Give Birth to New Ideas: An Innovative Model for Gestational Diabetes Management

In a large academic medical center with over 90 ambulatory care clinics, obstetrical care accounts for approximately 24,000 visits annually. Historically, gestational diabetics were managed without any consistent education or standard algorithm of screening among obstetrical/gynecological and maternal fetal medicine clinics. Having dedicated services providing co-management of care for pregnant diabetic patients or newly diagnosed gestational diabetics before 2018 was identified as a gap in care.
Mothers who were diagnosed with gestational diabetes giving birth in the United States rose from an estimated 6% in 2016 to 8.3% in 2021. This highlighted the need for improved awareness and screening efforts in prenatal care settings. The importance of improving the standard of care was further underlined in 2017 with the American College of Obstetricians and Gynecologists (ACOG) collaboration with the American Diabetes Association development a screening strategy in detecting gestational diabetes or pre-diabetes.
One of the OB/GYN and MFM clinics took the lead, transitioning a registered nurse to the role of diabetic educator in 2018. Over five years with services aimed at closing the gap and under new leadership, in 2022, a registered dietitian holding a diabetic care and education specialist (CDCES) certification was hired. To improve education and compliance with appropriate screening, the CDCES interventions started with following patients from diagnosis through delivery. The biweekly appointments with the CDCES offered education, including basic pathophysiology of gestational diabetes and individualized diet modifications based on gestational age. Glucose monitoring via glucometer or a continuous glucose monitoring (CGM) device analyzed by the CDCES provided insulin recommendations to the provider. This collaborative model encouraged a personalized approach to the management of gestational diabetes.
Once referred to the CDCES, the cadence of follow-up visits is determined based on insulin requirements. For diet-controlled gestational diabetics (A1DM), glucose logs were reviewed weekly, with a telehealth visit every two weeks. For insulin-dependent gestational diabetics (A2DM), blood glucose was reviewed, and the patients were seen weekly. To provide ongoing continuity of care, all patients received individualized post-delivery guidelines one week before delivery, as well as a diabetes prevention visit at six weeks postpartum.
The intent of the CDCES role and implementation of the algorithm would reflect an improved compliance percentage in alignment with ACOG and ADA-recommended screenings. To determine compliance, a review of charts from delivered patients in September with a diagnosis of gestational diabetes were compared starting in 2019 at 2-year intervals until the 2023 implementation of the algorithm, then compared with the patients for the month of September the following year. The compliance percentage doubled in one year post-implementation of the algorithm for 2024.