Q J Med 1999; 92: 175-176
© 1999 Association of Physicians
Pre-conception diabetes care in insulin-dependent diabetes mellitus
From the 1 Department of Diabetic Medicine 3 CRC Trials Unit, University Hospital Trust (Selly Oak) Birmingham 2 Department of Obstetrics, Birmingham Womens Hospital, Birmingham, UK
Received 24 August 1998 and in revised form 11 December 1998
Dr F.P. Dunne, Department of Diabetic Medicine, University Hospital Trust (Selly Oak), Raddlebarn Road, Birmingham B29 6JD
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Summary |
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Prospective studies of pre-conception diabetes care have confirmed its positive impact on the incidence of malformations by improving glycaemic control. Less information is available on the impact of pre-conception care on maternal and neonatal morbidity. This audit addresses its impact on timing and mode of delivery, incidence of macrosomia and rate of admission to neonatal unit care in addition to sociodemographic factors which may influence attendance at such a service. Attenders were more likely to be in a stable relationship and be non- smokers. They were more likely to book for antenatal care earlier and with a lower glycated haemoglobin. There were no early deliveries (i.e. <30 weeks) or small for gestational age (SGA) babies in those who attended for pre-conception care and no neonatal deaths. Admission to NNU care was reduced by 50% in those who attended for pre-conception care. Although the rate of macrosomia was reduced, there was no impact on the Caesarian section rate. A pre-conception diabetes clinic may have a positive impact on neonatal morbidity.
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Introduction |
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Fetal malformations in diabetic mothers occur before the seventh gestational week, and are associated with elevated glycated haemoglobin.1 Prospective studies have demonstrated that pre-conception counselling reduces the incidence of malformations,2 but less information is available on its impact on neonatal and maternal morbidity. Many diabetes units now routinely provide such a service. At the initial visit, diabetic medical and obstetrical histories are taken, diabetic complications are assessed with particular reference to retinopathy and nephropathy, and glycaemic control is optimized. Patients are followed to conception and transferred to a combined antenatal/diabetes clinic.
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Methods |
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We retrospectively audited our clinic over a 2-year period to examine its impact on pregnancy outcome in women with IDDM. Attenders at the pre-conception clinic (group 1) and non-attenders (group 2) were compared. A retrospective review of case notes was carried out for age ethnicity and marital status, smoking history, duration and complications of diabetes, time and glycaemic control at antenatal booking, time and mode of delivery, neonatal unit care (NNU), macrosomia (>90th centile for gestational age), small for gestational age (SGA, <10th centile) and neonatal mortality. The
2 test (with a Yates corrected test) was used for analysis of categorical data, and the Mann-Whitney test for the remaining data. |
Results |
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Forty-seven women with IDDM attended our combined antenatal/diabetes clinic over a 2-year period. 12 (26%) were attenders (group 1) while 35 (74%) were non-attenders (group 2) at the pre-conception clinic. Most women were Caucasian, with no significant difference in age, duration of diabetes, or diabetic complications between groups. Marital status was significantly different, with 100% married or in a stable relationship (group 1) vs. 54% (group 2) (p=0.004), and attenders were less likely to smoke: 8% (group 1) vs. 28% (group 2) (p=0.3). HbAlC improved significantly in group 1 from a mean of 9.2% at first pre-conception visit to 7.9% at first antenatal attendance (p=0.007). HbAlc at booking was significantly lower in attenders: 7.9% (range 6.3–11%) (group 1) vs. 9.6% (6.9–17%) (group 2) (p=0.008). HbAlc continued to improve throughout gestation in group 1, reaching a mean of 8.4% in trimester 1, 7.2% in trimester 2, and 7.6% in trimester 3. In comparison, HbAlc did not alter greatly in group 2, with a mean of 9.8% in T1, 9.2% in T2 and 8.9% in T3. Attenders (group 1) also booked earlier for antenatal care at 7.5 (6–13) vs. 9 (5–22) (group 2) weeks (p=0.09).
