Risk and Recurrence of Serious Adverse Outcomes in the First and Second Pregnancies of Women With Preexisting Diabetes

Abstract

OBJECTIVEWomen with preexisting (type 1 or type 2) diabetes experience an increased risk of serious adverse pregnancy outcomes. It is not known, however, how these risks change between the first and second pregnancy and whether there is an increased risk of recurrence. This study describes the absolute risks and recurrence of serious adverse pregnancy outcomes in 220 women with preexisting diabetes. RESEARCH DESIGN AND METHODSA total of 440 pregnancies occurring in 220 women with preexisting diabetes who delivered successive singleton pregnancies in the North of England during 1996-2008 were identified from the Northern Diabetes in Pregnancy Survey (NorDIP). Predictors of serious adverse outcome were estimated by competing-risks regression. RESULTSSixty-seven first pregnancies (30.5%) ended in serious adverse outcome, including 14 (6.4%) with congenital anomalies and 53 (24.1%) additional fetal or infant deaths. Thirty-seven second pregnancies (16.8%) ended in serious adverse outcomedhalf the rate among first pregnancies (P = 0.0004)dincluding 21 (9.5%) with congenital anomalies and 16 (7.3%) additional fetal or infant deaths. Serious adverse outcomes in the second pregnancy occurred twice as frequently in women who experienced a previous adverse outcome than in those who did not (26.9% vs. 12.4%, P = 0.004), but previous adverse outcome was not associated with preparation for the following pregnancy. CONCLUSIONSSerious adverse outcomes are less common in the second pregnancies of women with preexisting diabetes, although the risk is comparable in those whose first pregnancy ends in adverse outcome. Reducing the risk of recurrence may require more support in the immediate period after an adverse pregnancy outcome.Serious adverse pregnancy outcomes, such as miscarriages, stillbirths, and congenital anomalies, are associated with significant psychological distress, and parents who experience such events are often very anxious about their chances of recurrence (1,2). In the general population, the risks of miscarriage, stillbirth, and congenital anomaly in the second pregnancy are approximately two times greater in women who experienced the same event in their first pregnancy (3-5), although the absolute risks remain low in the absence of clear genetic or physiological factors.

Pregnancy in Diabetes: challenges and opportunities for improving pregnancy outcomes

“…Similar to NPID findings, pregnancy preparation was suboptimal, with less than a quarter of women achieving HbA 1c < 53 mmol/mol (7%) and 27% taking folic acid before their first pregnancy. Despite some improvement in preparation for the second pregnancy, in general, women who were better or poorly prepared for their first pregnancy, were also better or poorly prepared for their second pregnancy . Hence, women with a previous adverse outcome were no more likely to prepare for the second pregnancy.…”

“…Tennant et al . reported on the first and second pregnancies of 220 women with diabetes in northeast England (89% Type 1), aiming to quantify the risk of recurrence of adverse pregnancy outcome. In this study, 30.5% of first pregnancies had a serious adverse outcome, defined as miscarriage, congenital anomaly (6.4%), stillbirth or infant death.…”

“…Longitudinal studies suggest that, for women without diabetes, the risk of a recurrent miscarriage, stillbirth and congenital anomaly are approximately doubled in a second pregnancy, if experienced in their first pregnancy [15][16][17]. Tennant et al [18] reported on the first and second pregnancies of 220 women with diabetes in northeast England (89% Type 1), aiming to quantify the risk of recurrence of adverse pregnancy outcome. In this study, 30.5% of first pregnancies had a serious adverse outcome, defined as miscarriage, congenital anomaly (6.4%), stillbirth or infant death.…”

Detailed description of a prepregnancy care program and its impact on maternal glucose control, weight gain, and dropouts

“…These findings support a recent study by Tennant et al in which women who had experienced an adverse event in a previous gestation did not improve preparation in the second gestation. 13 This could reflect the persistence of poor self-management behaviors between pregnancies or the loss of fear in the absence of problems in previous pregnancies.…”

Care of women with diabetes before, during and after pregnancy: time for a new approach?

“…The increased rate of adverse pregnancy outcomes experienced by women with diabetes can be reduced by optimizing diabetes control [1][2][3][4][5]. Women with diabetes therefore tend to be highly motivated to achieve the tight treatment goals recommended during pregnancy and typically receive intensive education and support from a specialist service [6,7].…”