Diabetes has been recognised as a risk factor in pregnancy for many years – indeed the need to reduce this risk was a pillar of the St Vincent declaration in 1989. Adverse outcomes were highlighted in the Confidential Enquiry into Maternal and Child Health report (CEMACH) in 2003 which has been followed by two cycles of NICE guidance in 2008 and 2015. The second (2014) National Diabetes in Pregnancy audit (NPID) gives a snapshot of the current levels of care in England and Wales by reviewing 2553 pregnancies from 150 sites – a significant increase from the initial 2013 audit. Both the national audits show a significant increase in the number of women with T2DM becoming pregnant compared with 2003 probably due to the rise in pregnancies from high risk ethnic groups including S Asians.
Unfortunately, despite a plethora of evidence, women continue to be poorly prepared for pregnancy with many becoming pregnant whilst taking potentially teratogenic drugs including ACE inhibitors. More than 50% of women were not taking the recommended higher dose (5mg) of folic acid. Pre-conceptual glycaemic control was also sub-optimal with only 15% of T1 and 35% of T2 patients having HbA1c <48mmol/mol. Whilst maternal care may remain an issue, with approx 10% of women in hospital having at least one hypo, there has been an improvement in the numbers of emergency sections since 2003 (30 vs 37%) although this still remains higher than the general population. The improvement is likely to be due to NICE recommendation about delivery at 38 weeks. Macrosomia also remains common, affecting one third of all babies, predominantly T1 patients, an issue exacerbated by poor control in the third trimester.
Overall, the NPID shows a modest improvement in outcomes since 2003. Engagement is clear from the number of centres submitting data but women are still being poorly prepared for pregnancy and outcomes have changed little since the 2003 CEMACH report. Given the change in epidemiology of pregnancy complicated by diabetes, both this and the initial 2013 audit should serve as a guide to health care professionals, commissioners and trusts as to making improvements in care. Clearly there remains a long way to go before the aims of the St Vincent declaration can be satisfied.
Dr Mark Freeman