beyond the evidence
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《英国医生杂志》
1 Newcastle Diabetes Centre, Newcastle General Hospital, Newcastle upon Tyne NE4 6BE, 2 Department of Obstetrics, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP
Correspondence to: G Hawthorne gillian.hawthorne@newcastle-pct.nhs.uk
Tommy's story shows the difficulty that is often encountered when looking after women with complex medical problems in pregnancy.1 There is simply insufficient evidence to customise the personal risk for a woman with diabetic complications who wishes to become pregnant. Women like Tommy need consensual advice and support from a highly skilled, well informed, multidisciplinary team with a good understanding of the complexity of the issues and the necessary skills to provide the required care. Good preconception care should, and in this case did, underpin the management and must include counselling about risk. This is not a generalist case, and we are not surprised that there were few rapid responses to this case.
Tommy changed her diabetes team in search of support for her desire for a baby. Once she made her decision, the ongoing support of the care team was paramount, whether or not they fully agreed with her. The failure to refer Tommy earlier for assisted conception when it was clear that there was a mechanical barrier to conception may have been a symptom of the team's ambivalence but not of their lack of commitment.
Assessment of diabetic control, diabetic retinopathy, hypertension, cardiac status, and renal function are vital before pregnancy. Glycaemic control can be optimised, blood pressure stabilised, and folic acid started. Ischaemic heart disease is an absolute contraindication to pregnancy, as suggested by the rapid responses. Angiotensin converting enzyme inhibitors can be continued until the pregnancy is diagnosed; they are not known to be teratogenic.2
Reports suggest that outcome of pregnancy is generally good in women with mild to moderate diabetic renal insufficiency, with a 90% take home baby rate.3 The woman would be at risk from pre-eclampsia, with attendant risks of intrauterine growth restriction and iatrogenic prematurity for the fetus. Aggressive control of blood pressure is therefore essential. No consensus exists on the effect of pregnancy on progression of diabetic nephropathy to end stage renal failure, although women with more severe disease are less likely to recover renal function after delivery of the baby.4 5
The risks of in vitro fertilisation in women with diabetic nephropathy have not been evaluated. As women with diabetic nephropathy have a shortened life expectancy, however, issues surrounding the welfare of the child must be discussed before treatment.
Pregnancy is not without risk. Care must be tailored to the individual and delivered by a team with sufficient expertise to provide the skilled support that women need.
Contributors: GH and MB discussed the case and jointly wrote the commentary.
Competing interests: GH and MB hold a preconception clinic at Newcastle Diabetes Centre
References
Piccoli GB, Mezza E, Grassi G, Burdese M, Todros T. A 35 year old woman with diabetic nephropathy who wants a baby: case outcome. BMJ 2004;329: 900.
Lip GYH, Churchill D, Beevers M, Auckett A, Beevers DG. Angiotensin converting enzyme inhibitors in early pregnancy. Lancet 1997;350: 1446-7.
Dunne FP, Chowdhury TA, Hartland A, Smith T, Brydon PA, McConkey C, Nicholson HO. Pregnancy outcome in women with insulin-dependent diabetes mellitus complicated by nephropathy Q J Med 1999;92: 451-4.
Biesenbach G, Grafinger P, Stoger H, Zazgornik J. How pregnancy influences renal function in nephropathic type 1 diabetic women depends on their pre-conceptual creatinine clearance. J Nephrolog 1999;12: 41-6.
Rossing K, Jacobsen P, Hommel E, Mathieson E, Svenningsen A, Rossing P, et al. Pregnancy and progression of diabetic nephropathy. Diabetologia 200245 : 36-41.(Gillian Hawthorne, consul)
Correspondence to: G Hawthorne gillian.hawthorne@newcastle-pct.nhs.uk
Tommy's story shows the difficulty that is often encountered when looking after women with complex medical problems in pregnancy.1 There is simply insufficient evidence to customise the personal risk for a woman with diabetic complications who wishes to become pregnant. Women like Tommy need consensual advice and support from a highly skilled, well informed, multidisciplinary team with a good understanding of the complexity of the issues and the necessary skills to provide the required care. Good preconception care should, and in this case did, underpin the management and must include counselling about risk. This is not a generalist case, and we are not surprised that there were few rapid responses to this case.
Tommy changed her diabetes team in search of support for her desire for a baby. Once she made her decision, the ongoing support of the care team was paramount, whether or not they fully agreed with her. The failure to refer Tommy earlier for assisted conception when it was clear that there was a mechanical barrier to conception may have been a symptom of the team's ambivalence but not of their lack of commitment.
Assessment of diabetic control, diabetic retinopathy, hypertension, cardiac status, and renal function are vital before pregnancy. Glycaemic control can be optimised, blood pressure stabilised, and folic acid started. Ischaemic heart disease is an absolute contraindication to pregnancy, as suggested by the rapid responses. Angiotensin converting enzyme inhibitors can be continued until the pregnancy is diagnosed; they are not known to be teratogenic.2
Reports suggest that outcome of pregnancy is generally good in women with mild to moderate diabetic renal insufficiency, with a 90% take home baby rate.3 The woman would be at risk from pre-eclampsia, with attendant risks of intrauterine growth restriction and iatrogenic prematurity for the fetus. Aggressive control of blood pressure is therefore essential. No consensus exists on the effect of pregnancy on progression of diabetic nephropathy to end stage renal failure, although women with more severe disease are less likely to recover renal function after delivery of the baby.4 5
The risks of in vitro fertilisation in women with diabetic nephropathy have not been evaluated. As women with diabetic nephropathy have a shortened life expectancy, however, issues surrounding the welfare of the child must be discussed before treatment.
Pregnancy is not without risk. Care must be tailored to the individual and delivered by a team with sufficient expertise to provide the skilled support that women need.
Contributors: GH and MB discussed the case and jointly wrote the commentary.
Competing interests: GH and MB hold a preconception clinic at Newcastle Diabetes Centre
References
Piccoli GB, Mezza E, Grassi G, Burdese M, Todros T. A 35 year old woman with diabetic nephropathy who wants a baby: case outcome. BMJ 2004;329: 900.
Lip GYH, Churchill D, Beevers M, Auckett A, Beevers DG. Angiotensin converting enzyme inhibitors in early pregnancy. Lancet 1997;350: 1446-7.
Dunne FP, Chowdhury TA, Hartland A, Smith T, Brydon PA, McConkey C, Nicholson HO. Pregnancy outcome in women with insulin-dependent diabetes mellitus complicated by nephropathy Q J Med 1999;92: 451-4.
Biesenbach G, Grafinger P, Stoger H, Zazgornik J. How pregnancy influences renal function in nephropathic type 1 diabetic women depends on their pre-conceptual creatinine clearance. J Nephrolog 1999;12: 41-6.
Rossing K, Jacobsen P, Hommel E, Mathieson E, Svenningsen A, Rossing P, et al. Pregnancy and progression of diabetic nephropathy. Diabetologia 200245 : 36-41.(Gillian Hawthorne, consul)