Q J Med 2000; 93: 813-818
© 2000 Association of Physicians
Fetal and maternal outcomes in Indo-Asian compared to Caucasian women with diabetes in pregnancy
From the Department of Diabetic Medicine, University Hospital Trust 1 Department of Obstetrics, Birmingham Womens Trust, and 2 School of Mathematics and Statistics, University of Birmingham, Birmingham, UK
Received 19 June 2000 Accepted for publication 28 September 2000.
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Summary |
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Maternal and fetal complications are increased when pregnancy is complicated by diabetes, and this may be further influenced by racial and cultural differences. We examined fetal and maternal outcomes in Indo-Asian and Caucasian women attending the same antenatal diabetes service to see if there were any differences. Women with diabetes mellitus (type 1, type 2 and gestationally-acquired disease) complicating pregnancy, registered at the combined diabetes/antenatal clinic of this University teaching hospital over the period 1990–1998 were included. Fetal outcomes examined were miscarriage <24 weeks, stillbirths, neonatal deaths up to 28 days of life, perinatal mortality, congenital malformations and size for gestational age. Maternal outcomes examined were rates of caesarean section and vaginal deliveries, and number of pre-term deliveries <37 completed weeks of gestation. Outcomes for Indo-Asian and Caucasian women were similar, with a take-home baby rate of 96% and 92%, respectively. There was no perinatal mortality in Indo-Asian women, who were more likely to have a vaginal delivery and less likely to have a baby large for gestational age. Pregnancies complicated by type 2 diabetes in both groups pose the greatest threat to a successful pregnancy outcome. Indo-Asian and Caucasian women attending the same antenatal diabetes service have comparable outcomes. Attendance for pre-pregnancy care needs to be encouraged to combat the high early pregnancy loss and congenital malformation rate identified, particularly in those with type 2 disease, irrespective of ethnicity.
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Introduction |
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Maternal and fetal complications of pregnancy are increased when a diabetic state is superimposed,1,2 and may be further influenced by racial and cultural differences. Maternal and fetal complications of diabetes in pregnancy are not well documented in Indo-Asian women residing in the United Kingdom (UK). Complications may be higher because of cultural differences, communication problems, lack of awareness of the consequences of the disease and inequality in the delivery of midwifery care. Indeed in the non-diabetic population, perinatal and neonatal mortality rates are higher in women of Bangladeshi, Pakistani and Indian origin when compared to the Caucasian population of the UK.3 The aim of this study was to determine the prevalence of fetal (miscarriage <24 weeks, stillbirth, neonatal deaths, perinatal mortality, congenital malformations and fetal size at delivery) and maternal (mode and time of delivery) outcomes in Asian women with diabetes and compare them to outcomes in Caucasian women attending the same diabetes-antenatal service.
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Methods |
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This study was performed in a university teaching hospital with a large fetal medicine unit serving a multi-ethnic population of approximately 2.5 m. Women with pre-gestational diabetes mellitus are encouraged to register early for antenatal care and are assigned to a single obstetrician (HG) with an interest in diabetes in pregnancy. For women who develop impaired glucose tolerance or gestational diabetes in the index pregnancy, their obstetric care is transferred to the designated obstetrician (HG). Diabetes care is provided by the Department of Diabetes Care, Division of Medical Sciences University of Birmingham by a diabetologist (FPD) with an interest in this area. All information on the index pregnancy is recorded on a computerized database and clinical records were reviewed for an 8-year period. This study details the information on all Indo-Asian and Caucasian women registered on this database during this period and compares fetal (miscarriage, i.e. fetal loss before <24 weeks gestation; stillbirth, i.e. fetal loss >24 weeks gestation; neonatal deaths during the first 28 days of life; perinatal mortality, i.e. stillbirths and neonatal deaths; congenital malformations; infant size at delivery) and maternal (mode of delivery, i.e. caesarean section vs. vaginal deliveries; time of delivery, i.e. preterm <37 weeks vs. term deliveries) outcomes in the two groups. Gestational diabetes mellitus (GDM) and impaired glucose tolerance (IGT) were diagnosed using a 75 g oral glucose tolerance test and WHO values of >7.8 mmol/l fasting and >11.1 mmol/l at 2 h for GDM, and 5.6–7.8 mmol/l fasting with a 2 h value of 7.8–11.1 for IGT. Type 1 and type 2 diabetes were defined on the basis of history of disease onset and treatment.
