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Research

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

Rapid Response:

Continued poor outcomes in diabetic pregnancy

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

04 July 2006
Tim Cundy
Professor of Medicine
University of Auckland, Auckland, New Zealand