Health care of pregnant women with diabetes in Spain: Approach using a questionnaire | Endocrinología y Nutrición (English Edition)

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Ginecología, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Endocrinología y Nutrición, Hospital Mutua de Terrassa, Barcelona, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Servicio de Endocrinología y Nutrición, Hospital Universitario Joan XXIII, Tarragona, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Asistencia sanitaria de la mujer gestante con diabetes en España: aproximación usando un cuestionario" ] ] "textoCompleto" => "IntroductionDiabetes mellitus is the endocrine-metabolic disease that most commonly complicates pregnancy, either as gestational diabetes (GD) or as pregestational diabetes (PGD). The significance of the disease stems from both its prevalence and the negative implications for the mother, fetus, and newborn,<a class="elsevierStyleCrossRef" href="#bib0150">1</a> despite the fact that the associated complications have decreased in the past four decades.<a class="elsevierStyleCrossRef" href="#bib0155">2</a> The treatment of GD is associated with a decreased frequency of preeclampsia, shoulder dystocia, and macrosomia.<a class="elsevierStyleCrossRef" href="#bib0160">3</a> On the other hand, the planning of pregnancy and preconception controls in PGD have been associated with a decreased frequency of congenital malformations, the risk of preterm delivery, and perinatal mortality.<a class="elsevierStyleCrossRefs" href="#bib0165">4,5</a>The objectives, management, and resources (both material and human) required for an adequate metabolic, obstetric, and perinatal control of pregnancies complicated with diabetes are regularly reviewed and published in the guidelines for care of the main scientific bodies.<a class="elsevierStyleCrossRefs" href="#bib0175">6–9</a> The Spanish Group on Diabetes and Pregnancy (GEDE) of the Spanish Diabetes Society (SED) recently updated its guidelines regarding patient care, adapting the scientific evidence available to the currently existing working environment.<a class="elsevierStyleCrossRef" href="#bib0150">1</a> In any health system, understanding the actual situation and the level of care provided to pregnant women with diabetes is essential in order to achieve adequate maternal and fetal outcomes, to be able to detect deficiencies, and to propose improvements.In this regard, the GEDE wanted to know as much as possible regarding the organization of care for pregnancies complicated by diabetes, the services provided, the material and human resources available and, especially, the diabetological care available. An attempt was made to estimate the number and characteristics of diabetes and pregnancy units (DPUs) and the population they cover.Patients and methodsThis observational, retrospective, cross-sectional study was designed to evaluate how care is provided to women with pregnancy complicated by diabetes in Spain, and to collect data on care activity during 2013. The study was conducted by distributing an online questionnaire to members of SED and the Spanish Society of Endocrinology and Nutrition (SEEN). The confidentiality of the demographic and personal data of the centers involved was preserved during the period of the study.The questionnaire was specifically designed with the study in mind. A preliminary questionnaire prepared by two of the authors (J.A. Rubio and M. Ontañon), which included the practical aspects of the GEDE guidelines,<a class="elsevierStyleCrossRef" href="#bib0150">1</a> was discussed and modified at an initial meeting, and subsequently through online contacts until agreement was reached on a final version. The first part of the questionnaire addressed sociodemographic and center data, while the second part contained 28 questions. Most of the questions required the selection of one answer from multiple alternatives, and there were no open questions (see supplemental material). To limit bias, the questions were carefully written to avoid influencing the answers to the survey.Dissemination of the questionnaireThe intention was to send the questionnaire to all physicians responsible for the care of women with pregnancy complicated by diabetes. With this aim in mind, the SED and SEEN were contacted, and these organizations sent to all their active members, by electronic mail, an invitation to participate in the study along with an electronic link to the website where the questionnaire could be found. The email specified that only one questionnaire per center should be completed, and that it was important to answer regardless of the complexity of care and of how it was being provided to pregnant women with diabetes. It was sent in October 2014 to all SED members, and in December 2014 to SEEN members. The questionnaire was closed on February 15, 2015. The authors did not make direct contact with any potential responder.Data analysisPopulation coverage was estimated as the percentage of the overall response of the responding centers. For this purpose, the whole reference population cared for by the centers in each autonomous community was divided by the census population of both the community and of Spain in 2013.<a class="elsevierStyleCrossRef" href="#bib0195">10</a> This methodology was also used to estimate the coverage of deliveries by the responding centers.<a class="elsevierStyleCrossRef" href="#bib0200">11</a> Data on the reference population of the hospitals and the deliveries attended were provided by the surveyed physicians and verified, or were collected from the annual reports or websites of the hospitals included in the survey.The question analyzing the existence of a DPU at the hospital was: is there at your hospital an outpatient clinic or unit that cares for most pregnant women with diabetes? A hospital was considered to have a DPU if two criteria were met: (1) there was at least one specialist each in endocrinology and obstetrics; and (2) the hospital had a preconception diabetes clinic.DPU complexity was then estimated based on the following predefined criteria: (1) a minimum model (MM): only the two prior criteria were met; (2) an intermediate model (IM): MM+a specific education nurse for monitoring pregnant women with diabetes and the availability of continuous subcutaneous insulin infusion (CSII) therapy; (3) a model of excellence (ME): IM+all three indicators of excellence (the participation in training of professionals, quality control at the unit, and participation in research projects [items 26–28]).The percentage of the population and the deliveries covered by DPUs throughout Spain was estimated using the same methods as used for the previously described analysis of population representativeness.To analyze the number of women with GD and PGD attending each hospital, the upper extreme outliers (values that differed from the third quartile by more than three times the interquartile range) were discarded. For hospitals caring for all women with GD, GD prevalence was estimated as the ratio between the number of women with GD seen at the hospital in 2013 and the number of deliveries in that same year. It was assessed whether the frequency of insulin therapy for GD by hospital varied depending on some care aspects (items 1, 2, 4, 12, 13, and 14) and whether these differences persisted as a function of the number of women with GD seen by hospital. To analyze data on PGD, only hospitals and specialized centers were considered. Type 1 DM (T1DM) vs type 2 DM (T2DM) ratios by center were obtained.Quantitative data were displayed as median (P25-P75) because they were not normally distributed (Kolmogorov–Smirnov test) and qualitative data as absolute value and percentage (%). A Mann-Whitney U test was used for comparative analysis of the frequency of insulin therapy between the groups. A two-sided value of p<0.05 was considered significant. Microsoft® Office Excel 2007 and statistical software Analyze-it for Microsoft Excel (version 2.20) were used.ResultsQuestionnaires completed and population representativenessEighty-seven questionnaires were received from 81 hospitals, four specialized centers, and two healthcare centers. Of these, 70, 8, and 9 were public, contracted, and private health centers respectively. The questionnaires were most commonly completed by endocrinologists (78, 90%), and to a lesser extent by multidisciplinary teams, an endocrinologist-pediatrician, an endocrinologist-obstetrician, or professionals from independent specialties such as internal medicine and obstetrics.Seventy-three centers had a total reference population of 23,684,467 inhabitants assigned, that is, 51% of the census population in Spain (as of January 1, 2014). Deliveries were done at 74 centers, but only data from 69 centers were available. The centers cared for a total of 164,108 deliveries, or 39% of the deliveries in Spain during 2013. No questionnaires were received from the community of Extremadura or the towns of Ceuta and Melilla, and these areas are therefore not represented.Organization of the care of pregnant women with diabetesWhen asked: is there an outpatient clinic or a unit that cares for most pregnant women with diabetes at your hospital?, 59 (68%) hospitals answered that they had endocrinologists and obstetricians for care, but that there were different types of organization, as shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Sixty-three (72%) centers answered that they had diabetes educators specifically caring for pregnant women (one nurse at 29 hospitals [48%], 2 at 25 [41%], and 3 at 7 [11%]). A nurse was available for educating patients with GD and PGD in 88% and 76% of hospitals, respectively, and for patient monitoring in 70% and 56% respectively. Twenty-four hospitals (28%) had some type of telematic application connecting pregnant patients and the team in charge of their monitoring.Diagnosis, control, and reassessment of gestational diabetesIn the first trimester, screening for GD was only performed in the risk groups at 76 hospitals (87%), while universal screening was performed in the second trimester at 86 hospitals (99%). The screening most commonly consisted of blood glucose measurement after the administration of 50g of glucose, with a cut-off point of 140mg/dL (7.8mmol/L), used at 85 hospitals (98%). The National Diabetes Data Group criteria after an oral glucose tolerance test (OGTT) of 100g were used at 77 centers (91%), and the Carpenter and Coustan criteria at 8 centers (9%). One center used the criteria of the International Association of Diabetes and Pregnancy Study Group.Seventy-one centers (82%) monitored all women diagnosed with GD in their areas, while 12 centers (14%) only monitored those with greater complexity, with the support of centers of excellence and specialties. Monitoring was done by both the physician and educator in 56 centers (64%), by educators following a protocol in 14 centers (16%), and by the physician alone in 17 centers (20%).Diabetes care was preferentially performed by a specific professional in 64 centers (74%), while obstetric care was provided by a specific professional in 45 centers (52%).GD monitoring and post-partum evaluation were usually performed at the same center (55, 63%), and less commonly in primary care (31, 36%). The most usual form of reassessment was an OGTT using 75g of glucose (41 centers, 48%), followed by an OGTT combined with HbA1c measurement (37 centers, 43%).Prevalence and frequency of insulin therapy in gestational diabetesA total of 10,676 women with GD were evaluated, with a median of 136 (71.5–250) by study center (n=59) and an 8.2% prevalence of GD (6.5%-10%) (n=40). Insulin therapy was administered to 28% of patients (15%–40%) (n=46). <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> analyzes the frequency of insulin therapy by type of care. Insulin therapy was more common at centers with a specific educator for GD control who was involved in monitoring, as compared to centers where monitoring was performed by physicians only. These differences continued after analysis depending on the number of women attending the centers, using the median as the cut-off point.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Care provided to pregnant women with pregestational diabetesAt specialized centers (n=85), the preconception visit was performed at individual consulting rooms by different professionals, endocrinologists or obstetricians, in 54 centers (63.5%) and at the same unit or consulting room by both specialists in 20 centers (23.5%). No preconception visits were performed in 11 centers (13%). Specific physicians were in charge of diabetes and obstetric care in 59 (69%) and 51 (60%) centers respectively. CSII, a blood glucose meter, and a bolus calculator were available and used if required in 59 (69.4%), 43 (50.5%), and 67 (78.8%) centers respectively. In 57 centers (67%), post-partum monitoring was performed at the same clinic as used during pregnancy, while in 28 centers (33%) patients were referred to the physician responsible for monitoring before pregnancy.Types of pregestational diabetesFifty-two centers reported care for 1161 females: 633 (54.5%) with T1DM, 485 (41.7%) with T2DM, and 43 (3.7%) with other types of DM, with a mean overall T1DM/T2DM ratio of 1.3. Forty-four centers caring for T1DM and T2DM had a T1DM/T2DM ratio of 1 (0.5–2.1).Indicators of excellence in diabetes and pregnancy careThree aspects were assessed (items 27–29): participation in professional training and retraining in 53 centers (62%), quality controls promoting action protocols and the keeping of registries in 46 (54%), and involvement in research projects or multicenter studies in 30 (35%) centers.Approximation to diabetes and pregnancy unitsFifty-three centers met the criteria required for being designated as DPUs. These covered 77% of the reference population of the study centers and 81% of deliveries occurring at the responding centers. <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows the distribution and estimation of the population covered by centers of the MM, IM, and ME models. Thirteen of the 14 MM centers were hospitals.