Fishers exact test, two-sample T test and a two-sample test of proportions were used where appropriate, with p<0.05 taken as significant.
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Results |
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Patient characteristics
Information was available on 312 pregnancies in Caucasian women and 128 pregnancies in Indo-Asian women. Of the Indo-Asian women, 85 were of Pakistan origin, 20 of Indian origin and 17 of Bangladeshi origin. Of the 128 pregnancies in Indo-Asian women, 12 (10%) occurred in established type 1 diabetes, 25 (20%) in established type 2 diabetes, 32 (25%) in gestational diabetes mellitus (GDM), and 59 (45%) in gestationally acquired impaired glucose tolerance (IGT). In Caucasian women, 55% had type 1 diabetes, 5% type 2, 10% GDM and 30% had IGT. Some 37/128 (29%) of pregnancies in Indo-Asian women resulted from a consanguineous relationship, primarily in those with type 2 disease (12/25, 48%). Only four Indo-Asian women attended for pre-pregnancy care, compared to 25% of the Caucasian group. Fifty percent of Indo-Asian women had a family history of diabetes, 48% had a history of a previous pregnancy loss and 12 had received fertility treatment.
The mean age, body mass index, duration of diabetes, parity and first attendance at antenatal clinic are shown in Table 1
. Indo-Asian women with type 1 disease were significantly younger (p<0.01) lighter (BMI) (p<0.01) and had their disease for a shorter period of time (p<0.01) when compared to Caucasian women. In addition, they were significantly more likely to attend later for antenatal care (p<0.05). Indo-Asian women with type 2 disease tended to be heavier than Caucasian women (p=0.06) but showed no difference in age, duration of diabetes or attendance for antenatal care. Women with gestationally acquired-disease were similar in age and body size (BMI) in both groups. Parity was significantly greater (mean of 4.8 vs. 2.8) in Indo-Asian compared to Caucasian women (p<0.01).
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Mean glycated haemoglobin values for each trimester in each sub-group are shown in Table 2
. Values were similar between Indo-Asian and Caucasian women.
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Fetal outcomes
Pregnancy loss before 24 weeks, stillbirths and neonatal deaths, and congenital abnormalities only occurred in women with established diabetes. All rates quoted are per 1000 births and are adjusted to reflect these groups only. Five of 37 (135 per 1000, 13.5%) pregnancy losses before 24 weeks occurred in Indo-Asian and 17/187 in Caucasian women (91 per 1000, 9.1%), showing no statistically significant difference. Three of the five losses in the Indo-Asian group occurred in those with type 2 disease. All three were of high parity (para 3, 4 and 11), and occurred in the second trimester (18, 22 and 23 weeks).
One hundred and twenty-four pregnancies in Indo-Asian women continued beyond 24 weeks and there were no stillbirths. This contrasts to two stillbirths in Caucasian women with type 1 disease (11.9/1000, adjusted for type 1 disease only). In the Indo-Asian cohort there were 127 live births and no neonatal deaths. This contrasts with six neonatal deaths in Caucasian women, five with type 1, and one with type 2 disease, respectively (36/1000). The neonatal deaths were contributed to by congenital malformations (2 cardiac, 1 diaphragmatic hernia, 1 triplet with tracheo-oesophageal fistula) and pre-term delivery (three deliveries at 26, 29 and 29 weeks). There was no perinatal mortality in the Indo-Asian cohort, compared to a rate of 47/1000 in Caucasian women.
