• Adil Bahauddin, Maryam Sina, and David Simmons.
• Department of Endocrinology, Campbelltown Hospital, New South Wales, Australia.
• Intern Med J. 2020 Aug 1; 50 (8): 972976972-976.

BackgroundPregnancy in women with pre-gestational types 1 (T1DM) and 2 (T2DM) diabetes mellitus can be a clinical challenge. This study assessed the association between introducing a structured diabetes in pregnancy proforma, on the quality of medical record documentation and pregnancy outcomes in women with T1DM and T2DM.AimsTo evaluate the impact of a proforma on the quality of documenting medical records and pregnancy/neonatal outcomes in women with pre-gestational diabetes.MethodsThis was a retrospective two-cycle audit: pre- and post-proforma introduction. The documentation quality was assessed based on the rate of missing pre-pregnancy/first trimester haemoglobin A1c (HbA1c), third trimester HbA1c, folate intake and dose, retinopathy and nephropathy progression. Changes in pregnancy outcomes were assessed by mode of delivery, preterm delivery, mean third trimester HbA1c, pre-eclampsia and foetal outcomes.ResultsThe pre- and post-proforma periods included 91 and 41 pregnancies, respectively. The quality of documentation improved in the post-proforma phase with the rate of missing data declining from 63.4% to 36.6% (P = 0.005) for pre-pregnancy/first trimester HbA1c, 30.8% to 12.2% (P = 0.009) for periconceptional folate intake, 42.9% to 14.6% (P = 0.001) for folate dose, 100% to 31.7% (P < 0.001) for retinopathy progression, 92.3% to 19.5% (P < 0.001) for nephropathy progression and 31.9% to 7.3% (P = 0.016) for third trimester HbA1c. Macrosomia significantly reduced in the second cycle (49% vs 21% P = 0.003).ConclusionThe quality of documentation improved significantly which is likely attributable to the implementation of the proforma. This study supports the use of structured documentation to reduce variation in care and potentially improve pregnancy outcomes.© 2019 Royal Australasian College of Physicians.

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