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>DiscussionThis study is the first approximation in Spain to the actual care currently being provided to pregnant women with diabetes, and shows an intermediate coverage with DPUs for the care of PGD and an adequate coverage for GD. It is estimated that 3 out of every 5 pregnant women with PGD were seen at DPUs with resources providing an adequate quality of care, but that 2 out of every 5 women either had no access to a DPU, or the DPU did not have the minimum resources to optimize blood glucose control, such as access to CSII therapy or a specific education nurse for the control of gestational diabetes.Most centers responding, 81 out of 87, were hospitals, which is where women with GD and PGD have traditionally been cared for in Spain. Only 4 centers of excellence and specialties answered the survey, which reflects the hierarchization of care in Spain, where those centers refer most women with GD and PGD to their reference hospital.While the number of centers surveyed was low as compared to the total number of centers of the NHS, 498 general or maternity hospitals,<a class="elsevierStyleCrossRef" href="#bib0205">12</a> they covered 51% of the 2013 Spanish population census and accounted for 39% of deliveries attended during that year. They are, in our view, a representative sample as regards current health care of these diseases, although with a certain bias toward centers with greater population coverage and, consequently, with probably more resources.The screening of the population at risk in the first trimester, diagnosis in two steps, and the preferential use of the National Diabetes Data Group criteria for GD show that most centers have decided to continue using the criteria recommended by the GEDE in 2006<a class="elsevierStyleCrossRef" href="#bib0210">13</a> and confirmed in 2015,<a class="elsevierStyleCrossRef" href="#bib0150">1</a> and have not implemented the recommendations of the International Association of Diabetes and Pregnancy Study Group.<a class="elsevierStyleCrossRef" href="#bib0215">14</a> The survey shows a consistent use of GEDE recommendations for the diagnosis of GD, with no differences in criteria between the different centers. This is important, because it avoids significant differences in prevalence depending on the area, which may have an impact on maternal and fetal outcomes, as seen in other countries.<a class="elsevierStyleCrossRef" href="#bib0220">15</a>The median GD prevalence at the centers that reported monitoring of the whole population was 8.2%, although 25% of the centers did not reach 6.6%. These fluctuations may be attributed to population differences, defects in detection, or the loss of cases in the population area. These data agree with those reported by other European centers<a class="elsevierStyleCrossRef" href="#bib0225">16</a> and a multicenter Spanish study.<a class="elsevierStyleCrossRef" href="#bib0230">17</a> Insulin therapy was administered to 28% of patients, with a very wide percentile distribution between the centers. The survey shows differences in the severity of metabolic impairment between the centers, and probably in standard clinical practice also. This latter possibility is supported by the greater frequency of insulin therapy in models in which nursing was involved in disease monitoring, showing once again the barrier that insulin therapy represents for pregnant women in everyday life,<a class="elsevierStyleCrossRef" href="#bib0235">18</a> and the significance of the role of specialized diabetes education for achieving adequate control.<a class="elsevierStyleCrossRef" href="#bib0240">19</a> A striking finding in this study was that, in 20% of the centers, metabolic monitoring was performed by a physician alone, with no support from the nursing staff. This contrasts with the recommendations in the main guidelines,<a class="elsevierStyleCrossRefs" href="#bib0175">6–9</a> based on the fact that such an approach is not associated with better maternal and fetal outcomes.<a class="elsevierStyleCrossRef" href="#bib0245">20</a>Post-partum reassessment was performed with almost the same frequency using OGTT (75g) alone or combining OGTT and HbA1c measurement, in contrast to recommendations by the GEDE<a class="elsevierStyleCrossRef" href="#bib0150">1</a> and most guidelines,<a class="elsevierStyleCrossRefs" href="#bib0180">7–9</a> which advise the use of OGTT with 75g for reclassification. The fact that post-partum reclassification and monitoring were mostly performed at hospitals rather than primary care, as recommended,<a class="elsevierStyleCrossRefs" href="#bib0150">1,21</a> appears to suggest both a lack of coordination and a lack of joint action protocols between care levels, with a resultant misuse of resources. This may also be explained by the traditionally insufficient involvement of primary care teams in pregnancy control.<a class="elsevierStyleCrossRef" href="#bib0255">22</a> Since a diagnosis of GD identifies a group of women at a high risk of DM requiring preventive actions, we think that action protocols are needed to coordinate post-partum monitoring with primary care.A relevant finding in this study was the significant deficiencies in the portfolio of services for patients with PGD at some centers. Thus, 13% of centers had no preconception clinic, and 30% did not have CSII as an option available for improving control.<a class="elsevierStyleCrossRefs" href="#bib0150">1,6–9</a> T1DM was predominant, but there was a great heterogeneity, in agreement with reports from other population studies.<a class="elsevierStyleCrossRef" href="#bib0260">23</a>The classification of DPUs into 3 models, MM, IM, and ME, allowed for an approach to their level of complexity. Based on the reference population and/or deliveries attended, it was estimated that 3 out of every 5 women with PGD received care at IM and ME. By contrast, 2 out of every 5 had no DPU or had a MM DPU, which, in our view, is clearly inadequate for women with PGD. The added value provided by multidisciplinary teams in the management of some diseases<a class="elsevierStyleCrossRef" href="#bib0265">24</a> is particularly evident in PGD.<a class="elsevierStyleCrossRefs" href="#bib0175">6–9</a> Aspects such as the type of center and team experience have a direct impact on control and neonatal outcomes.<a class="elsevierStyleCrossRef" href="#bib0270">25</a> By contrast, women with GD were seen at DPUs in basically a hospital setting, with less regard being paid to the complexity of their management, and thus, possibly with an inadequate use of the available resources.It should finally be noted that only 28% of the centers used telemedicine for monitoring pregnant women with diabetes, despite the potential savings in medical visits and the improvement of the quality of life in women with both GD and PGD, although in GD improvement has only been reported in metabolic control, but not in other maternal and fetal outcomes.<a class="elsevierStyleCrossRefs" href="#bib0275">26,27</a> The conclusions of such studies are limited by the few studies available which have analyzed this type of care and the low number of women enrolled, particularly with PGD and specifically with T1DM.<a class="elsevierStyleCrossRef" href="#bib0285">28</a> The implementation of telemedicine for monitoring pregnant women with diabetes, as well as further research, is, therefore, required.This study has a number of limitations. First of all, evaluation of the actual care provided to pregnant women with DM was partial, because it mainly focused on endocrine control, only limited attention being paid to obstetric care. As the survey was distributed through the SED and SEEN, it may not have reached DPUs managed by physicians who are not active members of these societies and who had therefore no access to the channels through which the questionnaire was disseminated. Second, the estimation of the population covered by the DPUs is based on the premise that 50% of the population not represented in the survey receives the same care as that provided in the responding centers. If this premise were not assumed, the deficiencies detected in care would be much greater.On the other hand, the strengths of this study include the wide dissemination of the survey throughout Spain, as well as the value shown by this information collection tool as regards reliability as compared to other methods (telephone interview or ordinary post).<a class="elsevierStyleCrossRef" href="#bib0290">29</a>It may be concluded from this study that the care provided for pregnant women with PGD has an intermediate coverage, with significant deficiencies in aspects such as preconception clinic and CSII, while the care provided for women with GD may be considered adequate. Aspects in need of improvement include the integration of diabetes educators and coordination with primary care for post-partum reclassification. Finally, most centers adhered to the criteria proposed by the GEDE for the diagnosis of GD.Conflicts of interestThe authors state that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres829152" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec825373" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres829151" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec825374" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Patients and methods" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Dissemination of the questionnaire" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Data analysis" ] ] ] 6 => array:3 [ "identificador" => "sec0025" "titulo" => "Results" "secciones" => array:8 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Questionnaires completed and population representativeness" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Organization of the care of pregnant women with diabetes" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Diagnosis, control, and reassessment of gestational diabetes" ] 3 => array:2 [ "identificador" => "sec0045" "titulo" => "Prevalence and frequency of insulin therapy in gestational diabetes" ] 4 => array:2 [ "identificador" => "sec0050" "titulo" => "Care provided to pregnant women with pregestational diabetes" ] 5 => array:2 [ "identificador" => "sec0055" "titulo" => "Types of pregestational diabetes" ] 6 => array:2 [ "identificador" => "sec0060" "titulo" => "Indicators of excellence in diabetes and pregnancy care" ] 7 => array:2 [ "identificador" => "sec0065" "titulo" => "Approximation to diabetes and pregnancy units" ] ] ] 7 => array:2 [ "identificador" => "sec0070" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0075" "titulo" => "Conflicts of interest" ] 9 => array:2 [ "identificador" => "xack278280" "titulo" => "Acknowledgments" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-10-15" "fechaAceptado" => "2015-11-13" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec825373" "palabras" => array:6 [ 0 => "Diabetes mellitus" 1 => "Pregnancy" 2 => "Gestational diabetes" 3 => "Pregestational diabetes" 4 => "Implementation guidelines" 5 => "Multidisciplinary team" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec825374" "palabras" => array:6 [ 0 => "Diabetes mellitus" 1 => "Embarazo" 2 => "Diabetes gestacional" 3 => "Diabetes pregestacional" 4 => "Implementación guías clínicas" 5 => "Equipo multidisciplinario" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectiveTo ascertain how health care for pregnant women with gestational diabetes (GD) and pregestational diabetes (PGD) is organized, and to estimate the number of Pregnancy and Diabetes Units (PDUs) in Spain in 2013. Material and methodsThe Spanish Group of Diabetes and Pregnancy (GEDE) developed and agreed on a questionnaire based on the recommendations of the group. The questionnaire was sent to members of the Spanish Society of Diabetes and the Spanish Society of Endocrinology and Nutrition. ResultsEighty-seven questionnaires were received from 81 hospitals, 4 outpatient specialty centers, and 2 primary healthcare centers, which accounted for 51% of the Spanish population and for 39% of births in 2013. GD was mainly diagnosed based on GEDE recommendations (98%), and less than 50% of women were reevaluated after delivery in primary care. Fourteen (26%) of the 53 centers identified as PDUs corresponded to a minimal model. Continuous subcutaneous insulin infusion (CSII) therapy was not available in 30% of centers, and 13% of hospitals had no preconceptional clinics. No nurse support was available in 20% of centers. ConclusionsCare of women with PGD has a fair coverage with PDU, but significant deficits still exist, for instance, in preconception clinic and CSII. However, organization of care for women with GD appears to be adequate. There are aspects in need of improvement such as integration of diabetes educators and coordination with primary care for postpartum reclassification." