Prepregnancy Care and Pregnancy Outcomes in Women With Type 1 Diabetes

Abstract

OBJECTIVE -The objective of this study was to examine the relationship between prepregnancy care, glycemic control, maternal hypoglycemia, and pregnancy outcomes in women with type 1 diabetes.RESEARCH DESIGN AND METHODS -This was a prospective observational cohort study of women with type 1 diabetes who delivered from 1991 to 2002. Outcome measures were attendance at a clinic for prepregnancy care, maternal HbA 1c (A1C) throughout pregnancy, maternal severe hypoglycemic episodes, macrosomia, preeclampsia, premature delivery (delivery before 37 weeks), very premature delivery (delivery before 34 weeks), spontaneous abortion, and adverse pregnancy outcome (defined as major malformation, stillbirth, and neonatal death).RESULTS -There were 290 pregnancies, in which 110 (38%) women had prepregnancy care. The prepregnancy care group contained more primiparous women (54.7 vs. 40.6%; P ϭ 0.021) and fewer smokers (9.4 vs. 28.7%; P Ͻ 0.0001). They registered earlier (6.6 vs. 8.3 weeks, P Ͻ 0.0001) and had a lower A1C at the initial visit (6.5% vs. 7.6%; P Ͻ 0.0001). Adverse pregnancy outcomes and very premature deliveries were significantly lower in women who received prepregnancy care (2.9 vs. 10.2%; P ϭ 0.03 and 5.0 vs. 14.2%; P ϭ 0.02, respectively). In contrast, between groups, there was no difference in A1C after 24 weeks or in the rates of macrosomia, preeclampsia, or maternal severe hypoglycemic episodes.CONCLUSIONS -Prepregnancy care was associated with improved glycemic control in early pregnancy and significant reductions in adverse pregnancy outcome (malformation, stillbirth, and neonatal death) and very premature delivery. However, prepregnancy care failed to have an impact on glycemic control in later pregnancy or to reduce the risk of macrosomia and preeclampsia. Diabetes Care 29:1744 -1749, 2006D iabetes is the most common medical condition to complicate pregnancy, affecting 1 pregnant woman in 250 in the U.K. (1). Women with type 1 diabetes have a poor outcome compared with women without diabetes, with increased rates of congenital malformations, preeclampsia, premature delivery, perinatal mortality, and risk of delivering a macrosomic baby (2). The Confidential Enquiry into Maternal and Child Health (CEMACH) confirms a nearly fourfold rise in perinatal mortality rates and twofold rise in congenital malformation rate in women with diabetes over baseline rates in England, Wales, and Northern Ireland (1). Studies suggest that the risk of adverse outcome (malformation and perinatal mortality) is related to poor glycemic control in early pregnancy (3,4). The critical time period for optimal glycemic control is before 7 weeks' gestation, during early organogenesis (5). Prepregnancy care is the only intervention that targets glycemic control at this critical early stage and has been associated with improvements in maternal and perinatal outcomes (4,6 -13). The association of prepregnancy care with reduced risk of major congenital malformation has been further confirmed on meta-analysis (14). Some studies of macr...

Changes in the Glycemic Profiles of Women With Type 1 and Type 2 Diabetes During Pregnancy

“…Clearly, prepregnancy care plays an important role, improving early glycemic control and reducing major malformation and perinatal mortality (29). However, our recent data suggest that even the significant improvements in glycemic control achieved by women attending prepregnancy care are still "not good enough," in that they fail to reduce rates of preeclampsia and macrosomia (24,30). These complications are believed to be related to hyperglycemic excursions during the second and third trimesters (30,31), which are clearly demonstrated in this study.…”

“…Women randomized to the CGMS intervention were encouraged to wear the device at 4-to 6-week intervals from the booking visit through to 34 weeks' gestation, since our clinical experience suggests greater discomfort associated with wearing the device in later pregnancy. The prepregnancy and antenatal care at these centers has been recently documented (24).…”

Absence of telomere shortening and oxidative DNA damage in the young adult offspring of women with pre-gestational type 1 diabetes

“…It is possible that the offspring of PGDM mothers with poorer glycaemic control during pregnancy would show abnormalities in glucose tolerance or telomere attrition. However, it should be stressed that PGDM mothers with good glycaemic control still suffer a high rate of fetal morbidity [49], and diabetic populations with good glycaemic control still demonstrate evidence of DNA damage and telomere attrition [18,50]. Second, we cannot exclude the possibility that the offspring of PGDM mothers who declined to participate were different from those who consented with respect to diet, lifestyle, social class and anthropometric measurements.…”

The interconnections between maternal and newborn health – evidence and implications for policy

“…A study by Tripathi et al [93] showed that diabetic women with preconception care were more likely to have better glycemic control 3 months preconception (OR 1.91, 95% CI 1.10-3.04) and in the first trimester (OR 2.05; 95% CI: 1.39 to 3.03). The study by Temple et al [94] showed that the risk of preterm births decreased in diabetic women receiving prepregnancy care (RR 0.64; 95% CI: 0.47 to 0.88). However, another study by the same author reported no difference in rates of pre-eclampsia (13.1 versus 12.6%) [95] between the women who did and those who did not attend prepregnancy care.…”