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Continued poor outcomes in diabetic pregnancy
- Tim Cundy (4 July 2006)
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High perinatal mortality and prevalence of congenital anomalies in the offspring of women with diabetes in the UK. Is it time for action?
- Abd A Tahrani, George I. Varughese (31 July 2006)
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Diabetes in pregnancy: rising prevalence presents challenges for maternity services
- Ruth Bell, Nick Lewis-Barned, Gillian Hawthorne and Tricia Cresswell on behalf of the Northern Diabetic Pregnancy Survey Steering Group (7 August 2006)
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Tim Cundy, Professor of Medicine University of Auckland, Auckland, New Zealand
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Mary Macintosh and colleagues report on the continued poor outcome of diabetic pregnancy in the UK, noting high rates of both perinatal mortality and congenital malformation in the babies of women with both 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 those with type 1 diabetes(2). In their study Macintosh et al found no such difference, and dismiss our findings as "not generalisable" (whatever that means). 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 due 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 the latter phenomenon is maternal obesity, which is strongly linked with type 2 diabetes and independently associated with late fetal loss(3,4). The question remains as to why perinatal mortality from late intrauterine death remains so high in women with type 1 diabetes in the UK. Macintosh and colleagues pin the blame on poor glycaemic control, and whilst this is of course of great importance, it may not be the whole story. In our unit, 42% of women with type 1 diabetes have HbA1c values ¡Ü7.0% at presentation to the diabetes pregnancy service, a figure not much better than the 35% reported by Macintosh et al(1), yet late intrauterine death has largely been eliminated. Successful outcomes in diabetic pregnancy depend on the combined expertise and commitment of all members of the diabetic and obstetric teams, and good communication and cooperation between them. Organizational 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 organizational deficits underlie poorer outcome in some clinics. 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, doi:10.1136/bmj.38856.692986.AE (published 16 June 2006) 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. 3. Cnattingius S, Bergstrom R, Lipworth L, Kramer MS. Prepregnancy weight and the risk of adverse pregnancy outcomes N Eng J Med 1998; 338: 147-52. 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 Competing interests: None declared |
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Abd A Tahrani, Specialist Registrar in Diabetes and Endocrinology University Hospital of North Staffordshire, ST4 6QG, George I. Varughese
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We have read the article by Macintosh et al with much interest. Macintosh et al found that the prevalence congenital anomalies and perinatal mortality in women with diabetes about four times higher than that of the general maternity population.1 Only 63% of the women with diabetes had satisfactory HbA1c.1 The results are similar to previous studies from that showed increased perinatal mortality and congenital anomalies in the offspring women with diabetes in the UK.2;3 Despite the national service framework (NSF) for diabetes states that “The NHS will develop, implement and monitor policies that seek to empower and support women with pre-existing diabetes and those who develop diabetes during pregnancy to optimize the outcomes of their pregnancy” 4 and 16 years on from saint Vincent declaration 5, perinatal mortality and congenital abnormalities are still much higher in women with diabetes compared to the general maternity population.1 The delivery of pre-pregnancy care in women with diabetes is still poor. The Confidential Enquiry into Maternal and Child Health (CEMACH) report into Pregnancy in women with type1 and type2 diabetes showed that only about one third of women with diabetes in England, Wales and Northern Ireland received pre-conception counselling, had pre-pregnancy glycaemic control measurement or received folic acid supplements prior to pregnancy.6 The CEMACH report also showed that only 38% of women managed to achieve HbA1c less than 7% by 13 weeks of gestation.6 Another important issue is that the number of pregnant women with type 2 diabetes is on the increase. Pre-gestaional type 2 diabetes accounted for 27.6% of diabetes in the CEMACH report.6 Women with Type 2 diabetes were more likely to come from ethnic minority origins and deprived social background and their pre-pregnancy care and pregnancy outcome are significantly worse than those with type 1 diabetes.7 With the evidence from Macintosh et al of increased adverse outcomes in the offspring of women with type 2 diabetes and the increasing numbers of women with type 2 diabetes at childbearing age there is a need for a more uniformed and structured approach across the UK in order to bring the perinatal mortality