies complicated by type 1, type 2 and gestational diabetes. Diabet Med 2020;37:138–46. https://doi.org/10.1111/dme.14137

Hamel MS, Kanno LM, Has P, et al. Intrapartum glucose management in women with gestational diabetes mellitus: a randomized controlled trial. Obstet Gynecol 2019;133:1171–7. https://doi.org/10.1097/AOG.0000000000003257

Dashora UK, Temple R, Murphy H, et al. Joint British Diabetes Societies Inpatient Care Group. Management of glycaemic control in pregnant women with diabetes on obstetric wards and delivery units. Available at http://www.diabetologists-abcd.org.uk/JBDS/JBDS_Pregnancy_201017.pdf(accessed 14 October 2020).

Dashora U, Murphy HR, Temple RC, et al. Joint British Diabetes Societies (JBDS) for Inpatient Care. Managing hyperglycaemia during antenatal steroid administration, labour and birth in pregnant women with diabetes. Diabet Med 2018;35:1005–10. https://doi.org/10.1111/dme.13674

Dashora U, Rafique S, Tharayil G, et al. The feasibility and impact of implementing NICE guidance on diabetes control during delivery. Br J Diabetes 2017;17:100–06. https://doi.org/10.15277/bjd.2017.137

National Institute for Health and Clinical Excellence. Clinical practice guideline. Safe midewifery staffing for maternity settings. February 2015. Available at https://www.nice.org.uk/guidance/ng4/resources/safe-midwifery-staffing-for-maternity-settings-51040125637 (accessed 20 November 2016).

Barrett HL, Morris J, McElduff A. Watchful waiting: a management protocol for maternal glycaemia in the peripartum period. Aust NZ J Obstet Gynaecol 2009;49:162–7. https://doi.org/10.1111/j.1479-828X.2009.00969.x

Fresa R, Visalli N, Di Blasi V, et al. Experiences of continuous subcutaneous insulin infusion in pregnant women with type 1 diabetes during delivery from four Italian centers: a retrospective observational study. Diabetes Technol Ther 2013;15:328–34. https://doi.org/10.1089/dia.2012.0260

Iafusco D, Stoppoloni F, Salvia G, et al. Use of real time continuous glucose monitoring and intravenous insulin in type 1 diabetic mothers to prevent respiratory distress and hypoglycaemia in infants. BMC Pregnancy Childbirth 2008;8:23. https://doi.org/10.1186/1471-2393-8-23

Koh TH, Eyre JA, Aynsley-Green A . Neonatal hypoglycaemia--the controversy regarding definition. Arch Dis Child 1988;63:1386–8. https://doi.org/10.1136/adc.63.11.1386

Metzger BE, Persson B, Lowe LP, et al. Hyperglycemia and adverse pregnancy outcome study: neonatal glycemia. Pediatrics 2010;126:e1545–52. https://doi.org/10.1542/peds.2009-2257

Cornblath M, Reisner SH. Blood glucose in the neonate and its clinical significance. N Engl J Med 1965;273:378–81. https://doi.org/10.1056/nejm196508122730707

Inder T. How low can I go? The impact of hypoglycemia on the immature brain. Pediatrics 2008;122:440–1. https://doi.org/10.1542/peds.2008-1417

Cornblath M, Hawdon JM, Williams AF, et al. Controversies regarding definition of neonatal hypoglycemia: suggested operational thresholds. Pediatrics 2000;105:1141–5. https://doi.org/10.1542/peds.105.5.1141

Ryan EA, Al-Agha R. Glucose control during labor and delivery. Curr Diab Rep 2014;14:450. https://doi.org/10.1007/s11892-013-0450-4

Agrawal RK, Lui K, Gupta JM. Neonatal hypoglycaemia in infants of diabetic mothers. J Paediatr Child Health 2000;36:354–6. https://doi.org/10.1046/j.1440-1754.2000.00512.x

