Preconception care for women with diabetes: is it effective and who should provide it?

Patient and provider perspectives on preterm birth risk assessment and communication

OBJECTIVE

To describe and compare how obstetric patients and care providers view preterm birth risk assessment and communication.

METHODS

We conducted eight focus groups with obstetric patients (n = 35) and 16 qualitative interviews with obstetric providers. Grounded theory was used to identify and analyze themes.

RESULTS

Patients' knowledge about preterm birth varied greatly. Similar benefits and risks of preterm birth risk counseling were discussed by patients and providers with notable exceptions: patients cited preparedness as a benefit and providers cited maternal blame, patient alienation, and estimate uncertainty as potential risks. Most patients expressed a desire to know their personalized preterm birth risk during pregnancy. Providers differed in whether they offer universal versus selective, and quantitative versus qualitative, preterm birth risk counseling. Many providers expressed concern about discussing social and structural risk factors for preterm birth.

CONCLUSION

While many patients desired knowing their personalized preterm birth risk, prenatal care providers' disclosure practices vary because of uncertainty of estimates, concerns about negative consequences and challenges of addressing systemic inequities and social determinants of health.

PRACTICE IMPLICATIONS

Given the existing asymmetry of information about preterm birth risk, providers should consider patient preferences regarding and potential benefits and risks of such disclosure in their practice.

Current practice and perspectives of healthcare providers regarding preconception care for women with type 1 diabetes in China

AIMS

We aimed to investigate the current practice and perspectives of healthcare providers (HCPs) regarding preconception care (PCC) for women with type 1 diabetes (T1D) in China.

MATERIALS AND METHODS

A questionnaire based on in-depth interviews with HCPs involved in PCC was released online and advertised via doctor unions in China. The data were categorical variables and were analysed by multivariable logistic regression, Chi-square test, or Wilcoxon rank-sum test.

RESULTS

From November 2016 to January 2017, 992 responses from 31 provinces of China were received (77.3% doctors and 22.7% nurses). Regarding the current status of PCC for T1D, 62.5% of HCPs treated ≤1 woman with T1D monthly on average. Only 16.5% thought they provided proper PCC, and 29.6% reported having sufficient knowledge. Regarding attitudes towards pregnancy with T1D, 92.2% were in favour of women with T1D getting pregnant after proper glycaemic control, and 94.7% perceived their worries regarding pregnancy. Regarding doctor-patient communication, 56.6% spent <10 min per visit, while 58.3% thought ≥20 min was required for adequate communication. HCPs emphasised the importance of multidisciplinary PCC, professional training, and social support. PCC practice was associated with hospital level (OR = 2.450, 95%CI: 1.580-3.799, p < 0.001), HCPs' experience of treating women with T1D (OR = 2.196, 95%CI: 1.516-3.180, p < 0.001), and their communication sufficiency (OR = 3.706, 95%CI: 2.550-5.387, p < 0.001).

CONCLUSIONS

The current PCC practice for T1D in China was suboptimal and it was associated with hospital level, HCPs' experience and communication. It is necessary to reinforce professional training and appeal for social resources to improve PCC.

Pregnancy Outcomes in Women with Long-Duration Type 1 Diabetes-25 Years of Experience

AIMS

Our study aimed to examine the pregnancy outcomes (maternal and fetal) concerning different models of antenatal care across a period of over 25 years (1993-2018) in 459 women with type 1 diabetes. Data from patients with a history of the condition lasting at least 15 years were considered eligible for analysis.

METHODS

The study group was divided into three cohorts based on the different models of treatment used in Poznan University Hospital, Poland: 1993-2000 (cohort I, n = 91), 2001-2005 (cohort II, n = 83), 2006-2018 (cohort III, n = 284). To identify predictors for the selected dichotomous outcomes, we calculated the risks for fetal or maternal complications as dependent variables for cohorts II and III against cohort I, using multivariate logistic regression analysis.

