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Are We Providing the Best Care to Our Mothers-to-Be with Diabetes?

One recent study examines how we’re doing.

There is no shortage of available information describing methods to reduce the number of poor outcomes in the pregnant diabetic population. It is well known that uncontrolled diabetes during gestation significantly increases certain fetal risks, including miscarriage, macrosomia and other structural defects, neonatal hypoglycemia, and neonatal hyperbilirubinemia. Risk of pre-eclampsia in the mother also increases in the presence of diabetes.  According to the annual ADA guidelines, diabetes during pregnancy increases the risks of developing obesity and type 2 diabetes later in the life of the child. Tight control with lifestyle modification, metformin, and (in cases where these are not effective) insulin can lead to increases in better outcomes in pregnant women with diabetes, with an average HbA1c < 6% to 6.5% early in gestation being associated with the lowest rates of fetal complications. If these levels can be maintained without hypoglycemia throughout the gestational periods, optimal outcomes will have the best chance of occurring. Having this information in hand, are we as health care providers truly reaching our intended targets and maximizing their chances at the best possible outcomes?

Recently, a group in Ireland performed a retrospective study looking at metabolic variables in pregnant women with type 1 and type 2 diabetes prior to conception and 12 months after delivery. Subjects were selected from four centers of antenatal care between January 2006 and December 2014. These women presented with either an established diagnosis of diabetes or HbA1c > 6.5% in the first trimester. At either 6-months pre-conception or on the first pre-pregnancy care visit, several data were recorded, including weight, blood pressure, smoking status, HbA1c, lipids, and urinary albumin/creatinine ratio. These same measures were also recorded upon the 12-month post-partum visit. In addition, subject demographics, pregnancy outcomes, and average HbA1c were recorded during each trimester.

During the study period, a free pre-pregnancy care program was made available to all women with pre-pregnancy diabetes in the region serviced by the four care centers.  In this program, pregnant women with diabetes attended a combined obstetric-diabetes antenatal care session, followed by review every 1-2 weeks. Several issues were presented to the patients, including monitoring glucose in the home, self-adjusting insulin, and management of hypoglycemia. Prior to post-partum discharge, patients were advised to attend a review at 6 weeks and a minimum of 2 follow-up visits based on clinical need. Paired and unpaired t-tests were used for hypothesis testing.  Χ-squared was used for comparing sample proportions. Missing data were not incorporated.

A total of 384 women (mean age 32.8 years) were followed, with type 1 diabetes present in 64.3% (247) and type 2 in 35.7% (137). 99.6% type 1s and 71.5% type 2s were of White European ethnicity, and had an average duration of diabetes of 14.5 and 2.7 years respectively. The average pre-conception HbA1c was 8.0% and 6.9%, with declines over each trimester demonstrated, and returns to pre-pregnancy levels seen at 12 months post-partum.  Smoking at the post-partum review was significantly lower in the type 1 group (14.6% at pre-conception vs 10.1% at post-partum; p < 0.001), while the type 2 group displayed a non-significant increase in smoking (10.2% vs 15.6%, p=0.23). Reviewing the number of subjects who had participated in the ante-care program, 111 (44.9%) with type 1 and 38 (27.7%) of with type 2 completed the program in full. Both sub-groups had a lower pre-conception HbA1c when compared to subjects who did not attend the program (T1D: 7.4% vs 9.1%; p<0.001, and T2D: 6.4% vs 7.5%; p=0.04).

Despite the presence a readily available pre-pregnancy care program, which had been demonstrated to be beneficial, only 38.8% of eligible subjects attended. While all subjects received intensive diabetes management during pregnancy, those who participated in the free program displayed better glycemic control throughout pregnancy, and had a higher likelihood of receiving specialized care post-partum due to their engagement. The overall improvement of HbA1c across the board may be more likely due to increased red blood cell turnover that occurs during pregnancy. The poor overall attendance figures support the need for universal pre-pregnancy care. While attendees in this program are likely more self-motivated, increases in attendance can be achieved using population targeted involvement. For instance, people with type 2 diabetes were especially poorly represented in the program, so recruitment efforts can be ramped up to improve their numbers. It should be noted that the sample size was small, and represented a very specific geographic region. While a larger, multi-national study could give a clearer global picture, the underlying theme that involvement of women with diabetes in pre-conception care is supported, and could certainly lead to improved outcomes in this population, as well as in their progeny.  Efforts to increase patient participation must be improved to achieve these outcomes.

Practice Pearls:

  • There remains consensus that tight glycemic control in pregnancy reduces complication risks in both mother and unborn child.
  • Pre-conception education of women with diabetes has been shown to improve glycemic control before, during, and after pregnancy.
  • Health care professionals should increase efforts to improve patient participation, especially in people with type 2 diabetes, where participation rates are considerably low.

American Diabetes Association. 12. Management of Diabetes in Pregnancy. Diabetes Care. 2016;39 Suppl 1:S94-8. doi: 10.2337/dc16-S015. PubMed PMID: 26696688.

Egan AM, Carmody L, Kirwan B, Dunne FP, Collaborators AD. Care of women with diabetes before, during and after pregnancy: time for a new approach? Diabet Med. 2017. Epub 2017/02/22. doi: 10.1111/dme.13342. PubMed PMID: 28226193.

Mark T. Lawrence, University of Colorado-Denver, School of Pharmacy NTPD