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

Abstract

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.

Increasing prevalence of gestational diabetes mellitus when implementing the IADPSG criteria: A systematic review and meta-analysis

“…Treatment for GDM compared to routine care has previously been shown to improve the quality of life with GDM treatment [8]. Health economic impacts, and workload on frontline teams, are probably able to be reduced by changing the model of care [62].…”

The ADIPS Pilot National Diabetes in Pregnancy Benchmarking Programme

“…However, the large variation in care and birth outcomes has continued. Since that first audit, the process for screening and diagnosing GDM has changed [ 19 ], new management approaches have been adopted in some services including metformin therapy, and a range of different models of care have been evolving [ 20 ]. It is possible that some sites missed women, particularly with diet-managed GDM, because they remained under general obstetric and/or private care and did not receive any local diabetes service support.…”

Continuing Challenges in The Medical Management of Gestational Diabetes Mellitus

“…In the interim, new models of care are now being introduced to deal with the larger numbers of patients, for example use of a risk-based step-up or step-down approach to more intensive management. 24 Up to 1.8% of individuals with GDM have undiagnosed monogenic diabetes, particularly with glucokinase mutations (maturity onset diabetes of the young [MODY 2]). 25 Individuals with MODY 2 have a high fasting glucose but often a normal postload glucose, hence are readily identified with an OGTT rather than GCT.…”