Gestational diabetes and progression to type two diabetes mellitus: missed opportunities of follow up and prevention?

Abstract Background: The incidence of type 2 diabetes (T2DM) is increasing. Having a pregnancy complicated by gestational diabetes mellitus (GDM) is a potent risk factor for the later development of T2DM. Aims: To explore the characteristics of women diagnosed with GDM in a single centre and their follow up for progression to T2DM. Methods: A retrospective cohort study using anonymised data of one hundred and fifty four (154) women with GDM receiving maternity care at the Oxford University Hospitals NHS Foundation Trust (OUHFT) in 2010 and their follow up until 2018. Results: The prevalence of GDM in women delivering in Oxfordshire in 2010 was 3.4%. 70% of pregnant women were overweight or obese (with 51% being obese) at booking. Gestational weight gain (GWG) was excessive in 29% of women, when compared to Institute of Medicine (IOM) guidelines. Almost a quarter of women (23.4%) had no follow up after delivery. Over a median follow up of 3.5 years (range 0-8 years) nearly one in six (16.9%) of the total cohort (22% of those tested) went on to develop T2DM. 74% of women with GDM were multiparous, and 65% of nulliparous women were tested compared to 81% of multiparous women. There was a significant difference between multiparous women (53.8%) compared to nulliparous women (46.2%) developing T2DM (p=0.01). There was no significant difference in BMI (p=0.866) or GWG (p=0.83) in women who progressed to T2DM versus those who did not. Conclusion: The risk of T2DM after GDM is substantial however, follow up rates of this population is poor. Subsequent screening of women with GDM and their management crosses secondary and primary care with scope for improvement in counselling of women of the importance of annual reviews, in data collection and follow up in both obstetrics and general practice. The implementation of a recall system, an education programme for general practitioners and/or a registry of women diagnosed with GDM could be useful to identify those at high risk of developing T2DM as well as providing a platform for the potential development of interventions to prevent progression to T2DM after GDM

A randomised controlled trial of blood pressure self-monitoring in the management of hypertensive pregnancy. OPTIMUM-BP:A feasibility trial

Objective: To assess the feasibility of a blood pressure self-monitoring intervention for managing pregnancy hypertension. Study design: OPTIMUM-BP was an unmasked randomised controlled trial comparing a self-monitoring of blood pressure (SMBP) intervention versus usual care for the management of pregnancy hypertension. Women with chronic (CH) or gestational hypertension (GH) from 4 UK centres were randomised (2:1) intervention to control. Self-monitoring involved daily home blood pressure (BP) measurements, with recording via study diary or telemonitoring. Clinicians were invited to use the home readings in clinical and antihypertensive titration decisions. Main outcomes: The primary outcomes were recruitment, retention, adherence and persistence with the intervention. Results: Women from four UK centres were randomised: 158/222 (71%) of those approached agreed, comprising: 86 women with chronic hypertension (55 SMBP, 31 control) and 72 with gestational hypertension (49 SMBP, 23 control) of whom outcome data were available from 154 (97%) and were included in the analysis. The median (IQR) number of days with home BP readings per week were 5.5 (3.1–6.5) for those with chronic hypertension and 6.1 (4.5–6.7) with gestational hypertension. Participants persisted with the intervention for 80% or more of their time from enrolment until delivery in 86% (43/50) and 76% (38/49) of those with chronic and gestational hypertension respectively. Recorded clinic and study BPs were similar for both groups. Conclusions: This is the first randomised investigation of BP self-monitoring for the management of pregnancy hypertension and indicates that a large RCT would be feasible.</p

Complex clinical data and Gestational Diabetes Mellitus

This Innovation Forum brought together a multidisciplinary group of researchers, clinicians, data scientists, industry partners, NHS Digital, and others to discuss the opportunities and challenges for improving clinical care using complex clinical data. The workshop focussed on one specific clinical challenge, Gestational Diabetes Mellitus (GDM), with consideration of other data science challenges and solutions in pregnancy care more widely and other clinical conditions. The Forum was an opportunity to learn about specific data challenges researchers had experienced, learn from what has worked, and where further research is needed. We identified several opportunities for GDM data research in the UK, including the commissioning of the first national GDM audit and a need to focus on preventing type 2 diabetes after GDM in young women. The Forum identified six areas for future work and funding: (i) support for infrastructure to enable data science in this field; (ii) the need to map available data sources in the UK for pregnancy research; (iii) streamlined solutions for ethical approvals and regulatory support; (iv) improving data quality, linkage and access for researchers; (v) development of machine learning and statistical approaches; and (vi) the need to collaborate with clinicians, women and their families to make sure data science improves lives

The feasibility and acceptability of self-testing for proteinuria during pregnancy: A mixed methods approach.

