Remote patient monitoring for management of diabetes mellitus in pregnancy is associated with improved maternal and neonatal outcomes

Abstract

Diabetes is a common medical complication of pregnancy and its treatment is complex. Recent years have seen an increase in the application of mobile health tools and advanced technologies, such as remote patient monitoring (RPM), to try to improve care of diabetes in pregnancy. Previous studies of these technologies for the treatment of diabetes in pregnancy have been small and have not clearly shown clinical benefit from implementing their use. RPM allows clinicians to monitor patients' health data (such as glucose values) in near real-time, in between clinic visits, to make timely adjustments to care. Our objective was to determine if using RPM for management of diabetes in pregnancy leads to improvement in maternal and neonatal outcomes. This was a retrospective cohort study of pregnant patients with diabetes managed by the Maternal Fetal Medicine practice at one academic institution between October 2019 - April 2021. The practice transitioned from paper blood glucose logs to RPM in February 2020. RPM options included: 1) Device integration with Bluetooth glucometers that automatically upload measured glucose values to the patient's Epic MyChart application or 2) Manual entry where patients manually log glucose readings into their MyChart application. Values in the MyChart application directly transfer to the patient's Electronic Health Record for review and changes in management by clinicians. In total, 533 patients were studied. We compared 173 patients managed with paper logs to 360 patients managed with RPM (176 device integration and 184 manual entry). Our primary outcomes were composite maternal morbidity (which included third/fourth-degree laceration, chorioamnionitis, postpartum hemorrhage requiring transfusion, postpartum hysterectomy, wound infection or separation, venous thromboembolism, and maternal admission to ICU) and composite neonatal morbidity (which included umbilical cord pH <7.00, 5 min APGAR <7, respiratory morbidity, hyperbilirubinemia, meconium aspiration, intraventricular hemorrhage, necrotizing enterocolitis, sepsis, pneumonia, seizures, hypoxic ischemic encephalopathy, shoulder dystocia, trauma, brain or body cooling, and NICU admission). Secondary outcomes were measures of glycemic control, as well as the individual components of the primary composite outcomes. We also performed a secondary analysis comparing patients utilizing the two aforementioned RPM options. Chi square, Fisher's exact, 2-sample t, and Mann-Whitney tests were used to compare the groups. A result was considered statistically significant at p<0.05. Maternal baseline characteristics were not significantly different between the RPM and paper groups, aside from a slightly higher baseline rate of chronic hypertension in the RPM group (6.1 vs 1.2%). The primary outcome of composite maternal and composite neonatal morbidity was not significantly different between the groups. However, RPM patients submitted more values, were more likely to achieve glycemic control in target range (79.2% vs 52.0%, p<0.0001), and achieved target range sooner (median 3.3 vs 4.1 weeks, p 0.025) than patients managed with paper logs. This was achieved without increasing in-person visits. RPM patients had lower rates of preeclampsia (5.8% vs 15.0%, p 0.0006) and their infants had lower rates of neonatal hypoglycemia in the first 24 hours of life (29.8% vs 51.7%, p<0.0001). Remote patient monitoring for management of diabetes in pregnancy is superior to a traditional paper-based approach in achieving glycemic control and is associated with improved maternal and neonatal outcomes.