Pre-Pregnancy Planning in Women with Diabetes
ABSTRACT & COMMENTARY
Synopsis: Even though most women with Type 1 diabetes know that excellent glucose control is important before conception, less than half of the pregnancies studied were planned.
Source: Holing EV, et al. Diabetes Care 1998;21: 889-895.
To determine why women with type 1 (insulin- dependent) diabetes mellitus do not plan their pregnancies, these investigators studied 85 women within six months after delivery in one of 15 hospitals in Washington. A planned pregnancy was defined as ". . . a pregnancy that was desired before conception and in which contraception was stopped or avoided for the purpose of becoming pregnant and in which the woman stated that she attempted to achieve optimal blood glucose (n = 50)." Pregnancies were compared using personal interviews, questionnaires, and medical record reviews. Women were excluded from the study if their infants had experienced an unfavorable perinatal outcome including a stillbirth, neonatal death, or major birth defect. While nearly 80% of the women in the study knew they should try to achieve excellent glucose control before conception, only 41% of the pregnancies were planned. Women with planned pregnancies were older, from families with a higher annual income, had more education, were more likely to have seen a health care provider for diabetes during the six months before pregnancy, more often had private insurance, and were more likely to have made at least one visit with a perinatologist or obstetrician before conception. Not only were women with planned pregnancies more likely to have a satisfying relationship with their partner, they were also more likely to report a positive and supportive relationship with their health care provider.
Holing and associates emphasize the importance that the relationship between a woman and her health care provider may play in pre-pregnancy planning, noting that a good relationship with health care providers is a key component of this program.
COMMENT BY STEVEN G. GABBE, MD
Pre-pregnancy planning is an important part of health care for women with medical complications, particularly Type 1 diabetes mellitus. It has been well established that excellent glucose control during the period of embryogenesis, approximately 5-8 weeks after the last normal menstrual period, will significantly reduce the risk of major fetal malformations.
In women whose diabetes is poorly controlled, the rate of major anomalies and miscarriage may exceed 25%. In women who achieve excellent control prior to and during the early weeks of pregnancy, the rate of malformation and miscarriage is no higher than that observed in the general population. Pre-pregnancy planning also allows the assessment of maternal vasculopathy, including an evaluation of retinal disease and renal involvement. One advantage of pre-pregnancy planning that has not been emphasized in the past is the importance of a supportive relationship between the patient and her health care provider. This study by Holing et al reveals that, even though most women with Type 1 diabetes know that excellent glucose control is important before conception, less than half of the pregnancies studied were planned. If women who had poor perinatal outcomes were included in this investigation, it is likely that the number of planned pregnancies would have been even lower. Importantly, Holing et al have observed that women who planned their pregnancies were more likely to be satisfied with the relationships with their partners and felt that their partners were well-informed about diabetes and pregnancy. Similarly, women who planned their pregnancies felt that their relationships with their health care providers were positive ones and were characterized by encouragement and reassurance, an important message for all of us to remember.
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