and congenital anomalies in the offspring of women with diabetes down to that of women without diabetes. The department of health, general practitioners, obstetricians, diabetes specialists and other allied professionals should all work together in order to improve pre-conception care for these patients. A UK-wide approach should be discussed, in particular how to target the groups with highest risk such as the Asian community and women from poorer backgrounds. Reference List (1) Macintosh MC, 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(7560):177. (2) Hawthorne G, Robson S, Ryall EA, Sen D, Roberts SH, Ward Platt MP. Prospective population based survey of outcome of pregnancy in diabetic women: results of the Northern Diabetic Pregnancy Audit, 1994. BMJ 1997; 315(7103):279-281. (3) Casson IF, Clarke CA, Howard CV, McKendrick O, Pennycook S, Pharoah PO et al. Outcomes of pregnancy in insulin dependent diabetic women: results of a five year population cohort study. BMJ 1997; 315(7103):275-278. (4) National Service Framework for Diabetes: Standards. Department of Health [ 2001 [cited 2006 July 30]; Available from: URL:http://www.dh.gov.uk/assetRoot/04/05/89/38/04058938.pdf (5) Diabetes care and research in Europe: the Saint Vincent declaration. Diabet Med 1990; 7(4):360. (6) Confidential Enquiry into Maternal and Child Health. PREGNANCY IN WOMEN WITH TYPE 1 AND TYPE 2 DIABETES 2002-2003 England, Wales and Northern Ireland Executive Summary. http://www cemach org uk/publications/Diabetes%20Exec%20summary/Exsum html. [ 2003 [cited 2006 July 30]; (7) Roland JM, Murphy HR, Ball V, Northcote-Wright J, Temple RC. The pregnancies of women with Type 2 diabetes: poor outcomes but opportunities for improvement. Diabet Med 2005; 22(12):1774-1777. Competing interests: None declared |
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Ruth Bell, Senior Lecturer in Public Health Institute of Health and Society, Newcastle University, Newcastle upon Tyne NE2 4HH, Nick Lewis-Barned, Gillian Hawthorne and Tricia Cresswell on behalf of the Northern Diabetic Pregnancy Survey Steering Group
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Mackintosh and colleagues report that more than a quarter of pregnancies complicated by diabetes in the UK now occur in women with type 2 diabetes (1), and rates of type 2 diabetes in young women are anticipated to rise. Macfarlane and Tuffnell note the paucity of data on changing prevalence of type 2 diabetes in pregnancy (2). We have maintained a continuous population based survey of pregnancies in women with pre-existing diabetes, and a review of nine years’ experience, including nearly 1200 pregnancies delivered between 1996 and 2004, has recently been completed (3). Over this period, the prevalence of births complicated by maternal diabetes (types 1 and 2) increased by around 50%, from 3.1 per 1000 total births in 1996-98 to 4.7 per 1000 births in 2002-04. When fetal losses and terminations of pregnancy are included, the increase is slightly less at around one third, from 4.0 per 1000 births in 1996-98 to 5.3 per 1000 in 2002-04. The difference reflects a reduction in fetal losses. The proportion of pregnancies to women with type 2 diabetes increased from 7% in 1996-98 to 10% in 1997-99, and then sharply to 26% in 2002-04, reaching a rate similar to that reported by Macintosh and colleagues. The prevalence of maternal type 2 diabetes (including fetal losses, terminations and births) increased more than four fold, from 0.3 per 1000 births to 1.4 per 1000 births. There was little change in the prevalence of maternal type 1 diabetes – 3.7 per 1000 births in 1996-98 and 3.9 per 1000 in 2002-04. Thus the increase in pregnancies complicated by diabetes in our region between 1996 and 2004 was almost entirely due to women with type 2 diabetes. Rising obesity in young women is likely to be the main underlying factor, in a region with a relatively low prevalence of Asian or Black ethnicity. Obesity is also a major factor in gestational diabetes, and with the recent publication of evidence that intervention improves outcomes in this group of women (4), maternity services are likely to experience a sharp rise in the numbers of women with diabetes in pregnancy requiring intensive surveillance. The challenge is to maintain and improve standards of care, and pregnancy outcomes, in the context of these increasing demands. Attention also needs to be directed towards implementing effective strategies for reducing obesity in young women. References 1. Macintosh M, Fleming K, Bailey J, Doyle P, Modder J, Acolet D, Golightly S, Miller A. 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;333:177-80. 2. Macfarlane A, Tuffnell D. Diabetes and pregnancy. British Medical Journal 2006;333:157-8. 3. Bailey K, Lewis-Barned N. Northern Diabetes in Pregnancy Survey - audit of units against standards of care. Occasional Paper No 19: North East Public Health Observatory, 2005. 4. Crowther C, Hiller J, Moss J, McPhee A, Jeffries W, Robinson J. Effect of treatment of gestational diabetes mellitus on pregnancy outcomes. New England Journal of Medicine 2005;352:2477-2468. Competing interests: None declared |
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