Pregnancy in women with pregestational diabetes mellitus (type 1 and type 2) carries increased risks of both maternal and neonatal complications due to maternal hyperglycemia and underlying chronic conditions and comorbidities. To reduce the risk of pregnancy complications or to mitigate their effects, numerous interventions are recommended at various times during pregnancy. Since 2016, the Society for Maternal-Fetal Medicine has posted a Diabetes Antepartum Checklist on its website. An updated version of this checklist is presented here, along with suggestions for implementation into the standard antenatal care of patients with type 1 and type 2 diabetes mellitus.
Key words
Introduction
The prevalence of diabetes mellitus among women of reproductive age in the United States exceeds 6%
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and has been increasing in recent decades in parallel with the increasing rate of obesity.2
The prevalence is much higher in African American (15%), Native American (10.1%), and Hispanic women (7.5%) than in non-Hispanic White (4.8%) and Asian women (4.5%).1
Pregnancy in women with pregestational diabetes mellitus (type 1 and type 2) carries increased risks of both maternal and neonatal complications attributable to the degree of maternal hyperglycemia and underlying chronic conditions and comorbidities of diabetes mellitus.
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Maternal risks include increased rates of preeclampsia and other hypertensive disorders, worsening of diabetic retinopathy, and diabetic ketoacidosis.4
Perinatal risks include increased rates of miscarriage, stillbirth, major congenital anomalies, preterm birth, fetal macrosomia, fetal hypertrophic cardiomyopathy, neonatal hypoglycemia, hyperbilirubinemia, and respiratory distress syndrome.5
Long-term risks to the offspring include increased rates of childhood obesity, childhood diabetes mellitus and prediabetes, and cardiovascular diseases in later life.5
Several interventions are recommended during pregnancy to reduce the risk of pregnancy complications or to mitigate their effects. These interventions include strict glycemic control, screening for comorbidities (foot exam, eye exam, thyroid function screening, urinary protein evaluation, electrocardiogram), diagnostic testing (eg, fetal anatomy ultrasound and fetal echocardiogram), preeclampsia prophylaxis (eg, low-dose aspirin), fetal surveillance, and individualized planning regarding the timing and mode of delivery.
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Because there are many care elements to consider and because they are distributed in time over the several months of pregnancy, there is a risk that practitioners will inadvertently omit 1 or more elements, thereby increasing the risk of an adverse outcome. A cognitive aid such as a checklist can help to minimize such errors of omission.
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Since 2016, the Society for Maternal-Fetal Medicine has posted a Diabetes Antepartum Checklist on its website.9
An updated version of this checklist is presented here, along with suggestions about how practices might implement the checklist into the standard antenatal care of patients with type 1 and type 2 diabetes mellitus.Society for Maternal-Fetal Medicine
SMFM patient safety checklists.
SMFM patient safety checklists.
https://www.smfm.org/checklists-and-safety-bundles
Date accessed: September 14, 2020
Checklist
A sample checklist is shown in the Box. This checklist should be considered an example. Individual practices should customize it by adding or deleting specific items as needed to reflect their actual local management.
Box
Sample checklist for antepartum care of pregestational (type 1 or type 2) diabetes mellitus
Checklist for Antepartum Care of Pregestational (Type 1 or Type 2) Diabetes Mellitus (DM)
- •This checklist is a sample and should be modified as needed to fit individual practice circumstances.
- •Items on the checklist are in addition to routine prenatal care and routine diabetes care.
- •Routine pregnancy care is assumed (eg, complete history and exam, routine lab assessments, prenatal vitamins, etc.).
- •Routine diabetes care is assumed (eg, glucose monitoring, glycemic targets, and glucose-lowering medications as needed).