OBJECTIVE: To investigate feasibility and acceptability of self-testing for proteinuria during pregnancy. STUDY DESIGN: Mixed methods approach which included: an accuracy study where pregnant women (n = 100) and healthcare professionals (n = 96) tested seven synthetic protein samples and completed a questionnaire, a feasibility study where pregnant women who were self-monitoring their blood pressure were asked to self-test for proteinuria (n = 30), and an online questionnaire about women's experiences of self-testing (n = 200). MAIN OUTCOME MEASURES: Sensitivity and specificity of testing and questionnaire results. RESULTS: There were no significant differences in the accuracy of synthetic sample testing by pregnant women (sensitivity 0.81 (95% confidence intervals (CI) 0.78-0.85), specificity 0.93 (95% CI 0.91-0.95)) and healthcare professionals: (sensitivity 0.83 (95% CI 0.79-0.86), specificity 0.92 (95% CI 0.90-0.94)). Automated readers had significantly better sensitivity (0.94 (0.91-0.97) (p ≤ .001 in each case), but worse specificity 0.78 (0.69-0.85). Similar results were gained using self-tested urine samples compared to staff-testing using a reference standard of laboratory urine protein-creatinine ratio (uPCR). Women who completed the online survey with experience of self-testing (n = 39, 20%) generally found it easy, and with support from healthcare professionals felt it improved involvement in their care and reduced anxiety. CONCLUSIONS: Self-testing for proteinuria by pregnant women had similar accuracy to healthcare professional testing and was acceptable to both groups. Self-testing of urine combined with self-monitoring of blood pressure could provide a useful adjunct to clinic-based surveillance for the detection of pre-eclampsia. Such novel strategies warrant further research

Blood pressure monitoring in high-risk pregnancy to improve the detection and monitoring of hypertension (the BUMP 1 and 2 trials): protocol for two linked randomised controlled trials.

INTRODUCTION: Self-monitoring of blood pressure (BP) in pregnancy could improve the detection and management of pregnancy hypertension, while also empowering and engaging women in their own care. Two linked trials aim to evaluate whether BP self-monitoring in pregnancy improves the detection of raised BP during higher risk pregnancies (BUMP 1) and whether self-monitoring reduces systolic BP during hypertensive pregnancy (BUMP 2). METHODS AND ANALYSES: Both are multicentre, non-masked, parallel group, randomised controlled trials. Participants will be randomised to self-monitoring with telemonitoring or usual care. BUMP 1 will recruit a minimum of 2262 pregnant women at higher risk of pregnancy hypertension and BUMP 2 will recruit a minimum of 512 pregnant women with either gestational or chronic hypertension. The BUMP 1 primary outcome is the time to the first recording of raised BP by a healthcare professional. The BUMP 2 primary outcome is mean systolic BP between baseline and delivery recorded by healthcare professionals. Other outcomes will include maternal and perinatal outcomes, quality of life and adverse events. An economic evaluation of BP self-monitoring in addition to usual care compared with usual care alone will be assessed across both study populations within trial and with modelling to estimate long-term cost-effectiveness. A linked process evaluation will combine quantitative and qualitative data to examine how BP self-monitoring in pregnancy is implemented and accepted in both daily life and routine clinical practice. ETHICS AND DISSEMINATION: The trials have been approved by a Research Ethics Committee (17/WM/0241) and relevant research authorities. They will be published in peer-reviewed journals and presented at national and international conferences. If shown to be effective, BP self-monitoring would be applicable to a large population of pregnant women. TRIAL REGISTRATION NUMBER: NCT03334149.This work is funded from a National Institute for Health Research (NIHR) Programme grant for applied research (RP-PG- 1209-10051) and an NIHR Professorship awarded to RJM (NIHR-RP- R2- 12-015). RJM and KLT receive funding from the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care Oxford at Oxford Health NHS Foundation Trust. JS is a National Institute for Health Research (NIHR) Senior Investigator and supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care South London (NIHR CLAHRC South London) at King’s College Hospital NHS Foundation Trust. Service support costs will be administered through the NIHR Clinical Research Network

