As a retrospective study, we selected pregnant and parturient women with GDM regularly receiving antenatal care in our hospital in 2019 as the research objects. The data volume was large, with 1393 subjects included. The one-day outpatient management program was designed to improve the maternal and infant health levels of GDM and reduce short- and long-term complications. Logistic regression, which evaluated the effects of promising management, was applied to detect the association between one-day outpatient management and pregnancy risk events, including preterm birth, macrosomia, and low-birth-weight infants.
GDM, a global metabolic disorder, consists of two major types. The first type is diabetes diagnosed before pregnancy, called “diabetes combined with pregnancy,” which was excluded from our study criteria. The second type refers to elevated blood glucose levels and decreased sensitivity to insulin, resulting from the changed body structure of pregnant women, and abnormal fluctuations of placental lactogen, estrogen, progesterone, cortisol, and placental insulinase in middle and late pregnancy. However, this glycometabolic disorder could return after delivery. In this study, only the second type of GDM, identified by the International Diabetes and Pregnancy Research Group diagnostic criteria, was incorporated. According to previous epidemiological data, the morbidity of GDM in China is 5.12–33.3%, which is rising because of the increase in elderly parturient women[23–26]. As a special type of diabetes, patients with GDM suffer a higher risk of T2DM after delivery. Also, during delivery, the risk of eclampsia increases for both mother and infant[27]. Hyperglycemia and adverse pregnancy outcome studies also showed that the risk of adverse outcomes[28], such as macrosomia, increases with rising blood glucose levels. Therefore, the timely detection of GDM and interventions in the lifestyle and nutrition of pregnant women are effective means by which to reduce the adverse pregnancy outcomes of GDM, especially for macrosomia.
As mentioned in the introduction, non-drug therapy is gradually being regarded as an effective means of blood glucose management in patients with GDM, which includes mainly diet management and physical exercise. In particular, the awareness of GDM management strategies to improve the implementation of these patients have a greater impact on blood glucose management. Blood glucose management consists mainly of periodic blood glucose detection and irregular propaganda and education. In clinical practice follow-up, it was found that after routine blood glucose management, pregnant women with GDM still suffered a higher risk of fasting blood glucose fluctuation. Therefore, a more effective mode should be exploited and applied to manage patients with GDM. Health professionals are constantly looking for practical methods to encourage a healthy lifestyle in patients with GDM, such as long-term guidance through Internet applications[29]. The one-day outpatient service is a multimodal management plan conducted through the face-to-face guidance of professional doctors and personal experience of comprehensive nursing services at one-day intervals[30]. The one-day outpatient health management program translated the abstract concept to concrete feelings of pregnant women, to establish an effective interaction between medical staff and pregnant women families, thereby enhancing the effects of health education on the whole perinatal health management.
Our hospital started the one-day outpatient service of GDM in 2015, and the relevant management content and level have improved based on clinical practices. This retrospective analysis of the data profile in 2019 revealed that only 38.41% of patients with GDM are likely to attend the one-day outpatient clinic, indicating the low popularity of the one-day outpatient clinic, which may be because of insufficient rate of GDM management education for pregnant women at the time of the first diagnosis. A total of 535 pregnant women with GDM participated in the outpatient service in a day, with macrosomia seen in 18 cases (3.36%), most of who did not participate in the outpatient service. Moreover, 858 people were recorded in a day, with macrosomia seen in 53 cases (6.18%). From single- and multiple-factor logistic regression analyses (ORs 0.537 and 0.474, respectively, with statistical significance), one-day of outpatient service for protecting macrosomia factors can effectively prevent the occurrence of macrosomia. However, the effects on preventing premature birth and low-birth-weight infants are not significant, because the main strategy of the one-day clinic of this project was to control blood sugar, without other special measures for premature birth and low-birth-weight infants, such as anemia and malnutrition. Although many studies have shown that a one-day clinic could prevent macrosomia occurrence[31, 32], the results were less convincing owing to the small sample size. However, the data profile of our retrospective analysis is extensive and more convincing. Therefore, combined with data of other scholars, pregnant women who attended the one-day outpatient service suffered a lower occurrence of macrosomia.
