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BMJ No 7103 Volume 315 Editorial Saturday 2 August 1997
Persistently poor pregnancy outcomes in women with insulin dependent diabetesSuccess in some countries shows that these can be reversedSee Papers (abstracts only) pp 275, 279Women with insulin dependent diabetes no longer "give birth astride of a grave."(1) By the time of the St Vincent declaration in 1989, with its goal of near normal pregnancy outcomes for diabetic women, non-randomised studies from specialist centres had clearly shown major reductions in fetal and neonatal loss down to 2-4%.(1,2) At the time, Drury proclaimed that "malformations constitute the last bastion to be conquered" among pregnant women with insulin dependent diabetes.(1) Non-randomised studies suggested that, with careful family planning and tight control of preconceptual glycaemia, even malformations could be reduced to near background rates.(3) It is therefore disappointing that the first published papers on this target of the St Vincent declaration, reported in this week's BMJ (pp 275, 279), indicate no local improvement in the rate of either mortality or malformation.(4,5) Why is it that in these two studies of populations in England the declaration's goal has not been achieved? The randomised Diabetes Control and Complications Trial confirmed major reductions in malformation rates with tight glucose control.(6) Even before this trial, pregnancy outcomes had started to improve in Scandinavia. Data from the pregnancies of 557 Swedish women with insulin dependent diabetes had shown similar rates of spontaneous abortion between diabetic and non-diabetic women, as well as lowered rates of major malformation - 2.0% in the diabetic cohort compared with 4.8% 10 years previously and 1.0% in the controls.(7) A decline in malformation rates had also been shown in Denmark.(8) Unpublished data presented at the fourth St Vincent conference suggested that Norway has normalised pregnancy outcomes among diabetic women. Perhaps Scandinavian and British care processes should be compared to identify methods for improving outcomes. The fact that normalisation of pregnancy outcomes can occur supports the view that the goal of the St Vincent declaration can be achieved by systematically identifying and addressing the barriers to optimising glycaemia. It is therefore worth noting that neither of the latest studies provide a measure of glycaemia that can be compared with other studies. Clearly a standard method for comparing haemoglobin A1c needs to be agreed. This should allow continuous improvement in the mean population haemoglobin A1c by creating benchmarks. Moreover, the regular measurement of haemoglobin A1c would provide individual patients with an objective measure of their progress and could be used to postpone pregnancy until an acceptable level of glycaemia was achieved. Although improvements in population and individual glycaemia may be possible, achieving euglycaemia is difficult and not without risk. In the Diabetes Control and Complications Trial, with its well motivated subjects, only 44% of all patients had a haemoglobin A1c concentration within the reference range at least once during the whole study.(9) As the haemoglobin A1c concentration improved, the frequency of hypoglycaemia increased and became a barrier to euglycaemia. The treatment regimen had to be carefully tailored to individual patients, requiring structured and intensive input by experienced members of the diabetes team. Such input includes frequent (perhaps even daily) contact with the diabetes team to discuss results of self monitoring of blood glucose. This is particularly important in pregnancy to keep abreast of the rapidly changing requirements for insulin. Whether this input was provided in the current studies was not reported. Newly developed drugs able to reduce the variance of glycaemia in individual patients may allow further improvements to occur (for example, the amylin and fast acting insulin analogues and better long acting insulin preparations). It would therefore seem that regular measures of haemoglobin A1c linked to intensive preconceptual specialist care, along with benchmarking with other centres, should ensure that the St Vincent targets are reached. However, unplanned pregnancies and pregnancies in women who have not received preconceptual care remain common, and pregnancies among fertile women with non-insulin dependent diabetes seem to be at similar risk to those among women with insulin dependent diabetes.(10) For these patients, the services for non-pregnant women need to be as effective as for those attending preconceptual and antenatal clinics. Diabetes services in general therefore need to be reconfigured to optimise glycaemia over the whole population. To achieve this, there is a need for a more integrated approach between primary and secondary care, increased use of information technology, implementation of existing guidelines, and the development of methods for maximising patient empowerment.(11,12) Staffing levels and the immediate costs of care will have to increase, but intensive therapy has already been shown to represent "good value."(3)(13) The final barriers to achieving the St Vincent goals for pregnancy are likely to be political: dependent on the integration of care between primary and secondary providers and obtaining the funding to provide the services. David Simmons Senior lecturer in medicine South Auckland Academic Division, References
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