RESULTS

The mean gestational age was 36.8 ± 2.4 weeks in the total cohort. The percentages of deliveries before the 33rd and the 37th weeks was high. We observed a decreasing percentage during the following periods, from 41.5% in the first period to 30.4% in the third group. There was a tendency for newborn weight to show a gradual increase across three time periods (2850, 3189, 3321 g, p < 0.0001). In the last period, we noticed significantly more newborns delivered after 36 weeks with a weight above 4000 g and below 2500 g. Caesarean section was performed in 88% of patients from the whole group, but in the subsequent periods this number visibly decreased (from 97.6%, 86.7%, to 71%, p = 0.001). The number of emergency caesarean sections was lowest in the third period (27.5%, 16.7%, 11.2%, p = 0.006). We observed a decreasing number of "small for gestational age" newborns (SGA) in consecutive periods of treatment (from 24.4% to 8.7%, p = 0.002), but also a higher percentage of "large for gestational age" (LGA) newborns (from 6.1% to 21.6%, p = 0.001). Modification of treatment might be associated with the gradual reduction of SGA rates (cohort I 3.6%, cohort III 2.3% p < 0,0005).

CONCLUSIONS

Strict glycemic and blood pressure control from the very beginning of pregnancy, as well as modern fetal surveillance techniques, may contribute to the improvement of perinatal outcomes in women with long-duration type 1 diabetes.

Pregnancy in women with diabetic nephropathy

The number of pregnancies in women with pregestational diabetes has been steadily increasing worldwide. These pregnancies are associated with an increased risk of a variety of complications, including miscarriages, congenital malformations, macrosomia, fetal growth restriction, preeclampsia, preterm delivery and stillbirth. In pregnant women with diabetic nephropathy it is important to evaluate both the effect of pregnancy on kidney function and the effect of kidney disease on pregnancy outcomes. Pregnant women with normal renal function and microalbuminuria have a low risk of loss of kidney function during pregnancy, while women with GFR < 60 ml/min and/or proteinuria ≥ 3 g/24 h at the beginning of pregnancy are at risk of permanent kidney damage. The risk of fetal and maternal complications is associated with the severity of chronic kidney disease and glycemic control. Advances in prenatal care have improved fetal and maternal outcomes and preconception counseling has become key for a successful pregnancy in all women with diabetes and especially in those with diabetes and chronic kidney disease.

Preconception Counseling for Adolescents and Young Adults with Diabetes: a Literature Review of the Past 10 Years

PURPOSE OF REVIEW

Women with diabetes who have unplanned pregnancies and uncontrolled blood sugars are at a higher risk for maternal and fetal morbidities and mortalities. Preconception counseling (PC) has been shown to decrease the risks and improve health outcomes. From 2009 to 2017, the American Diabetes Association has recommended that preconception counseling be given at each clinic visit for all women with diabetes of childbearing age starting at puberty (prior to sexual debut).

RECENT FINDINGS

This article reports both national and international progress in PC efforts for adolescents and young adults (12-34 years) with diabetes over the past decade. Twenty-eight publications were identified and included in this article (11 were research, 12 clinical guidelines, and 5 reviews). Despite recommendations to start PC at puberty, only four studies had interventions that targeted the adolescent and young adult age group. Three of them were associated with the same PC awareness program. Positive outcomes were reported in all of these studies. Greater family vigilance was observed in a long-term follow-up of a cohort of women who received PC as teens. Adolescents should receive awareness PC. More early PC interventions and cohort follow-up studies are needed among adolescents and young adults, using technology that appeals to this age group. Programs should be expanded to include other populations like males with diabetes and females from other cultures and religions that would require program modification.

Effect of implementation of a preconception counselling resource for women with diabetes: A population based study

AIM

To evaluate the effect of regional implementation of a preconception counselling resource into routine diabetes care on pregnancy planning indicators.

METHODS

A preconception counselling DVD was distributed to women by diabetes care teams and general practices. Subsequently, in a prospective population-based study, pregnancy planning indicators were evaluated. The post-DVD cohort (n=135), including a viewed-DVD subgroup (n=58), were compared with an historical cohort (pre-DVD, n=114). Primary outcome was HbA1c at first diabetes-antenatal visit. Secondary outcomes included preconception folic acid consumption, planned pregnancy and HbA1c recorded in the 6 months preconception.

RESULTS

Mean first visit HbA1c was lower post-DVD vs. pre-DVD: 7.5% vs. 7.8% [58.4 vs. 61.8mmol/mol]; p=0.12), although not statistically significant. 53% and 20% of women with type 1 and 2 diabetes, respectively, viewed the DVD. The viewed-DVD subgroup were significantly more likely to have lower first visit HbA1c: 6.9% vs. 7.8% [52.1 vs. 61.8mmol/mol], P<0.001; planned pregnancy (88% vs. 59%, P<0.001); taken folic acid preconception (81% vs. 43%, P=0.001); and had HbA1c recorded preconception (88% vs. 53%, P<0.001) than the pre-DVD cohort.