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "ObjetivoConocer la organización de la atención sanitaria de las gestantes con diabetes gestacional (DG) y diabetes pregestacional, y estimar el número de unidades de diabetes y gestación en España en 2013. Material y métodosEl Grupo Español de Diabetes y Embarazo elaboró y consensuó un cuestionario basándose en las recomendaciones de la guía asistencial del grupo. El cuestionario fue enviado a los miembros de la Sociedad Española de Diabetes y de la Sociedad Española de Endocrinología y Nutrición. ResultadosSe recibieron 87 cuestionarios (81 hospitales, 4 centros de especialidades, 2 centros de salud), que representaban al 51% de la población censada en España y el 39% de los partos atendidos en el año 2013. El diagnóstico de la DG se hizo mayoritariamente siguiendo recomendaciones del Grupo Español de Diabetes y Embarazo (98%), y en menos del 50% de los casos la reclasificación posparto se realizó en atención primaria. De los 53 centros considerados unidades de diabetes y gestación 14 (26%) respondían a un modelo mínimo. El 13% de los centros no realizan clínica preconcepcional, y un 30% no contaban con terapia con infusión subcutánea continua de insulina. En un 20% de los centros la asistencia la realizaba el facultativo sin apoyo de enfermería. ConclusionesLa asistencia de las mujeres gestantes con diabetes pregestacional tiene una cobertura intermedia con carencias importantes, como clínica preconcepcional e infusión subcutánea continua de insulina, mientras que en las mujeres con DG se puede considerar suficiente. Existen aspectos a mejorar, como la integración de la educadora en diabetes y la coordinación con atención primaria para la reclasificación posparto." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Rubio JA, Ontañón M, Perea V, Megia A, en representación del Grupo Español de Diabetes y Embarazo. Asistencia sanitaria de la mujer gestante con diabetes en España: aproximación usando un cuestionario. Endocrinol Nutr. 2016;63:113–120." ] 1 => array:3 [ "etiqueta" => "◊" "nota" => "The Grupo Español de Diabetes y Embarazo (GEDE) is a multidisciplinary group composed of members of the Sociedad Española de Diabetes (SED) and the Sociedad Española de Ginecología y Obstetricia (SEGO), whose current composition stated in Appendix A." "identificador" => "fn1" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:2 [ 0 => array:4 [ "apendice" => "Domingo Acosta, Hospital U. Virgen del Rocío, Seville; Montserrat Balsells, Hospital Mutua de Terrassa, Barcelona; Mónica Ballesteros, Hospital U. Joan XXIII, Tarragona; María Orosia Bandres, Hospital Royo Villanova, Saragossa; José Luis Bartha, Hospital U. La Paz, Madrid; Jordi Bellart, Hospital Clínico, Barcelona; Ana Isabel Chico, Hospital Santa Creu i Sant Pau, Barcelona; Mercedes Codina, Hospital U. Son Espases, Palma de Majorca; Rosa Corcoy, Hospital Santa Creu i Sant Pau, Barcelona; Alicia Cortázar, Hospital de Cruces, Baracaldo, Biscay; Sergio Donnay, Hospital U. Fundación Alcorcón, Madrid; María del Carmen Gómez, C.S. Velez-Norte, Málaga; Nieves Luisa González, Hospital U. de Canarias, Las Palmas; María del Mar Goya, Hospital U. Vall d’ Hebrón, Barcelona; Lucrecia Herranz, Hospital U. La Paz, Madrid; José López, Hospital Virgen de la Salud, Toledo; Patricia Martín, Hospital U. Fundación Alcorcón, Madrid; Ana Megía, Hospital U. Joan XXIII, Tarragona; Eduardo Moreno, Hospital U. Virgen del Rocío, Seville; Juan Mozas, Hospital Materno Virgen de las Nieves, Granada; Marta Ontañón, Hospital U. Príncipe de Asturias, Alcalá de Henares, Madrid; Verónica Perea, Hospital Mutua de Terrassa, Barcelona; José Antonio Rubio, Hospital U. Príncipe de Asturias, Alcalá Henares, Madrid; María Antonia Sancho, Hospital Clínico U. Lozano Blesa, Saragossa; Berta Soldevila, Hospital Germán Trias i Pujol, Badalona, Barcelona; Begoña Vega, Hospital Universitario Materno Infantil de Canarias, Las Palmas; Irene Vinagre, Hospital Clínico y Provincial de Barcelona, Barcelona." "etiqueta" => "Annex 1" "titulo" => "Members of the Spanish Group on Diabetes and Pregnancy (GEDE)" "identificador" => "sec0080" ] 1 => array:4 [ "apendice" => "<elsevierMultimedia ident="upi0005"></elsevierMultimedia>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0090" ] ] ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "First column: number of centers and percentage of all centers, n=87. Second column: sum of the reference population of centers giving the same answer and percentage of the population of responding centers, n=23,684,467 inhabitants. Third column: sum of the deliveries attended at centers giving the same answer and percentage of all deliveries at the responding centers, n=164,108 deliveries." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No. of centers (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Reference population (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Deliveries attended (%) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Clinic shared by endocrinologist and obstetrician \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 (17) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4,987,978 (21) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">37,718 (23) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Different endocrinology and obstetrics clinics working in coordination through a telematic application \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 (21) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5,805,869 (25) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">38,220 (23) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Different endocrinology and obstetrics clinics working in coordination with no telematic support \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26 (30) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8,348,461 (35) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">60,358 (37) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">At an endocrinology clinic alone \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (11) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2,319,046 (11) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8627 (5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">At an obstetrics clinic alone \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">132,500 (1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1046 (1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No specific clinics, or care provided by different endocrinologists and obstetricians \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 (20) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2,189,931 (9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18,139 (11) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1395105.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Distribution of the organization of care for pregnant women with diabetes." ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Data are percentages, median (P25–P75]. Calculation was only performed for centers doing total monitoring of women." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Joint or coordinated endocrinological and obstetric care (item 1)</th><th class="td" title="table-head " align="left" valign="top" scope="col">p \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Yes \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">All women with GD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">29 (14.6–40), n>34 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">26 (15–40), n>12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.900 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="top"></td><td class="td" title="table-entry " colspan="2" align="center" valign="top">Care with specific educator (item 2)</td><td class="td" title="table-entry " rowspan="2" align="char" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">All women with GD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">31.5 (19.4–42.9), n>36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15 (8.10–15), n>10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.004 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Centers with <136 GD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">33 (19.7–50), n>17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12.5 (6–8. 8. 9. 9–15), n>6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.017 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Centers with >136 GD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30 (16.2–40), n>19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15 (8.15–23), n>4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.164 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="top"></td><td class="td" title="table-entry " colspan="2" align="center" valign="top">Care with telematic application (item 4)</td><td class="td" title="table-entry " rowspan="2" align="char" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">All women with GD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30 (17.7–43), n>17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">27 (13.1–40), n>29 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.417 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="top"></td><td class="td" title="table-entry " colspan="2" align="center" valign="top">Responsible for metabolic control (item 12)</td><td class="td" title="table-entry " rowspan="2" align="char" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Physician only \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">With educator \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">All women with GD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15 (4.10–25), n>10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30 (16.7–42.9), n>36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.012 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Centers with <136 GD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12.5 (3.6–9. 9–26) n>6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30 (17.7–50), n>17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.092 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Centers with >136 GD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15 (1–8. 8–12. 12–23), n>4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30 (16.2–40), n>19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.086 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="top"></td><td class="td" title="table-entry " colspan="2" align="center" valign="top">Specific diabetes care (item 13)</td><td class="td" title="table-entry " rowspan="2" align="char" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">All women with GD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30 (14.6–40), n>38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">17.5 (15–32), n>8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.485 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="top"></td><td class="td" title="table-entry " colspan="2" align="center" valign="top">Specific obstetric care (item 14)</td><td class="td" title="table-entry " rowspan="2" align="char" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">All women with GD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30 (13.3–40), n>25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25 (15–36.7), n>21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.921 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1395106.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Frequency of insulin therapy in women with GD by type of care.*." ] ] 2 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "First column: distribution and percentage of all responding centers, n=87. Second column: sum of the reference population of centers with DPUs and percentage of the population of responding centers, n=23,684,467 inhabitants. Third column: sum of the deliveries attended at centers with DPUs and percentage of all deliveries at the responding centers, n=164,108 deliveries. ME: IM+all three indicators of excellence (participation in the training of professionals, quality control at the unit, or participation in research projects); IM: MM+specific education nurse for monitoring pregnant women with diabetes and availability of CSII; MM: (1) at least one specialist each in endocrinology and obstetrics available; and (2) a preconception diabetes clinic." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No. of centers (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Reference population (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Deliveries attended (%) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Minimum model (MM) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 (16.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3,872,468 (16) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30,685 (19) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Intermediate model (IM) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 (23) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6,172,431 (26) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">39,416 (24) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Model of excellence (ME) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 (21.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8,267,323 (35) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">62,345 (38) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53 (60.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18,312,222 (77) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">132,446 (81) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1395104.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Diabetes and pregnancy units grouped by model." ] ] 3 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.pdf" "ficheroTamanyo" => 110491 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:29 [ 0 => array:3 [ "identificador" => "bib0150" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Asistencia a la gestante con diabetes. 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Health care of pregnant women with diabetes in Spain: Approach using a questionnaire

