Rate of Preconception Care in Women with Type 2 Diabetes Still Lags behind that of Women with Type 1 Diabetes

Pregnancy outcomes in type 2 diabetes: a systematic review and meta-analysis

OBJECTIVE

Type 2 diabetes (T2D) now accounts for the majority of pre-existing diabetes affecting pregnancy in the UK. Our aim was to determine its impact on pregnancy outcomes compared to type 1 diabetes (T1D), gestational diabetes (GDM), and nondiabetes pregnancies.

DATA SOURCES

PubMed was searched 1 January 2009 to 2024.

STUDY ELIGIBILITY CRITERIA

Cohort observational studies reporting original data on at least one of the primary outcomes in ten or more T2D pregnancies were eligible for inclusion. Comparative diabetes and nondiabetes pregnancies were also collected.

METHODS

Primary outcomes included congenital anomalies, stillbirths, neonatal and perinatal mortality, birthweight, rates of large for gestational age (LGA), small for gestational age (SGA), and macrosomia. PROSPERO ID CRD42023411057.

RESULTS

Forty seven studies were analyzed. The number of pregnancies in each analysis varied depending on the available data from the outcome being analyzed but ranged from 723 to 4,469,053 pregnancies. When compared with T1D pregnancies, T2D were more likely to have SGA babies as well as greater neonatal and perinatal mortality (OR 2.29, 95% CI 1.12-4.67; OR 1.53 95% CI 1.20-1.94, and OR 1.31 95% CI 1.07-1.61, respectively). When compared with GDM, T2D were more likely to have babies with congenital anomalies (OR 1.91, 95% CI 1.04-3.50), LGA (OR 3.49, 95% CI 2.49-4.89), neonatal mortality (OR 3.96, 95% CI 3.38-4.64), and stillbirth (OR 16.55, 95% CI 5.69-48.11). In comparison to nondiabetic pregnancy, T2D were more likely to have babies with congenital anomalies (OR 1.76, 95% CI 1.11-2.79), LGA (OR 2.79, 95% CI 1.93-4.04), perinatal mortality (OR 4.18, 95% CI 2.91-6.01), and stillbirth (OR 7.27, 95% CI 3.01-17.53).

CONCLUSION

T2D pregnancies are associated with a greater perinatal mortality than other forms of diabetes in pregnancy. Given its increasing prevenance, greater awareness of the adverse pregnancy outcomes associated with T2D is needed, by both healthcare providers and policy makers, to improve care.

Pre-existing Diabetes and Stillbirth or Perinatal Mortality: A Systematic Review and Meta-analysis

OBJECTIVE

Despite the well-recognized association between pre-existing diabetes mellitus and stillbirth or perinatal mortality, there remain knowledge gaps about the strength of association across different populations. The primary objective of this systematic review and meta-analysis was to quantify the association between pre-existing diabetes and stillbirth or perinatal mortality, and secondarily, to identify risk factors predictive of stillbirth or perinatal mortality among those with pre-existing diabetes.

DATA SOURCES

MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials from inception to April 2022.

METHODS OF STUDY SELECTION

Cohort studies and randomized controlled trials in English or French that examined the association between pre-existing diabetes and stillbirth or perinatal mortality (as defined by the original authors) or identified risk factors for stillbirth and perinatal mortality in individuals with pre-existing diabetes were included. Data extraction was performed independently and in duplicate with the use of prespecified inclusion and exclusion criteria. Assessment for heterogeneity and risk of bias was performed. Meta-analyses were completed with a random-effects model.