CONCLUSIONS

Implementation of a preconception counselling resource was associated with improved pregnancy planning indicators. Women with type 2 diabetes are difficult to reach. Greater awareness within primary care of the importance of preconception counselling among this population is needed.

The Relationship between Constitution of Traditional Chinese Medicine in the First Trimester and Pregnancy Symptoms: A Longitudinal Observational Study

Objective. We report on the distribution of traditional Chinese medicine (TCM) constitution in the first trimester and on the association between TCM constitution and maternal symptoms related to pregnancy. Methods. Participants were followed up until delivery to observe primary measures (gestational hypertension and gestational diabetes mellitus) and secondary measures (signs of miscarriage, miscarriage, nausea and vomiting, and sleepiness and defecation during pregnancy). Descriptive analysis, t-tests, chi-square tests, and logistic regression analysis were used in this study. Results. 61.8% of the participants had unbalanced constitutions. We did not find a significant association between the TCM constitution and gestational hypertension, gestational diabetes, miscarriage, signs of miscarriage, and defecation during pregnancy. And we found that women with unbalanced constitutions in early pregnancy had a greater likelihood of severe nausea and vomiting and poor sleep during pregnancy in the logistic regression analysis. Conclusions. These results have implications for female health care providers and policy makers. Identification of TCM constitution may be helpful for understanding nausea and vomiting and poor sleepiness during pregnancy, especially in the condition that can not be explained by modern medical science, and be helpful for making program to improve these uncomfortable symptoms.

[Pregravid preparation of diabetic women]

Pregnancy in women with type 1 or 2 diabetes mellitus (DM) is associated with an increased risk for complications in both the mother and her fetus. The impact of these complications on modifiable risk factors may substantially improve pregnancy outcomes and reduce malformation rates in children. This is a goal of pregravid preparation (PGP) in this category of patients. The review gives the main points of PGP in patients with types 1 and DM and shows the results of main studies providing evidence for PGP in DM. In particular, by the moment of conception, DM patients should achieve a glycosylated hemoglobin (HbA1c) goal of <6% no later than 4 weeks before conception and during the first trimester of pregnancy, take folic acid in a high dose (at least 4000 µg, or 4 mg, daily), quit tobacco smoking and alcohol use, receive potentially teratogenic drugs, and, if need be, lose weight (the target body mass index of <27 kg/m2).

[Type 2 diabetes and pregnancy: epidemiology and obstetrical consequences. A 97 women continuous series]

OBJECTIVES

To update the epidemiologic data of pregnant women with type 2 diabetes and to assess obstetrical outcomes.

PATIENTS AND METHODS

The pregnant women with type 2 diabetes who delivered between 2002 and 2010 were systematically involved in an observational study. Maternal and fetal outcomes were reviewed, as well as the potential impact of preconceptional management. The presented data were compared with those from the 2010 French perinatal study.

RESULTS

A rise in the incidence of type 2 diabetes was observed during the study period (from 0.19% to 0.35% between 2002 and 2010). Women with diabetes (n=97) were older and had a higher BMI than the general population (>35years: 49% vs 19%, P<0.00001, BMI>25: 86% vs 27.2, P<0.00001). The delivery mode was, for half of these women with diabetes, a C-section. Pregnancy was scheduled in only 4% of cases. Compared to the general population, prematurity rate was multiplied by 6 (28.7% vs 4.7%, P<0.0001) and the malformation rate by 3.2 (7.22% vs 2.2%, P<0.00001).

CONCLUSION

Obstetrical complications were more frequent than in the general population. Preconception care was almost inexistent, despite its potential benefits for the mother and child.

Fifteen-year trends and predictors of preparation for pregnancy in women with pre-conception Type 1 and Type 2 diabetes: a population-based cohort study

AIMS

To investigate trends in indicators of preparation for pregnancy in women with Type 1 and Type 2 diabetes and explore their predictors.