Asistencia sanitaria de la mujer gestante con diabetes en España: aproximación usando un cuestionario

José Antonio Rubioa,b,

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joseantonio.rubio@salud.madrid.org
jarubiogarcia@gmail.com

Corresponding author.

, Marta Ontañónc, Verónica Peread, Ana Megiae, on behalf of the Spanish Group of Diabetes and Pregnant ◊

a Servicio de Endocrinología y Nutrición, Hospital Universitario Príncipe de Asturias , Alcalá de Henares, Madrid, Spain

b Departamento de Ciencias Biomédicas, Universidad de Alcalá, Alcalá de Henares, Spain

c Servicio de Obstetricia y Ginecología, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain

d Servicio de Endocrinología y Nutrición, Hospital Mutua de Terrassa, Barcelona, Spain

e Servicio de Endocrinología y Nutrición, Hospital Universitario Joan XXIII, Tarragona, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Diabetes mellitus is the endocrine-metabolic disease that most commonly complicates pregnancy&#44; either as gestational diabetes &#40;GD&#41; or as pregestational diabetes &#40;PGD&#41;&#46; The significance of the disease stems from both its prevalence and the negative implications for the mother&#44; fetus&#44; and newborn&#44;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">1</span></a> despite the fact that the associated complications have decreased in the past four decades&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">2</span></a> The treatment of GD is associated with a decreased frequency of preeclampsia&#44; shoulder dystocia&#44; and macrosomia&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">3</span></a> On the other hand&#44; the planning of pregnancy and preconception controls in PGD have been associated with a decreased frequency of congenital malformations&#44; the risk of preterm delivery&#44; and perinatal mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">4&#44;5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The objectives&#44; management&#44; and resources &#40;both material and human&#41; required for an adequate metabolic&#44; obstetric&#44; and perinatal control of pregnancies complicated with diabetes are regularly reviewed and published in the guidelines for care of the main scientific bodies&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">6&#8211;9</span></a> The Spanish Group on Diabetes and Pregnancy &#40;GEDE&#41; of the Spanish Diabetes Society &#40;SED&#41; recently updated its guidelines regarding patient care&#44; adapting the scientific evidence available to the currently existing working environment&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">1</span></a> In any health system&#44; understanding the actual situation and the level of care provided to pregnant women with diabetes is essential in order to achieve adequate maternal and fetal outcomes&#44; to be able to detect deficiencies&#44; and to propose improvements&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In this regard&#44; the GEDE wanted to know as much as possible regarding the organization of care for pregnancies complicated by diabetes&#44; the services provided&#44; the material and human resources available and&#44; especially&#44; the diabetological care available&#46; An attempt was made to estimate the number and characteristics of diabetes and pregnancy units &#40;DPUs&#41; and the population they cover&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Patients and methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">This observational&#44; retrospective&#44; cross-sectional study was designed to evaluate how care is provided to women with pregnancy complicated by diabetes in Spain&#44; and to collect data on care activity during 2013&#46; The study was conducted by distributing an online questionnaire to members of SED and the Spanish Society of Endocrinology and Nutrition &#40;SEEN&#41;&#46; The confidentiality of the demographic and personal data of the centers involved was preserved during the period of the study&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The questionnaire was specifically designed with the study in mind&#46; A preliminary questionnaire prepared by two of the authors &#40;J&#46;A&#46; Rubio and M&#46; Onta&#241;on&#41;&#44; which included the practical aspects of the GEDE guidelines&#44;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">1</span></a> was discussed and modified at an initial meeting&#44; and subsequently through online contacts until agreement was reached on a final version&#46; The first part of the questionnaire addressed sociodemographic and center data&#44; while the second part contained 28 questions&#46; Most of the questions required the selection of one answer from multiple alternatives&#44; and there were no open questions &#40;see supplemental material&#41;&#46; To limit bias&#44; the questions were carefully written to avoid influencing the answers to the survey&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Dissemination of the questionnaire</span><p id="par0030" class="elsevierStylePara elsevierViewall">The intention was to send the questionnaire to all physicians responsible for the care of women with pregnancy complicated by diabetes&#46; With this aim in mind&#44; the SED and SEEN were contacted&#44; and these organizations sent to all their active members&#44; by electronic mail&#44; an invitation to participate in the study along with an electronic link to the website where the questionnaire could be found&#46; The email specified that only one questionnaire per center should be completed&#44; and that it was important to answer regardless of the complexity of care and of how it was being provided to pregnant women with diabetes&#46; It was sent in October 2014 to all SED members&#44; and in December 2014 to SEEN members&#46; The questionnaire was closed on February 15&#44; 2015&#46; The authors did not make direct contact with any potential responder&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Data analysis</span><p id="par0035" class="elsevierStylePara elsevierViewall">Population coverage was estimated as the percentage of the overall response of the responding centers&#46; For this purpose&#44; the whole reference population cared for by the centers in each autonomous community was divided by the census population of both the community and of Spain in 2013&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">10</span></a> This methodology was also used to estimate the coverage of deliveries by the responding centers&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">11</span></a> Data on the reference population of the hospitals and the deliveries attended were provided by the surveyed physicians and verified&#44; or were collected from the annual reports or websites of the hospitals included in the survey&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The question analyzing the existence of a DPU at the hospital was&#58; is there at your hospital an outpatient clinic or unit that cares for most pregnant women with diabetes&#63; A hospital was considered to have a DPU if two criteria were met&#58; &#40;1&#41; there was at least one specialist each in endocrinology and obstetrics&#59; and &#40;2&#41; the hospital had a preconception diabetes clinic&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">DPU complexity was then estimated based on the following predefined criteria&#58; &#40;1&#41; a minimum model &#40;MM&#41;&#58; only the two prior criteria were met&#59; &#40;2&#41; an intermediate model &#40;IM&#41;&#58; MM<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>a specific education nurse for monitoring pregnant women with diabetes and the availability of continuous subcutaneous insulin infusion &#40;CSII&#41; therapy&#59; &#40;3&#41; a model of excellence &#40;ME&#41;&#58; IM<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>all three indicators of excellence &#40;the participation in training of professionals&#44; quality control at the unit&#44; and participation in research projects &#91;items 26&#8211;28&#93;&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The percentage of the population and the deliveries covered by DPUs throughout Spain was estimated using the same methods as used for the previously described analysis of population representativeness&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">To analyze the number of women with GD and PGD attending each hospital&#44; the upper extreme outliers &#40;values that differed from the third quartile by more than three times the interquartile range&#41; were discarded&#46; For hospitals caring for all women with GD&#44; GD prevalence was estimated as the ratio between the number of women with GD seen at the hospital in 2013 and the number of deliveries in that same year&#46; It was assessed whether the frequency of insulin therapy for GD by hospital varied depending on some care aspects &#40;items 1&#44; 2&#44; 4&#44; 12&#44; 13&#44; and 14&#41; and whether these differences persisted as a function of the number of women with GD seen by hospital&#46; To analyze data on PGD&#44; only hospitals and specialized centers were considered&#46; Type 1 DM &#40;T1DM&#41; vs type 2 DM &#40;T2DM&#41; ratios by center were obtained&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Quantitative data were displayed as median &#40;P25-P75&#41; because they were not normally distributed &#40;Kolmogorov&#8211;Smirnov test&#41; and qualitative data as absolute value and percentage &#40;&#37;&#41;&#46; A Mann-Whitney <span class="elsevierStyleItalic">U</span> test was used for comparative analysis of the frequency of insulin therapy between the groups&#46; A two-sided value of <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05 was considered significant&#46; Microsoft<span class="elsevierStyleSup">&#174;</span> Office Excel 2007 and statistical software Analyze-it for Microsoft Excel &#40;version 2&#46;20&#41; were used&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Questionnaires completed and population representativeness</span><p id="par0065" class="elsevierStylePara elsevierViewall">Eighty-seven questionnaires were received from 81 hospitals&#44; four specialized centers&#44; and two healthcare centers&#46; Of these&#44; 70&#44; 8&#44; and 9 were public&#44; contracted&#44; and private health centers respectively&#46; The questionnaires were most commonly completed by endocrinologists &#40;78&#44; 90&#37;&#41;&#44; and to a lesser extent by multidisciplinary teams&#44; an endocrinologist-pediatrician&#44; an endocrinologist-obstetrician&#44; or professionals from independent specialties such as internal medicine and obstetrics&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Seventy-three centers had a total reference population of 23&#44;684&#44;467 inhabitants assigned&#44; that is&#44; 51&#37; of the census population in Spain &#40;as of January 1&#44; 2014&#41;&#46; Deliveries were done at 74 centers&#44; but only data from 69 centers were available&#46; The centers cared for a total of 164&#44;108 deliveries&#44; or 39&#37; of the deliveries in Spain during 2013&#46; No questionnaires were received from the community of Extremadura or the towns of Ceuta and Melilla&#44; and these areas are therefore not represented&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Organization of the care of pregnant women with diabetes</span><p id="par0075" class="elsevierStylePara elsevierViewall">When asked&#58; is there an outpatient clinic or a unit that cares for most pregnant women with diabetes at your hospital&#63;&#44; 59 &#40;68&#37;&#41; hospitals answered that they had endocrinologists and obstetricians for care&#44; but that there were different types of organization&#44; as shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Sixty-three &#40;72&#37;&#41; centers answered that they had diabetes educators specifically caring for pregnant women &#40;one nurse at 29 hospitals &#91;48&#37;&#93;&#44; 2 at 25 &#91;41&#37;&#93;&#44; and 3 at 7 &#91;11&#37;&#93;&#41;&#46; A nurse was available for educating patients with GD and PGD in 88&#37; and 76&#37; of hospitals&#44; respectively&#44; and for patient monitoring in 70&#37; and 56&#37; respectively&#46; Twenty-four hospitals &#40;28&#37;&#41; had some type of telematic application connecting pregnant patients and the team in charge of their monitoring&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Diagnosis&#44; control&#44; and reassessment of gestational diabetes</span><p id="par0085" class="elsevierStylePara elsevierViewall">In the first trimester&#44; screening for GD was only performed in the risk groups at 76 hospitals &#40;87&#37;&#41;&#44; while universal screening was performed in the second trimester at 86 hospitals &#40;99&#37;&#41;&#46; The screening most commonly consisted of blood glucose measurement after the administration of 50<span class="elsevierStyleHsp" style=""></span>g of glucose&#44; with a cut-off point of 140<span class="elsevierStyleHsp" style=""></span>mg&#47;dL &#40;7&#46;8<span class="elsevierStyleHsp" style=""></span>mmol&#47;L&#41;&#44; used at 85 hospitals &#40;98&#37;&#41;&#46; The National Diabetes Data Group criteria after an oral glucose tolerance test &#40;OGTT&#41; of 100<span class="elsevierStyleHsp" style=""></span>g were used at 77 centers &#40;91&#37;&#41;&#44; and the Carpenter and Coustan criteria at 8 centers &#40;9&#37;&#41;&#46; One center used the criteria of