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

Type 1 and type 2 diabetes have traditionally been managed differently. As the prevalence of type 2
diabetes in pregnancy increases, it is appropriate to review how we manage women of childbearing age
with known type 2 diabetes. Also, women with gestational diabetes (GDM) are at increased risk of type
2 diabetes after pregnancy, and in some populations up to 20% of women diagnosed to have gestational
diabetes actually have previously undiagnosed type 2 diabetes. This brings them into a high risk group for
future pregnancies, and although this report did not address gestational diabetes, these women may also
benefi t from properly structured management strategies including pre-pregnancy care.
Although retinopathy is much less common in women with type 2 diabetes it is present in a signifi cant
minority and they are presumably equally vulnerable to deterioration of retinopathy during pregnancy. They
therefore need to be enrolled in a suitable annual review outside pregnancy, either in primary or secondary
care. They are likely to benefi t as much as women with type 1 diabetes from digital retinal photography.
In the CEMACH enquiry, unplanned pregnancy and preconception folic acid use was equivalent in women
with type 1 and type 2 diabetes, and women with type 2 diabetes appeared less likely to use contraception.
It is important that both groups of women should have messages reinforced about pregnancy preparation.
During pregnancy, it is clear that women with type 2 diabetes should have the same standard of maternal
and fetal surveillance as women with type 1 diabetes. However, women with type 2 diabetes have a
relative rarity of severe hypoglycaemia requiring third party assistance.
During labour, fewer women with type 2 diabetes receive intravenous insulin and dextrose; this is perhaps
a refl ection of reasonable clinical practice in that these women may very well have shorter labours and are
certainly at less risk of serious metabolic disturbance during labour.
The fi nding that women with type 2 diabetes are less likely to receive postnatal contraceptive advice is
of concern, and the importance of providing contraceptive advice to this particular group of women must
be emphasised through adult diabetes services and general practitioners. It may also be worthwhile to
extend education about the pregnancy risks for women with type 2 diabetes to other primary care health
professionals such as Family Planning practitioners and nurses.
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