Department of Medicine, Division of Endocrinology and Metabolism, University of Calgary, Calgary, Canada.
Wolfson Diabetes and Endocrine Clinic, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
Diabetologia. 2018 Jul;61(7):1528-1537. doi: 10.1007/s00125-018-4613-3. Epub 2018 May 9.
AIMS/HYPOTHESIS: Women with diabetes remain at increased risk of adverse pregnancy outcomes associated with poor pregnancy preparation. However, women with type 2 diabetes are less aware of and less likely to access pre-pregnancy care (PPC) compared with women with type 1 diabetes. We developed and evaluated a community-based PPC programme with the aim of improving pregnancy preparation in all women with pregestational diabetes.
This was a prospective cohort study comparing pregnancy preparation measures before and during/after the PPC intervention in women with pre-existing diabetes from 1 June 2013 to 28 February 2017. The setting was 422 primary care practices and ten National Health Service specialist antenatal diabetes clinics. A multifaceted approach was taken to engage women with diabetes and community healthcare teams. This included identifying and sending PPC information leaflets to all eligible women, electronic preconception care templates, online education modules and resources, and regional meetings and educational events. Key outcomes were preconception folic acid supplementation, maternal HbA level, use of potentially harmful medications at conception and gestational age at first presentation, before and during/after the PPC programme.
A total of 306 (73%) primary care practices actively participated in the PPC programme. Primary care databases were used to identify 5075 women with diabetes aged 18-45 years. PPC leaflets were provided to 4558 (89.8%) eligible women. There were 842 consecutive pregnancies in women with diabetes: 502 before and 340 during/after the PPC intervention. During/after the PPC intervention, pregnant women with type 2 diabetes were more likely to achieve target HbA levels ≤48 mmol/mol (6.5%) (44.4% of women before vs 58.5% of women during/after PPC intervention; p = 0.016) and to take 5 mg folic acid daily (23.5% and 41.8%; p = 0.001). There was an almost threefold improvement in 'optimal' pregnancy preparation in women with type 2 diabetes (5.8% and 15.1%; p = 0.021). Women with type 1 diabetes presented for earlier antenatal care during/after PPC (54.0% vs 67.3% before 8 weeks' gestation; p = 0.003) with no other changes.
CONCLUSIONS/INTERPRETATION: A pragmatic community-based PPC programme was associated with clinically relevant improvements in pregnancy preparation in women with type 2 diabetes. To our knowledge, this is the first community-based PPC intervention to improve pregnancy preparation for women with type 2 diabetes.
Further details of the data collection methodology, individual clinic data and the full audit reports for healthcare professionals and service users are available from https://digital.nhs.uk/data-and-information/clinical-audits-and-registries/our-clinical-audits-and-registries/national-pregnancy-in-diabetes-audit .
目的/假设：患有糖尿病的女性仍面临与妊娠准备不足相关的不良妊娠结局的风险增加。然而，与 1 型糖尿病女性相比，2 型糖尿病女性对妊娠准备的认识程度较低，获得妊娠前护理 (PPC) 的可能性也较低。我们开发并评估了一种基于社区的 PPC 计划，旨在改善所有患有孕前糖尿病的女性的妊娠准备。
这是一项前瞻性队列研究，比较了 2013 年 6 月 1 日至 2017 年 2 月 28 日期间患有糖尿病的女性在 PPC 干预前后的妊娠准备措施。研究地点为 422 个初级保健诊所和 10 个国民保健署（NHS）专科产前糖尿病诊所。采取了多方面的方法来让糖尿病女性和社区医疗团队参与。这包括向所有符合条件的女性发送 PPC 信息传单、电子孕前护理模板、在线教育模块和资源，以及区域会议和教育活动。主要结局是孕前叶酸补充、母体 HbA 水平、受孕时和首次就诊时使用潜在有害药物，以及 PPC 计划前后的情况。
共有 306 个（73%）初级保健诊所积极参与了 PPC 计划。初级保健数据库被用来确定 5075 名年龄在 18-45 岁之间的糖尿病女性。为 4558 名（89.8%）符合条件的女性提供了 PPC 传单。在患有糖尿病的女性中，有 842 例连续妊娠：502 例在 PPC 干预之前，340 例在 PPC 干预期间。在 PPC 干预期间，2 型糖尿病孕妇更有可能达到 HbA 水平≤48mmol/mol（6.5%）的目标（干预前的女性为 44.4%，干预后的女性为 58.5%；p=0.016），并且更有可能每天服用 5mg 叶酸（干预前的女性为 23.5%，干预后的女性为 41.8%；p=0.001）。2 型糖尿病女性的“最佳”妊娠准备情况几乎改善了三倍（干预前的女性为 5.8%，干预后的女性为 15.1%；p=0.021）。1 型糖尿病女性在 PPC 期间更早地接受了产前护理（54.0% 与 8 周前妊娠的 67.3%相比；p=0.003），但没有其他变化。
结论/解释：基于社区的实用 PPC 计划与 2 型糖尿病女性妊娠准备的临床相关改善相关。据我们所知，这是第一个针对 2 型糖尿病女性改善妊娠准备的基于社区的 PPC 干预措施。
有关数据收集方法、个别诊所数据以及针对医疗保健专业人员和服务用户的完整审计报告的更多详细信息可在 https://digital.nhs.uk/data-and-information/clinical-audits-and-registries/our-clinical-audits-and-registries/national-pregnancy-in-diabetes-audit 处获得。