Initial Visit
- □Record age at onset of DM
- □History of DM complications:
- oKetoacidosis
- oHypoglycemia
- oGastroparesis
- oNephropathy
- oNeuropathy
- oRetinopathy
- oHypertension
- oCoronary artery disease
- oArterial occlusive disease
- o
- □Physical exam of lower extremities
- oPerfusion (color, pulses)
- oSensory exam (touch, pain)
- oProper fit of footwear
- o
- □Referral for retinal examination
- □Pneumococcus vaccine
- □Patient education
- oRelationship between glycemic control and adverse pregnancy outcomes (miscarriage, birth defects, fetal growth restriction, macrosomia, stillbirth, preterm birth)
- oMaternal adverse effects (hypertension/preeclampsia, worsening retinopathy or nephropathy)
- oMedic alert bracelet or necklace
- o
- □Family education
- oRecognition and management of hypoglycemia
- oUse of glucagon kit
- o
- □Laboratory Tests:
- oHemoglobin A1c
- oComprehensive metabolic panel
- oThyroid-stimulating hormone (TSH)
- oUrinary albumin/creatinine or protein/creatinine ratio
- oElectrocardiogram if age ≥35 yrs or cardiac symptoms or risk factors are present
- o
Second Trimester
- □Low-dose aspirin 81 mg daily (start between 12 and 28 weeks of gestation, optimally before 16 weeks)
- □Detailed fetal anatomy ultrasound
- □Fetal echocardiogram
Third Trimester
- □Antepartum fetal surveillance starting at 32 to 34 weeks of gestation (eg, nonstress test, amniotic fluid assessment, biophysical profile)
Delivery Planning
- □Ultrasound for fetal growth assessment
- □Consider cesarean delivery if estimated fetal weight ≥4500 g
- □Delivery timing:
- oGood glycemic control, no vascular complications: deliver at 39 0/7 to 39 6/7 weeks of gestation
- oPoor glycemic control, vascular complications, or prior stillbirth: deliver at 36 0/7 weeks to 38 6/7 weeks
- oPregnancy complications such as fetal growth restriction or preeclampsia: delivery timing individualized depending on complication severity
- o
Postpartum
- □Ensure transition of care to endocrinology or primary care provider
Version: September 14, 2020.
Hameed. SMFM Special Statement: Updated checklist for antepartum care of pregestational diabetes. Am J Obstet Gynecol 2020.
The design of the form follows the guidelines published in A Checklist for Checklists by Ariadne Labs.
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For example, the checklist uses a sans-serif font with black text on a white background; avoids the use of color; fits on 1 page; has a simple, uncluttered format; includes a version date; and does not include routine items that are at low risk of being omitted.Ariadne Labs
A checklist for checklists.
A checklist for checklists.
https://www.ariadnelabs.org/wp-content/uploads/sites/2/2019/10/checklist_for_checklists_final_10.3-1-1.pdf
Date accessed: August 18, 2020
Updates from the 2016 version include condensing the form to 1 page and some minor changes in verbiage. To minimize clutter, references supporting the suggested interventions are cited in the text
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rather than in footnotes of the checklist. The interventions themselves are essentially unchanged.This checklist is focused on antepartum care. The American Diabetes Association recently introduced a separate checklist for preconception care for women with diabetes mellitus.
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Suggestions for Implementation
The checklist is primarily intended to be used in the prenatal care clinic and not the hospital. Its purpose is to increase the probability that obstetrical care professionals will perform all of the special tasks expected for the management of these complex pregnancies.
Implementation typically starts with the assembly of a team of relevant and engaged providers to spearhead the process. The team should likely include at least 1 physician, nurse, diabetes mellitus educator, and practice manager.
The team should first decide whether they want obstetrical care professionals to use the checklist or whether they expect them to rely on training and memory to perform all the tasks listed. Errors of omission are less likely to occur if the checklist is used.
If the practice decides to use the checklist, the team should carefully review the checklist items to determine whether they are consistent with current local practice. If there are elements that are not consistent, then either the checklist should be modified to reflect actual practice or an education process should be developed to align the practice with the checklist. The team should also decide whether they wish to add items that we have omitted based on our assumption that they are so routine that they are unlikely to be omitted (eg, teaching about glucose monitoring and diet or routine prenatal care items).
An important point for each practice to consider is whether to have each checklist exist as a digital form in the patient’s electronic health record, a paper form in a physical chart, or simply a task list for obstetrical care professionals to reference without specifically including the form in each patient’s record. If a practice wants to use digital forms, resources will need to be directed toward the development of a special module within the electronic charting system. Paper chart forms may be relatively easier to implement, but they raise additional questions. For example, does each entry need the obstetrical care professional’s signature, date, and time? Where will the paper form be kept if the practice primarily uses electronic charting? If a practice decides to use the checklist as a reference and not include it in the patient chart, will a copy of the checklist be kept in a location where the staff can quickly reference it, such as a laminated sheet placed at each desk, a wall chart in diabetes mellitus education rooms, a practice protocol binder, or a digital file?
