Audit Of Follow-up Of Mothers With Gestational Diabetes Mellitus
Mohammad Abu-Jeyyab, Ghadah Al-Husban, Sondos Saleh, Balqees Al-Haytham, Mohammad Al-Romi Asem Shahin, Seif Al Rawashdeh, Dima Rahhal, Mo'ath Alqramsah, Ashwaq Tarawnehand Ahlam Kharabsheh
Women with gestational diabetes should get specialized advice and treatment as soon as possible and should be assessed by specialists of the diabetes and prenatal team within one week after being diagnosed. The team should advise the lady on why gestational diabetes arises, possible risks and consequences, and therapies to reduce those risks.
On suspicion that GDM pregnant ladies where not being followed up properly post diagnosis we performed an audit to check follow up and review of GDM mothers post diagnosis at al-Karak hospital antenatal clinics according to the latest nice guidelines.
We did a prospective collection of data from patients who were diagnosed with GDM. Data was collected from the patient and clinicians’ notes. The following information was gathered: Name, Date and gestational age at time of diagnosis, diagnostic test, treatment, previous obstetric history, Appointment after diagnosis and finally Gestation age of the patient at the time of taking the notes.
A total of 40 patients were recorded in which 24 patients out of 40 patients were confirmed to have sought antenatal care within the first two weeks post diagnosis.29 patients sought antenatal care with the first 3 weeks post diagnosis.
Pregnancy in women with gestational diabetes mellitus is associated with an increased risk of various adverse outcomes—both for mothers and for their offspring. These morbidities include preeclampsia, preterm delivery, cesarean section delivery, and large for gestational age infant. Long term adverse health outcomes in the offspring have also been reported such as obesity, insulin resistance, beta cell dysfunction, diabetes mellitus, and cardiovascular dysfunction. Management of pregnant women with diabetes focuses on the importance of good glycemic control before and during pregnancy, to decrease the frequency of adverse outcomes for both infants and mothers.
so in this audit we decided to follow up and review mothers with GDM post diagnosed at karak hospital antenatal clinics according to the latest nice guidelines on suspicion if they are not followed properly post diagnosis.
Materials and Methods
We did a prospective collection of data from all women with gestational diabetes who diagnosed in the Al-Karak Governmental Hospital between January2022 and June2022. Data was collected from the patients and electronic databases. we started by taken their personal information and their phone numbers to contact with them closely to monitor their blood sugar readings and act quickly to control their readings , we take a relevant history about their current pregnancy (gestational age , time and route of diagnosis , and the drugs history ). Diagnosis of GDM was made using oral glucose tolerance test (OGTT). Women with OGTT ≥200 mg/dL (11.1 mmol/L) according to WHO criteria were considered as having gestational diabetes.
The principal findings have shown that the patients in this audit had sought the hospital for diagnosis and medication for their gestational diabetes. As a total, 85% of patients were diagnosed by OGTT (50% of those patients were diagnosed before 24 weeks of gestation, 13% were diagnosed between weeks 24-28 and 31% were diagnosed after 28 weeks of gestation). 12% of patients were tested by random glucose check and 3% of patients by HbA1C test.
As a result, they attended the hospital for antenatal care after diagnosis for treatment and monitoring. Metformin and Insulin were the mainstream medications given to these patients, where 65% of patients were on both Metformin and Insulin, 23% were solely on Metformin with diet, and 13% were only on Insulin. It’s important to note that 10% of those patients had previous history of gestational diabetes.
Some major challenges in this Audit were GDM awareness, adherence to medication, diet and exercise, poor interaction with the health care providers as well as transportation to nearest hospitals and primary care centers. In order to alleviate and limits these obstacles in the future we have to Improve information management and communication, implementation of health systems intervention to improve models of antenatal care for women with GDM thus Enhancing policies and guidelines in the matter of GDM.
Diagnosing gestational diabetes as early as possible throughout pregnancy plays a leading role in managing GDM patients; specially if its within 1 week’s interval, almost all women in this audit went to clinics and primary care centers only after one week or so of confirming their diagnosis, this immediate contact between the patient and healthcare professionals is crucial to achieve the paramount coordination between obstetric and diabetes care, all in the best interest of patients thus ensuring that these patients gets the medical consultation without any delay and their diabetes is being controlled as well as their care is planned and fulfilled appropriately and during their pregnancy. Another tool that will determine how long the changes will take effect is fetal biometry, with strict vs moderate glycemic control being advocated for fetuses with greater or normal abdominal circumferences, respectively.
By following the NICE guidelines these women got tested by monitoring their blood glucose and preforming an OGTT test, a decent portion of them got their HbA1c levels tested, and others got asked to self-monitor and write their blood glucose readings. The importance of following the NICE guidelines and recommendations comes from the fact that glycemic control appears to be the key to the improvement and prevention of adverse antenatal and postnatal outcomes , this can be achieved by Giving these patients the support that they need thus providing them with information and advice upon their situation and how diabetes will affect their pregnancy, as well as the role of diet , body weight exercise , glucose checking and adherence to medications, and regimen of medical care . The NICE guidelines also emphasize the importance of renal and retinal assessment in the preconception period thus planning for next pregnancies as a part of diabetic education.
Improving the role of nutritionists and endocrinologists is very important; by placing these patients on a designated diet and keeping the relationship between patients and health care professionals as close as possible are the most important aspects for reauditing. Increasing workforce skills and knowledge thus improving the health literacy and access to healthcare through clinically appropriate pathway considers the ultimate target for this Audit.
There are no plans in the future to conduct another audit, as the diabetes clinic is doing well regarding the studied standards.
Our plans for following and monitoring the standards are based on the doctors’ notes on the online medical system “Hakeem”.
We found out that 90% of the patients were seen within a week of the first diagnosis.
No actions needed to be taken and efforts must be preserved to stay on the same level of patient care and management.
This research was mentored and supervised by the Mutah Research and Audit Society (MRAS).
Conflict of Interest
The authors declare no conflict of interest.
All Authors contributed the same. All authors read, revised and accepted the final draft of the manuscript.
1- 2020 NICE guideline update: Good news for pregnant women with type 1 diabetes and past or current gestational diabetes ( Wiley online library)
2- Diabetes in pregnancy / quality standard ( NICE : national institute for health and care excellence)
3- Diabetes in pregnancy guidelines for management ( NHS : National Devon Healthcare)
4- Nice diabetes in pregnancy guidelines ( GUIDELINES .co UK )