Pre-gestational diabetes and pregnancy

Published on October 7, 2014   29 min

Other Talks in the Series: Diabetes in Perspective

0:00
In this talk, I will discuss pre-gestational diabetes, its impact on mother and the developing child, and its management. First to introduce myself, I'm Jeremy Oats. I'm an obstetrician with a longstanding interest in the care of women with diabetes, both pre-gestational and gestational. I work in the Diabetes Service at the Royal Women's Hospital, Melbourne, Australia, which is a tertiary referral University-affiliated hospital.
0:27
Pre-gestational diabetes-- that is diabetes that predates the pregnancy-- comprises type 1 diabetes, previously called insulin dependent diabetes, reflecting its autoimmune etiology that results in the destruction of the beta islet cells of the pancreas. And now increasingly, type 2 diabetes. It is caused by increasing insulin resistance and an incapacity of the beta islet cells to secrete sufficient insulin to maintain normoglycemia. The other most common type of diabetes in pregnancy is gestational diabetes, which is the subject of a separate presentation.
1:07
Incidence. This pre-gestational diabetes complicates between 0.2% to 0.3% of pregnancies. GDM used to affect 1% to 5% of pregnancies. But with the adoption of the WHO IADPSG criteria, this is increasing to around 10% to 20%. There is considerable ethnic variation largely reflecting the background of type 2 diabetes rates. Rates are reported to be low in rural Melanesian women in Papua, New Guinea, and high in groups such as the American Indians, including the well-documented Pima Indians and other indigenous populations, including the Australian Aboriginal population, especially those who moved from traditional diets to ones dominated by high-carbohydrate fast food. Accurate estimates are hampered by an incomplete ascertainment within many communities underdiagnosed as both type 2 diabetes and its precursors, impaired fasting glucose and impaired glucose tolerance.
2:16
Before we consider the management of pre-gestational diabetes in the 21st century, it is worth reflecting on where we have come from. In 1856, Blott wrote that quote, "True diabetes is inconsistent with conception," end quote. In 1909, Peel summarized the United Kingdom experience, reporting that the maternal mortality rate was 27% within two weeks of delivery, 18% of recognized pregnancies miscarried, and that 33% of the pregnancies result in a fetal death in utero if they went to term. This, of course, preceded the discovery and the introduction of insulin, which quickly resulted in a dramatic fall in mortality.
3:02
The next three sides summarize the outcomes of women with pre-gestational diabetes managed at the Royal Women's Hospital, Melbourne, Australia, between 1970 and 1990. We've chosen these three decades because during this time, there were major changes in the management of both the pregnancy and the offspring of mother with pre-gestational diabetes. This resulted in a fall in the perinatal mortality from 20%, made up of 10% for both neonatal and stillbirths. And this has now fallen to 2% for neonatal mortality and 1% for stillbirths. Frustratingly, over the next 25 years, there's been little further improvement. And for the state of Victoria overall, there has been in fact a small but persistent rise in perinatal mortality. And we will look at some of the possible causes of this later.
3:57
This slide superimposes the changes in neonatal care and maternal diabetes care that occurred during this time. In 1968, the precursors of more intensive neonatal care were introduced, followed by what we understand now as intensive neonatal care, including ventilatory support in the early 1970s and the commencement of much tighter maternal glycemic control in the mid '70s, which was aided by the advent of home blood glucose monitoring.
4:33
This slide summarizes the principal causes of neonatal death during the three decades. Despite the numbers of women with pre-gestational diabetes increasing from 195 to 355 in the five-year cohorts, the numbers of babies dying from respiratory distress syndrome or Hyaline Membrane Disease fell from 12 to zero. And again, the rates of major fetal malformation-associated deaths fell, but still are a persistent feature that continues to this day. And this will also be discussed further in this presentation. Birth trauma is now a very uncommon cause of death, largely due to the ready recourse to delivery by cesarean section, either when the fetus is perceived to be necrozymic, and/or the progress of labor is slow. Infection, asphyxia, and necrotizing enterocolitis remain uncommon but important causes.
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Pre-gestational diabetes and pregnancy

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