Management of diabetic women with threatened preterm birth: a survey of Maternal-Fetal Medicine providers

Objective:To evaluate variation in management of diabetic women with threatened preterm birth (PTB). Study design:Thirty-two-question electronic maternal-fetal medicine (MFM) provider survey advertised on the Society for MFM website, newsletter, and Facebook page with questions about antenatal steroid use in diabetic women and glycemic management strategy after steroid administration. Descriptive statistics were used to summarize respondent characteristics, practice patterns, and satisfaction with current practice. Multivariable logistic regression was performed to determine if there were any factors independently associated with provider-reported satisfaction. Result:We obtained 159 completed surveys: 69% from board-certified MFM providers and 31% from MFM fellows. Almost half (48%) of respondents reported caring for diabetic women with threatened PTB at least weekly. Overall, 74% were concerned about the risk of maternal hyperglycemia after steroids, but 86% believed the neonatal benefit outweighed maternal risk. More than half (64%) agreed or strongly agreed that steroids for diabetic pregnant women were "evidence-based," and as such, the majority answered that they administer steroids always or most of the time, ranging from 92% for women with uncontrolled type 1 diabetes to 100% for women with diet-controlled gestational diabetes. The frequency of hospitalization and management approach to obtain glycemic control varied by diabetes type and degree of antepartum glycemic control. Two-thirds of MFM providers reported being satisfied with their current practice in caring for these women. Use of a standard protocol for glycemic management was also associated with increased odds of satisfaction (aOR 4.5, 95% CI 1.3-16.1) whereas use of a continuous insulin infusion for all women with insulin-dependent diabetes was associated with decreased odds of satisfaction (aOR 0.3, 95% CI 0.1-0.8). There was no significant association observed between number of years in practice or frequency of care for diabetic women with threatened PTB and provider satisfaction. Overall, 49% of respondents desired a protocol to guide glycemic management, and 74% believed more research is needed to optimize care of diabetic women receiving steroids for threatened PTB. Conclusion:While there are no prospective studies examining the neonatal benefit of antenatal steroids in diabetic women, MFM respondents believe steroid use in this context is evidence-based and report they are administering steroids almost universally in this population. Variation exists in the glycemic management strategy used after steroid administration. While use of a standard protocol for glycemic control was associated with practice satisfaction, routine use of a continuous insulin infusion for all women with insulin-dependent diabetes was associated with lower odds of satisfaction. More research is needed to optimize care of diabetic women receiving steroids for threatened PTB as maternal and neonatal outcomes related to these practices remain unknown.