West TE, Lowy C. Control of blood glucose during labour in diabetic women with combined glucose and low-dose insulin infusion. Br Med J 1977; 1:1252–4. https://doi.org/10.1136/bmj.1.6071.1252

Kline GA, Edwards A. Antepartum and intra-partum insulin management of type 1 and type 2 diabetic women: impact on clinically significant neonatal hypoglycemia. Diabetes Res Clin Pract 2007;77:223–30. https://doi.org/10.1016/j.diabres.2006.10.024

Van Haltren K, Malhotra A. Characteristics of infants admitted with hypoglycemia to a neonatal unit. J Pediatr Endocrinol Metab 2013;26:525–9. https://doi.org/10.1515/jpem-2013-0009

Henquin JC, Sempoux C, Marchandise J, et al. Congenital hyperinsulinism caused by hexokinase I expression or glucokinase-activating mutation in a subset of β-cells. Diabetes 2013;62:1689–96. https://doi.org/10.2337/db12-1414

Hussain K, Aynsley-Green A. Hyperinsulinaemic hypoglycaemia in preterm neonates. Arch Dis Child Fetal Neonatal Ed 2004;89:F65–7. https://doi.org/10.1136/fn.89.1.f65

Feldberg D, Dicker D, Samuel N, et al. Intrapartum management of insulin‐dependent diabetes mellitus (IDDM) gestants. Acta Obstet Gynecol Scand 1988;67:333–8.

Achong N, Duncan EL, McIntyre HD, Callaway L. Peripartum management of glycaemia in women with type 1 diabetes. Diabetes Care 2014;37:364–71. https://doi.org/10.2337/dc13-1348

Lean ME, Pearson DW, Sutherland HW. Insulin management during labour and delivery in mothers with diabetes. Diabet Med 1990;7:162–4. https://doi.org/10.1111/j.1464-5491.1990.tb01352.x

Balsells M, Corcoy R, Adelantado JM, et al. Gestational diabetes mellitus: metabolic control during labour. Diabetes Nutr Metab 2000;13:257–62.

Rosenberg VA, Eglinton GS, Rauch ER, Skupski DW. Intrapartum maternal glycemic control in women with insulin requiring diabetes: a randomized clinical trial of rotating fluids versus insulin drip. Am J Obstet Gynecol 2006;195:1095–9. https://doi.org/10.1016/j.ajog.2006.05.051

Njenga E, Lind T, Taylor R. Five year audit of peripartum blood glucose control in type 1 diabetic patients. Diabet Med 1992;9:567–70. https://doi.org/10.1111/j.1464-5491.1992.tb01840.x

Carron Brown S, Kyne‐Grzebalski D, Mwangi B, Taylor R. Effect of management policy upon 120 type 1 diabetic pregnancies: policy decisions in practice. Diabet Med 1999;16:573–8. https://doi.org/10.1046/j.1464-5491.1999.00124.x

Levy N, Hall GM. National guidance contributes to the high incidence of inpatient hypoglycaemia. Diabet Med 2019;36:120–1. https://doi.org/10.1111/dme.13795

Yamamoto JM, Murphy HR. Inpatient hypoglycaemia; should we focus on the guidelines, the targets or our tools? Diabet Med 2019;36:122–3. https://doi.org/10.1111/dme.13814

Dashora U, George S, Sampson M, et al. National guidelines have contributed to safer care for inpatients with diabetes. Diabet Med 2019; 36:124–6. https://doi.org/10.1111/dme.13815

Yamamoto JM, Corcoy R, Donovan LE, et al, CONCEPTT Collaborative Group. Maternal glycaemic control and risk of neonatal hypoglycaemia in type 1 diabetes pregnancy: a secondary analysis of the CONCEPTT trial. Diabet Med 2019;36:1046–53. https://doi.org/10.1111/dme.13988

Downloads

Published

2021-05-28

Issue

Section

Original Research

Most read articles by the same author(s)

1 2 3 4 > >>