Letters

Outcome of pregnancy in women with insulin dependent diabetes

BMJ 1998; 316 doi: https://doi.org/10.1136/bmj.316.7130.550 (Published 14 February 1998) Cite this as: BMJ 1998;316:550

Centralisation of care leads to better outcome

  1. David Hadden, Honorary professor of endocrinologya,
  2. Anthony Traub, Consultant obstetriciana
  1. a Diabetes Pregnancy Clinic, Royal Maternity Hospital, Belfast BT12 6BA
  2. b Department of Endocrinology, Diabetes and Metabolic Medicine, UMDS, St Thomas's Hospital, London SE1 7EH
  3. c Department of Obstetrics, 9000 Aalborg, Denmark
  4. d Medical Department V, Aarhus University Hospital, 8000 Aarhus, Denmark
  5. e Danish Epidemiology Science Centre, Steno Institute of Public Health, University of Aarhus
  6. f Department of Obstetrics, Aalborg Hospital, 9000 Aalborg
  7. g Institute of Epidemiology and Social Medicine, University of Aarhus
  8. h Bradford Royal Infirmary, Bradford, West Yorkshire BD9 6RJ
  9. i Broadgreen Hospital, Liverpool L14 3LD,
  10. j School of Biological Sciences, University of Liverpool, Liverpool L69 3BX
  11. k Fetal and Infant Pathology, University of Liverpool
  12. l Department of Public Health, University of Liverpool
  13. m Women's Hospital, Liverpool L8 7NJ

    Editor—The finding of a persistently poor outcome of pregnancy in women with insulin dependent diabetes in two (northern) English regions is an important statement of the problem.1 2 Both studies provide figures and show outcomes that are no different from those widely reported in the past. Unfortunately, neither give evidence of any degree of centralisation of obstetric or diabetic care, with on-site neonatal intensive care, although this is a proved means of improving the outcome of pregnancy for diabetic mothers.3 The St Vincent declaration guidelines on the outcome of pregnancy, referred to in the accompanying editorial (p 263), are based on the Scandinavian reports held up as examples of good practice and state that “an interdisciplinary team should provide centralized diabetic pregnancy care in a hospital treating at least 20–30 cases a year. Pregnant diabetic patients should regularly visit the centre, before, during, and after the pregnancy.”

    The combined diabetes pregnancy clinic at the Royal Maternity Hospital in Belfast has existed for over 40 years, and outcome audit has shown the value of this approach.4 In an audit of over 800 pregnancies in diabetic mothers identified in Northern Ireland over the past 10 years the perinatal mortality in mothers cared for throughout at this centralised clinic during 1985–95 was 27/1000, compared with 70/1000 for patients referred later in pregnancy and 33/1000 for those mothers cared for in other maternity hospitals in Northern Ireland.

    Overall perinatal mortality for the whole population of Northern Ireland (1.5 million) during this decade was 9.3/1000 total births, so that even at a centralised clinic there is still an increased risk in diabetic pregnancy. Centralisation of care and improved cooperation among the obstetricians and diabetes physicians within a health region will lead to a better outcome.5

    References

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    Rate of congenital malformations is almost certainly gross underestimate

    1. Clara Lowy, Reader in medicineb
    1. a Diabetes Pregnancy Clinic, Royal Maternity Hospital, Belfast BT12 6BA
    2. b Department of Endocrinology, Diabetes and Metabolic Medicine, UMDS, St Thomas's Hospital, London SE1 7EH
    3. c Department of Obstetrics, 9000 Aalborg, Denmark
    4. d Medical Department V, Aarhus University Hospital, 8000 Aarhus, Denmark
    5. e Danish Epidemiology Science Centre, Steno Institute of Public Health, University of Aarhus
    6. f Department of Obstetrics, Aalborg Hospital, 9000 Aalborg
    7. g Institute of Epidemiology and Social Medicine, University of Aarhus
    8. h Bradford Royal Infirmary, Bradford, West Yorkshire BD9 6RJ
    9. i Broadgreen Hospital, Liverpool L14 3LD,
    10. j School of Biological Sciences, University of Liverpool, Liverpool L69 3BX
    11. k Fetal and Infant Pathology, University of Liverpool
    12. l Department of Public Health, University of Liverpool
    13. m Women's Hospital, Liverpool L8 7NJ

      Editor—Casson et al make several misrepresentations …

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