Term deliveries were similar, 58% (group 1) vs. 57% (group 2). All preterm deliveries (<37 weeks) in group 1 occurred after 30 weeks while 6 (17%) in group 2 occurred in weeks 26–30. The caesarian section rate was high and similar between groups, 75% (group 1) vs. 74.2% (group 2). There were no congenital anomalies. Macrosomia was reduced from 40% (14/35) (group 2) to 25% (4/12) (group 1) (p=0.9). There were no SGA babies in group 1 compared to 3 (8.5%) in group 2 and no neonatal deaths in group 1 vs. 2 (5.7%) in group 2. Admissions to NNU care were halved from 34% (12/35) in group 2 to 17% (2/12) in group 1 (p=0.4).
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Discussion |
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While benefits of pre-conception care through improving glycaemic control are well established, it is alarming that only 26% of women in this study received such care; numbers similar to those reported by Janz3 but strikingly different to the attendence rate of 78% noted by Steel and coworkers in an earlier report.4 This of course may be due to population differences, especially with regard to ethnicity, but other factors such as financial obstacles and organizational problems need to be considered. The significant factors influencing attendance were marital status and current smoking history, which may reflect social class, and these sociodemographic characteristics were also noted to be important in the study by Janz.3 In addition, these factors have previously been found to be important in surveys of unintended pregnancy. Gregory and Tattersall (1992) reviewed the literature on diabetic pre-pregnancy clinics and concluded that the availability of pre-pregnancy clinics separates diabetic women into a highly-motivated well-controlled group who attend and the remainder who book late,5 and this conclusion is reflected here in antenatal booking time and glycaemic control at booking.
Neonatal mortality (neonatal deaths) and morbidity (deliveries <30 weeks, SGA and macrosomic babies, NNU admissions) were lower in attenders compared to non-attenders, but this may be due to a selection bias favouring the highly-motivated attenders. On the other hand, glycaemic control in group 1 improved significantly by attendance at the pre-conception clinic and this improvement continued throughout gestation, which is likely to have had a positive impact on these neonatal outcomes. Although the differences in rates are clinically significant, they have not reached statistical significance, due to the group numbers. Nonetheless NNU admissions have financial implications which although not examined here, would offset some costs of establishing a pre-conception service. The reduction in macrosomia was not accompanied by an expected reduction in caesarian sections; a similar unexplained observation was noted in the Toronto Tri-Hospital Diabetes Project.6
In conclusion, as well as the beneficial effects already established on the incidence of congenital malformations, a pre-conception service for women with IDDM has a positive impact on neonatal mortality and morbidity. An improvement in pick-up rate for at-risk women is needed and may be achieved through a computerized diabetes register. A systematic approach to pregnancy planning, avoiding unintended pregnancies through contraception, repeated emphasis by providers on the importance of pre-conception care and availability of pre-conception services are essential components of a comprehensive diabetic management programme.
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References |
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1. Miller E, Hare JW, Cloherty JP, Dunn PJ, Gleason RE, Soeldner JS, Kitzmiller JL. Elevated maternal haemoglobin Alc in early pregnancy and major congenital anomalies in infants of diabetic mothers. N Engl J Med 1981; 304:1331–4.[Web of Science][Medline]
2. Fuhrmann K, Reiher H, Semmler K, Fischer F, Fischer M, Glockner E. Prevention of congenital malformations in infants of insulin-dependent diabetic mothers. Diabetes Care 1983; 6:219–23.[Abstract]
3. Janz NK, Herman WH, Becker MP, Charron-Prochownik D, Shayna VL, Lesnick TG, Jacober SJ, Fachnie JD, Kruger DF, Sanfield JA. Diabetes and Pregnancy; Factors associated with seeking pre-conception care. Diabetes Care 1995; 18:157–65.[Abstract]
4. Steel JM, Johnstone FD, Smith AF, Duncan LJP. Five years experience of a pre-pregnancy clinic for insulin dependent diabetics. Br Med J 1982; 285:353–6.
5. Gregory R, Tattersall RB. Are diabetic pregnancy clinics worthwhile? Lancet 1992; 340:656–8.[Medline]
6. Sermer M, Naylor CD, Gare DJ, et al. Impact of increasing carbohydrate intolerance on maternal-fetal outcomes in 3637 women without gestational diabetes. The Toronto Tri-Hospital Gestational Diabetes Project. Am J Obstet Gynaecol 1995; 173:146–56.[Web of Science][Medline]
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