Type 2 diabetes needs the same level of care as type 1 in pregnancy

The evidence that rates of type 2 diabetes in pregnancy are rising is largely based on global figures and individual clinicians' reports of younger pregnant women with the condition. Until recently, care for women with diabetes in pregnancy has focused on type 1 diabetes. A paper in a recent BMJ finds that high rates of congenital anomalies, stillbirth, and neonatal death were reported in women with type 2 diabetes as well as those with type 1 diabetes.

The Confidential Enquiry into Maternal and Child Health undertaken in England, Wales, and Northern Ireland audited 3808 pregnancies in 3733 women with pregestational diabetes who booked for care or delivered between 1 March 2002 and February 2003. The article by staff from the confidential inquiry is based on the 2359 pregnancies audited in the women whose diabetes was diagnosed at least a year before the pregnancy. Perinatal mortality rates in babies of women with type 1 and 2 diabetes were similar (31.7 and 32.3 per 1000 total births respectively) and nearly four times higher than in the corresponding general population; for both types of diabetes, the prevalence of major congenital anomalies was more than double that expected. The study supports the view that type 2 diabetes requires the same level of care as type 1 diabetes.

However, the study made no statistical adjustment for the high proportion of South Asian women in the type 2 diabetes group, 16% of whom were of Pakistani origin, a group with high rates of congenital anomalies. On the other hand a recent study in Bradford adjusted for ethnic origin and showed that diabetes increased the rate of congenital anomalies among Pakistani women. In addition, rates were higher in women with type 2 diabetes who were using insulin.

Better care before conception and good glycaemic control can improve outcome in women with diabetes. Women with diabetes and their clinicians should recognise the possibility of pregnancy, particularly at the extremes of reproductive age. Contraception should be available to minimise unplanned pregnancies, since women need to optimise glycaemic control before planning a pregnancy. Women being treated for subfertility in particular need to have good glycaemic control before conception.

Because of the high rate of neural tube defects in women with diabetes, women should take 5 mg of folic acid a day when planning pregnancy. The high rate of cardiac anomalies requires detailed feotal cardiac assessment, which may be difficult to provide in many areas and countries.

The benefit of interventions in late pregnancy to reduce stillbirth is less clear, since optimisation of glycaemic control to avoid macrosomia and early delivery has not yet reduced stillbirth rates. A study in the Netherlands of women with type 1 diabetes (84% of whose pregnancies were planned) showed that even though good control could be achieved, complication rates were still higher than for women without diabetes.

This continuing high rate of problems therefore implies that close monitoring and interventions aimed at avoiding late intrauterine death should continue.

As in earlier studies in the United Kingdom and elsewhere, the management of many women in the study fell short of recommended standards. This may be because women with type 2 diabetes were more likely to live in disadvantaged areas and come from black and minority ethnic groups.

In view of these difficulties, efforts to improve outcomes should focus on identifying at risk groups—in particular, women with a history of gestational diabetes—as well as on opportunistic screening for early case finding. Ideally, public health measures are needed to prevent the onset of type 2 diabetes, especially among younger women.

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Adherence to drug therapy and mortality

About one in four people do not adhere well to prescribed drug therapy. Following principles of evidence based medicine, clinicians use the most relevant and available evidence to guide decisions on drug therapy. Once the prescription is written, however, the fate of drug therapy is with the patient. Poor adherence is considered a critical barrier to treatment success and remains one of the leading challenges to healthcare professionals.

A recent BMJ study has evaluated the relation between adherence to drug therapy, including a placebo arm, and mortality using a meta-analysis of observational studies.

Data were extracted for disease, drug therapy groups, methods for measurement of adherence rate, definition for good adherence, and mortality. Data were available from 21 studies, including eight studies with placebo arms. Compared with poor adherence, good adherence was associated with lower mortality (odds ratio 0.56). Good adherence to placebo was associated with lower mortality (0.56), as was good adherence to beneficial drug therapy (0.55). Good adherence  to harmful drug therapy was associated with increased mortality (2.90).

The authors conclude that good adherence to drug therapy is associated with positive health outcomes. Moreover, the observed association between good adherence to placebo and mortality supports the existence of the "healthy adherer" effect, whereby adherence to drug therapy may be a surrogate marker for overall healthy behaviour.

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Telemedicine for stroke

Telemedicine networks are a new approach to improve stroke care in community settings. Five community hospitals without pre-existing specialised stroke care were included in a network with telemedicine support by two academic hospitals.

In a non-randomised, open intervention study, five community hospitals without specialised stroke care served as the control group, matched individually to the network hospitals by predefined characteristics. Stroke patients admitted consecutively to one of the participating hospitals were included in the study. Patients in network and control hospitals were assessed in the same manner and were followed up for vital status, living situation, and disability at 3 months

5696 patients with a sudden, non-convulsive loss of neurological function consistent with having stroke were admitted to the hospitals participating in the study. 63% were treated in the network hospitals. After 3 months, 44% of patients treated in network hospitals versus 54% treated in control hospitals had a poor outcome. In multivariate regression analysis, treatment in network hospitals independently reduced the probability of a poor outcome

Telemedicine appears to offer an innovative approache to improve acute stroke care at community level for stroke patients living in non-urban areas.

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