Another point to consider is whether and how checklists that are started in an outpatient clinic will be transferred to the hospital when patients are admitted for antepartum hospitalization or delivery. If the clinic and hospital share a common electronic record platform, integration of the checklist into the records at both sites will be relatively straightforward, but some technical support may be needed to accomplish this. If the clinic and hospital records are not integrated, then cross-site availability of the checklist will be more challenging.
Quality Indicators and Revisions
Once the checklist has been implemented, the team should consider tracking whether it is being used effectively. If the obstetrical care professionals are not using it routinely, then barriers to use should be identified and solved. A targeted quality audit can reveal areas that need additional attention. Useful indicators might include the percentage of gravidas with pregestational diabetes mellitus who (1) started low-dose aspirin at 12 to 16 weeks’ gestation (optimal timing),
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(2) started low-dose aspirin at 12 to 28 weeks’ gestation (acceptable timing),11
(3) had a baseline assessment of urinary albumin or total protein excretion,3
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and (4) received pneumococcus vaccine or had documentation of previous vaccination.12
Each of the above indicators should be stratified by race and ethnicity to ensure that the checklist is equitably implemented and to evaluate for possible unintended consequences in particular racial and ethnic groups.
Revisions to the checklist may be needed to improve adherence, clarify questions that may arise, or align with new standards of care that may be introduced. If revisions are made, the version date should be edited, and any circulating copies of older versions should be discarded.
References
- Racial/ethnic disparities in diabetes diagnosis and glycemic control among women of reproductive age.J Womens Health (Larchmt). 2018; 27: 1271-1277
- Diabetes 2030: insights from yesterday, today, and future trends.Popul Health Manag. 2017; 20: 6-12
- American Diabetes Association. 14. Management of diabetes in pregnancy: standards of medical care in diabetes-2020.Diabetes Care. 2020; 43: S183-S192
- Management of diabetic ketoacidosis in pregnancy.Obstet Gynaecol. 2017; 19: 55-62
- The offspring of the diabetic mother--short- and long-term implications.Best Pract Res Clin Obstet Gynaecol. 2015; 29: 256-269
- American Diabetes Association. 4. Comprehensive medical evaluation and assessment of comorbidities: standards of medical care in diabetes-2020.Diabetes Care. 2020; 43: S37-S47
- ACOG Practice Bulletin no. 201: pregestational diabetes mellitus.Obstet Gynecol. 2018; 132: e228-e248
- The development and implementation of checklists in obstetrics.Am J Obstet Gynecol. 2017; 217: B2-B6
- SMFM patient safety checklists.(Available at:)https://www.smfm.org/checklists-and-safety-bundlesDate accessed: September 14, 2020
- A checklist for checklists.(Available at:)https://www.ariadnelabs.org/wp-content/uploads/sites/2/2019/10/checklist_for_checklists_final_10.3-1-1.pdfDate accessed: August 18, 2020
- American College of Obstetricians and Gynecologists. Committee Opinion no. 743: low-dose aspirin use during pregnancy.Obstet Gynecol. 2018; 132: e44-e52
- American College of Obstetricians and Gynecologists. Committee Opinion no. 741: maternal immunization.Obstet Gynecol. 2018; 131: e214-e217
- American College of Obstetricians and Gynecologists. Committee Opinion no. 764: medically indicated late-preterm and early-term deliveries.Obstet Gynecol. 2019; 133: e151-e155
Article info
Publication history
Published online: August 27, 2020
Footnotes
All authors and Committee members have filed a conflict of interest disclosure delineating personal, professional, and/or business interests that might be perceived as a real or potential conflict of interest in relation to this publication. All conflicts have been resolved through a process approved by the Executive Board. The Society for Maternal-Fetal Medicine (SMFM) has neither solicited nor accepted any commercial involvement in the development of the content of this publication.
This document has undergone an internal peer review through a multilevel committee process within SMFM. This review involves critique and feedback from the SMFM Patient Safety and Quality and Document Review Committees and final approval by the SMFM Executive Committee. SMFM accepts sole responsibility for document content. SMFM publications do not undergo editorial and peer review by the American Journal of Obstetrics & Gynecology. Publications are reviewed 36 to 48 months and updates are issued as needed. Further details regarding SMFM publications can be found at www.smfm.org/publications.
Identification
Copyright
© 2020 Published by Elsevier Inc.