TABULATION, INTEGRATION, AND RESULTS

From 7,777 citations, 91 studies met the inclusion criteria. Pre-existing diabetes was associated with higher odds of stillbirth (37 studies; pooled odds ratio [OR] 3.74, 95% CI, 3.17-4.41, I2 =82.5%) and perinatal mortality (14 studies; pooled OR 3.22, 95% CI, 2.54-4.07, I2 =82.7%). Individuals with type 1 diabetes had lower odds of stillbirth (pooled OR 0.81, 95% CI, 0.68-0.95, I2 =0%) and perinatal mortality (pooled OR 0.73, 95% CI, 0.61-0.87, I2 =0%) compared with those with type 2 diabetes. Prenatal care and prepregnancy diabetes care were significantly associated with lower odds of stillbirth (OR 0.26, 95% CI, 0.11-0.62, I2 =87.0%) and perinatal mortality (OR 0.41, 95% CI, 0.29-0.59, I2 =0%).

CONCLUSION

Pre-existing diabetes confers a more than threefold increased odds of both stillbirth and perinatal mortality. Maternal type 2 diabetes was associated with a higher risk of stillbirth and perinatal mortality compared with maternal type 1 diabetes.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42022303112.

Perceptions of diabetes distress during pregnancy in women with type 1 and type 2 diabetes: a qualitative interpretive description study

BACKGROUND

Diabetes distress is commonly seen in adults with pre-existing diabetes and is associated with worsened glycemic management and self-management practices. While a majority of women report increased stress during pregnancy, it is unknown how women with type 1 or type 2 diabetes experience diabetes distress during this unique and transitional time.

PURPOSE

This study aimed to understand the experiences and perceptions of diabetes distress in women with pre-existing diabetes during pregnancy.

METHODS

A qualitative study using an interpretive description approach was conducted. In-depth, one to one interviewing was used to capture rich descriptions of the pregnancy experience. Nested, stratified, and theoretical sampling was used to recruit 18 participants with type 1 and type 2 diabetes from the quantitative strand of this mixed methods study. Constant comparative analysis was used to inductively analyze the data and develop themes.

FINDINGS

Four themes, each with several subthemes, emerged under the main finding of "Diabetes Distress": 1) Worry for Baby's Health - "What's this going to do to the baby?"' 2) Feeling Overwhelmed with Diabetes Management-"It just seemed unattainable"; 3) Living with Diabetes - "There's no way out" and 4) Cycle of Diabetes Distress.

CONCLUSIONS

The findings from this study identify the sources and experiences of diabetes distress during pregnancy in women with pre-existing diabetes. Diabetes distress often presents as cyclical and multifaceted during pregnancy, with elements of fear for the unborn baby, difficulties with diabetes management, and having negative lived experiences of diabetes. Further work is needed to develop appropriate screening tools for pregnancy and interventions to mitigate diabetes distress. Diabetes educators are well-positioned provide emotional support and person-centred self-management education to individuals with diabetes.

Type 1 diabetes and pregnancy: An update on glucose monitoring and insulin treatment

The relevance of type 1 diabetes during pregnancy stems from its impact on the health of mother and offspring and its increasing prevalence. Glycemic control during pregnancy is one of the main risk factors for adverse events. Besides, treatment becomes a major challenge not only due to the modifications in insulin requirements due to changes in hormones and cytokines but also to the stricter control targets. Given the recent appearance of new ultra-rapid and basal insulin analogues and the constant evolution of technology to treat people with diabetes, we review these aspects in relation to the treatment of women with type 1 diabetes during pregnancy.

Systematic review and meta-analysis of the effectiveness of pre-pregnancy care for women with diabetes for improving maternal and perinatal outcomes

Background

Pre-gestational diabetes mellitus is associated with increased risk of maternal and perinatal adverse outcomes. This systematic review was conducted to evaluate the effectiveness and safety of pre-conception care (PCC) in improving maternal and perinatal outcomes.

Methods

Databases from MEDLINE, EMBASE, WEB OF SCIENCE, and Cochrane Library were searched, including the CENTRAL register of controlled trials, and CINHAL up until March 2019, without any language restrictions, for any pre-pregnancy care aiming at health promotion, glycemic control, and screening and treatment of diabetes complications in women with type I or type II pre-gestational diabetes. Trials and observational studies were included in the review. Newcastle-Ottawa scale and the Cochrane collaboration methodology for data synthesis and analysis were used, along with the GRADE tool to evaluate the body of evidence.