the International Association of Diabetes and Pregnancy Study Group&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Seventy-one centers &#40;82&#37;&#41; monitored all women diagnosed with GD in their areas&#44; while 12 centers &#40;14&#37;&#41; only monitored those with greater complexity&#44; with the support of centers of excellence and specialties&#46; Monitoring was done by both the physician and educator in 56 centers &#40;64&#37;&#41;&#44; by educators following a protocol in 14 centers &#40;16&#37;&#41;&#44; and by the physician alone in 17 centers &#40;20&#37;&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Diabetes care was preferentially performed by a specific professional in 64 centers &#40;74&#37;&#41;&#44; while obstetric care was provided by a specific professional in 45 centers &#40;52&#37;&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">GD monitoring and post-partum evaluation were usually performed at the same center &#40;55&#44; 63&#37;&#41;&#44; and less commonly in primary care &#40;31&#44; 36&#37;&#41;&#46; The most usual form of reassessment was an OGTT using 75<span class="elsevierStyleHsp" style=""></span>g of glucose &#40;41 centers&#44; 48&#37;&#41;&#44; followed by an OGTT combined with HbA1c measurement &#40;37 centers&#44; 43&#37;&#41;&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Prevalence and frequency of insulin therapy in gestational diabetes</span><p id="par0105" class="elsevierStylePara elsevierViewall">A total of 10&#44;676 women with GD were evaluated&#44; with a median of 136 &#40;71&#46;5&#8211;250&#41; by study center &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>59&#41; and an 8&#46;2&#37; prevalence of GD &#40;6&#46;5&#37;-10&#37;&#41; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>40&#41;&#46; Insulin therapy was administered to 28&#37; of patients &#40;15&#37;&#8211;40&#37;&#41; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>46&#41;&#46; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> analyzes the frequency of insulin therapy by type of care&#46; Insulin therapy was more common at centers with a specific educator for GD control who was involved in monitoring&#44; as compared to centers where monitoring was performed by physicians only&#46; These differences continued after analysis depending on the number of women attending the centers&#44; using the median as the cut-off point&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Care provided to pregnant women with pregestational diabetes</span><p id="par0110" class="elsevierStylePara elsevierViewall">At specialized centers &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>85&#41;&#44; the preconception visit was performed at individual consulting rooms by different professionals&#44; endocrinologists or obstetricians&#44; in 54 centers &#40;63&#46;5&#37;&#41; and at the same unit or consulting room by both specialists in 20 centers &#40;23&#46;5&#37;&#41;&#46; No preconception visits were performed in 11 centers &#40;13&#37;&#41;&#46; Specific physicians were in charge of diabetes and obstetric care in 59 &#40;69&#37;&#41; and 51 &#40;60&#37;&#41; centers respectively&#46; CSII&#44; a blood glucose meter&#44; and a bolus calculator were available and used if required in 59 &#40;69&#46;4&#37;&#41;&#44; 43 &#40;50&#46;5&#37;&#41;&#44; and 67 &#40;78&#46;8&#37;&#41; centers respectively&#46; In 57 centers &#40;67&#37;&#41;&#44; post-partum monitoring was performed at the same clinic as used during pregnancy&#44; while in 28 centers &#40;33&#37;&#41; patients were referred to the physician responsible for monitoring before pregnancy&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Types of pregestational diabetes</span><p id="par0115" class="elsevierStylePara elsevierViewall">Fifty-two centers reported care for 1161 females&#58; 633 &#40;54&#46;5&#37;&#41; with T1DM&#44; 485 &#40;41&#46;7&#37;&#41; with T2DM&#44; and 43 &#40;3&#46;7&#37;&#41; with other types of DM&#44; with a mean overall T1DM&#47;T2DM ratio of 1&#46;3&#46; Forty-four centers caring for T1DM and T2DM had a T1DM&#47;T2DM ratio of 1 &#40;0&#46;5&#8211;2&#46;1&#41;&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Indicators of excellence in diabetes and pregnancy care</span><p id="par0120" class="elsevierStylePara elsevierViewall">Three aspects were assessed &#40;items 27&#8211;29&#41;&#58; participation in professional training and retraining in 53 centers &#40;62&#37;&#41;&#44; quality controls promoting action protocols and the keeping of registries in 46 &#40;54&#37;&#41;&#44; and involvement in research projects or multicenter studies in 30 &#40;35&#37;&#41; centers&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Approximation to diabetes and pregnancy units</span><p id="par0125" class="elsevierStylePara elsevierViewall">Fifty-three centers met the criteria required for being designated as DPUs&#46; These covered 77&#37; of the reference population of the study centers and 81&#37; of deliveries occurring at the responding centers&#46; <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows the distribution and estimation of the population covered by centers of the MM&#44; IM&#44; and ME models&#46; Thirteen of the 14 MM centers were hospitals&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Discussion</span><p id="par0130" class="elsevierStylePara elsevierViewall">This study is the first approximation in Spain to the actual care currently being provided to pregnant women with diabetes&#44; and shows an intermediate coverage with DPUs for the care of PGD and an adequate coverage for GD&#46; It is estimated that 3 out of every 5 pregnant women with PGD were seen at DPUs with resources providing an adequate quality of care&#44; but that 2 out of every 5 women either had no access to a DPU&#44; or the DPU did not have the minimum resources to optimize blood glucose control&#44; such as access to CSII therapy or a specific education nurse for the control of gestational diabetes&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Most centers responding&#44; 81 out of 87&#44; were hospitals&#44; which is where women with GD and PGD have traditionally been cared for in Spain&#46; Only 4 centers of excellence and specialties answered the survey&#44; which reflects the hierarchization of care in Spain&#44; where those centers refer most women with GD and PGD to their reference hospital&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">While the number of centers surveyed was low as compared to the total number of centers of the NHS&#44; 498 general or maternity hospitals&#44;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">12</span></a> they covered 51&#37; of the 2013 Spanish population census and accounted for 39&#37; of deliveries attended during that year&#46; They are&#44; in our view&#44; a representative sample as regards current health care of these diseases&#44; although with a certain bias toward centers with greater population coverage and&#44; consequently&#44; with probably more resources&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">The screening of the population at risk in the first trimester&#44; diagnosis in two steps&#44; and the preferential use of the National Diabetes Data Group criteria for GD show that most centers have decided to continue using the criteria recommended by the GEDE in 2006<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">13</span></a> and confirmed in 2015&#44;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">1</span></a> and have not implemented the recommendations of the International Association of Diabetes and Pregnancy Study Group&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">14</span></a> The survey shows a consistent use of GEDE recommendations for the diagnosis of GD&#44; with no differences in criteria between the different centers&#46; This is important&#44; because it avoids significant differences in prevalence depending on the area&#44; which may have an impact on maternal and fetal outcomes&#44; as seen in other countries&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">15</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">The median GD prevalence at the centers that reported monitoring of the whole population was 8&#46;2&#37;&#44; although 25&#37; of the centers did not reach 6&#46;6&#37;&#46; These fluctuations may be attributed to population differences&#44; defects in detection&#44; or the loss of cases in the population area&#46; These data agree with those reported by other European centers<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">16</span></a> and a multicenter Spanish study&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">17</span></a> Insulin therapy was administered to 28&#37; of patients&#44; with a very wide percentile distribution between the centers&#46; The survey shows differences in the severity of metabolic impairment between the centers&#44; and probably in standard clinical practice also&#46; This latter possibility is supported by the greater frequency of insulin therapy in models in which nursing was involved in disease monitoring&#44; showing once again the barrier that insulin therapy represents for pregnant women in everyday life&#44;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">18</span></a> and the significance of the role of specialized diabetes education for achieving adequate control&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">19</span></a> A striking finding in this study was that&#44; in 20&#37; of the centers&#44; metabolic monitoring was performed by a physician alone&#44; with no support from the nursing staff&#46; This contrasts with the recommendations in the main guidelines&#44;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">6&#8211;9</span></a> based on the fact that such an approach is not associated with better maternal and fetal outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">20</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Post-partum reassessment was performed with almost the same frequency using OGTT &#40;75<span class="elsevierStyleHsp" style=""></span>g&#41; alone or combining OGTT and HbA1c measurement&#44; in contrast to recommendations by the GEDE<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">1</span></a> and most guidelines&#44;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">7&#8211;9</span></a> which advise the use of OGTT with 75<span class="elsevierStyleHsp" style=""></span>g for reclassification&#46; The fact that post-partum reclassification and monitoring were mostly performed at hospitals rather than primary care&#44; as recommended&#44;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">1&#44;21</span></a> appears to suggest both a lack of coordination and a lack of joint action protocols between care levels&#44; with a resultant misuse of resources&#46; This may also be explained by the traditionally insufficient involvement of primary care teams in pregnancy control&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">22</span></a> Since a diagnosis of GD identifies a group of women at a high risk of DM requiring preventive actions&#44; we think that action protocols are needed to coordinate post-partum monitoring with primary care&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">A relevant finding in this study was the significant deficiencies in the portfolio of services for patients with PGD at some centers&#46; Thus&#44; 13&#37; of centers had no preconception clinic&#44; and 30&#37; did not have CSII as an option available for improving control&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">1&#44;6&#8211;9</span></a> T1DM was predominant&#44; but there was a great heterogeneity&#44; in agreement with reports from other population studies&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">23</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">The classification of DPUs into 3 models&#44; MM&#44; IM&#44; and ME&#44; allowed for an approach to their level of complexity&#46; Based on the reference population and&#47;or deliveries attended&#44; it was estimated that 3 out of every 5 women with PGD received care at IM and ME&#46; By contrast&#44; 2 out of every 5 had no DPU or had a MM DPU&#44; which&#44; in our view&#44; is clearly inadequate for women with PGD&#46; The added value provided by multidisciplinary teams in the management of some diseases<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">24</span></a> is particularly evident in PGD&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">6&#8211;9</span></a> Aspects such as the type of center and team experience have a direct impact on control and neonatal outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">25</span></a> By contrast&#44; women with GD were seen at DPUs in basically a hospital setting&#44; with less regard being paid to the complexity of their management&#44; and thus&#44; possibly with an inadequate use of the available resources&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">It should finally be noted that only 28&#37; of the centers used telemedicine for monitoring pregnant women with diabetes&#44; despite the potential savings in medical visits and the improvement of the quality of life in women with both GD and PGD&#44; although in GD improvement has only been reported in metabolic control&#44; but not in other maternal and fetal outcomes&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">26&#44;27</span></a> The