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177: A stratified approach to the management of gestational diabetes - An effective alternative model of care?

      Objective

      Rates of gestational diabetes (GDM) are increasing worldwide, a trend that is likely to continue with rising obesity rates and lower threshold diagnostic criteria. This has significant resource implications; healthcare systems need to develop cost effective strategies that optimize maternal and neonatal outcomes. We sought to examine the effectiveness of such a protocol by comparing outcomes before and after its introduction.

      Study Design

      This is a prospective observational cohort study of GDM cases from a tertiary center over 5 years. Two models of prenatal care were compared. In the first (2009-2011) all new GDM cases were transferred from routine prenatal care to a combined obstetric/endocrinology clinic. Management comprised lifestyle and dietary intervention followed by insulin therapy where necessary. In the second (2012-2013) all cases commenced the same dietary and lifestyle intervention and attended for midwife-led glucose monitoring. Prenatal care otherwise remained routine. If glycemic control was inadequate care was escalated to the combined obstetric/endocrinology clinic. A comparison of outcomes between the two models of care was performed.

      Results

      During the study period there were 1558 cases of GDM, 916 from 2009-11 (Model 1) and 642 in 2012-13 (Model 2). There were no differences between the two models in the need for insulin therapy (44%[399/916] vs. 44%[286/642], p=0.7). Rates of induction of labor were similar (35%[324/916] vs. (36%[234/642], p=0.6), as were cesarean (45%[417/916] vs. 47%[305/642], p=0.4) and operative vaginal delivery (14%[129/916] vs. 14%[87/642], p=0.8) rates. No differences in birthweight >4kg (17%[156/916] vs. 19%[120/642], p=0.4) or >4.5kg (4%[36/916] vs. 4%[26/642], p=0.9) were noted. There was no significant difference in neonatal unit admission rates (16.5%[151/916] vs. 20%[131/642], p=0.05). There were 3 stillbirths and 7 cases of HIE in the first model, with 1 stillbirth and no HIE recorded in the second time period.

      Conclusion

      The implementation of a stratified model of care in GDM is not associated with excess maternal or neonatal risk, and may represent a more efficient and cost effective use of limited healthcare resources.