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

doi:10.1016/j.bpobgyn.2010.10.001

Best Practice & Research Clinical Obstetrics & Gynaecology

Volume 25, Issue 1, February 2011, Pages 3-14

https://doi.org/10.1016/j.bpobgyn.2010.10.001 Get rights and content

The association between hyperglycaemia and congenital malformations was first recognised over 40 years ago and was followed by the development of preconception clinics for women with diabetes. A fresh look at preconception care is needed as many studies were conducted during the late 1970s and early 1980s, before the introduction of regular home blood glucose monitoring and glycosylated haemoglobin assays, and when many patients with diabetes had microvascular complications. Recent observational studies and a meta-analysis suggest preconception care is effective with an approximately threefold reduction in the risk of malformations. There is now a worldwide epidemic of type 2 diabetes, but only few studies of preconception care have included women with type 2 diabetes. Furthermore, few studies have addressed the relationship between preconception care and perinatal morbidity. This article will review the evidence for preconception care in women with diabetes, evaluate different models of preconception care and discuss future strategies.

Section snippets

Relationship between hyperglycaemia and poor pregnancy outcome

Molsted-Pedersen first described the high incidence of congenital malformations in women in 1964 with 6.4% of infants of their diabetic mothers showing a malformation compared with 2.1% of women without diabetes.⁶ More recent studies, in women with type 1 and type 2 diabetes, have confirmed that there is a two-to threefold increase in risk of malformations in women with diabetes compared with women without diabetes.1, 2 Hyperglycaemia has been proposed as a possible mechanism with both animal

Diabetes and antenatal care in the late 1970s

It is important to look back at routine diabetes and antenatal care in the 1970s to fully understand both the aims of PCC in the earlier studies, why the development of this care was so important at that time and to interpret results of the studies.

In the late 1970s, routine diabetes care consisted of large diabetic clinics, often staffed by junior doctors with relatively limited diabetes expertise. Patients, usually with type 1 diabetes, controlled their diabetes with once- or twice-daily

PCC and congenital malformations in type 1 and type 2 diabetes

The majority of studies of PCC were carried out 20–30 years ago and have usually evaluated the effect of PCC on the risk of malformation.16, 17, 19, 20, 21, 22, 23, 24, 25, 26 Most studies have included only women with type 1 diabetes. However, a small number, including a large recent study from the United Kingdom, have also included up to 40% women with type 2 diabetes. Results from these studies, including years of study, numbers of patients and type of diabetes, study setting and HbA1c

Lessons learnt from the confidential enquiry into maternal and child health diabetes programme

The Confidential Enquiry into Maternal and Child Health (CEMACH) Diabetes programme, undertaken in England, Wales and Northern Ireland, is the largest published study of diabetes and pregnancy and highlights the benefits of PCC and good preparation for pregnancy. It included a survey of maternity services, and a study of outcomes of 3808 pregnancies in women with type 1 or type 2 diabetes over a 12-month period (1 March 2002–28 February 2003). There was also a confidential enquiry, which

Lack of randomised controlled studies of PCC

Because hyperglycaemia is related to adverse pregnancy outcome in women with diabetes, and as both observational studies and a meta-analysis have shown that PCC is associated with a reduced risk of congenital malformations, it is unlikely that a randomised controlled trial (RCT) of PCC will ever be conducted in the future.

It has often been suggested that, as the Diabetes Control and Complications Trial (DCCT) was an RCT, the pregnancy outcomes study can be considered as an RCT of PCC.³⁴ The

Glycaemic control

Whether glucose is a teratogen, or a surrogate marker of a teratogen, is not known. It has generally been accepted that improving glycaemic control is an important component of PCC in reducing malformations. This is supported by the lower HbA1c levels in women accessing PCC (Table 3). Unfortunately, there is limited data on glycaemic control in women before pregnancy to know whether women with PCC are a self-selected group with improved glycaemic control outside pregnancy, compared with women

Delivery of PCC: who, where and when?

It is important to review studies of PCC to try to identify whether any particular ways of delivering care are associated with significant improvements in outcome.