Results

The search identified 8500 potentially relevant citations of which 40 reports of 36 studies were included. The meta-analysis results show that PCC reduced congenital malformations risk by 71%, (Risk ratio (RR) 0.29; 95% CI: 0.21–0.40, 25 studies; 5903 women; high-certainty evidence). The results also show that PCC may lower HbA1c in the first trimester of pregnancy by an average of 1.27% (Mean difference (MD) 1.27; 95% CI: 1.33–1.22; 4927 women; 24 studies, moderate-certainty evidence). Furthermore, the results suggest that PCC may lead to a slight reduction in the risk of preterm delivery of 15%, (RR 0.85; 95% CI: 0.73–0.99; nine studies, 2414 women; moderate-certainty evidence). Moreover, PCC may result in risk reduction of perinatal mortality by 54%, (RR 0.46; 95% CI: 0.30–0.73; ten studies; 3071 women; moderate-certainty evidence). There is uncertainty about the effects of PCC on the early booking for antenatal care (MD 1.31; 95% CI: 1.40–1.23; five studies, 1081 women; very low-certainty evidence) and maternal hypoglycemia in the first trimester, (RR 1.38; 95% CI: 1.07–1.79; three studies; 686 women; very low- certainty evidence). In addition, results of the meta-analysis indicate that PCC may lead to 48% reduction in the risk of small for gestational age (SGA) (RR 0.52; 95% CI: 0.37–0.75; six studies, 2261 women; moderate-certainty evidence). PCC may reduce the risk of neonatal admission to intensive care unit (NICU) by 25% (RR 0.75; 95% CI: 0.67–0.84; four studies; 1322 women; moderate-certainty evidence). However, PCC may have little or no effect in reducing the cesarean section rate (RR 1.02; 95% CI: 0.96–1.07; 14 studies; 3641 women; low-certainty evidence); miscarriage rate (RR 0.86; 95% CI: 0.70–1.06; 11 studies; 2698 women; low-certainty evidence); macrosomia rate (RR 1.06; 95% CI: 0.97–1.15; nine studies; 2787 women, low-certainty evidence); neonatal hypoglycemia (RR 0.93; 95% CI: 0.74–1.18; five studies; 880 women; low-certainty evidence); respiratory distress syndrome (RR 0.78; 95% CI: 0.47–1.29; four studies; 466 women; very low-certainty evidence); or shoulder dystocia (RR 0.28; 95% CI: 0.07–1.12; 2 studies; 530 women; very low-certainty evidence).

Conclusion

PCC for women with pre-gestational type 1 or type 2 diabetes mellitus is effective in improving rates of congenital malformations. In addition, it may improve the risk of preterm delivery and admission to NICU. PCC probably reduces maternal HbA1C in the first trimester of pregnancy, perinatal mortality and SGA. There is uncertainty regarding the effects of PCC on early booking for antenatal care or maternal hypoglycemia during the first trimester of pregnancy. PCC has little or no effect on other maternal and perinatal outcomes.

Preconceptions and awareness of good glycemic control, pregnancy contraindications, and maternal and fetal adverse events in Sudan

Awareness around glycemic control was very low among women in Sudan who were pregnant and had diabetes.

Trends in Obstetric Intervention and Pregnancy Outcomes of Canadian Women With Diabetes in Pregnancy From 2004 to 2015

Context:

Multiple consensus statements decree that women with diabetes mellitus should have comparable birth outcomes to women without diabetes mellitus; however, there is a scarcity of contemporary population-based studies on this issue.

Objective:

To examine temporal trends in obstetric interventions and perinatal outcomes in a population-based cohort of women with type 1, type 2, or gestational diabetes mellitus compared with a control population.

Design:

Cross-sectional study.

Setting:

National hospitalization data (Canada except Quebec) from 2004 to 2015.

Patients:

Pregnant women with type 1 (n = 7362), type 2 (n = 11,028), and gestational diabetes mellitus (n = 149,780) and women without diabetes mellitus (n = 2,688,231).