conclusions of such studies are limited by the few studies available which have analyzed this type of care and the low number of women enrolled&#44; particularly with PGD and specifically with T1DM&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">28</span></a> The implementation of telemedicine for monitoring pregnant women with diabetes&#44; as well as further research&#44; is&#44; therefore&#44; required&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">This study has a number of limitations&#46; First of all&#44; evaluation of the actual care provided to pregnant women with DM was partial&#44; because it mainly focused on endocrine control&#44; only limited attention being paid to obstetric care&#46; As the survey was distributed through the SED and SEEN&#44; it may not have reached DPUs managed by physicians who are not active members of these societies and who had therefore no access to the channels through which the questionnaire was disseminated&#46; Second&#44; the estimation of the population covered by the DPUs is based on the premise that 50&#37; of the population not represented in the survey receives the same care as that provided in the responding centers&#46; If this premise were not assumed&#44; the deficiencies detected in care would be much greater&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">On the other hand&#44; the strengths of this study include the wide dissemination of the survey throughout Spain&#44; as well as the value shown by this information collection tool as regards reliability as compared to other methods &#40;telephone interview or ordinary post&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">29</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">It may be concluded from this study that the care provided for pregnant women with PGD has an intermediate coverage&#44; with significant deficiencies in aspects such as preconception clinic and CSII&#44; while the care provided for women with GD may be considered adequate&#46; Aspects in need of improvement include the integration of diabetes educators and coordination with primary care for post-partum reclassification&#46; Finally&#44; most centers adhered to the criteria proposed by the GEDE for the diagnosis of GD&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Conflicts of interest</span><p id="par0190" class="elsevierStylePara elsevierViewall">The authors state that they have no conflicts of interest&#46;</p></span></span>"
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              "titulo" => "Questionnaires completed and population representativeness"
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              "titulo" => "Organization of the care of pregnant women with diabetes"
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              "titulo" => "Diagnosis&#44; control&#44; and reassessment of gestational diabetes"
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              "titulo" => "Prevalence and frequency of insulin therapy in gestational diabetes"
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              "titulo" => "Care provided to pregnant women with pregestational diabetes"
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              "titulo" => "Types of pregestational diabetes"
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              "titulo" => "Indicators of excellence in diabetes and pregnancy care"
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              "titulo" => "Approximation to diabetes and pregnancy units"
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            1 => "Pregnancy"
            2 => "Gestational diabetes"
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            0 => "Diabetes mellitus"
            1 => "Embarazo"
            2 => "Diabetes gestacional"
            3 => "Diabetes pregestacional"
            4 => "Implementaci&#243;n gu&#237;as cl&#237;nicas"
            5 => "Equipo multidisciplinario"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To ascertain how health care for pregnant women with gestational diabetes &#40;GD&#41; and pregestational diabetes &#40;PGD&#41; is organized&#44; and to estimate the number of Pregnancy and Diabetes Units &#40;PDUs&#41; in Spain in 2013&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The Spanish Group of Diabetes and Pregnancy &#40;GEDE&#41; developed and agreed on a questionnaire based on the recommendations of the group&#46; The questionnaire was sent to members of the Spanish Society of Diabetes and the Spanish Society of Endocrinology and Nutrition&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Eighty-seven questionnaires were received from 81 hospitals&#44; 4 outpatient specialty centers&#44; and 2 primary healthcare centers&#44; which accounted for 51&#37; of the Spanish population and for 39&#37; of births in 2013&#46; GD was mainly diagnosed based on GEDE recommendations &#40;98&#37;&#41;&#44; and less than 50&#37; of women were reevaluated after delivery in primary care&#46; Fourteen &#40;26&#37;&#41; of the 53 centers identified as PDUs corresponded to a minimal model&#46; Continuous subcutaneous insulin infusion &#40;CSII&#41; therapy was not available in 30&#37; of centers&#44; and 13&#37; of hospitals had no preconceptional clinics&#46; No nurse support was available in 20&#37; of centers&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Care of women with PGD has a fair coverage with PDU&#44; but significant deficits still exist&#44; for instance&#44; in preconception clinic and CSII&#46; However&#44; organization of care for women with GD appears to be adequate&#46; There are aspects in need of improvement such as integration of diabetes educators and coordination with primary care for postpartum reclassification&#46;</p></span>"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Conocer la organizaci&#243;n de la atenci&#243;n sanitaria de las gestantes con diabetes gestacional &#40;DG&#41; y diabetes pregestacional&#44; y estimar el n&#250;mero de unidades de diabetes y gestaci&#243;n en Espa&#241;a en 2013&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">El Grupo Espa&#241;ol de Diabetes y Embarazo elabor&#243; y consensu&#243; un cuestionario bas&#225;ndose en las recomendaciones de la gu&#237;a asistencial del grupo&#46; El cuestionario fue enviado a los miembros de la Sociedad Espa&#241;ola de Diabetes y de la Sociedad Espa&#241;ola de Endocrinolog&#237;a y Nutrici&#243;n&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se recibieron 87 cuestionarios &#40;81 hospitales&#44; 4 centros de especialidades&#44; 2 centros de salud&#41;&#44; que representaban al 51&#37; de la poblaci&#243;n censada en Espa&#241;a y el 39&#37; de los partos atendidos en el a&#241;o 2013&#46; El diagn&#243;stico de la DG se hizo mayoritariamente siguiendo recomendaciones del Grupo Espa&#241;ol de Diabetes y Embarazo &#40;98&#37;&#41;&#44; y en menos del 50&#37; de los casos la reclasificaci&#243;n posparto se realiz&#243; en atenci&#243;n primaria&#46; De los 53 centros considerados unidades de diabetes y gestaci&#243;n 14 &#40;26&#37;&#41; respond&#237;an a un modelo m&#237;nimo&#46; El 13&#37; de los centros no realizan cl&#237;nica preconcepcional&#44; y un 30&#37; no contaban con terapia con infusi&#243;n subcut&#225;nea continua de insulina&#46; En un 20&#37; de los centros la asistencia la realizaba el facultativo sin apoyo de enfermer&#237;a&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La asistencia de las mujeres gestantes con diabetes pregestacional tiene una cobertura intermedia con carencias importantes&#44; como cl&#237;nica preconcepcional e infusi&#243;n subcut&#225;nea continua de insulina&#44; mientras que en las mujeres con DG se puede considerar suficiente&#46; Existen aspectos a mejorar&#44; como la integraci&#243;n de la educadora en diabetes y la coordinaci&#243;n con atenci&#243;n primaria para la reclasificaci&#243;n posparto&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Objetivo"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Material y m&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
    ]
    "NotaPie" => array:2 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Rubio JA&#44; Onta&#241;&#243;n M&#44; Perea V&#44; Megia A&#44; en representaci&#243;n del Grupo Espa&#241;ol de Diabetes y Embarazo&#46; Asistencia sanitaria de la mujer gestante con diabetes en Espa&#241;a&#58; aproximaci&#243;n usando un cuestionario&#46; Endocrinol Nutr&#46; 2016&#59;63&#58;113&#8211;120&#46;</p>"
      ]
      1 => array:3 [
        "etiqueta" => "&#9674;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">The Grupo Espa&#241;ol de Diabetes y Embarazo &#40;GEDE&#41; is a multidisciplinary group composed of members of the Sociedad Espa&#241;ola de Diabetes &#40;SED&#41; and the Sociedad Espa&#241;ola de Ginecolog&#237;a y Obstetricia &#40;SEGO&#41;&#44; whose current composition stated in Appendix A&#46;</p>"
        "identificador" => "fn1"
      ]
    ]
    "apendice" => array:1 [
      0 => array:1 [
        "seccion" => array:2 [
          0 => array:4 [
            "apendice" => "<p id="par0200" class="elsevierStylePara elsevierViewall">Domingo Acosta&#44; Hospital U&#46; Virgen del Roc&#237;o&#44; Seville&#59; Montserrat Balsells&#44; Hospital Mutua de Terrassa&#44; Barcelona&#59; M&#243;nica Ballesteros&#44; Hospital U&#46; Joan XXIII&#44; Tarragona&#59; Mar&#237;a Orosia Bandres&#44; Hospital Royo Villanova&#44; Saragossa&#59; Jos&#233; Luis Bartha&#44; Hospital U&#46; La Paz&#44; Madrid&#59; Jordi Bellart&#44; Hospital Cl&#237;nico&#44; Barcelona&#59; Ana Isabel Chico&#44; Hospital Santa Creu i Sant Pau&#44; Barcelona&#59; Mercedes Codina&#44; Hospital U&#46; Son Espases&#44; Palma de Majorca&#59; Rosa Corcoy&#44; Hospital Santa Creu i Sant Pau&#44; Barcelona&#59; Alicia Cort&#225;zar&#44; Hospital de Cruces&#44; Baracaldo&#44; Biscay&#59; Sergio Donnay&#44; Hospital U&#46; Fundaci&#243;n Alcorc&#243;n&#44; Madrid&#59; Mar&#237;a del Carmen G&#243;mez&#44; C&#46;S&#46; Velez-Norte&#44; M&#225;laga&#59; Nieves Luisa Gonz&#225;lez&#44; Hospital U&#46; de Canarias&#44; Las Palmas&#59; Mar&#237;a del Mar Goya&#44; Hospital U&#46; Vall d&#8217; Hebr&#243;n&#44; Barcelona&#59; Lucrecia Herranz&#44; Hospital U&#46; La Paz&#44; Madrid&#59; Jos&#233; L&#243;pez&#44; Hospital Virgen de la Salud&#44; Toledo&#59; Patricia Mart&#237;n&#44; Hospital U&#46; Fundaci&#243;n Alcorc&#243;n&#44; Madrid&#59; Ana Meg&#237;a&#44; Hospital U&#46; Joan XXIII&#44; Tarragona&#59; Eduardo Moreno&#44; Hospital U&#46; Virgen del Roc&#237;o&#44; Seville&#59; Juan Mozas&#44; Hospital Materno Virgen de las Nieves&#44; Granada&#59; Marta Onta&#241;&#243;n&#44; Hospital U&#46; Pr&#237;ncipe de Asturias&#44; Alcal&#225; de Henares&#44; Madrid&#59; Ver&#243;nica Perea&#44; Hospital Mutua de Terrassa&#44; Barcelona&#59; Jos&#233; Antonio Rubio&#44; Hospital U&#46; Pr&#237;ncipe de Asturias&#44; Alcal&#225; Henares&#44; Madrid&#59; Mar&#237;a Antonia Sancho&#44; Hospital Cl&#237;nico U&#46; Lozano Blesa&#44; Saragossa&#59; Berta Soldevila&#44; Hospital Germ&#225;n Trias i Pujol&#44; Badalona&#44; Barcelona&#59; Bego&#241;a Vega&#44; Hospital Universitario Materno Infantil de Canarias&#44; Las Palmas&#59; Irene Vinagre&#44; Hospital Cl&#237;nico y Provincial de Barcelona&#44; Barcelona&#46;</p>"
            "etiqueta" => "Annex 1"
            "titulo" => "Members of the Spanish Group on Diabetes and Pregnancy &#40;GEDE&#41;"
            "identificador" => "sec0080"
          ]
          1 => array:4 [
            "apendice" => "<p id="par0210" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Supplementary data"
            "identificador" => "sec0090"
          ]
        ]
      ]
    ]
    "multimedia" => array:4 [
      0 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
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        "mostrarDisplay" => false
        "detalles" => array:1 [
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          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">First column&#58; number of centers and percentage of all centers&#44; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>87&#46; Second column&#58; sum of the reference population of centers giving the same answer and percentage of the population of responding centers&#44; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>23&#44;684&#44;467 inhabitants&#46; Third column&#58; sum of the deliveries attended at centers giving the same answer and percentage of all deliveries at the responding centers&#44; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>164&#44;108 deliveries&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No&#46; of centers &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Reference population &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Deliveries attended &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Clinic shared by endocrinologist and obstetrician&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15 &#40;17&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#44;987&#44;978 &#40;21&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">37&#44;718 &#40;23&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Different endocrinology and obstetrics clinics working in coordination through a telematic application&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18 &#40;21&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#44;805&#44;869 &#40;25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">38&#44;220 &#40;23&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Different endocrinology and obstetrics clinics working in coordination with no telematic support&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26 &#40;30&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&#44;348&#44;461 &#40;35&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">60&#44;358 &#40;37&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">At an endocrinology clinic alone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10 &#40;11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#44;319&#44;046 &#40;11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8627 &#40;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">At an obstetrics clinic alone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">132&#44;500 &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1046 &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No specific clinics&#44; or care provided by different endocrinologists and obstetricians&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17 &#40;20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#44;189&#44;931 &#40;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18&#44;139 &#40;11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Distribution of the organization of care for pregnant women with diabetes&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Table "
