Risks


The risk to women with diabetes and the fetus are significant during pregnancy.

By planning ahead, women with diabetes can make sure they are ready for pregnancy, giving themselves enough time to make important changes that will reduce the risks for both them and their baby.

 

So what are the risks? -  Keep watching to find out more.

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 Remember

♦ Improving blood sugar control and lowering HbA1c will reduce the risk of complications in pregnancy

♦ Referral to the multidisciplinary team as soon as possible for care is essential

◊ As not all pregnancies are planned, refer women to their Specialist Diabetes Care Team immediately

♦ Close and frequent monitoring during pregnancy - fortnightly visits to the multidisciplinary team; serial ultrasound scans from 28 weeks; aim for vaginal birth prior to 40 weeks gestation

 

rollover 1 Macrosomia

Macrosomia

Fetal macrosomia describes a newborn with a birthweight greater than 4500g or 9lbs 9oz. Women with diabetes face an increased risk of having a large baby when blood glucose levels are not managed.

 

NICE clinical Guidelines state that 'good blood glucose control throughout pregnancy will reduce the risk of fetal macrosomia, trauma during birth (for her and her baby), induction of labour and / or caesarean section, neonatal hypoglycaemia and perinatal death'
rollover 2 Congenital Anomalies

Congenital Anomalies

Congenital anomalies are a major cause of stillbirth and neonatal morbidity for infants born to women with diabetes. See Bell et al., (2012) and Kitzmiller, Wallerstein, Correa & Kwan, (2010) for more information. The risk in Women with Diabetes is strongly associated with glycaemic control. 

 

 

‘I got a scan and I was told the baby’s not going to survive—multiple abnormalities… I later found out, through my own research, that this was due to high blood sugars in early pregnancy. It’s… I never knew those sorts of things could happen.’

‌ What's the evidence?
  • Bell, Glinianaia & Tennant (2012) studied a total of 401,149 singleton pregnancies to assess the risk of major congenital anomaly in pregnancy in women with both type 1 and type 2 diabetes (n=1,677), concluding that the risk of a pregnancy affected by congenital anomaly in women with diabetes was over three times higher than the general maternity population (RR 3.3 [95% CI 2.8, 3.9]).
  • Macintosh et al., (2006) found the risk of major congenital anomalies for infants born to women with diabetes was more than twice that of the general population in a study of 2359 pregnancies to women with type 1 or type 2 diabetes.
  • Suhonen et al., (2000) and Hanson et al., (1990) also noted an increase in the risk of congenital anomalies with increasing HbA1c values in women with type 1 diabetes.

 

“For each percentage (11 mmol/mol) increase in HbA1c, the odds of a pregnancy being affected by congenital anomaly increased by 30% .. a steadily increasing effect for HbA1c values above 6.3% (45 mmol/mol)”

 

 

Practice Point! What this evidence means..
 
  •  Folic Acid! 5mg dose daily

  • Optimise Glycaemic Control with the help of the Specialist Diabetes Team

 

 
Rollover 3 Perinatal Morality

Perinatal Mortality

Major fetal malformations as a result of poor glycaemic control have emerged as a significant cause of perinatal mortality (Boulet et al., 2003). Such malformations and subsequent perinatal mortality can be prevented by excellent glycaemic control before and during pregnancy, particularly in the early weeks following conception. Find out more here.

Poor preconception glycaemic control has also been linked to an increased rate of spontaneous abortion.

‌ What's the evidence?
  • In a large population based study of pregnancy outcomes for 2359 pregnancies to women with type 1 or type 2 diabetes in England, Wales and Northern Ireland, Macintosh et al., (2006) found perinatal mortality in babies of women with diabetes to be 31.8/1000 births. A striking finding was that perinatal mortality in women with diabetes was almost four times greater than the general maternity population.
  • Hawthorne et al., (1997), in a prospective population based study of 111 women with diabetes found the perinatal mortality rate was 48/1000 for diabetic pregnancies compared with 8.9/1000 for the background population.
  • Pre-pregnancy care (Wahabi et al., 2012) and optimising HbA1c (Boulot et al., 2003) have been linked to reduced pertinatal mortality.

 

Practice Point! What this evidence means..
 
  •   Optimise Glycaemic Control Pre-Pregnancy!

 

 
Rollover 4 Retinopathy

Retinopathy

Retinopathy is a disease of the retina that results in impairment or loss of vision. Most people with diabetes will show signs of retinopathy after 25 years of duration, however only a few progress to the severest form. The most effective treatment for retinopathy is improvement of glycaemic control which will slow progression of the condition. Pregnancy is a risk factor for the progression of diabetic retinopathy and as such, all women with diabetes should have a detailed examination pre-conceptually. 

The UK NICE Guideline reccommends that women with pre-existing diabetes are offered retinal assessement by digital imaging with mydriasis using tropicamide following their first antenatal clinic appointment (unless they have had a retinal assessment in the last 3 months) and again at 28 weeks.


The NHS website provides a great video on diabetic retinopathy. Find out more here!

Pregnancy can accelerate existing retinopathy - in fact, if a women improves her glycaemic control too quickly in pregnancy, this can have a negative effect on retinopathy. Therefore, it is extremely important to carry out a full retinal assessment, ideally pre-conceptually or in early pregnancy, and then repeat assessments during pregnancy to check for any signs of deterioration. This is why women with diabetes need to bring their blood glucose levels down under the guidance of the specialist diabetes care team. For more information on the effect of pregnancy on the progression of retinopathy in diabetic women, see: Chew et al., (1995); Axer-Siegel et al., (1996); Klein, Moss & Klein, (1989).

 

 

Practice Point! What this evidence means..
 
  • Optimise Glycaemic Control

  • Obtain Baseline Retinal Assessment

 

 
Rollover 5 Nephropathy

Nephropathy

Diabetic nephropathy is kidney disease caused by diabetes and clinical diagnosis is based on detection of proteinuria in the absence of another obvious cause such as infection. The most effective treatment for nephropathy is improvement of glycaemic control and careful management of blood pressure which will slow progression of the condition.

Whilst the evidence is unclear, some have found that pregnancy can accelerate existing nephropathy (Purdy et al., 1996), whereas others have not (Young et al., 2011). Urinalysis testing pre-conceptually to detect proteinuria and regular urine testing during pregnancy is recommended. Testing for urinary microalbuminuria would also be recommended. In order to optimize pregnancy outcome, tight blood glucose control and blood pressure should be emphasized before and during pregnancy, alongside close fetal surveillance and timely delivery (McCance, 2011).

 

Practice Point! What this evidence means..
 
  • Optimise Glycaemic Control

  • Obtain Baseline Retinal Assessment

 

 
Roll over images above for more information.

Self-Assessment

Which of the following are risks to the fetus in a pregnancy where the mother has diabetes?

Which of the following maternal complications in pregnancy is closely associated with diabetes?

In relation to which risk is it particularly important that women work with their specialist diabetes care team to achieve optimal glycaemic control?

In reflection which risk is it particularly important that women work with their specialist diabetes care team to achieve optimal glycaemic control?

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