Differences between women who do or do not plan their pregnancies

The differences between women who do or do not attend for PCC are well documented (Table 4).26, 43, 44, 45 A recent study in women with type 1 diabetes showed there was no difference in duration of diabetes, maternal weight or incidence of diabetic complications between women with and without PCC.²⁵ A study of 29 women with type 1 and type 2 diabetes, which included semi-structured interviews, showed how many of the women had been educated about the benefits of PCC. ⁴⁵ Knowledge concerning

Cost-effectiveness of PCC

To date, there are only a small number of studies evaluating the cost-effectiveness of PCC. These do, however, support the view that PCC is cost-effective. One study considered a combination of literature review, expert opinion and surveys of medical care to estimate the costs and clinical consequences of PCC compared with no PCC. It calculated that, from a combination of reduced antenatal care costs and fewer adverse maternal and neonatal outcomes, there was a saving of $1.86 for each dollar

Summary

The effectiveness of PCC in reducing the risk of congenital malformations in type 1 diabetes is well documented. Despite the overall improvement in diabetes care over the last 30 years, recent population studies continue to confirm that PCC is associated with improved pregnancy outcome for women with type 1 and type 2 diabetes, with reductions in the risk of malformations. By contrast, to date, there is very limited data suggesting PCC can impact on rates of premature delivery, macrosomia or

References (47)

D.S. Feig et al.
Type 2 diabetes in pregnancy: a growing concern
Lancet
(2002)
K. Karlsson et al.
The outcome of diabetic pregnancies in relation to the mother’s blood sugar level
Am J Obstet Gynecol
(1972)
J.A. Goldman et al.
Pregnancy outcome in patients with insulin-dependent diabetes mellitus with preconceptional diabetic control: A comparative study
Am J Obstet Gynaecol
(1986)
L. Cousins
The California diabetes and pregnancy Programme: a statewide collaborative program for the pre-conception and prenatal care of diabetic women
Ballieres Clin Obstet Gynecol
(1991)
D. Dicker et al.
Spontaneous abortions in patients with insulin-dependent diabetes mellitus: the effect of preconceptual diabetic control
Am J Obstet Gynecol
(1988)
S.Y. Chu et al.
Maternal obesity and risk of stillbirth: a meta-analysis
Am J Obstet Gynecol
(2007)
M.C. Macintosh et al.
Perinatal mortality and congenital anomalies in babies of women with type 1 or type 2 diabetes in England, Wales, and Northern Ireland: population based study
BMJ
(2006)
I.M. Evers et al.
BMJ
Risk of complications of pregnancy in women with type 1 diabetes: nationwide prospective study in the Netherlands
(2004)
N.W. Cheung et al.
Type 2 diabetes in pregnancy: a wolf in sheep’s clothing
Aust N Z J Obstet Gynaecol
(2005)
J.M. Roland et al.
The pregnancies of women with type 2 diabetes: poor outcomes but opportunities for improvement
Diabet Med
(2005)

L.M. Pedersen et al.

Congenital malformations in newborn infants of diabetic women

Lancet

(1964)

K. Morii et al.

Experimental diabetes in pregnant mice: prevention of congenital malformations in the offspring by insulin

Diabetes

(1966)

E. Miller et al.

Elevated maternal HbA1c in early pregnancy and major congenital malformations in infants of diabetic mothers

N Engl J Med

(1981)

A. Ylinen et al.

Risk of minor and major malformations in diabetics with high haemoglobin A1c values in early pregnancy

Br J Med

(1984)

R. Temple et al.

Association between outcome of pregnancy and glycaemic control in early pregnancy in type 1 diabetes: population based study

BMJ

(2002)

M.E. Inkster et al.

Poor glycated haemoglobin control and adverse pregnancy outcomes in type 1 and type 2 diabetes mellitus: systematic review of observational studies

BMC Pregnancy and Childbirth

(2006)

A. Guerin et al.

Use of maternal GHb concentration to estimate the risk of congenital anomalies in the offspring of women with prepregnancy diabetes

Diabetes Care

(2007)

J. Pedersen

Congenital malformations

J.M. Steel

Personal experience of pre-pregnancy care in women with insulin-dependent diabetes

Aust NZ J Obstet Gynaecol

(1994)

K. Fuhrmann et al.

Prevention of malformations in infants of insulin-dependent diabetic mothers

Diabetes Care

(1983)

NICE guideline 63: diabetes in pregnancy. Management of diabetes and its complications in pregnancy from the pre-conception to the postnatal period

(2008)

J.L. Mills et al.

