Women With Diabetes Neglected Before and During Pregnancy

November 28, 2013

There is much room for improvement in the medical care of women with diabetes before they conceive and during pregnancy, new research indicates. This neglect gives rise to poor outcomes, with a significantly higher rate of stillbirth and infant death than is seen in the general population, one of the studies illustrates.

Although the new research was conducted separately in 2 countries with different healthcare systems — Israel and the United Kingdom — both studies reveal that there is a big gap between what is recommended and what is happening in practice for such women. Furthermore, the British study documented no improvement in outcomes for diabetes patients having babies over the 12 years studied, from 1996 to 2008.

"Diabetic women and their physicians need to be better prepared for pregnancy," lead author of the Israeli study, Shlomit Riskin-Mashiah, MD, from the University of Haifa in Israel, told Medscape Medical News. "Diabetes needs their attention all of the time and especially at the beginning of pregnancy and during gestation."

She stressed that many of the outcomes they examined during preconception and pregnancy — such as whether women got eye exams and had good glycemic control — "should be just usual diabetes care." Although monitoring during this period does not appear to be worse than it is at other times in a diabetic woman's life, "it should be much better — there needs to be greater awareness of the importance of periconception care in diabetes," she urged.

The authors of the British study, led by Peter W.G. Tennant, MSc, from Newcastle University, agree. "In the North of England, fewer than half of women with preexisting diabetes attend preconception care, with the proportion declining over time. To achieve any reduction in the relative risk of stillbirth and infant death in women with preexisting diabetes, the barriers to uptake of preconception care and adequate preparation for pregnancy must be urgently understood and addressed," they implore.

The study by Dr. Riskin-Mashiah and colleagues was published online November 12 in Diabetes Care. The study be Tennant and colleagues was published online in Diabetologia.

Diabetes Increases Risk for Pregnancy Complications

Both studies explain that preexisting diabetes increases the risk for pregnancy complications to the mother, fetus, and newborn infant.

The British study set out to specifically document the rate of adverse pregnancy outcomes in women with diabetes in a contemporary setting.

Tennant and colleagues surveyed 1206 women with type 1 diabetes and 342 women with type 2 diabetes who gave birth to single babies.

They found the risk for stillbirth (at 3%) was nearly 6 times greater in women with preexisting diabetes than in those without the condition (relative risk [RR], 4.56; P < .0001); the risk for infant death (at 0.7%) was nearly twice as high (RR, 1.86; P = .046). There was no difference in the risk for fetal and infant death between women with type 1 and type 2 diabetes,

Blood glucose concentration around the start of pregnancy was the most important predictor of fetal and infant death, with the odds increasing by 33% and 42%, respectively, for each 1-percentage-point increase in HbA1c.

The researchers did demonstrate, however, a J-shaped association, with the lowest risk in those with periconception HbA1c around 6.6%

"We would therefore recommend good, but not overly strict, control [of HbA1c] before and throughout pregnancy," Tennant told Medscape Medical News.

However, even in women with optimal periconception HbA1c, the risk for fetal death was still more than twice as high as in women with diabetes, suggesting other risk factors have an effect.

Prepregnancy consumption of folic acid was associated with half the risk for fetal or infant death, however. Women with preexisting diabetes are advised to take high doses (5 mg/day) of folic acid. Although this was originally intended to reduce the risk of having a baby with a neural-tube defect, Tennant said the findings suggest there are additional benefits of folic acid in this patient group.

Poor Care Persists for Pregnant Diabetics

Startlingly, in the British study, there was no reduction in the excess risk for fetal and infant death in women with diabetes over the 12-year study period.

This is despite guidance from organizations such as the American Diabetes Association recommending daily folate supplementation from preconception; good metabolic control — preferably with HbA1c below 6% to 7% with appropriate insulin therapy; dietary consultation; assessment for systemic complications, including diabetic nephropathy, retinopathy, and thyroid disease; and review of treatment to rule out, preconceptually, the use of potentially hazardous medications.

In addition, one of the goals of the St. Vincent declaration, issued in 1989, was to achieve, within 5 years, "pregnancy outcomes in women with diabetes that approximate those of women without diabetes," both the British and Israel researchers explain.

Yet both studies illustrate that suboptimal patient care and poor outcomes persist in women with diabetes before and during pregnancy.

"Too many pregnancies are still unplanned, and many diabetic women get pregnant without proper preparation and with poor glycemic control and have high rates of pregnancy complications," Dr. Riskin-Mashiah noted.

In their study, she and her colleagues set out to the document the quality of periconception and gestational medical care in women with preexisting diabetes and to assess the influence of sociodemographic characteristics on that care.

They retrospectively studied the electronic healthcare records of women from the Clalit Healthcare Services database — a nonprofit health maintenance organization covering more than half of the Israeli population — who had preexisting diabetes (type 1 or type 2) and who gave birth from 2008 to 2011. There were 180 deliveries to 166 women.

They found that kidney-function tests were performed in just 30% of women and only 41.1% got ophthalmology exams. Although 81% had HbA1c measured, only 49% had HbA1c levels below 7.0%. In addition, 45% took folic acid and 13.9% used potentially teratogenic drugs, such as statins and ACE inhibitors, during the first 3 months of pregnancy.

A third of the women overall got low-quality care, particularly those of lower socioeconomic class, which included immigrant Jews (odds ratio [OR], 3.73; P = .018), women of Arab ethnicity (OR, 3.76; P = .01), and those with multiple births (OR, 3.43; P = .01).

They did not find significant differences in the quality of periconception care between women with type 1 and type 2 diabetes, except that the latter had significantly lower median HbA1c.

Prepregnancy Care as Essential as Antenatal in Diabetes

"If we want to achieve the goals of the St. Vincent declaration and improve pregnancy outcomes of women with diabetes to the level of the nondiabetic population, we need to understand that for women with diabetes, prepregnancy care is as essential as antenatal care," Dr. Riskin-Mashiah and colleagues observe.

"A multidisciplinary team approach is needed, with specialized clinics that can give optimal preconception evaluation and care for patients with diabetes prior to pregnancy. The service should be highly accessible and culturally oriented to the specific target population," they conclude.

The authors of the 2 studies have disclosed no relevant financial relationships.

Diabetes Care. Published online November 12, 2013. Abstract

Diabetologia. Published online before print. Abstract

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