Glycaemic control in labour with diabetes: GILD, a scoping study
Jones NW., Mitchell EJ., Walker KF., Ayers S., Bradshaw L., Constantinou G., Gazis T., Ojha S., Pallotti P., Petrou S., Plachcinski R., Rimmer M., Schroeder L., Thornton JG., Wakefield N.
Background: Diabetes in pregnancy is common, affecting 5-10% of pregnant women. Poor glycaemic control in labour is associated with neonatal hypoglycaemia and other adverse outcomes for mother and baby, but tight glucose control is burdensome, intrusive and may not always be necessary. The ideal intrapartum glucose target level is unknown, traditionally 'tight' control (target 4-7 mmol/l) has been recommended; however, this increases the risk of maternal hypoglycaemia. Objective: To determine the feasibility of a randomised clinical trial to compare clinical and cost-effectiveness of permissive versus intensive intrapartum glycaemic control in labour in pregnancies complicated by diabetes. Design: A mixed-methods study including audit of clinical guidelines from United Kingdom maternity units, online surveys of women with diabetes and healthcare professionals, service evaluation of intrapartum glycaemic care, Delphi survey and consensus meeting. Data from these work packages led to the design of a clinical trial, and qualitative interviews were held to understand acceptability of the trial. Setting: National Health Service maternity services and online input from service users. Participants: Healthcare professionals and women with type 1 or type 2 diabetes mellitus or gestational diabetes (currently pregnant or having birthed after active labour in past 3 years). Results: There is significant variation in the recommended frequency of testing for gestational diabetes in labour, technologies used to test glucose levels in labour and administer insulin in type 1 diabetes mellitus, and in how neonatal hypoglycaemia is defined. Of surveyed women, 66% would be willing to participate in a future trial, with 23% unsure without further information. The service evaluation showed that once glucose testing had commenced, it was repeated after 1 hour in 18%, 2 hours in 38% and 4 hours in 45% of women. Neonatal hypoglycaemia was considered the most important neonatal outcome for a future trial, with maternal satisfaction the most important maternal outcome. The incidence of neonatal hypoglycaemia (defined as glucose