Ellen Knox, West Midlands Perinatal Institute
Fidelma Dunne, Birmingham Univ. & Selly Oak Hospital

October 2001

Established Diabetes Mellitus (Types 1 and 2) is the most common pre existing medical condition to affect pregnant women with a frequency of 2-5/1000 pregnancies (1). Although common this means that in a unit delivering 4000 babies per year there will only be 8-20 cases each year. This reinforces the need for diabetic mothers to be managed in joint clinics with a named obstetrician and physician and standardised protocols for management.

Why is it a problem?

The maternal and perinatal mortality has improved dramatically over the past century to such an extent that in 1989 the St Vincent declaration stated that as a five year goal the "outcome of diabetic pregnancy should approximate that of a non diabetic pregnancy" (2)

However, 10 years later, a study from the Birmingham Women's hospital showed the outcomes of stillbirth, congenital abnormalities, neonatal death rate and perinatal mortality remain higher than that of the background population although the results had improved compared to data 10 years previously (3). The following table compares that data to results from the North east and North west region of the country.

The situation is not the same throughout the world however, with outcome data from Norway almost the same in diabetic as non diabetic pregnancies (4).

PERINATAL FORUM - SEPTEMBER 2001

Our September forum focused on some of the issues that may contribute to our suboptimal outcomes in Britain.
Only pre-gestational diabetes was discussed. This can be largely divided into:

Type 1- this results from autoimmune destruction of the insulin-producing islet cells. The condition therefore requires insulin and tends to present in childhood.

Type 2- this results from a state of relative insulin resistance. It was formerly referred to as "maturity onset" but this is no longer the case and data is fast emerging from the Children's hospital that it is becoming a disease of the young as well (especially those from an Indo-Asian background). Sufferers may be treated with diet, hypoglycaemic drugs or insulin.

One of the key messages from the forum was that ladies with type 2 diabetes are almost twice as likely than those with type 1 to have miscarriages and congenital malformations. In addition their babies are more likely to be large for gestational age and to be born before 37 weeks gestation (5). Unfortunately type 2 diabetes has long been, misguidedly, regarded by some as less severe than type 1 and this is clearly not the case. Indeed part of the reason for the adverse pregnancy outcome in this group is the poor attendance for pre pregnancy care, later booking for antenatal care and poor glycaemic control at booking.

References

1. The Centres for Disease Control. JAMA 1990; 264:437-40, Abstract

2. World Health Organisation (Europe) and International Diabetes Federation (Europe). The St Vincent Declaration. Diabetic Med 1990; 7:360-365.

3.Dunne F, Brydon P, Proffitt M, Smith T, Gee H, Holder R. Approaching St Vincent. Diabetic medicine 2001; 18:333-334

4.Hawthorne G, Irgens L M, Lie R T. Outcome of pregnancy in diabetic women in northeast England and Norway, 1994-7. BMJ 2000; 321:730-1, Abstract

5. Brydon P, Smith T, Proffitt M, Gee H, Holder R, Dunne F. Pregnancy outcome in women with Type 2 Diabetes mellitus needs to be addressed. IJCP September 2000; 54(7): 418-9, Abstract