Two infants were born with congenital cardiac abnormalities (ventricular septal defect, pulmonary stenosis) and one with a diaphragmatic hernia to Indo-Asian mothers with type 2 and type 1 disease, respectively (i.e. CMR of 93/1000 in Indo-Asian women with pre-gestational disease). Sixteen infants were delivered with malformations to Caucasian women, 13 (7 cardiac, 1 renal, 3 skeletal, 1 anencephaly and 1 tracheo-oesophageal fistula) in type 1 and 3 (all cardiac) in type 2 disease (i.e. CMR of 94/1000 in Caucasian women with pre-gestational disease).
In our unit, gestational size at delivery is determined using Gardner-Pearson charts which do not allow for differences related to ethnicity. Overall more Indo-Asian than Caucasian babies were born appropriate in size for gestational age (AGA) (63% vs. 55%). There were fewer Indo-Asian babies born large for gestational age (LGA) (25% vs. 37%) (p<0.01) (Table 3). In women with type 1 disease, fewer Indo-Asian babies were born LGA (9% vs. 38%) (p<0.05), and in those with type 2 disease, more Indo-Asian babies were AGA (65% vs. 33%) (p<0.05). In those with gestationally-acquired disease, there was no significant difference in infant size between groups.
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Maternal outcomes
Overall, 60% of Indo-Asian compared to 38% of Caucasian women delivered vaginally (p<0.001), the difference being most notable in those with type 2 disease (p<0.05) where twice as many Indo-Asian as Caucasian (68% vs. 33%) women had a vaginal delivery (Table 4). This difference in caesarean section (CS) rates in those with type 2 disease (p<0.05) was unrelated to the presence of retinopathy/nephropathy, but may be related to parity, which was significantly greater in Indo-Asian (6.96±2.9, mean±SD) compared to Caucasian (2.9±2.1) women with type 2 disease (p<0.01). In Indo-Asian women there were 19 (40%) elective CS, the majority due to elective repeats (12 elective repeats, 2 unstable lie, 1 IUGR, 1 macrosomia, 1 pre-eclampsia, 2 because of history of diabetes). The 29 (60%) emergency CS were primarily due to fetal distress/malpresentation (2 eclampsia, 12 fetal distress, 5 fetal malpresentation, 1 prolapsed cord) or obstetric complications (1 failure to progress, 2 placenta praevia, 1 abruption, 1 polyhydramnios, 1 infection). In Caucasian women, there were 92 (52%) elective CS, the majority due to elective repeats (52 repeats, 8 macrosomia, 14 eclampsia, 8 unstable lie, 1 placenta praevia, 1 fetal distress). The 48% emergency CS were primarily due to fetal distress/eclampsia (31 fetal distress/13 eclampsia, 1 placenta praevia 2 unstable lie, 14 repeat CS, 1 macrosomia, 4 delay in 1st stage). There were more macrosomic babies (9) in the Caucasian group, but this did not influence the CS rate as the greatest difference in CS was seen in those with type 2 disease while the macrosomic babies were in type 1 disease (3) and in IGT/GDM (6). In type 1 disease, 35% of Indo-Asians and 28% of Caucasians delivered before 37 weeks, increasing to 48% and 55%, respectively, in those with type 2 disease.
