Diabetes in Pregnancy Project -- Maine, 1986-1987

Approximately 15,000 infants are born to women with established diabetes (diabetes known to exist prior to conception) each year in the United States (1). These infants are at increased risk for a number of medical problems including large size for gestational age, low blood sugar, immature lungs, and congenital malformations. Other biochemical abnormalities have also been noted.

To address the problems associated with diabetes during pregnancy, the state of Maine initiated the Maine Diabetes in Pregnancy Project (MDPP), a special program that operates within the Maine Diabetes Control Project. MDPP's goal is to improve pregnancy outcomes of women with established diabetes. Participants receive preconception counseling and are cautioned to undergo a period of metabolic adjustment to establish normoglycemia before conception. MDPP has developed guidelines for management of these high-risk pregnancies, including a schedule of tests for the patient and instructions for both the patient and her health-care provider. In addition, a network of providers who are knowledgeable in the management of pregnancies complicated by diabetes and available to take referrals has been established. All blood specimens for monitoring glucose control during gestation are analyzed at a central laboratory. To evaluate the MDPP, data are collected using a standardized questionnaire that solicits demographic information, previous obstetric history, current pregnancy information, and neonatal outcome variables.

Participation in MDPP is voluntary. Initially, project coordinators sent information on MDPP to all providers who are on the mailing list maintained by the state health department and who might care for women with diabetes during pregnancy and asked them to participate. Those electing to become part of the project then asked their eligible patients to enroll. An estimated 90% of the providers responded positively. The proportion of their patients who are enrolled in MDPP is not known. A central registry is kept of all participating women 15-44 years of age, regardless of pregnancy status.

Active registration of participants began in January 1986. One hundred twenty- four women (representing 35 providers) have registered with MDPP. All have been provided with educational materials about diabetes during pregnancy. From January 1, 1987, to August 31, 1987, 52* pregnancies were identified among these 124 women. Sixty percent of these pregnant women received preconception counseling through MDPP.

Outcomes have occurred in 41 of the 52 pregnancies. Data on maternal age were available for 38 (93%) of the women. Twenty-five (66%) of them were 30 years of age or under, and 13 (34%) were over 30. Twelve (29%) of the 41 women had had no previous conceptions, and the remainder had had two or more. Seven (17%) of the women had previously had spontaneous abortions. There were two previous stillbirths and one previous neonatal death. Gestational age at delivery was available for 40 of the 41 newborns. Sixty-eight percent were delivered at 37 weeks or more.

Control of diabetes during pregnancy (measured by percentage of glycosylated hemoglobin) was considered good to excellent for all participants. The group's glycosylated hemoglobin values were averaged for each trimester. Mean glycosy- lated hemoglobin values declined (indicating improved glucose control) from 8.8% during the first trimester to 7.1% during the second trimester and, finally, to 6.5% during the third trimester.**

Pregnancy outcomes were available for 37 of the participants. Thirty-three (89%) of the pregnancies resulted in live births. There were three spontaneous abortions and one neonatal death. The neonatal death was due to multiple congenital malformations; the mother involved had not sought prenatal care until late in her pregnancy. Neonatal morbidity involved conditions that primarily were not life-threatening. They included macrosomia, mild hypoglycemia, and respiratory distress. The frequency of neonatal complications in this population is lower than expected among infants born to women with established diabetes who do not receive appropriate preconception and gestational management (Table 1). Reported by: B Willhoite, MS, H Bennert, MD, Maine Diabetes in Pregnancy Project; J Wallace, MPA, Maine Diabetes Control Program; R Schwartz, MSPH, Maine Dept of Human Svcs. Technology and Operational Research Br, Div of Diabetes Control, Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: The ability to improve the outcome of pregnancies complicated by diabetes has resulted from two recent advances: the establishment of comprehensive team care of pregnant women with diabetes and the recognition of the role of strict glycemic control prior to and during gestation. Prior to the use of insulin, maternal mortality among women with diabetes was as high as 40%, and 50% of pregnancies complicated by diabetes did not result in live births (4). More intensive management of pregnancies complicated by diabetes, including better identification of women at risk, improved glycemic control, early hospital admission, and coordinated team approaches using practitioners of varying disciplines, have markedly decreased the rates of maternal and infant mortality. The majority of perinatal morbidity and mortality currently noted in pregnancies complicated by diabetes is due to congenital malformations (6).