METHODS

Data on 2293 pregnancies delivered during 1996-2010 by women with Type 1 (n = 1753) and Type 2 (n = 540) diabetes were obtained from the Northern Diabetes in Pregnancy Survey. Multiple logistic regression was used to analyse the relationship between potential predictors and three indicators of inadequate pregnancy preparation: non-attendance for pre-conception care; no pre-conception folate consumption; and peri-conception HbA(1c) ≥ 53 mmol/mol (≥ 7%).

RESULTS

Overall, 40.3% of women with diabetes attended pre-conception care, 37.4% reported pre-conception folate consumption, and 28.2% had adequate peri-conception HbA1c . For all patients, pre-conception folate consumption improved over time, while peri-conception glucose control did not. Attendance for pre-conception care for women with Type 1 diabetes significantly declined. Residence in deprived areas, smoking and younger maternal age (for women aged < 35 years) were independently associated with all three indicators of inadequate preparation for pregnancy. Additional predictors of inadequate peri-conception HbA(1c) were: Type 1 diabetes (adjusted odds ratio 5.51, 95% CI 2.71-11.22), longer diabetes history (adjusted odds ratio 1.16, 95% CI 1.09-1.23 per year increase for those with < 15 years' diabetes duration), non-white ethnicity (adjusted odds ratio 3.13, 95% CI 1.23-7.97) and higher BMI (adjusted odds ratio 1.05, 95% CI 1.01-1.09 per 1-kg/m(2) increase). Non-attendance for pre-conception care was additionally associated with Type 2 diabetes (P = 0.003) and multiparity (P < 0.0001).

CONCLUSIONS

There are socio-demographic inequalities in preparation for pregnancy among women with diabetes. Women with Type 2 diabetes were less likely to attend pre-conception care. Pre-conception services need to be designed to maximize uptake in all groups.

Preconception care for healthy women and those with medical conditions

All women benefit from some pre-pregnancy care. Those with co-existing medical conditions need advice about their medication, the impact of pregnancy on their disease and the impact of their disease (particularly their medication) on their pregnancy. This article will help health professionals give evidence-based advice.

Multiple daily injections of insulin versus continuous subcutaneous insulin infusion for pregnant women with type 1 diabetes

AIMS

The aim was to evaluate the outcome of pregnancies with type 1 diabetes (T1DM) treated from the first trimester with continuous subcutaneous insulin infusion (CSII) or multiple daily injections (MDI).

METHODS

In a retrospective, observational study, we matched 64 CSII patients for age, age at onset and duration of diabetes and HbA1c in the first trimester with 64 MDI pregnancies. We analysed carbohydrate metabolism, insulin requirements, development of PIH, progression of retinopathy and fetal outcome.

RESULTS

In CSII group, we found a significantly smaller insulin requirement both at the beginning of pregnancy and before delivery, significant decrease in HbA1c levels and significantly smaller number of hypoglycaemic episodes in the second trimester and significantly more hyperglycaemic episodes in the first trimester. In both groups, maternal, fetal and perinatal outcomes were similar and the number of hypo- and hyperglycaemic episodes decreased throughout pregnancy.

CONCLUSION

Continuous subcutaneous insulin infusion (CSII) treatment in pregnant women with type 1 diabetes is associated with a reduced number of hypoglycaemia and decreased insulin requirement. We noted no difference in perinatal outcome comparing women on multiple insulin injections with those on continuous insulin infusion.

Continuous subcutaneous insulin infusion for managing diabetes: women's health implications

The use of continuous subcutaneous insulin infusion (CSII), also called insulin pump therapy, is increasing for management of type 1 diabetes. This article provides a comprehensive background on CSII, reviews recent studies comparing it to multiple daily insulin injections, offers strategies to troubleshoot potential problems, and discusses the implications of CSII for women's health across the lifespan.

Analysis & commentary: Global prevention and control of type 2 diabetes will require paradigm shifts in policies within and among countries

Continued increases in the prevalence of and disproportionate health spending associated with type 2 diabetes argue for policies focused on preventing that condition and treating it appropriately, even as we strive to improve coordination of care for coexisting chronic diseases. This article argues that four policy paradigm shifts will be necessary to achieve that specific emphasis on type 2 diabetes: conceptually integrating primary and secondary prevention along a clinical continuum; recognizing the central importance of early detection of prediabetes and undiagnosed diabetes in implementing cost-effective prevention and control; integrating community and clinical expertise, and resources, within organized and affordable service delivery systems; and sharing and adopting evidence-based policies at the global level.