Based on statistical analyses and clinical experiences regarding the one-day outpatient service in our hospital, the reasons for preventing macrosomia in the one-day outpatient service may be summarized as three points. First, it improved the compliance of pregnant women with GDM. Patients with GDM who attended the one-day outpatient management service showed higher awareness of disease prevention and compliance with medical advice than other patients with GDM. The one-day outpatient health management program further improved pregnant women’s compliance, including diet control and exercise[31].The participation of the patient’s family members, especially the improvement of their knowledge about GDM, assisted daily management efficiently. The second reason is the efficient, whole process, and professional health education of medical staff. Unlike traditional education during pregnancy, medical staff is required to accompany pregnant women all day in the process of a one-day outpatient clinic. Through interesting courses, food models, video clips, and other methods, pregnant women could grasp the general knowledge of GDM prevention in a relaxing atmosphere, and gradually master the self-management of blood sugar, which could lay a solid foundation for the home management of blood sugar in the late-pregnancy period. Studies have shown that a one-day outpatient clinic can enhance the knowledge awareness rate of GDM and improve the self-management ability at home[33]. The third reason is the power from peer effects, namely, companions, including healthcare workers and the pregnant women’s partners. In the one-day outpatient clinic, pregnant women are accompanied by medical staff in the whole process and receive mutual encouragement and support from other pregnant women[34]. Therefore, they are psychologically satisfied, with reduced anxiety and depression, and are more likely to accept disease prevention knowledge and improve self-management ability. Finally, we believe that the main management strategies of the one-day outpatient service should be further researched and demonstrated through clinical practice.
The main strategies of this one-day outpatient service are diet management, exercise management, blood glucose monitoring, and professional education of GDM. This involves nutritional medicine, sports medicine, diabetes, gynecology, and obstetrics. Therefore, multidisciplinary experts must devise a management strategy of a one-day outpatient service and revise it based on clinical practice. Moreover, individualized management strategies should be developed for individual patients with GDM after the one-day outpatient service to improve their knowledge of GDM management to maintain their blood glucose and weight at home.
The function of the one-day clinic in preventing premature delivery and low-birth-weight is still controversial. Barakat et al.[32] found that the incidence of premature birth in the group participating in a one-day clinic was 5.60%, lower than the 7.20% in the control group; however, there was no statistical difference. Liao et al.[33] found that the rate of premature birth for patients with GDM who attended the one-day clinic was 7.5%, which was significantly lower than 14.00% in the control group, similar to the incidence rate of low-birth-weight children. Yang et al.[35, 36] found that the proportion of low-birth-weight children in their study group was 5.3%, which was almost the same as that in the control group. The reason for these discrepancies may be the different methods and management strategies adopted in different one-day outpatient departments. For example, GDM strategies focused mainly on blood glucose management through exercise and diet control, whereas those for preterm and low-birth-weight infants focused mainly on nutrition support therapy.
Some studies have added other methods based on the traditional one-day outpatient service, which further improved the pregnancy outcomes for GDM. For example, guiding pregnant women to join the Internet home-care platform after attending the one-day outpatient service for GDM and assigning specialized nurses to provide long-term guidance on the Internet platform. Gardsten et al.[37] adopted continuous follow-up based on the one-day outpatient service and established GDM-tracking cards for relatives to solve the potential problem in a timely manner. In summary, the one-day outpatient service is a management strategy that combines multidisciplinary guidance and linkage. Thus, a professional one-day outpatient service strategy should be developed for pregnant women.
This study has two advantages. First, it has a large sample size. Although it is a retrospective study, the research data are complete and reliable. Second, multivariate logistic regression was used to control the confounding factors, such as advanced age and pre-pregnancy BMI, which initially confirmed that the one-day clinic program was an independent protective factor for macrosomia.