Lack of relation of increased malformation rates in infants of diabetic mothers to glycaemic control during organogenesis

N Engl J Med

(1988)

J.L. Kitzmiller et al.

Pre-conception care of diabetes: glycaemic control prevents congenital anomalies

JAMA

(1991)

Cited by (28)

Patient and provider perspectives on preterm birth risk assessment and communication
2021, Patient Education and Counseling
Citation Excerpt :
Heterogeneity in patients' knowledge about preterm birth and some protective factors highlight an opportunity for initiatives to increase awareness, which has also been noted by others [12,13]. As evidence mounts regarding the potential effectiveness of optimal health prior to pregnancy [14–18], midwifery care [19–23], group prenatal care [24,25], and doulas [26–29] in lowering preterm birth rates, dissemination of this information to birthing people should be prioritized so that they can make informed decisions regarding their health and care. A desire for such information has been reported among research priorities identified by women of color at higher risk of preterm birth [8].
To describe and compare how obstetric patients and care providers view preterm birth risk assessment and communication.
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.
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.
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.
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.
Constitution of traditional chinese medicine and related factors in women of childbearing age
2018, Journal of the Chinese Medical Association
This study investigates the constitution of traditional Chinese medicine (TCM) among women who want to be pregnant in one year and explores factors related to TCM constitution.
This study was conducted on women who participated in free preconception check-ups provided by the Zhabei District Maternity and Child Care Center in Shanghai, China. The information regarding the female demographic characteristics, physical condition, history of pregnancy and childbearing, diet and behavior, and social psychological factors was collected, and TCM constitution assessment was performed. The Chi-square test, t-test, logistic regression analysis, and multinomial logistic regression analysis were used to explore the related factors of TCM constitution.
The participants in this study were aged 28.3 ± 3.0 years. Approximately fifty-five women in this study had Unbalanced Constitution. Logistic regression analysis showed that Shanghai residence, dysmenorrhea, gum bleeding, aversion to vegetables, preference for raw meat, job stress, and economic stress were significantly and negatively associated with Balanced Constitution. Multinomial logistic analysis showed that Shanghai residence was significantly associated with Yang-deficiency, Yin-deficiency, and Stagnant Qi Constitutions; gum bleeding was significantly associated with Yin-deficiency, Stagnant Blood, Stagnant Qi, and Inherited Special Constitutions; aversion to vegetables was significantly associated with Damp-heat Constitution; job stress was significantly associated with Yang-deficiency, Phlegm-dampness, Damp-heat, Stagnant Blood, and Stagnant Qi Constitutions; and economic stress was significantly associated with Yang-deficiency, and Stagnant Qi Constitutions.
The application of TCM constitution to preconception care would be beneficial for early identification of potential TCM constitution risks and be beneficial for early intervention (e.g., health education, and dietary education), especially during the women who do not have a medical condition and those who have related factors found in this study.
Effect of implementation of a preconception counselling resource for women with diabetes: A population based study
2017, Primary Care Diabetes
Citation Excerpt :
However, preconception counselling rates among women with diabetes remain low [13,14], with preconception counselling or contraception discussed with only 25% of women attending for annual review in one study [14]. In distinction from preconception counselling, pre-pregnancy care (PPC) is targeted specifically at women who are preparing for pregnancy [15]. While the emphasis of PPC is on glycemic control, other key components include prescription of high dose folic acid preconception and review of medications to ensure women avoid potentially teratogenic drugs.
To evaluate the effect of regional implementation of a preconception counselling resource into routine diabetes care on pregnancy planning indicators.
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.
Mean first visit HbA1c was lower post-DVD vs. pre-DVD: 7.5% vs. 7.8% [58.4 vs. 61.8 mmol/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. 61.8 mmol/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.
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.
Management of diabetes in pregnancy: Antenatal follow-up and decisions concerning timing and mode of delivery
2015, Best Practice and Research: Clinical Obstetrics and Gynaecology
Citation Excerpt :
Poor glucose control is associated with an increased risk of abortion and congenital malformations. The latter risk continues to increase with near-optimal glucose values (glycosylated hemoglobin (HbA1c) 2–4 standard deviation (SD) above the mean), and most population studies continue to show increased incidences of fetal malformations, to two to four times that in nondiabetic populations [1–11]. In most cases, it is impossible to achieve real normoglycemia.
