Pre-conception planned pregnancy improves glycaemic control in women with diabetes

The Confidential Enquiry into Maternal and Child Health (CEMACH, 2005) revealed that the baby of a woman with pre-gestational diabetes is five times more likely to be stillborn, three times more likely to die in the first month of life, the baby is twice as likely to have a congenital malformation and is twice as likely to be over 4 kg. Recommendations included pre-conception services, multidisciplinary care and improving care for women with type 2 diabetes (CEMACH, 2007).

Aim and methodology
The aim of this audit was to collect information on outcomes of diabetes in pregnancy to highlight the areas where improvements are feasible using our current resources. Retrospective data were collected on 100 pregnancies. The data presented here are an extract from an Abracadabra Diabetes Nursing Conference Award entry.

Results
Of the 100 women audited (mean age 31 years), 63 had type 1 diabetes and 37 had type 2 diabetes. Thirty-eight per cent attended the clinical midwife specialist-led pre-conception care clinic and 44% took pre-pregnancy folic acid 5 mg. 

HbA_1c levels on first appointment (booking) were significantly different between the two groups: 7% (53 mmol/mol) for women with type 1 diabetes and 6.7% (50 mmol/mol) for those with type 2 diabetes (P=0.035). Mean HbA_1c level on booking for those who attended for pre-conception care was 6.6% (49 mmol/mol) compared with 7.5% (58 mmol/mol) for those who did not attend. Median HbA_1c level at delivery was 6.1% (43 mmol/mol). 

There was no statistically significant association between birth weight and HbA_1c level on booking (P=0.51) or at delivery (P=0.183). A total of 35% of women had a vaginal delivery and 42% had a caesarean section (national background caesarian section rate 28%; National Perinatal Epidemiology Centre [NPEC], 2008).

Live births accounted for 74% of deliveries. Twenty-three per cent were miscarriages, which is similar to the national background rate, and 3% were stillbirths (national background rate 0.5%; NPEC, 2008); there were no neonatal deaths (national background rate 0.4%; NPEC, 2008). Neither the 21% incidence of macrosomia (birth weight >4 kg; P=0.157) or median birth weight of 3440 g (P=0.088) were significantly different between women with type 1 or 2 diabetes.

Conclusion 
This cohort of women achieved reasonable HbA_1c levels before attending for pre-conception care and the majority achieved good glycaemic control with conventional insulin treatment. In this audit, women who participated in pre-conception planned pregnancy achieved better glycaemic control.

The authors recommened that the number of women with type 1 or 2 diabetes attending for pre-conception care should be increased; that pregnant women with pre-existing diabetes should be encouraged to book for antenatal care before 8 weeks gestation; and that caesarian section rates should be further reduced.