Diabetes in pregnancy: are we providing the best care ... - HQIP
Diabetes in pregnancy: are we providing the best care ... - HQIP
Diabetes in pregnancy: are we providing the best care ... - HQIP
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7. Social and lifestyle issues<br />
Learn<strong>in</strong>g po<strong>in</strong>ts<br />
• Women with diabetes do not appear to be adequately prep<strong>are</strong>d for <strong>pregnancy</strong>.<br />
• Two thirds of women with diabetes had suboptimal glycaemic control before and dur<strong>in</strong>g <strong>the</strong> fi rst<br />
trimester of <strong>pregnancy</strong>.<br />
• Suboptimal glycaemic control before and dur<strong>in</strong>g <strong>pregnancy</strong>, and a suboptimal approach of <strong>the</strong><br />
woman to manag<strong>in</strong>g her diabetes, <strong>we</strong>re associated with poor <strong>pregnancy</strong> outcome.<br />
• The ma<strong>in</strong> underly<strong>in</strong>g issues for women with diabetes <strong>we</strong>re:<br />
- non-attendance at planned appo<strong>in</strong>tments<br />
- non-adherence to medical advice about diabetes management<br />
- unplanned <strong>pregnancy</strong><br />
- social factors <strong>in</strong>clud<strong>in</strong>g language diffi culties and domestic circumstances.<br />
7.1 Introduction<br />
The prevalence of diabetes <strong>in</strong> <strong>the</strong> UK is <strong>in</strong>creas<strong>in</strong>g, with an <strong>in</strong>creas<strong>in</strong>g number of young people be<strong>in</strong>g<br />
diagnosed. 1-3 There <strong>are</strong> an estimated 131 000 women diagnosed with diabetes of childbear<strong>in</strong>g age <strong>in</strong><br />
England (<strong>Diabetes</strong> UK, personal communication) . The CEMACH report on 3808 pregnancies to women<br />
with type 1 and type 2 diabetes has shown that women <strong>in</strong> England, Wales and Nor<strong>the</strong>rn Ireland <strong>are</strong> poorly<br />
prep<strong>are</strong>d for <strong>pregnancy</strong>. 4<br />
This chapter exam<strong>in</strong>es some of <strong>the</strong> underly<strong>in</strong>g issues that <strong>we</strong>re identifi ed dur<strong>in</strong>g panel reviews of<br />
442 s<strong>in</strong>gleton pregnancies to women with diabetes <strong>in</strong> England, Wales and Nor<strong>the</strong>rn Ireland.<br />
7.2 Preparation for <strong>pregnancy</strong><br />
Development of <strong>the</strong> fetal organs occurs dur<strong>in</strong>g <strong>the</strong> fi rst three months of <strong>pregnancy</strong>, and <strong>the</strong>re is evidence<br />
that good glycaemic control <strong>in</strong> <strong>the</strong> preconception period and dur<strong>in</strong>g <strong>the</strong> fi rst trimester of <strong>pregnancy</strong><br />
decreases <strong>the</strong> risk of fetal congenital anomaly and miscarriage. 5-7 Women with diabetes of childbear<strong>in</strong>g<br />
age need to use an effective and reliable method of contraception to avoid unplanned <strong>pregnancy</strong>, and it<br />
is recommended that women plann<strong>in</strong>g a <strong>pregnancy</strong> should cont<strong>in</strong>ue contraception until good glycaemic<br />
control has been achieved. 8 In addition, it has been shown that high dose (5mg) folic acid commenced<br />
before <strong>pregnancy</strong> decreases <strong>the</strong> risk of fetal neural tube defects <strong>in</strong> high risk populations 9 and this is<br />
recommended for women with diabetes. 1,10 Smok<strong>in</strong>g <strong>in</strong>creases <strong>the</strong> risk of diabetes vascular complications<br />
and placental <strong>in</strong>suffi ciency, and women should be advised and encouraged to stop smok<strong>in</strong>g.<br />
7.2.1 Enquiry fi nd<strong>in</strong>gs<br />
Less than half (41%, 158/384) of women <strong>in</strong> <strong>the</strong> enquiry (35% of 197 cases a and 48% of 187 controls b )<br />
<strong>we</strong>re documented to have planned <strong>the</strong>ir current <strong>pregnancy</strong>, comp<strong>are</strong>d to a planned <strong>pregnancy</strong> rate of 58%<br />
<strong>in</strong> 2001-02 <strong>in</strong> <strong>the</strong> general maternity population. 11 T<strong>we</strong>nty seven percent (107/32) of women (19% of 196<br />
cases and 36% of 196 controls) <strong>we</strong>re documented to have been us<strong>in</strong>g any form of contraception <strong>in</strong> <strong>the</strong><br />
12 months before conception. T<strong>we</strong>nty seven percent of 380 women <strong>we</strong>re documented to have commenced<br />
32