Pregnancy in women with diabetes remains complicated despite improvements in glucose control. This seems mainly due to the fact that normoglycemia is still outside of reach. Congenital malformations are already significantly increased in the case of HbA1c values of 2–4SD above the mean, and fetal macrosomia is increasing in incidence. The latter may be due to an increase in maternal body mass index (BMI), absence of cardiovascular complications, better placentation, and increased weight gain during pregnancy. Severe maternal hypoglycemia is a frequent complication during the first trimester of pregnancy. The outcome is generally poorer in the case of type-2 diabetes as compared to type-1, which is likely to be due to a higher incidence of maternal metabolic syndrome. In this article, preconceptional and antenatal management and the mode and timing of delivery are discussed, both for women with preexisting diabetes and for those with gestational diabetes mellitus.
Type 2 diabetes and pregnancy: Epidemiology and obstetrical consequences. A 97 women continuous series
2015, Journal de Gynecologie Obstetrique et Biologie de la Reproduction
Actualiser les données épidémiologiques dans une population française diabétique de type 2 et évaluer les conséquences obstétricales.
Dans une étude rétrospective de 2002 à 2010, les issues maternelles et fœtales ont été évaluées chez 97 patientes présentant un diabète de type 2, ainsi que l’impact d’une prise en charge préconceptionnelle. Ces données ont été comparées à celles de la population française, recueillies lors de l’enquête périnatale de 2010.
Une augmentation de la prévalence du diabète de type 2 a été observée (0,19 % en 2002 et 0,35 % en 2010). Les patientes étaient plus âgées et avaient un IMC plus élevé que la population générale (n = 14681) (> 35 ans : 49 % vs 19 %, p < 0,00001, IMC > 25 : 86 % vs 27,2, p < 0,00001). La voie d’accouchement était pour moitié la césarienne. La grossesse n’a été programmée que dans 4 % des cas. Comparé à la population générale, la prématurité était multipliée par 6 (28,7 % vs 4,7 %, p < 0,0001), le taux de malformations était 3,2 fois plus important (7,22 % vs 2,2 %, p < 0,00001).
Les complications obstétricales étaient plus fréquentes que dans la population générale. La prise en charge préconceptionnelle était quasiment inexistante malgré son intérêt potentiel.
To update the epidemiologic data of pregnant women with type 2 diabetes and to assess obstetrical outcomes.
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.
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 (> 35 years: 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).
Obstetrical complications were more frequent than in the general population. Preconception care was almost inexistent, despite its potential benefits for the mother and child.
Pregnancy preparation for diabetic women: Impact of the educational day in Toulouse about pregnancy and follow-up?
2013, Revue Sage - Femme
La grossesse chez la femme diabétique est considérée à haut risque en raison des complications maternelles et fœtales potentiellement graves qui peuvent en découler. Les études ont montré qu’une programmation de la grossesse ainsi qu’une prise en charge préconceptionnelle diminuent ces complications. Cependant, il existe aujourd’hui une grande variabilité en matière de programmes d’éducation préconceptionnelle. L’impact de chacun de ces programmes reste très peu évalué.
Pour mieux connaître l’impact de la journée d’éducation préconceptionnelle proposée à Toulouse, nous avons réalisé une étude rétrospective sur dossiers : la première partie consiste à analyser, chez des patientes ayant participé à cette journée d’éducation, l’évolution de plusieurs critères reflétant l’équilibre du diabète et l’hygiène de vie entre la journée d’éducation et le premier trimestre de la grossesse. La seconde partie compare des critères concernant le déroulement de la grossesse, de l’accouchement et du nouveau-né chez des patientes qui ont bénéficié de la journée d’éducation et chez celles qui n’en ont pas bénéficié.
On retrouve une amélioration de l’équilibre du diabète chez les patientes qui ont participé à la journée d’éducation reflétée notamment par une diminution de l’hémoglobine glyquée. Le taux d’issues défavorables de la grossesse est réduit chez les patientes qui ont participé à la journée d’éducation en préconceptionnel.
Il serait intéressant de pouvoir comparer différents protocoles de prise en charge préconceptionnelle par des études randomisées comportant un nombre de cas plus importants.
Diabetic women's pregnancy is considered as a risk pregnancy on account of the serious complications on both mother and foetus that can potentially follow. Surveys show that the occurrence of these complications can be reduced by preconceptional care and a planned pregnancy. However, a huge diversity among preconceptional care programs is to be underlined and the real impact of each program hasn’t been measured yet.
To have a better knowledge of the preconceptional care day suggested in Toulouse, we’ve done a restrospective study on records. The first part of our study concerns women who attended a preconceptional care day. We’ve analysed the evolution of a few criteria reflecting their diabetes balance and their lifestyle between preconceptional care day and the first term of pregnancy. The second part compares some criteria concerning the development of the pregnancy, the birth and the newborn, on patients who assisted the day of information then on patients who didn’t.
We found a better balance of diabetes reflected particularly by a decrease of glycohemoglobin on patients who attended a preconceptional care day. The rate of adverse pregnancy outcomes is also reduced among patients who attended a preconceptional care day.
A comparison between various preconceptional care protocols based on randomized trials including a greater number of cases could be interesting.

