Thank you for the interesting article by Verheijen et al.1 It has highlighted the need to consider Asian ethnicity as a risk factor for poor outcome, when caring for diabetic pregnancies. The health survey for England has shown that doctor-diagnosed diabetes was significantly higher in Pakistani women (8.6%) compared with 3.4% in the general population. I would agree that information on body mass index (BMI) would have been helpful, and like your study group, in our hospital audits as well, we have noted BMI documentation to be suboptimal.
There are three further areas that would have helped add clarity to the discussions.
- 1Was glycaemic control similar in those with good and poor outcome?
- 2What was the indication for insulin in the type II diabetics?
- 3Did social deprivation have an added effect for poor outcome?
There are several factors that determines outcome in diabetic pregnancies. Studies have shown that type II diabetes have higher perinatal mortality despite better control. The non-Nordic population accounted for 41% of the type II diabetics in Denmark study consisting of 61 type II diabetics from 1996 to 2001. The non-native, non-Nordic population had poorer outcome and higher median HbA1c level, although the numbers in this group were small.2 However, there is a scope for good outcome, as in the Hungarian study. This showed congenital malformation rate and perinatal mortality to be better in diabetic than in nondiabetic pregnancies by appropriate glucose control and fetal surveillance.3
Of the total 130 Asians in your study, only 28 were type II diabetics, who were on insulin pre-pregnancy. Could the change to insulin treatment have improved a potentially much higher adverse outcome?
Data on social deprivation score would have been a helpful predictor of adverse outcome even in the absence of diabetes. Fifty percent of type II diabetics in the Confidential Enquiries into Maternal and Child Health report on maternity care for diabetics in England, Wales and Northern Ireland are nonwhite, and just under 45% live in deprived areas.4