Are care standards for diabetic pregnant patients being achieved?The short answer to the question is NO. The National Diabetes Audit indicates that while the diabetes epidemic continues to grow, medical care continues to fall way short of the standards devised to reduce the burden of complications both on individuals and the economy.
Women who are pregnant tend to get off to a bad start by not being on the right dose of folic acid before they embark on the pregnancy. They are advised to take 5mg of the vitamin a day in order to reduce the chance of their baby developing spina bifida. Of the type one diabetic women 45% met this standard but only 24% of type two diabetic women did so.
In order to eliminate foetal abnormalities related to hyperglycaemia the HbA1c should be preferably below 6.0 in the first trimester and yet only 8% of women with type one and 22% of those with type two managed a HbA1c of 6.1% (43 mmol/mol) or less. Pregnancy is advised to be avoided all together if the HbA1c is over 10% (86) but 12% of type ones and 8% of type two women were over this. The women most adversely affected tended to be living in the greatest areas of deprivation, and also of Asian or Black ethnicity.
Oral glucose lowering drugs apart from metformin are advised for women trying for a baby and insulin should be used if necessary to achieve blood sugar targets. Statins, ACE inhibitors (prils), and ARBS (sartans) should be stopped prior to pregnancy as these can be teratogenic. But 57% of type two diabetic women were on at least one of these drugs at the onset of pregnancy.
Hypoglycaemia, severe enough to need hospital treatment, was experienced by 9.3% of pregnant women with type one diabetes.
Currently 67% of type one women have a caesarean section compared with 52% of type twos. The rates of stillbirth for offspring are almost 12.8 per 1000 births compared to 4.7 for the general population. Neonatal deaths are 7.6 per 1000 compared to 2.6 for the general population. The rate of congenital abnormalities approximately double that for the general population at 44.2 per 1000 compared to 22.7. Adverse pregnancy outcomes of all types are related to the HbA1c particularly in the first and third trimesters.
Despite the growth of specialist diabetic-obstetric teams there has been very little improvement in these outcomes over the last ten years. How can we help diabetic women prepare for their pregnancies? Why are so many women and babies not getting the medical care that could help them?
Some basic advice: see your GP well before you plan a pregnancy if you have diabetes and tell them that you are planning for having a baby.
Use effective contraception until your glycaemic goals have been met. For most women this means a Hba1c of 6.5% or under and ideally under 6.0%.
Start folic acid 5mg daily.
Stop statins, ACE inhibitors, ARBs and seek alternative blood pressure control drugs instead, if you have high blood pressure.
Get your weight down to normal if at all possible.
Start a gentle exercise regime if you haven’t already started.
If you have type two diabetes discuss moving onto insulin with your consultant diabetologist.
If you have type two diabetes you will usually continue metformin but stop other drugs on the advice of your consultant diabetologist or GP.
Based on Analysing newly-published diabetes audits: are care standards being achieved? Written by Steve Chaplin B Pharm MSc Medical Correspondent in Practical Diabetes March 2016
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