Gestational diabetes

System-wide changes needed to improve outcomes for pregnant women with diabetes

Rates of major adverse pregnancy outcomes have not improved for women with diabetes over the last five years, with others potentially worsening despite progress to improve care, findings from the largest study to date of women with diabetes reveal.

The analysis comes from the five-year audit of maternity clinics in the UK, including 8690 in women with type 1 diabetes and 8685 in women with type 2 diabetes. Investigators reported 700 congenital anomalies and 345 perinatal deaths (195 stillbirths, 150 neonatal deaths) among the two groups between 2014 and 2018, exposing  significant gaps in support available to women with diabetes before and during their pregnancy.

Discussing the study with the limbic, leading endocrinologist Distinguished Professor David Simmons, Director of the Diabetes Obesity and Metabolism Translation Unit in NSW, said pregnancy outcomes were similar – if not worse – in Australia.

According to Professor Simmons, who is also Head of the Campbelltown Hospital Endocrinology Department, pregnancy malformation rates for women with diabetes across some parts of NSW were as high as 12%, and in other other parts of the country as high as 18% compared to a background rate of 2-4%.

Describing the figures as ‘devastating’ he said a system-wide change involving better integration between primary and secondary care was needed if outcomes were to be improved.

“We’ve published on this in Australia and we know this is a major problem – we’re talking about holes in the heart, malformed spines, sacral agenesis – major malformations each of which carry the lifelong cost per patient of millions dollars. It’s devastating for the family and obviously lifelong for that child.”

And that’s just the malformations, he added.

“That’s not counting for stillbirths and the high level of caesarian intervention and other adverse outcomes associated with poorly controlled diabetes in pregnancy.”

The UK analysis showed similar rates of congenital anomalies in both type 1 and type 2 diabetes, with the risk significantly increased in women with HbA1c levels of 6.5% or higher in the first trimester, and for those who did not take folic acid prior to conception.

Meanwhile, having third trimester HbA1c levels of 6.5% (48 mmol/mol) or higher was independently associated with an increased risk for perinatal death, as was being in the highest versus the lowest deprivation quintile for all women.

Rates of stillbirth were similar in the two groups, but seemed to increase in women with type 2 diabetes during the last two years of the study while remaining stable in those with type 1 diabetes.

Pre-pregnancy interventions

Writing in a linked commentary published alongside the report. Professor Simmons said the latest outcomes occurred despite each service having access to aggregated, benchmarked measures of planning, periconceptual and antenatal glycaemia, and outcomes for pregnant women with diabetes.

Professor Simmons, who has established a pre-pregnancy clinic for women with diabetes in South West Sydney said the risks of an unplanned pregnancy in this setting were still very much ‘under appreciated by a long way.’

“Many health professionals are not aware of these major risks, they don’t necessarily communicate them to the women and certainly many of the women aren’t aware of the complications or the risk they run with an unplanned pregnancy,” he told the limbic.

“It’s devastating, I see women come to the clinic quite late – 15-20 weeks into their pregnancy – and by then it’s too late, the baby has already got their malformations and when you have to tell them this they cry; many say they didn’t know the risks, that they weren’t told.

“As health professionals we may think that people know all the complications; we don’t like to talk about complications. It’s horrible to talk about malformations, holes in the heart, damaged collar bones, damaged nerves, and stillbirths – but this is the reality for a lot of these women and they need the information to make decisions. If they then decide that they’re willing to take those risks that’s their decision and we, as health professions, will support them in every way we can to minimise those risks.”

While progress in this area had been made – such as the decision to roll out funded Continuous Glucose Monitoring for pregnant women in Australia with type 1 diabetes – Professor Simmons said he still had women attending pre-pregnancy clinics who did not know they had access to the technology, Similarly, he saw women with type 2 diabetes who were pregnant on statins and other drugs that could lead to adverse pregnancy outcomes.

“We need to embed decision support software into our systems in general practice, within specialist services so that we can talk to patients about fertility and pre-pregnancy planning at crucial points – these are things that are do-able, we know they work and yet they’re not in place,” he said.

Meanwhile, younger women were more likely to have a pregnancy with high periconceptional HbA1c. And notably these women were also more likely to have unplanned pregnancies, noted Professor Simmons, suggesting that opportunities to discuss and remove barriers to effective contraception should also be embedded into existing services.

“It’s a major systems issues – we’re in an era where we can provide this kind of intensive management – we have sensors, databases, electronic records, decision support; we have pre-pregnancy clinics that can provide that intensive management to get the glucose as close to normal as they can without inducing hyoglycaemia,” he said.

In addition, women with diabetes became more sensitive to insulin as a result of pregnancy hormones, putting them at risk of hypoglycaemia.

“There’s a lot of planning that needs to go into place – women really need the support to be ready for the pregnancy or to be supported if they’ve decided they don’t want a baby, which means having some discussions around appropriate contraception and rapid access to long-acting reversible contraception,” said Professor Simmons

He also stated a case for additional payment to the primary care centre if women with diabetes and of reproductive age had received counselling, contraception discussion, and pregnancy preparation, including referral. While, for secondary care, a payment like the best practice tariff could be made for pregnancy planning involving frequent review by the diabetes team, including a dietitian and diabetes psychologist, he argued.

“There are a lot behavioural issues and a lot of complexities but the women who come to pre-pregnancy clinics have got a 75% less chance of having malformations and a two thirds less chance of having a stillbirth. So we won’t make this perfect, but we certainly can get down to a rate of 3-4% background malformations. We’ve got interventions we can do now and we should be getting on with them,” he concluded.

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