Diabetes in pregnancy: are we providing the best care ... - HQIP

8. Clinical care issues: preconception
Learning points
• In the CEMACH survey of maternity services, only 17% of maternity units in England, Wales and
Northern Ireland reported providing structured multidisciplinary preconception care for women
with diabetes. A quarter of women in the enquiry were reported to have had preconception care
at a multidisciplinary hospital clinic.
• Two thirds of women in the enquiry had suboptimal preconception care. One of the main
underlying issues was failure of health professionals to provide appropriate care such as
preconception advice and higher dose folic acid. There was poor documentation of
pre-pregnancy counselling.
• Suboptimal preconception care was associated with poor pregnancy outcome.
8.1 Introduction
Women with type 1 and type 2 diabetes represent a high-risk population during pregnancy. Clinicians have
a responsibility to provide appropriate information, effective fetal and maternal surveillance, and timely
health care interventions to achieve the best possible outcome for the woman and her baby. The Diabetes
National Service Framework (NSF) emphasises the importance of an effective multidisciplinary team, both
to support and empower women to plan their pregnancies, optimise glycaemic control before conception
and improve the quality of antenatal care during pregnancy. 1 However, the recent CEMACH descriptive
study of 3808 pregnancies to women with type 1 and type 2 diabetes found that the majority of women
with pre-existing diabetes in England, Wales and Northern Ireland are poorly prepared for pregnancy. 2
8.2 Preconception care services
The increased risk of fetal congenital anomalies (with the main contributors being neural tube and cardiac
defects) 3 and perinatal death in babies of women with pre-existing diabetes 2 can be minimised by ensuring
good glycaemic control before and during pregnancy 4 and by commencing high dose (5mg daily) folic acid
before conception. 5
During the CEMACH survey of maternity services (2004) 6 , only 17% of maternity units in England, Wales
and Northern Ireland reported that they provided a multidisciplinary diabetes preconception service. The
CEMACH descriptive study found that only 35% of women were documented in the medical notes to have
had pre-pregnancy counselling, with only a tenth of these seen in a formal preconception clinic. 2 During the
enquiry, general practitioners and adult diabetes services were also asked where preconception care had
been provided.
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