With diabetes reaching epidemic proportions, the evidence suggests that early treatment to maintain optimum glucose levels will reduce the future burden of complications. This is especially so for diabetes in pregnancy, which can affect both mother and child. This case study is examining how to help pregnant women with diabetes, in partnership with their health practitioners, to use clinical decision-systems in conjunction with self-testing of blood glucose to manage both lifestyle and appropriate pharmacotherapy.

During pregnancy, the body produces hormones and some of these hormones can have a blocking effect on insulin. Gestational diabetes is a condition in which a hormone produced by the placenta prevents the body from using insulin effectively. As a consequence, the level of glucose in the blood remains high. To compensate the increased amount of glucose in the blood, the body should produce more insulin. Occasionally, the amount of insulin produced is not enough to transport the glucose into the cells, or the body cells become more resistant to insulin. This condition is known as gestational diabetes mellitus and it can be defined as carbohydrate intolerance.

Although any woman can develop GDM during pregnancy, some of the factors that may increase the risk include: being overweight or obese, sedentary lifestyle, poor diet, family history of diabetes or having given birth previously to infants who are large for gestational age (LGA), age (women who are older than 25 are at a greater risk of developing gestational diabetes than younger women) and prediabetes (impaired glucose tolerance). Besides these factors, specific ethnicities of women have long been considered as a risk factor for developing GDM, women of South Asian heritage are disproportionately affected.

In the UK, 8-24% of pregnancies are affected by GDM and this is the most common complication in pregnancy. In the past, maternal and fetal mortality from GDM was high, but adverse perinatal outcomes are now infrequent due to intensive supervision and monitoring of pregnant woman with GDM. Risks of GDM-related perinatal complications include fetal macrosomia, preterm delivery, clinical neonatal hypoglycemia and cesarean delivery. Women with GDM have an increased incidence of hypertensive disorders and postpartum diabetes.

Evidence suggests that early treatment in order to maintain normal glucose levels can reduce future complications. Screening GDM can be a complex process which involves some tests for measuring the amount of glucose in the blood and resistance to insulin. The National Institute for Health and Care Excellence (NICE) suggests that testing for gestational diabetes should be offered women with any one of the risk factors.

Recently, a report from the National Institute for Health Research (NIHR) showed that the health economic costs of identifying and treating GDM exceed health benefits. This evidence impacts the delivery of GDM screening and care in a situation of high prevalence and where resources are increasingly limited. Through the use of an intelligent decision-making system, women can be empowered and encouraged in self-monitoring and home care, the pressure in clinical settings can be reduced and, as a consequence, health care costs can be reduced. For this reason, a decision support system for GDM care capable of grounding complex and risk-based decision-making is needed.

Currently, more than 12,000 women receive screening for GDM at Barts Health per year, this amount corresponds to 80% of the women admitted to Barts Health. The considerable number of admitted women contribute to a significant cost and demand to routine antenatal care, provided by Barts Health NHS Trust to at least 1500 women per year who are diagnosed with GDM at Royal London and Newham Hospitals. These women receive education and support to make intensive changes in their diet and physical activity levels and should self-monitor capillary blood glucose 4-7 times per day. 20-30% of women present mildly elevated glucose levels and, in these cases, the care may be delivered in community midwifery clinics. Maternal blood glucose levels and other parameters are monitored by clinicians involved in the care pathway and safety and appropriateness of this care is evaluated constantly. Additionally, women will typically have clinical appointments and review of the GDM at least fortnightly. 40-70% of women will develop type 2 diabetes within 5-10 years of GDM.

During the pregnancy, clinicians are requested to perform frequent and complex risk-based decisions to guide treatment. The time of delivery will be determined according to blood glucose monitoring, fetal growth and other important measurements including focusing on avoiding adverse perinatal outcomes, e.g. macrosomia or stillbirth. The postpartum management of type 2 diabetes risk is based on glucose tests to evaluate if GDM has fully resolved. Knowledge about appropriate risk stratification and management is limited and the transition of care across multiple sectors is poorly performed and, for these reasons, risk identification and stratification are not always managed correctly.

Risk stratification for GDM screening and treatment is complex and challenging. At present, women receive a non-personalized and inflexible antenatal care based on intensive use of medicine. Decision support systems that can be implemented in multi-sectoral clinical pathways, support both patients and clinicians and ground complex and risk-based decision-making in GDM care are needed. Up to 100 women may be seen each week in a half day antenatal clinic at a single Barts Health site evidencing the urgency of developing safe and effective decision support systems that can be embedded in clinical care.