Antenatal models of care for women with gestational diabetes mellitus: Vignettes from an international meeting.

BACKGROUND: Gestational diabetes (GDM) is one of the commonest pregnancy complications and is placing an increasing burden on diabetes and obstetric resources. AIMS: To describe different antenatal models of care that have developed to address the increasing proportion of pregnancies complicated by GDM. MATERIALS AND METHODS: Narrative review with thematic analysis from 15 volunteer antenatal diabetes in pregnancy services from Australia and New Zealand identified through a national diabetes organisation. Main outcomes were approaches to patient education, medical nutrition therapy (MNT), ongoing management and escalation of therapy for women with GDM. RESULTS: All clinics provided at least one group education and one MNT session within 1-2 weeks of GDM diagnosis. Women from culturally and linguistically diverse communities usually required 1:1 education. Ongoing management of women with GDM was through either all women being seen in the GDM clinic, a step-up approach (ongoing management by the primary antenatal team with diabetes team referral if self-blood glucose monitoring (SBGM) or insulin therapy dosage criteria are reached) or step-down approach (ongoing management by the diabetes team with step-down to the primary antenatal team if SBGM criteria are reached). Telehealth was used to reduce the burden of clinic attendance, particularly in rural areas. CONCLUSIONS: Increasing numbers, earlier diagnoses, the need to provide care to women in rural, remote areas, and cultural/language differences, have generated a range of different antenatal models of care, allowed better workload accommodation and probably reduced costs. Randomised controlled trials of different models of care, with associated health economic analyses, are urgently needed.

Timing of diagnosis of gestational diabetes and pregnancy outcomes: A retrospective cohort.

BACKGROUND: Recent guidelines suggest screening high-risk women in early pregnancy for gestational diabetes (GDM); however, there is little evidence to support this. AIMS: To compare pregnancy outcomes associated with diabetes for women with risk factors for GDM according to gestation of diagnosis. Early GDM was defined as a positive test before 20 weeks gestation, late GDM as a positive test at 20 or more weeks and no GDM when both tests were negative. MATERIALS AND METHODS: Retrospective analysis in an Australian tertiary hospital of women who underwent a glucose tolerance test in pregnancy prior to 20 weeks gestation, and a repeat test after 20 weeks gestation if the initial test was negative. Results were adjusted for maternal demographics. RESULTS: Women with early GDM (n = 170) were no more likely to experience the obstetric composite outcome than women with late GDM (n = 171) or no GDM (n = 547) (early odds ratio (OR) 1.16, 95%CI 0.79-1.71; late OR 0.78, 95%CI 0.53-1.12). Infants of women with early GDM, but not late GDM, were more likely (early OR 1.8, 95%CI 1.15-2.92; late OR 1.4, 95%CI 0.90-2.23) to have the neonatal composite outcome than infants of women without GDM, predominantly due to an increase in neonatal hypoglycaemia. CONCLUSIONS: This result may be due to careful management of GDM, or because, after adjustment for maternal demographics, the early diagnosis of GDM does not substantially increase rates of adverse outcomes compared to GDM diagnosed in later pregnancy or no GDM in women with risk factors for GDM.

Advising women with diabetes in pregnancy to express breastmilk in late pregnancy (Diabetes and Antenatal Milk Expressing [DAME]): a multicentre, unblinded, randomised controlled trial.

BACKGROUND: Infants of women with diabetes in pregnancy are at increased risk of hypoglycaemia, admission to a neonatal intensive care unit (NICU), and not being exclusively breastfed. Many clinicians encourage women with diabetes in pregnancy to express and store breastmilk in late pregnancy, yet no evidence exists for this practice. We aimed to determine the safety and efficacy of antenatal expressing in women with diabetes in pregnancy. METHODS: We did a multicentre, two-group, unblinded, randomised controlled trial in six hospitals in Victoria, Australia. We recruited women with pre-existing or gestational diabetes in a singleton pregnancy from 34 to 37 weeks' gestation and randomly assigned them (1:1) to either expressing breastmilk twice per day from 36 weeks' gestation (antenatal expressing) or standard care (usual midwifery and obstetric care, supplemented by support from a diabetes educator). Randomisation was done with a computerised random number generator in blocks of size two and four, and was stratified by site, parity, and diabetes type. Investigators were masked to block size but masking of caregivers was not possible. The primary outcome was the proportion of infants admitted to the NICU. We did the analyses by intention to treat; the data were obtained and analysed masked to group allocation. This trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12611000217909. FINDINGS: Between June 6, 2011, and Oct 29, 2015, we recruited and randomly assigned 635 women: 319 to antenatal expressing and 316 to standard care. Three were not included in the primary analysis (one withdrawal from the standard care group, and one post-randomisation exclusion and one withdrawal from the antenatal expressing group). The proportion of infants admitted to the NICU did not differ between groups (46 [15%] of 317 assigned to antenatal expressing vs 44 [14%] of 315 assigned to standard care; adjusted relative risk 1·06, 95% CI 0·66 to 1·46). In the antenatal expressing group, the most common serious adverse event for infants was admission to the NICU for respiratory support (for three [<1%] of 317. In the standard care group, the most common serious adverse event for infants was moderate to severe encephalopathy with or without seizures (for three [<1%] of 315). INTERPRETATION: There is no harm in advising women with diabetes in pregnancy at low risk of complications to express breastmilk from 36 weeks' gestation. FUNDING: Australian National Health and Medical Research Council.