            "rol" => "short"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Data are percentages&#44; median &#40;P25&#8211;P75&#93;&#46; Calculation was only performed for centers doing total monitoring of women&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Joint or coordinated endocrinological and obstetric care &#40;item 1&#41;</th><th class="td" title="table-head  " align="left" valign="top" scope="col"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">All women with GD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">29 &#40;14&#46;6&#8211;40&#41;&#44; n<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">26 &#40;15&#8211;40&#41;&#44; n<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;900&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top"></td><td class="td" title="table-entry  " colspan="2" align="center" valign="top">Care with specific educator &#40;item 2&#41;</td><td class="td" title="table-entry  " rowspan="2" align="char" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">All women with GD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">31&#46;5 &#40;19&#46;4&#8211;42&#46;9&#41;&#44; n<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15 &#40;8&#46;10&#8211;15&#41;&#44; n<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;004&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Centers with &#60;136 GD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">33 &#40;19&#46;7&#8211;50&#41;&#44; n<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&#46;5 &#40;6&#8211;8&#46; 8&#46; 9&#46; 9&#8211;15&#41;&#44; n<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;017&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Centers with &#62;136 GD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30 &#40;16&#46;2&#8211;40&#41;&#44; n<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15 &#40;8&#46;15&#8211;23&#41;&#44; n<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;164&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top"></td><td class="td" title="table-entry  " colspan="2" align="center" valign="top">Care with telematic application &#40;item 4&#41;</td><td class="td" title="table-entry  " rowspan="2" align="char" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">All women with GD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30 &#40;17&#46;7&#8211;43&#41;&#44; n<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">27 &#40;13&#46;1&#8211;40&#41;&#44; n<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;417&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top"></td><td class="td" title="table-entry  " colspan="2" align="center" valign="top">Responsible for metabolic control &#40;item 12&#41;</td><td class="td" title="table-entry  " rowspan="2" align="char" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Physician only&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">With educator&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">All women with GD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15 &#40;4&#46;10&#8211;25&#41;&#44; n<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30 &#40;16&#46;7&#8211;42&#46;9&#41;&#44; n<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Centers with &#60;136 GD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&#46;5 &#40;3&#46;6&#8211;9&#46; 9&#8211;26&#41; n<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30 &#40;17&#46;7&#8211;50&#41;&#44; n<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;092&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Centers with &#62;136 GD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15 &#40;1&#8211;8&#46; 8&#8211;12&#46; 12&#8211;23&#41;&#44; n<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30 &#40;16&#46;2&#8211;40&#41;&#44; n<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;086&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top"></td><td class="td" title="table-entry  " colspan="2" align="center" valign="top">Specific diabetes care &#40;item 13&#41;</td><td class="td" title="table-entry  " rowspan="2" align="char" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">All women with GD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30 &#40;14&#46;6&#8211;40&#41;&#44; n<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">17&#46;5 &#40;15&#8211;32&#41;&#44; n<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;485&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top"></td><td class="td" title="table-entry  " colspan="2" align="center" valign="top">Specific obstetric care &#40;item 14&#41;</td><td class="td" title="table-entry  " rowspan="2" align="char" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">All women with GD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30 &#40;13&#46;3&#8211;40&#41;&#44; n<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25 &#40;15&#8211;36&#46;7&#41;&#44; n<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;921&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Diabetes and pregnancy units grouped by model&#46;</p>"
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          "identificador" => "bibs0005"
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            0 => array:3 [
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
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                      "autores" => array:1 [
                        0 => array:2 [
                          "colaboracion" => "Grupo Espa&#241;ol de Diabetes y Embarazo &#40;GEDE&#41;"
                          "etal" => false
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
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            1 => array:3 [
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prepregnancy counseling&#44; assessment and management of women with preexisting diabetes or previous gestational diabetes"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "D&#46;R&#46; Coustan"
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                    0 => array:1 [
                      "LibroEditado" => array:6 [
                        "editores" => "D&#46;R&#46;Coustan"
                        "paginaInicial" => "5"
                        "paginaFinal" => "26"
                        "edicion" => "5th ed&#46;"
                        "serieTitulo" => "Medical management of pregnancy complicated by diabetes"
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            2 => array:3 [
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "L&#46; Hartling"
                            1 => "D&#46;M&#46; Dryden"
                            2 => "A&#46; Guthrie"
                            3 => "M&#46; Muise"
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                      "doi" => "10.7326/0003-4819-159-2-201307160-00661"
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                        "volumen" => "159"
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            3 => array:3 [
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
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                      "titulo" => "Pre-pregnancy care for women with pre-gestational diabetes mellitus&#58; a systematic review and meta-analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "H&#46;A&#46; Wahabi"
                            1 => "R&#46;A&#46; Alzeidan"
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                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1186/1471-2458-12-792"
                      "Revista" => array:5 [
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            4 => array:3 [
              "identificador" => "bib0170"
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              "referencia" => array:1 [
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effectiveness of a regional prepregnancy care program in women with type 1 and type 2 diabetes&#58; benefits beyond glycemic control"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "H&#46;R&#46; Murphy"
                            1 => "J&#46;M&#46; Roland"
                            2 => "T&#46;C&#46; Skinner"
                            3 => "D&#46; Simmons"
                            4 => "E&#46; Gurnell"
                            5 => "N&#46;J&#46; Morrish"
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                      ]
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                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.2337/dc10-1113"
                      "Revista" => array:6 [
                        "tituloSerie" => "Diabetes Care"
                        "fecha" => "2010"
                        "volumen" => "33"
                        "paginaInicial" => "2514"
                        "paginaFinal" => "2520"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21115765"
                            "web" => "Medline"
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                  ]
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            ]
            5 => array:3 [
              "identificador" => "bib0175"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "NICE guideline&#46; Diabetes in pregnancy&#58; management of diabetes and its complications from preconception to the postnatal period &#91;accessed 22 Sep 2015&#93;&#46; Available from&#58; nice&#46;org&#46;uk&#47;guidance&#47;ng3&#46;"
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0180"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Diabetes and pregnancy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "colaboracion" => "Canadian Diabetes Association Clinical Practice Guidelines Expert Committee"
                          "etal" => false
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jcjd.2013.01.044"
                      "Revista" => array:7 [
                        "tituloSerie" => "Can J Diabetes"
                        "fecha" => "2013"
                        "volumen" => "37"
                        "numero" => "Suppl&#46; 1"
                        "paginaInicial" => "S168"
                        "paginaFinal" => "S183"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24070943"
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              "identificador" => "bib0185"
              "etiqueta" => "8"
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                0 => array:1 [
                  "referenciaCompleta" => "IDF&#46; Global Guideline on pregnancy and diabetes &#91;accessed 22 Sep 2015&#93;&#46; Available from&#58; <a href="http://www.idf.org/guidelines/pregnancy-and-diabetes">http&#58;&#47;&#47;www&#46;idf&#46;org&#47;guidelines&#47;pregnancy-and-diabetes</a>&#46;"
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              ]
            ]
            8 => array:3 [
              "identificador" => "bib0190"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Diabetes&#44; pregnancy&#58; an endocrine society clinical practice guideline"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "I&#46; Blumer"
                            1 => "E&#46; Hadar"
                            2 => "D&#46;R&#46; Hadden"
                            3 => "L&#46; Jovanovi&#269;"
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                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1210/jc.2013-2465"
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                        "tituloSerie" => "J Clin Endocrinol Metab"
                        "fecha" => "2013"
                        "volumen" => "98"
                        "paginaInicial" => "4227"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24194617"
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                      ]
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                ]
              ]
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            9 => array:3 [
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Article information

