BMJ  2006;333:304 (5 August), doi:10.1136/bmj.333.7562.304-a

Letter

Why do poor outcomes persist in diabetic pregnancy?

EDITOR—Macintosh et al report the continued poor outcome of diabetic pregnancy in the United Kingdom, noting high rates of perinatal mortality and congenital malformation in the babies of women with type 1 and type 2 diabetes.¹ We reported some years ago that in our population, perinatal mortality in babies of women with type 2 diabetes was higher than in babies of women with type 1 diabetes.² Macintosh et al found no such difference and dismiss our findings as "not generalisable."

They seem not to have grasped one of the main points of our study, that in women with type 1 diabetes, perinatal mortality was no different to the background (non-diabetic) rate because pregnancy loss owing to late intrauterine death had become rare in type 1 diabetes. The higher rate of perinatal mortality in the babies of women with type 2 diabetes was largely due to the continued occurrence of late intrauterine deaths.² A factor of likely importance in late intrauterine death is maternal obesity, which is strongly linked with type 2 diabetes and independently associated with late fetal loss.^{3 4}

The question remains why perinatal mortality from late intrauterine death remains so high in women with type 1 diabetes in the UK. Macintosh et al blame poor glycaemic control, but it may not be the whole story. In our unit 42% of women with type 1 diabetes have HbA_1c values 7.0% at presentation to the diabetes pregnancy service, a figure not much better than the 35% reported by Macintosh et al, yet late intrauterine death has largely been eliminated. Successful outcomes in diabetic pregnancy depend on the combined skill and commitment of all members of the diabetic and obstetric teams, and good communication and cooperation between them. Organisational issues are likely to be critical. It would be interesting to know from the UK data if some units consistently perform better than others, and, if so, to explore whether organisational deficits underlie poorer outcome in some clinics.

Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland, New Zealand t.cundy{at}auckland.ac.nz

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Competing interests: None declared.

References

1. Macintosh MCM, Fleming KM, Bailey JA, Doyle P, Modder J, Acolet D, et al. Perinatal mortality and congenital anomalies in babies of women with type 1 or type 2 diabetes in England, Wales, and Northern Ireland: population based study. BMJ 2006;333: 171-80. (22 July.)[Abstract/Free Full Text]
2. Cundy T, Gamble G, Townend K, Henley PG, Macpherson P, Roberts AB. Perinatal mortality in type 2 diabetes mellitus. Diabet Med 2000;17: 33-9.[CrossRef][ISI][Medline]
3. Cnattingius S, Bergstrom R, Lipworth L, Kramer MS. Pre-pregnancy weight and the risk of adverse pregnancy outcomes. N Engl J Med 1998;338: 147-52.[Abstract/Free Full Text]
4. Kristensen J, Vestergaard M, Wisborg K, Kesmodel U, Secher NJ. Pre-pregnancy weight and the risk of stillbirth and neonatal death. Br J Obstet Gynaecol 2005;112: 403-8.

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