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Unimproved perinatal outcomes with gestational diabetes warrant renewed efforts
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With congenital anomalies in children of pregnant women with diabetes down only slightly in the past decade and perinatal mortality yet unchanged, the risk for both is still elevated compared with women without diabetes.
Therefore, researchers are calling for efforts to reduce the adverse events and their future impact on society.
“There is increasing evidence that offspring of women with diabetes in pregnancy have increased rates of childhood obesity and diabetes later in life,” Denice S. Feig, MD, of the department of medicine at the University of Toronto, told Endocrine Today. “The burden on society is not only that of caring for these high-risk pregnancies, but may have far-reaching consequences on the next generations.”
Denice S. Feig
Feig and colleagues performed a population-based cohort study of 1,109,605 women who gave birth in Ontario, Canada, from 1996 to 2010. Participants aged 15 to 50 years were categorized as having gestational diabetes (GDM; n=45,384), pregestational diabetes (pre-GDM; n=13,278) or no diabetes (n=1,050,943). The researchers calculated annual age-adjusted rates of diabetes in pregnancy and compared rates of serious perinatal outcomes between groups and by year using Poisson regression.
The rates of both GDM and pre-GDM doubled over 14 years (2.7–5.6% and 0.7–1.5%, both P<.001), with nearly 1 in 10 pregnant women aged >30 years diagnosed with diabetes by 2010. The rate of congenital anomalies declined by 23%, but the rate of perinatal mortality did not change significantly.
Compared with pregnant women with no diabetes, those with pre-GDM and GDM faced an increased risk for congenital anomalies (RR=1.86; 95% CI, 1.49-2.33 and RR=1.26; 1.09-1.45, respectively), and perinatal mortality remained elevated in women with pre-GDM (RR=2.33; 95% CI, 1.59-3.43).
“Although we have come a long way in improving care for women with diabetes in pregnancy,” the researchers wrote, “further efforts are needed to reverse the trend toward increased type 2 diabetes in women of child-bearing age and to decrease the prevalence of these serious perinatal outcomes in women with diabetes through improved preconception and perinatal care.”
Improving education and ensuring availability of quality care could improve outcomes, Feig said.
“I would like to see increased efforts to educate and help women with diabetes to plan their pregnancies so that the rates of congenital anomalies can approach those of non-diabetic women. Increased efforts to gain access to care in rural areas, and receive treatment from multi-disciplinary teams including obstetricians, may help reduce the rates of perinatal mortality.” – by Allegra Tiver
Disclosure: This research was funded in part by the Canadian Diabetes Association, and the study was supported by the Institute for Clinical Evaluative Services.
Perspective
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Donald R. Coustan, MD
Consistent with the worldwide epidemic of obesity and type 2 diabetes, this population-based 16-year data analysis from Ontario reveals that gestational diabetes (GDM) and preexisting diabetes in pregnancy doubled during that time. Perinatal mortality in pregnancies with preexisting diabetes remained more than twofold higher than in pregnancies without diabetes, while in GDMs it was slightly lower than background. This apparent “protective effect” might be attributable to identification and treatment of GDM, including fetal assessment and delivery no later than the estimated date of confinement. Congenital malformations declined in both groups by approximately 20 percent. This may reflect preconception care in preexisting diabetes. While malformations may not be increased with GDM, the analysis considered any woman diagnosed with diabetes at any time during pregnancy to have GDM, some of whom undoubtedly had diabetes that was previously undiagnosed. Because the criteria used for diagnosing GDM were not reported and may have varied, the absolute numbers are less relevant than the trends. These data suggest that identification and treatment of diabetes in pregnancy has paid off in Ontario Province.
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