Main Outcome Measures:

Rates of obstetric intervention, maternal morbidity, and neonatal morbidity/mortality.

Results:

A consistent relationship was generally observed between diabetes mellitus subtype and obstetric outcomes, with women with type 1 diabetes mellitus having the highest rate of intervention and the highest rates of adverse perinatal outcomes followed by women with type 2 diabetes mellitus and women with gestational diabetes mellitus. Rates of severe preeclampsia were 1.2% among women without diabetes mellitus, 2.1% among women with gestational diabetes mellitus, 4.2% among women with type 2 diabetes mellitus, and 7.5% among women with type 1 diabetes mellitus (P < 0.001). The rate of neonatal morbidity ranged from 8.7% in women without diabetes mellitus to 11.0%, 17.4%, and 24.1% in women with gestational, type 2, and type 1 diabetes mellitus, respectively (P < 0.001).

Conclusions:

In a contemporary obstetric population, women with diabetes mellitus remain at increased risk of adverse pregnancy outcomes compared with women without diabetes mellitus.

A core outcome set for studies evaluating the effectiveness of prepregnancy care for women with pregestational diabetes

AIMS/HYPOTHESIS

The aim of this study was to develop a core outcome set (COS) for trials and other studies evaluating the effectiveness of prepregnancy care for women with pregestational (pre-existing) diabetes mellitus.

METHODS

A systematic literature review was completed to identify all outcomes reported in prior studies in this area. Key stakeholders then prioritised these outcomes using a Delphi study. The list of outcomes included in the final COS were finalised at a face-to-face consensus meeting.

RESULTS

In total, 17 outcomes were selected and agreed on for inclusion in the final COS. These outcomes were grouped under three domains: measures of pregnancy preparation (n = 9), neonatal outcomes (n = 6) and maternal outcomes (n = 2).

CONCLUSIONS/INTERPRETATION

This study identified a COS essential for studies evaluating prepregnancy care for women with pregestational diabetes. It is advocated that all trials and other non-randomised studies and audits in this area use this COS with the aim of improving transparency and the ability to compare and combine future studies with greater ease.

The prevalence and nature of the use of preconception services by women with chronic health conditions: an integrative review

Background

There is growing evidence that preconception care may have an important role in preventing short and long term adverse health consequences for women and their offspring. This is particularly the case for women with chronic health conditions due to the rising prevalence of chronic disease in global populations. With this in mind, this paper presents an integrative systematic review of contemporary research outlining the use of preconception services and practices by women with chronic health conditions.

Methods

A search was conducted through PubMed, CINAHL, AMED, and Maternity and Infant Care databases which identified 672 papers examining preconception care and preconception services for women with chronic health conditions. Fourteen papers which were written in English, presented original research, and reported on the prevalence or nature of use of preconception care by women with chronic health conditions were included in the review. Critical appraisal of study quality and thematic categorical grouping of identified papers was undertaken.

Results

Current research evidence, as identified through this review, examines three major topic areas: the prevalence of preconception care practices, use of services and characteristics of users; knowledge of the value and impact of preconception care and availability of preconception services for women with chronic health conditions; and women’s attitudes, approaches and experiences of preconception care and preconception services. Prevalence estimates of engagement with preconception care range between 18.1% and 45%, with most studies focusing on women with type 1 or 2 diabetes. Significant gaps in women’s knowledge of preconception care for women with chronic health conditions were also identified. Women with chronic health conditions reported experiencing emotional distress as a result of their engagement with preconception care services. They also commonly described feeling a need to employ discipline to comply with preconception care programs, and experiencing a fear of pregnancy complications.

Conclusion

Future research requires a broad and sophisticated approach to research design and analysis, improved consideration of temporal changes to women’s health behaviour, representative samples to more effectively inform health policy, and a deeper understanding of women’s motivations, attitudes and perceptions of preconception care to assist in the development of tailored preconception health services.