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 doi: https://doi.org/10.1136/bmj.38856.692986.AE (Published 20 July 2006) Cite this as: BMJ 2006;333:177
All rapid responses
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
Competing interests: No competing interests
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
Competing interests: No competing interests
Diabetes in pregnancy: rising prevalence presents challenges for maternity services
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
Competing interests: No competing interests