No single factor has been shown to account for the entire spectrum of perinatal morbidity and mortality associated with pregnancies complicated by diabetes. Although differences in immunologic status, amino acid metabolism, and other biochemical and physiologic differences have been shown to exist in such pregnancies (7), many of the complications may be consequences of the increased concentrations of glucose received by the fetus. This increased glucose flux between mother and fetus causes fetal hyperinsulinism, which contributes to fetal and neonatal morbidity and mortality.

Before organogenesis (approximately the first 7 weeks of gestation), an increased glucose load and an altered fetal environment are thought to be teratogenic. After 7 weeks gestation, these alterations create an aberrant fetal physiology that can cause macrosomia and other pathology affecting organ systems including the liver, pancreas, heart, and lungs.

Although notable decreases in rates of adverse outcomes of pregnancies among women with diabetes have occurred, the prevalence of congenital malformations in children born to these women remains elevated above that expected in the general population of women (6). Preconception counseling regarding the value of planned pregnancies and strict glycemic control before conception and throughout gestation have been shown to reduce the risk of congenital malformations in this group (1). Preconception counseling coupled with team management and careful monitoring of maternal and fetal well-being throughout pregnancy are now considered optimal care for the delivery of a healthy newborn.

Public health officials may consider including the following major components in programs designed to prevent adverse outcomes in pregnancies complicated by diabetes:

Identification of women of childbearing age with established diabetes mellitus.

Patient education on the value of planned pregnancies and strict metabolic control prior to conception and throughout gestation.

Professional education to ensure that providers are knowledgeable about effective strategies to manage pregnancies complicated by diabetes.

Interventions to ensure that women of childbearing age with diabetes receive optimal health care and achieve adequate levels of glycemic control.

Strict control of blood glucose from conception throughout gestation and particularly during the period of organogenesis is essential since congenital malformations now account for most of the perinatal morbidity and mortality among infants born to women with diabetes. Consequently, the most critical component of a prevention program is the identification and education of women with established diabetes prior to conception.

References

1. Freinkel N, Metzger BE, Potter JM. Pregnancy in diabetes. In: Ellenberg M, Rifkin H, eds. Diabetes mellitus: theory and practice. 3rd ed. New York: Medical Examination Publishing, 1983:689-714.

2. Small M, Cameron A, Lunan CB, MacCuish AC. Macrosomia in pregnancy complicated by insulin-dependent diabetes mellitus. Diabetes Care 1987;10:594-9.

3. National Center for Health Statistics. Advance report of final natality statistics, 1985. Hyattsville, Maryland: National Center for Health Statistics, 1987; DHHS publication no. (PHS)87-1120. (Monthly vital statistics report; vol. 36, no. 4, supplement).

4. Hare JW. Pregnancy and diabetes. In: Marble A, Krall LP, Bradley RF, Christlieb AR, Soeldner JS, eds. Joslin's diabetes mellitus. 12th ed. Philadelphia: Lea and Febiger, 1985:698-711.

5. Lufkin EG, Nelson RL, Hill LM, Melton LJ III, O'Fallon WM, Evans AT III. An analysis of diabetic pregnancies at Mayo Clinic, 1950-79. Diabetes Care 1984;7:539-47.

6. Olofsson P, Sj|$$|Adoberg N-O, Solum T, Svenningsen NW. Changing panorama of perinatal and infant mortality in diabetic pregnancy. Acta Obstet Gynecol Scand 1984;63:467-72.

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