Sweet de­liv­ery

Pre­par­ing women with di­a­betes for preg­nancy

The Irish Times - Tuesday - Health - - Front Page - Sheila Way­man sway­man@irish­times.com

A sig­nif­i­cant num­ber of ab­nor­mal­i­ties re­lated to di­a­betic preg­nancy oc­cur in the first eight weeks when the baby is de­vel­op­ing. So if you are wait­ing for women to have a pos­i­tive preg­nancy test and ap­pear at ante-na­tal clin­ics, you have lost a lot of the op­por­tu­nity to make a change

Anna-Maria Kir­rane (39) be­lieves there is no way she would be on baby num­ber four without the help of a pi­o­neer­ing, pre-preg­nancy care pro­gramme that women like her can avail of in the west of Ire­land.

She faced ex­tra risks on be­com­ing preg­nant – to both her­self and the baby – be­cause she has di­a­betes. A life­long con­di­tion, di­a­betes is caused by a lack of the hor­mone in­sulin, a sub­stance made by the pan­creas that reg­u­lates blood sugar. Type 1 tends to oc­cur in child­hood or early adult­hood while type 2 usu­ally de­vel­ops slowly in adult­hood.

A na­tive of Inish­mor, Kir­rane was di­ag­nosed with type 1 di­a­betes at the age of 19, when she was study­ing ho­tel and ca­ter­ing man­age­ment. She started los­ing weight and feel­ing ex­tremely thirsty but there was no his­tory of di­a­betes in the fam­ily.

“When I went home for Christ­mas my mum took one look at me and said ‘oh jeep­ers’ and sent me straight to the GP.”

Her con­di­tion was iden­ti­fied im­me­di­ately and she was sent to hos­pi­tal for a cou­ple of days, where she re­mem­bers in­ject­ing or­anges to prac­tise for self-ad­min­is­ter­ing in­sulin.

“I was quite healthy up to then, so it was a bit of a shock but it was man­age­able.” Al­though she soon be­came well used to mon­i­tor­ing her­self and in­ject­ing in­sulin four times a day, the prospect of preg­nancy af­ter she got mar­ried in 2009 was a “lit­tle bit scary”.

It was when at­tend­ing the di­a­betic clinic at Univer­sity Hos­pi­tal Gal­way for her an­nual check-up that she saw a poster ad­ver­tis­ing the pre-preg­nancy care pro­gramme.

While “it takes a lit­tle of the spon­tane­ity and ro­mance out of the whole thing”, she says with a laugh, she en­rolled in the pro­gramme when she and her hus­band, John Kir­rane, were think­ing of start­ing a fam­ily at their home in Mill­town, out­side Tuam, Co Gal­way. “You want to do your best for a new baby and you want to give your­self the best chance.”

Op­ti­mis­ing health

The At­lantic Di­a­betes in Preg­nancy pro­gramme was de­vel­oped to try to op­ti­mise the health of women with di­a­betes be­fore con­cep­tion. The ini­tia­tive, led by NUI Gal­way’s Prof Fidelma Dunne, started as a re­search project into di­a­betes and preg­nancy, funded by the Health Re­search Board.

“The first thing we no­ticed was that out­comes for women were very poor,” she says. “We started to in­ves­ti­gate why and one of the main fac­tors was that they were not prop­erly pre­pared for preg­nancy and that is when we set up the pre-preg­nancy pro­gramme.”

A sig­nif­i­cant num­ber of ab­nor­mal­i­ties re­lated to di­a­betic preg­nancy oc­cur in the first eight weeks when the baby is de­vel­op­ing. “So if you are wait­ing for women to have a pos­i­tive preg­nancy test and ap­pear at an­te­na­tal clin­ics, you have lost a lot of the op­por­tu­nity to make a change,” says Dunne.

The Saolta Univer­sity Health Care Group im­ple­mented the pro­gramme on a re­gional ba­sis through Univer­sity Hos­pi­tal Gal­way, Mayo Univer­sity Hos­pi­tal, Castle­bar and Let­terkenny Gen­eral Hos­pi­tal in Co Done­gal. The re­search data is now there (see panel on op­po­site page) to demon­strate its ef­fec­tive­ness not only for im­proved health among women and ba­bies but also in re­duc­ing costs for the health ser­vice.