Management of sickle cell disease in pregnancy. A British Society for Haematology Guideline

This guideline was compiled according to the British Societyof Haematology (BSH) process at https://b-s-h.org.uk/guidelines/proposing-and-writing-a-new-bsh-guideline/. The Grad-ing of Recommendations Assessment, Development and Evaluation (GRADE) nomenclature was used to evaluatelevels of evidence and to assess the strength of recommenda-tions. The GRADE criteria can be found at http://www.gradeworkinggroup.or

Blood pressure self-monitoring in pregnancy (BuMP) feasibility study; a qualitative analysis of women's experiences of self-monitoring

Background Hypertensive disorders in pregnancy are a leading cause of maternal and fetal morbidity worldwide. Raised blood pressure (BP) affects 10% of pregnancies worldwide, of which almost half develop pre-eclampsia. The proportion of pregnant women who have risk factors for pre-eclampsia (such as pre-existing hypertension, obesity and advanced maternal age) is increasing. Pre-eclampsia can manifest itself before women experience symptoms and can develop between antenatal visits. Incentives to improve early detection of gestational hypertensive disorders are therefore strong and self-monitoring of blood pressure (SMBP) in pregnancy might be one means to achieve this, whilst improving women’s involvement in antenatal care. The Blood Pressure Self-Monitoring in Pregnancy (BuMP) study aimed to evaluate the feasibility and acceptability of SMBP in pregnancy. Methods To understand women’s experiences of SMBP during pregnancy, we undertook a qualitative study embedded within the BuMP observational feasibility study. Women who were at higher risk of developing hypertension and/or pre-eclampsia were invited to take part in a study using SMBP and also invited to take part in an interview. Semi-structured interviews were conducted at the women’s homes in Oxfordshire and Birmingham with women who were self-monitoring their BP as part of the BuMP feasibility study in 2014. Interviews were conducted by a qualitative researcher and transcribed verbatim. A framework approach was used for analysis. Results Fifteen women agreed to be interviewed. Respondents reported general willingness to engage with monitoring their own BP, feeling that it could reduce anxiety around their health during pregnancy, particularly if they had previous experience of raised BP or pre-eclampsia. They felt able to incorporate self-monitoring into their weekly routines, although this was harder post-partum. Self-monitoring of BP made them more aware of the risks of hypertension and pre-eclampsia in pregnancy. Feelings of reassurance and empowerment were commonly reported by the women in our sample

Blood pressure self-monitoring in pregnancy: examining feasibility in a prospective cohort study

Background: Raised blood pressure (BP) affects approximately 10% of pregnancies worldwide, and a high proportion of affected women develop pre-eclampsia. This study aimed to evaluate the feasibility of self-monitoring of BP in pregnancy in women at higher risk of pre-eclampsia. Methods: This prospective cohort study of self-monitoring BP in pregnancy was carried out in two hospital trusts in Birmingham and Oxford and thirteen primary care practices in Oxfordshire. Eligible women were those defined by the UK National Institute for Health and Care Excellence (NICE) guidelines as at higher risk of pre-eclampsia. A total of 201 participants were recruited between 12 and 16 weeks of pregnancy and were asked to take two BP readings twice daily three times a week through their pregnancy. Primary outcomes were recruitment, retention and persistence of self-monitoring. Study recruitment and retention were analysed with descriptive statistics. Survival analysis was used to evaluate the persistence of self-monitoring and the performance of self-monitoring in the early detection of gestational hypertension, compared to clinic BP monitoring. Secondary outcomes were the mean clinic and self-monitored BP readings and the performance of self-monitoring in the detection of gestational hypertension and pre-eclampsia compared to clinic BP. Results: Of 201 women recruited, 161 (80%) remained in the study at 36 weeks or to the end of their pregnancy, 162 (81%) provided any home readings suitable for analysis, 148 (74%) continued to self-monitor at 20 weeks and 107 (66%) at 36 weeks. Self-monitored readings were similar in value to contemporaneous matched clinic readings for both systolic and diastolic BP. Of the 23 who developed gestational hypertension or pre-eclampsia and self-monitored, 9(39%) had a raised home BP prior to a raised clinic BP. Conclusions: Self-monitoring of BP in pregnancy is feasible and has potential to be useful in the early detection of gestational hypertensive disorders but maintaining self-monitoring throughout pregnancy requires support and probably enhanced training