View all citing articles on Scopus

View full text

1Preconception care for women with diabetes: is it effective and who should provide it?

Section snippets

Relationship between hyperglycaemia and poor pregnancy outcome

Diabetes and antenatal care in the late 1970s

PCC and congenital malformations in type 1 and type 2 diabetes

Lessons learnt from the confidential enquiry into maternal and child health diabetes programme

Lack of randomised controlled studies of PCC

Glycaemic control

Delivery of PCC: who, where and when?

Differences between women who do or do not plan their pregnancies

Cost-effectiveness of PCC

Summary

Lancet

Am J Obstet Gynecol

Am J Obstet Gynaecol

Ballieres Clin Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Perinatal mortality and congenital anomalies in babies of women with type 1 or type 2 diabetes in England, Wales, and Northern Ireland: population based study

BMJ

BMJ

Risk of complications of pregnancy in women with type 1 diabetes: nationwide prospective study in the Netherlands

Type 2 diabetes in pregnancy: a wolf in sheep’s clothing

Aust N Z J Obstet Gynaecol

The pregnancies of women with type 2 diabetes: poor outcomes but opportunities for improvement

Diabet Med

Congenital malformations in newborn infants of diabetic women

Lancet

Experimental diabetes in pregnant mice: prevention of congenital malformations in the offspring by insulin

Diabetes

Elevated maternal HbA1c in early pregnancy and major congenital malformations in infants of diabetic mothers

N Engl J Med

Risk of minor and major malformations in diabetics with high haemoglobin A1c values in early pregnancy

Br J Med

Association between outcome of pregnancy and glycaemic control in early pregnancy in type 1 diabetes: population based study

BMJ

Poor glycated haemoglobin control and adverse pregnancy outcomes in type 1 and type 2 diabetes mellitus: systematic review of observational studies

BMC Pregnancy and Childbirth

Use of maternal GHb concentration to estimate the risk of congenital anomalies in the offspring of women with prepregnancy diabetes

Diabetes Care

Congenital malformations

Personal experience of pre-pregnancy care in women with insulin-dependent diabetes

Aust NZ J Obstet Gynaecol

Prevention of malformations in infants of insulin-dependent diabetic mothers

Diabetes Care

NICE guideline 63: diabetes in pregnancy. Management of diabetes and its complications in pregnancy from the pre-conception to the postnatal period

Lack of relation of increased malformation rates in infants of diabetic mothers to glycaemic control during organogenesis

N Engl J Med

Pre-conception care of diabetes: glycaemic control prevents congenital anomalies

JAMA

1
Preconception care for women with diabetes: is it effective and who should provide it?