“What we have shown from this pro­gramme is that we can re­duce con­gen­i­tal mal­for­ma­tions in ba­bies, neo-na­tal mor­tal­ity in ba­bies that is of­ten re­lated to pre­ma­tu­rity, re­duce pre­ma­tu­rity, and re­duce the need for ex­ten­sive neo-na­tal care for ba­bies be­cause that is what the HSE counts,” says Dunne.

Sci­en­tific eval­u­a­tion of the pro­gramme has found that the av­er­age cost of com­pli­ca­tions for those with di­a­betes who re­ceived stan­dard an­te­na­tal care was ¤2,578 more than for those who had at­tended for pre-preg­nancy care as well. The av­er­age cost of de­liv­er­ing the pre-preg­nancy care is just ¤449 per preg­nancy.

Hav­ing been ad­judged Best Sus­tain­able Health­care Project, as well as win­ning the over­all tro­phy, at the Ir­ish Health­care Awards last Novem­ber, the pro­gramme has built up a con­vinc­ing case for na­tional im­ple­men­ta­tion.

Na­tional im­ple­men­ta­tion

Con­sid­er­ing the life­long ef­fects of con­gen­i­tal mal­for­ma­tions and de­vel­op­men­tal is­sues re­lat­ing to pre­ma­tu­rity, for both chil­dren and their fam­i­lies, not to men­tion the eco­nomic bur­den on the health ser­vice, you would ex­pect a proven, cost-ef­fec­tive way of re­duc­ing these to be em­braced. That’s without fac­tor­ing in the trauma and heart­break that is avoided for each fewer still­birth.

But Dunne is not hold­ing her breath for this pro­gramme be­ing ex­tended to other parts of Ire­land.

“The HSE is not into pre­ven­tion. It is into treat­ing com­pli­ca­tions, that is where one has to have a whole mind-set change to im­ple­ment some­thing like this.”

With the data that has now been pro­duced in re­search stud­ies eval­u­at­ing the At­lantic Di­a­betes in Preg­nancy pro­gramme, you would ex­pect the HSE to say that is very good ev­i­dence, we will im­ple­ment that, she con­tin­ues. “But that never hap­pens with the HSE be­cause im­ple­men­ta­tion costs money. That is where we make no progress in the HSE in Ire­land.”

Re­gional change can be achieved in health­care de­liv­ery if you have a very mo­ti­vated per­son cham­pi­oning the cause, says Dunne, who is sat­is­fied that this pro­gramme is now em­bed­ded in rou­tine care in the Saolta area.

Re­search shows peo­ple who most need to at­tend a pre-preg­nancy care pro­gramme are of­ten those in ru­ral lo­ca­tions, who don’t have enough money for travel, or who may be of lower in­tel­li­gence or of a lower so­cio-eco­nomic sta­tus, she ex­plains. This is why they fo­cused on bring­ing the

ser­vice to the peo­ple, rather than cen­tral­is­ing it in a ter­tiary-level hos­pi­tal.

“We were try­ing to pro­vide ge­o­graph­i­cal cov­er­age and be in­clu­sive of all types.” This re­quired train­ing of lo­cal hos­pi­tal staff and on­go­ing aware­ness-rais­ing, by send­ing out fly­ers an­nu­ally not only to women at­tend­ing di­a­betic clin­ics but also to GPs who may be the only health­care pro­fes­sion­als car­ing for those with type 2 di­a­betes.

Mo­ti­va­tion

Par­tic­i­pants in the pro­gramme, for which there is no wait­ing list, also have to be very mo­ti­vated; a min­i­mum of three months is rec­om­mended but most need up to six months. The aim, gen­er­ally, is to get women’s HbA1c (which in­di­cates their av­er­age blood sugar lev­els) down to or below 6.5 per cent when they are en­ter­ing the first trimester and eval­u­a­tion of the pro­gramme has shown that the num­ber achiev­ing this has in­creased from 16 to 33 per cent.

“It is not easy to get to the goals you’re ask­ing them to do,” says Dunne. With an em­pha­sis on the re­stric­tion of in­take of sugar, the diet can be­come bor­ing. They are also ask­ing women to test their sugar lev­els seven times a day, to ex­er­cise ev­ery day and to re­duce their body mass in­dex.

“You are ask­ing them to be su­per good.” How­ever, an out­line of the im­pli­ca­tions of start­ing preg­nancy when their health is not op­ti­mised is per­sua­sive be­cause “the con­se­quences are aw­ful”, she points out.