ISSN: 21735093
Original language: English

DOI:10.1016/j.endoen.2015.11.017

The statistics are updated each day

Year/Month	Html	Pdf	Total

2024 November	7	0	7
2024 October	33	5	38
2024 September	51	6	57
2024 August	30	6	36
2024 July	30	3	33
2024 June	25	3	28
2024 May	29	5	34
2024 April	31	4	35
2024 March	42	6	48
2024 February	33	3	36
2024 January	26	7	33
2023 December	29	10	39
2023 November	31	7	38
2023 October	35	7	42
2023 September	34	1	35
2023 August	24	9	33
2023 July	15	9	24
2023 June	19	5	24
2023 May	26	5	31
2023 April	33	6	39
2023 March	25	6	31
2023 February	24	14	38
2023 January	28	9	37
2022 December	26	19	45
2022 November	51	14	65
2022 October	33	12	45
2022 September	22	11	33
2022 August	20	7	27
2022 July	23	17	40
2022 June	24	9	33
2022 May	36	4	40
2022 April	20	20	40
2022 March	30	10	40
2022 February	20	12	32
2022 January	43	6	49
2021 December	28	15	43
2021 November	46	14	60
2021 October	37	14	51
2021 September	33	18	51
2021 August	44	7	51
2021 July	15	13	28
2021 June	20	14	34
2021 May	36	16	52
2021 April	84	20	104
2021 March	43	9	52
2021 February	37	27	64
2021 January	46	21	67
2020 December	44	12	56
2020 November	29	12	41
2020 October	14	7	21
2020 September	34	7	41
2020 August	33	10	43
2020 July	28	10	38
2020 June	25	8	33
2020 May	36	7	43
2020 April	45	9	54
2020 March	17	3	20
2020 February	27	2	29
2020 January	17	12	29
2019 December	24	7	31
2019 November	11	5	16
2019 October	20	12	32
2019 September	23	4	27
2019 August	12	1	13
2019 July	15	17	32
2019 June	48	16	64
2019 May	130	32	162
2019 April	52	21	73
2019 March	23	8	31
2019 February	20	7	27
2019 January	15	6	21
2018 December	10	6	16
2018 November	12	3	15
2018 October	18	6	24
2018 September	33	3	36
2018 August	11	7	18
2018 July	13	8	21
2018 June	17	2	19
2018 May	20	8	28
2018 April	9	9	18
2018 March	13	4	17
2018 February	10	1	11
2018 January	16	1	17
2017 December	11	3	14
2017 November	20	1	21
2017 October	7	2	9
2017 September	20	4	24
2017 August	14	2	16
2017 July	7	4	11
2017 June	14	4	18
2017 May	30	3	33
2017 April	41	3	44
2017 March	54	1	55
2017 February	46	2	48
2017 January	23	2	25
2016 December	20	7	27
2016 November	32	4	36
2016 October	31	3	34
2016 September	38	4	42
2016 August	5	1	6
2016 June	1	1	2

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Now is Endocrinología, Diabetes y Nutrición (English ed.). More information

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Now is Endocrinología, Diabetes y Nutrición (English ed.). More information

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