Factors associated with breastfeeding to 3 months postpartum among women with type 1 and type 2 diabetes mellitus: An exploratory study.

PROBLEM: Breastfeeding has significant health benefits for maternal and infant health, yet women with pre-pregnancy diabetes (type 1 or type 2 diabetes mellitus) are often less likely to breastfeed compared with other childbearing women. BACKGROUND: Intention to breastfeed and making the decision to breastfeed during pregnancy are significant predictors of breastfeeding in the general population, but intention to breastfeed has not been assessed during pregnancy among women with pre-pregnancy diabetes. AIM: To investigate factors associated with breastfeeding to three months postpartum, including demographic, health and reproductive characteristics, perceived support and pre-birth intention to breastfeed, among women with pre-pregnancy diabetes. METHODS: A prospective cohort of women with pre-pregnancy diabetes was recruited at three metropolitan hospitals in Melbourne, Australia. Women completed surveys during the third trimester of pregnancy (including intention to breastfeed) and at approximately 3 months postpartum (including current breastfeeding). Factors associated with any breastfeeding at 3 months postpartum were investigated using logistic regression. FINDINGS: Pregnancy surveys were completed by 79 women; three-month postpartum data were available for 47 women. Of these, more than two-thirds (n=32, 68%) indicated that they were breastfeeding. Controlling for other relevant variables, only pre-birth intention to breastfeed was significantly associated with any breastfeeding at three months (Adjusted Odds Ratio (95% confidence intervals, p)=20.49 (20.18-20.80, 0.017)). DISCUSSION: Pre-birth intention to breastfeed was the only significant predictor of continued breastfeeding to 3 months postpartum. CONCLUSION: Pregnancy provides an important opportunity for health professionals to educate and support women with pre-pregnancy diabetes about their breastfeeding intentions.

Psychosocial wellbeing among new mothers with diabetes: Exploratory analysis of the postnatal wellbeing in transition questionnaire.

OBJECTIVE: The Postnatal Wellbeing in Transition (PostTrans) Questionnaire assesses psychosocial wellbeing among women transitioning to motherhood while managing pre-existing diabetes. Face and content validity have been previously reported; however the PostTrans questionnaire has 51 items which imposes a substantial burden on respondents. The aim of this study was exploratory analysis of the PostTrans questionnaire to investigate whether a reduction in the number of items was statistically supported, and whether clinically meaningful subscales could be derived. METHODS: A prospective cohort of women with type 1 or type 2 diabetes was recruited from three metropolitan hospitals in Melbourne, Australia. Women completed surveys across three postnatal time points. Data were pooled for the analysis. Suitability for factor analysis was confirmed and exploratory Principal Components Analysis with oblique rotation was conducted. RESULTS: The number of responses in the pooled dataset was 117. The reduced PostTrans scale has 27 items and six factors, which together explain 68.7% of the variance. The subscales assess: feeling as if one is coping with diabetes and the infant; feeling anxious and guilty about diabetes; feeling supported by family; sensitivity to the opinions of others; prioritising self-care; and health professional support. CONCLUSION: The number of items in the PostTrans Questionnaire was reduced from 51 to 27 items. Six meaningful subscales emerged, which can help health professionals identify and address areas in which women with diabetes are experiencing psychosocial difficulties. The revised scale provides a feasible instrument to be tested for psychometric properties in a larger sample.

Safety and efficacy of antenatal milk expressing for women with diabetes in pregnancy: protocol for a randomised controlled trial.

INTRODUCTION: Many maternity providers recommend that women with diabetes in pregnancy express and store breast milk in late pregnancy so breast milk is available after birth, given (1) infants of these women are at increased risk of hypoglycaemia in the first 24 h of life; and (2) the delay in lactogenesis II compared with women without diabetes that increases their infant's risk of receiving infant formula. The Diabetes and Antenatal Milk Expressing (DAME) trial will establish whether advising women with diabetes in pregnancy (pre-existing or gestational) to express breast milk from 36 weeks gestation increases the proportion of infants who require admission to special or neonatal intensive care units (SCN/NICU) compared with infants of women receiving standard care. Secondary outcomes include birth gestation, breastfeeding outcomes and economic impact. METHODS AND ANALYSIS: Women will be recruited from 34 weeks gestation to a multicentre, two arm, unblinded randomised controlled trial. The intervention starts at 36 weeks. Randomisation will be stratified by site, parity and diabetes type. Women allocated to the intervention will be taught expressing and encouraged to hand express twice daily for 10 min and keep an expressing diary. The sample size of 658 (329 per group) will detect a 10% difference in proportion of babies admitted to SCN/NICU (85% power, α 0.05). Data are collected at recruitment (structured questionnaire), after birth (abstracted from medical record blinded to group), and 2 and 12 weeks postpartum (telephone interview). DATA ANALYSIS: the intervention group will be compared with the standard care group by intention to treat analysis, and the primary outcome compared using χ(2) and ORs. ETHICS AND DISSEMINATION: Research ethics approval will be obtained from participating sites. Results will be published in peer-reviewed journals and presented to clinicians, policymakers and study participants. TRIAL REGISTRATION NUMBER: Australian Controlled Trials Register ACTRN12611000217909.