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Discussion |
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The differences in the diabetes sub-types in the Caucasian and Asian populations found in this study are to be expected. More Indo-Asian than Caucasian women have GDM (25% vs. 10%). This reflects the UK figures for the prevalence of GDM, which have been estimated at 1.2% for Caucasians and 5.8% for Indo-Asian women.4,5 The risk of GDM occurring in pregnancy approximately mirrors that of the underlying frequency of type 2 diabetes in the population.6,7 Consequently, in the Indo-Asian cohort 25% had GDM and 20% had type 2 diabetes. Similarly in the Caucasian cohort 10% had GDM and 5% had type 2 diabetes. Pregnancy outcome is influenced by the subtype of glucose abnormality. Consequently, when discussing gestational size and mode of delivery subgroups are compared with each other (Tables 3
and 4). Pregnancy loss before 24 weeks, stillbirth and neonatal deaths and congenital abnormalities occurred only in women with established diabetes, and the rates quoted are corrected for this high-risk group. The introduction of pre-conception care, improvements in glycaemic control, better methods of fetal monitoring and sophisticated neonatal care have resulted in a dramatic improvement in fetal and maternal outcomes for women whose pregnancy is complicated by diabetes mellitus. This has resulted in a decrease in summary statistics such as stillbirth neonatal and perinatal mortality rates. In non-diabetic populations, perinatal and neonatal mortality rates are greater in women from the Indian sub-continent when compared to women of UK origin.3,8–10 In one study, congenital malformations contributed enormously to the stillbirth neonatal and perinatal mortality rates, and it was acknowledged that consanguinity was a contributory factor.11 It has been argued that Black and ethnic minority populations suffer inequalities in health,12–16 and authors highlight discrimination, communication barriers and culture blaming as contributory factors to adverse birth outcome.14 There are also suggestions in the midwifery literature that there is unequal access to midwifery care among ethnic minority groups, and that the care available can be inappropriate, inaccessible and inadequate.15,16 Indo-Asian patients account for 25% of our clinic population, and this reflects the population subgroups of the last census in Birmingham published in 1991. This showed that ethnic minority groups formed 8.2% of the total population. In the age 20–29 years, this increased to 10% and in those under 15 years of age the figure rose to 15% (this is the group now reaching maximum fertility).17 Before the collection of data on ethnicity of births in Birmingham ceased in the mid 1980s, it was noted that one in three births in the city was to a mother from a minority ethnic group: expert opinion now suggests that this proportion is now nearer to one in two.18
It is re-assuring, despite the above reports, that in this population the outcomes in Asian women are comparable to those for the Caucasian cohort attending the same service. There were no stillbirths, neonatal deaths or perinatal mortality in Indo-Asian women, who had a take-home baby rate of 96%. The pregnancy loss before 24 weeks, although similar to that in Caucasians, remains excessive in both groups, especially in those with type 2 disease. The rate of pregnancy loss <24 weeks reported here is similar to figures reported in other studies,1,2 although the populations and ethnicities are likely to be different between the three centres. The congenital malformation rate in Indo-Asian and Caucasian women with pre-gestational disease is similar (90/1000). However it is 5.6 times that seen in the background population (16/1000), a figure similar to that reported in other larger series for both Indo-Asian19,20 and Caucasian women.1,2
It is interesting that the CS rate in Caucasian women is almost twice that seen in Indo-Asian women (p<0.001) and the difference occurs predominantly in those with type 2 disease (p<0.05). This rate in Indo-Asian women is similar to that reported in an indigenous south Asian community.23 The CS rate may be related to macrosomia, which is greater in Caucasian women overall (p<0.01), primarily in those with type 1 disease (p<0.05); however the greatest difference in CS rates are seen in those with type 2 disease (p<0.05). The difference may be contributed to by parity, which is significantly less (p<0.01) in Caucasian women than in Indo-Asian women with type 2 disease.
Overall, Indo-Asian babies were more likely to be born AGA, with significantly less born LGA (p<0.01). However the Gardiner-Pearson charts do not account for ethnicity, and these differences may alter when babies are reclassified to allow for the ethnicity variable; a project currently underway.
Despite literature reports showing worse pregnancy outcomes in Indo-Asian compared to Caucasian women in normal pregnancy, this study in pregnancies complicated by diabetes is reassuring as it shows comparable outcomes. There was no perinatal mortality in Indo-Asian women, who were more likely to have a vaginal delivery and less likely to have a baby large for gestational age. Pregnancies complicated by type 2 disease pose the greatest threat to a successful pregnancy outcome in both groups, showing the greatest number of pregnancy losses before 24 weeks and the greatest number of congenital malformations. Attendance for pre-pregnancy care remains poor, especially in Indo-Asian women. This needs to be encouraged to combat the high early pregnancy loss and congenital malformation rates identified in the study.
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Notes |
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Address correspondence to Dr F.P. Dunne, Department of Medicine, University Hospital Trust, Raddlebarn Road, Birmingham B29 6JD. e-mail: Fidelma.Dunne{at}University-b.wmids.nhs.uk
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