Obstetric interventions for women with type 1 or type 2 diabetes.

OBJECTIVE: To determine whether differences exist in the rates of obstetric intervention between women with type 1 diabetes and those with type 2 diabetes, and whether there has been any change in cesarean rates over time, paralleling that seen in the general obstetric population. METHODS: Data were examined from a prospectively collected series on the outcomes of 1030 deliveries (382 by women with type 1 diabetes, 648 by women with type 2 diabetes) from 1988 to 2008. RESULTS: There was a secular trend to increasing maternal age (type 1, P < 0.003; type 2, P < 0.03). Intervention rates (induction of labor or elective cesarean) did not differ between type 1 (88%) and type 2 (85%) diabetes. The overall cesarean rate was 52%-55% with no secular trend. Poorer glycemic control in early pregnancy and primiparity were associated with primary cesarean in both groups. In women with type 1 diabetes, greater maternal obesity and retinopathy were also associated with primary cesarean. CONCLUSION: Intervention rates are high in pregnancies among women with type 1 diabetes and those with type 2 diabetes but they have not changed significantly. Secular trends toward increasing maternal age and obesity suggest that intervention rates are unlikely to decrease in the near future.

The 'unified airway': the RCPCH care pathway for children with asthma and/or rhinitis.

AIMS: The Royal College of Paediatrics and Child Health (RCPCH) Science and Research Department was commissioned by the Department of Health to develop national care pathways for children with allergies: the asthma/rhinitis care pathway is the third such pathway. Asthma and rhinitis have been considered together. These conditions co-exist commonly, have remarkably similar immuno-pathology and an integrated management approach benefits symptom control. METHOD: The asthma/rhinitis pathway was developed by a multidisciplinary working group and was based on a comprehensive review of evidence. The pathway was reviewed by a broad group of stakeholders including the public and was approved by the Allergy Care Pathways Project Board and the RCPCH Clinical Standards Committee. RESULTS: The pathway entry points are defined by symptom type and severity at presentation. Acute severe rhinitis and life-threatening asthma are presented as distinct entry routes to the pathway, recognising that initial care of these conditions requires presentation-specific treatments. However, the pathway emphasises that ideal long term care should take account of both conditions in order to achieve maximal improvements in disease control and quality of life. CONCLUSIONS: The pathway recommends that acute presentations of asthma and/or rhinitis should be treated separately. Where both conditions exist, ongoing management should address the upper and lower airways. The authors recommend that this pathway is implemented locally by a multidisciplinary team (MDT) with a focus on creating networks. The MDT within these networks should work with patients to develop and agree on care plans that are age and culturally appropriate.