Pre-pregnancy care: We must heed findings from the national audit when implementing the new NICE guideline

The challenges of managing pregnancy in women with pre-existing diabetes are well understood. Reducing the risk to both mother and baby can be achieved with pre-pregnancy preparation, optimal glycaemic control and frequent monitoring throughout the term.  

The first National Pregnancy in Diabetes Audit (NPID; Health and Social Care Information Centre,  2014) has provided valuable information on the current level of care offered throughout England and Wales, and offers the opportunity to explore changes to service provision in light of these findings and the newly revised diabetes and pregnancy NICE guidance (NICE, 2015). The NPID was undertaken throughout 2013 and a total of 126 units filed audit data on over 1700 pregnancies. 

Of the few signs of encouragement from this audit, it does appear that there has been a sizeable reduction in the number of babies born large for dates and the numbers of babies being separated from mothers at birth, due to their requiring neonatal high dependency or special care cots, has also reduced dramatically from 70.3% to 42.8%. Alarmingly, however, many other aspects of care have not improved at all and the changing demographic of mothers in the audit has highlighted areas for concern that demand immediate consideration.  

The NPID audit shows that pre-pregnancy preparation remains poor. The new NICE guideline defines adequate control as taking folic acid prior to conception and achieving an HbA_1c result of 48 mmol/mol (6.5%; NICE 2015). The NPID reported that only a minority of women achieved both these targets. Only 33% of women were taking the recommended 5 mg of folic acid, with a further 7.1% taking the lower dose of 400 µg. Furthermore, only 5.1% of women with type 1 diabetes achieved the NICE (2008) HbA_1c target of 43 mmol/mol (6.1%) and a quarter achieved the 53 mmol/mol (7%). A greater percentage of women with type 2 diabetes achieved pre-conception glycaemic targets (18.5% and 45.9% for the 43 mmol/mol [6.1%] and 53 mmol/mol [7%], respectively).

This audit has also highlighted the rapidly changing demographic of the women embarking on a pregnancy. Almost half of the women had type 2 diabetes. The additional concern this has highlighted is the number of women conceiving on medications that are contraindicated in pregnancy, as women with type 2 diabetes are more likely to be taking additional medications, such as angiotensin-converting enzyme (ACE) inhibitors and statins. The NPID indicates that 6% of women were taking either, or both, of these medications. Furthermore, women with pre-existing type 2 diabetes are more likely to have a larger BMI at conception, are older and present later to the specialist teams for the pregnancy. Most of these women will have had their diabetes managed exclusively in primary care and, therefore, will be completely unknown to the specialist teams. This is a real change from previous decades when predominantly the women with diabetes embarking on a pregnancy would have had type 1 diabetes and their diabetes care would have been provided wholly in secondary care. This highlights the importance of the provision of regular education for primary care staff about the risks of pregnancy in these women and the vital need to ensure adequate pre-pregnancy preparation and early referral to the specialist teams.

Equally, healthcare professionals should ensure that adequate contraception is taken in women of child-bearing age, who are not actively planning a pregnancy, but have been prescribed medications that are contraindicated in pregnancy.

Clearly much still has to be done to improve the outcomes of pregnancy for women with pre-existing diabetes; however, this first NPID has provided valuable information and a platform on which to continue to develop services, alongside the recently updated NICE guideline (NICE, 2015). It is hoped that greater awareness about adequate pre-pregnancy care will be demonstrated in future NPID audits.