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
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. 2005 NEJM, 358(19): 1991-2001, Landon, M. B. 2009 NEJM, 361(14)
Gestational Diabetes in Australia 11% annual increase in diagnosis Prevalence 4 8%, 1998 ADIPS criteria Prevalence 10.7% in Qld, 2015 29% are prescribed insulin https://www.ndss.com.au/data-snapshots Perinatal Statistics Queensland Health, 2015
Lawlor DA et al. Am J Epidemiol. 2007;165:418 424 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
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
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)
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, 2012 33% in a rural Victorian cohort, 2013 MC Inner regional Outer regional Remote www.aihw.gov.au/australias-health/2014/understanding-health-illness, AIHW 2011, Australia s mothers and babies, Cunningham MJA 2013: 39-42
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
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 (2012-13) o All women diagnosed with GDM o GDM care received o BGLs & GDM management o Perinatal outcome data
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
Results: Women with GDM DDHHS, 2012-13 300 250 200 150 100 50 281 n = 447 Early referral n = 31 Late transfer n = 40 170 [VALUE] 113 0 Tertiary Centre Large hospital Rural women Small hospital
Baseline characteristics Toowoomba (n=281) Rural (n=170) p-value Age (years) (mean±sd) 29.9±5.6 29.5±5.7 0.473 Aboriginal & Torres Strait Islander 23 (8.3) 23 (13.9) 0.060 Smoking 60 (21.4) 49 (29.3) 0.057 Weight at first visit (kg) (mean±sd) 86.0±23.9 83.1±22.5 0.207 Body Mass Index 30 kg/m 2 154 (55.5) 80 (48.8) 0.166 Gestational age at booking visit (mean±sd) 13.5±4.9 17.6±6.0 <0.001 Primiparous 66 (23.7) 42 (24.9) 0.774 Multiple pregnancy 11 (3.9) 4 (2.4) 0.588 Average fasting OGTT result (mmol/l) (mean±sd) 5.1±0.9 5.2±1.2 0.239 Average 2 hour OGTT result (mmol/l) (mean±sd) 8.8±1.5 9.1±1.6 0.064
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 <0.001 78.00% Tertiary Rural
Results: Treatment of GDM 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% P<0.001 9% 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
Results: Adequacy of glucose control 70% 60% 58% P<0.001 P= NS 59% P<0.001 50% 43% 40% 30% 20% 24% 35% 30% 19% 27% 10% 7% 0% Good control Moderate control Poor control Toowoomba Rural shared care Rural ANC
Results: Mode of delivery 60.00% 53.60% 50.00% 40.00% 49.00% 41.00% 39% 44.80% OR 4.05 (1.78-9.25) 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
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
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
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 <0.001 0.00% Toowoomba Rural, early referral Rural, late transfer Rural care
Results: Rates of Breastfeeding 90% 80% 70% 60% 78% 67% 69% P<0.001 50% 46% 40% 30% 20% 10% 0% Toowoomba Rural shared care Rural transfer Rural delivery
Results: Maternal Length of Stay 6 5 4.6 5.4 4.7 Days 4 3 2 3.2 P<0.001 1 0 Toowoomba Rural shared Rural transfer Rural care
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
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
Acknowledgments Staff at Stanthorpe, Warwick, Goondiwindi, Kingaroy, Chinchilla, Dalby Hospitals and Toowoomba Hospitals University of Queensland Rural Clinical School
Thank you Questions?
Results: Neonatal Respiratory distress 25% 20% 21% 19% 15% 13% 10% 5% 0% Toowoomba Rural, early referral Rural, late transfer Rural care 1%