Women are likely to be mo­ti­vated enough to reach their best tar­gets by six months and the sit­u­a­tion is then re­viewed.

“We may say that is the best you are go­ing to achieve and then out­line the risk for the preg­nancy re­lated to their best tar­get.” It is up to them to de­cide whether or not they want to pro­ceed with try­ing to con­ceive.

Some peo­ple make more progress than oth­ers on the pro­gramme “but ev­ery bit of progress has a pos­i­tive im­pact”, she says. About one in 250 preg­nan­cies in Ire­land is to a woman with ei­ther type 1 or type 2 di­a­betes, not to be con­fused with ges­ta­tional di­a­betes that about one in 12 women here now de­vel­ops dur­ing preg­nancy and which, typ­i­cally, goes away af­ter the birth.

The in­ci­dence of all di­a­betes is on the rise, but par­tic­u­larly type 2 and ges­ta­tional which are driven partly by weight is­sues.

Dunne, who is ex­pect­ing to see this in­crease cause a lot more is­sues for re­pro­duc­tive health, out­lines three main ar­eas of con­cern that the pre-preg­nancy care pro­gramme ad­dresses:

The sugar con­trol of the woman – the higher the lev­els are for the woman, the worst the out­come.

Use of folic acid – women with di­a­betes need to take high-dose folic acid, which re­quires a pre­scrip­tion. “We would gen­er­ally treat them with five mil­ligrams of folic acid, whereas the folic acid you buy over the counter is 400 mi­cro­grams.”

Use of other med­i­ca­tions – those used nor­mally in the treat­ment of women with di­a­betes may not be good for preg­nancy. “A lot of the newer med­i­ca­tions for the treat­ment of type 2 di­a­betes, which are fine out­side preg­nancy, are not suit­able for preg­nancy. This is an op­por­tu­nity to deal with all of that,” she adds.

Au­dit

The next step to­wards get­ting the pro­gramme im­ple­mented through­out the coun­try is a na­tional au­dit of the out­comes of preg­nancy for women with type 1 or type 2 di­a­betes. Dunne ex­pects this to be­gin in Fe­bru­ary or March, with re­sults col­lated by the au­tumn.

“All our col­leagues around the coun­try have agreed to par­tic­i­pate in that with no monies com­ing from the HSE,” she says. “This is money I have got in through re­search that will kick­start it.”

She ex­pects the au­dit to show ge­o­graph­i­cal vari­a­tions and hopes the best re­sults can be taken as the norm, with ev­ery­body then striv­ing to meet that norm.

Be­fore at­tend­ing the pre-preg­nancy care pro­gramme, Anna-Maria Kir­rane hadn’t known about her need for a higher dose of folic acid than other women.

“You need to have that in your sys­tem three to six months prior [to con­cep­tion]. They check your iron lev­els, sugar lev­els and get you into the rou­tine of check­ing your sugar lev­els through­out the day.”

Dur­ing preg­nancy you need to check your sugar lev­els be­tween five and seven times a day, she says, “to make sure you are keep­ing on top of the highs and lows as well”.

Af­ter six months on the pro­gramme, Kir­rane says: “I knew my body was ready. I knew I had done as much as I could do.”

It took an­other four or five months un­til she be­came preg­nant the first time and she then started to at­tend the com­bined preg­nancy clinic at Univer­sity Hos­pi­tal Gal­way ev­ery two weeks, see­ing both the di­a­betes and gy­nae­col­ogy teams.

“You are sent home with a di­ary and you record your sugar lev­els – your spikes, your highs, your lows.

“The weeks you are not present the nurse rings and goes through your lev­els and if you need to in­crease or de­crease [in­sulin].” She also had her eyes checked in each trimester.

Kir­rane has felt “un­be­liev­ably well mon­i­tored” through­out all her preg­nan­cies. She at­tributes be­ing “so blessed” with three healthy chil­dren – Tara (five), Aoife (four) and Ais­ling (two) – and 37 weeks preg­nant with her fourth when we speak to this level of care be­fore and af­ter con­cep­tion.

“If I hadn’t that sup­port and back-up,” she adds, “I prob­a­bly wouldn’t have had the con­fi­dence to go for our fourth child.”

PHO­TO­GRAPHS: JOE O’SHAUGHNESSY

Anna-Maria Kir­rane at home with her daugh­ters – Tara (5), Aoife (4), and Ash­ling (2).

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