Gestational Diabetes in Rural Antenatal Clinics:

Transcription

1 Gestational Diabetes in Rural Antenatal Clinics: How do we compare? Cook SJ 1,2, Phelps L 1, Kwan M 2 Darling Downs Health and Hospital Service University of Queensland Rural Clinical School

2 Gestational Diabetes Mellitus Carbohydrate intolerance arising in pregnancy Prevalence ~9% in Australia Hyperglycaemia predicts higher rates of: Macrosomia Shoulder dystocia Instrumental delivery Neonatal hypoglycaemia, jaundice, respiratory distress Obesity, type 2 diabetes, cardiovascular disease ABS 2014, Metzger, BE NEJM, 358(19): , Landon, M. B NEJM, 361(14)

3 Gestational Diabetes in Australia 11% annual increase in diagnosis Prevalence 4 8%, 1998 ADIPS criteria Prevalence 10.7% in Qld, % are prescribed insulin Perinatal Statistics Queensland Health, 2015

4 Lawlor DA et al. Am J Epidemiol. 2007;165: Fetal overnutrition in Gestational Diabetes Maternal circulation Fetal circulation Glucose & Free fatty acids Inflammatory mediators Δ Gut Microbiome Placenta Placental dysregulation Proinflammatory response Hyperinsulinaemia Nutritional programming Macrosomia fat accrual Hypoglycaemia Polycythaemia jaundice Respiratory distress Hypocalcaemia Lifelong consequences

5 Intrauterine overnutrition = obesity & chronic disease Adiposity Skeletal muscle Hepatic effects Insulin resistance Fatty liver Pancreas β-cell deficiency Brain Altered appetite regulation Leptin resistance = obesity Altered Gut microbiome Risk of obesity Offspring are: Fatter Hungrier Less likely to exercise Obesity Type 2 Diabetes

6 Universal screening OGTT Multidisciplinary care Dietitian and Diabetes educator Medical care Midwives & Obstetrician Diet and exercise Glucose monitoring Consistent glucose targets Insulin & Metformin Fetal surveillance Delivery at term Post partum OGTT Improved neonatal outcomes: Macrosomia Shoulder dystocia Hypoglycaemia Childhood obesity *Jiang S, Aust N Z J Obstet Gynaecol 2017; 1 7, Crowther C et al, NEJM 2005; 352(24)

7 30% of Australians live in rural areas 18% in inner regional 9% in outer regional 1% in remote 1% in very remote Rates of overweight & obesity 72.80% 29% of women deliver outside of major cities 12% deliver in outer regional or remote areas? Gestational Diabetes in rural Australia 61.60% 66.80% 68.40% Maternal obesity 19% of Australian women, % in a rural Victorian cohort, 2013 MC Inner regional Outer regional Remote AIHW 2011, Australia s mothers and babies, Cunningham MJA 2013: 39-42

8 Aims 1. Profile the diabetic antenatal services in rural hospitals of DDHHS 2. Compare the outcomes for women & babies Access to diabetes education, antenatal & perinatal care Treatment of GDM Adequacy of glucose control Mode of delivery Neonatal outcomes

9 Method Service Audit of antenatal services in our district o 1 Tertiary hospital o 6 rural hospitals 3 small, 3 larger o Semi-structured interviews conducted in 2015 Retrospective chart audit ( ) o All women diagnosed with GDM o GDM care received o BGLs & GDM management o Perinatal outcome data

10 Results: Access to GDM Service Audit Antenatal diabetes care Tertiary hospital Large rural hospitals Small rural hospitals Diabetes nurse education available Dietitian available Glucose monitors provided Consistent glucose targets Start & titrate medical treatment Ultrasound available Neonatal IV dextrose available

11 Results: Women with GDM DDHHS, n = 447 Early referral n = 31 Late transfer n = [VALUE] Tertiary Centre Large hospital Rural women Small hospital

12 Baseline characteristics Toowoomba (n=281) Rural (n=170) p-value Age (years) (mean±sd) 29.9± ± Aboriginal & Torres Strait Islander 23 (8.3) 23 (13.9) Smoking 60 (21.4) 49 (29.3) Weight at first visit (kg) (mean±sd) 86.0± ± Body Mass Index 30 kg/m (55.5) 80 (48.8) Gestational age at booking visit (mean±sd) 13.5± ±6.0 <0.001 Primiparous 66 (23.7) 42 (24.9) Multiple pregnancy 11 (3.9) 4 (2.4) Average fasting OGTT result (mmol/l) (mean±sd) 5.1± ± Average 2 hour OGTT result (mmol/l) (mean±sd) 8.8± ±

13 Access to Diabetes Education 96.00% 94.80% 94.00% 92.00% 90.00% 88.00% 86.00% 84.00% 82.00% 80.00% 83.80% P < % Tertiary Rural

14 Results: Treatment of GDM 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% P< % 6% 8% 15% 13% 31% 45% Good glucose control achieved 52% 73% Good glucose control achieved 43% 0% Tertiary hospital Rural ANC Diet control Metformin +/- insulin Insulin only No followup

15 Results: Adequacy of glucose control 70% 60% 58% P<0.001 P= NS 59% P< % 43% 40% 30% 20% 24% 35% 30% 19% 27% 10% 7% 0% Good control Moderate control Poor control Toowoomba Rural shared care Rural ANC

16 Results: Mode of delivery 60.00% 53.60% 50.00% 40.00% 49.00% 41.00% 39% 44.80% OR 4.05 ( ) 30.00% P-value = NS 20.00% 22.50% 20.30% 21% 15.50% 13.80% 17.00% 19.60% 10.00% 0.00% IOL Elective CS Emergency CS Toowoomba Rural shared care Rural transfer Rural care

17 Results: Birthweight and macrosomia (>4000g) 18% 16% 14% 12% Average birthweight 3292g 3386g 3291g 3417g P-values NS 10% 8% 11% 10% 17% 11% 6% 4% 2% 0% Macrosomia Toowoomba Rural, early referral Rural, late transfer Rural care

18 Results: Neonatal Hypoglycaemia 20% 18% 16% 17% 15% 19% 14% 12% 10% 8% 6% 4% 2% 2% Rate of documented glucose measures 76% in rural hospitals 96% in tertiary hospital 0% Toowoomba Rural early referral Rural, late transfer Rural care

19 Results: Shoulder dystocia 8.00% 7.00% 7% 6.00% 5.00% 4.00% 3.00% 2.00% 1.00% 1 event 0.30% 3% 1 event 3 events 2% 2 events P < % Toowoomba Rural, early referral Rural, late transfer Rural care

20 Results: Rates of Breastfeeding 90% 80% 70% 60% 78% 67% 69% P< % 46% 40% 30% 20% 10% 0% Toowoomba Rural shared care Rural transfer Rural delivery

21 Results: Maternal Length of Stay Days P< Toowoomba Rural shared Rural transfer Rural care

22 Summary: Comparing Toowoomba to rural hospitals Women in both groups comparable at baseline Rural shared care women Most likely to commence insulin Poorest glucose control Highest rates of elective Caesarean Rural women experience: Less access to education Lower rates of medical treatment Poorer glucose control Shoulder dystocia Perinatal outcomes were comparable Caesarean section, IOL, gestational age Birthweight, macrosomia, hypoglycaemia, RDS, jaundice Rates of breast feeding Length of stay

23 Recommendations Rural women need better access to diabetes education & glucose management Rural women can safely deliver in their home town Improve breastfeeding rates Better partnerships between our hospital ANC services

24 Acknowledgments Staff at Stanthorpe, Warwick, Goondiwindi, Kingaroy, Chinchilla, Dalby Hospitals and Toowoomba Hospitals University of Queensland Rural Clinical School

25 Thank you Questions?

26 Results: Neonatal Respiratory distress 25% 20% 21% 19% 15% 13% 10% 5% 0% Toowoomba Rural, early referral Rural, late transfer Rural care 1%