Such counseling in diabetic women has been shown to be efective. Leguizam6n and associates (2007) identiied 12 studies that included more than 3200 pregnancies in women with insulin-dependent diabetes. Of the 1618 women without precon o..Ac) 'uE ..
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FIGURE 8-1 Relationship between first-trimester glycosylated hemoglobin values and risk for major congenital malformations in 320 women with insulin-dependent diabetes. (Data from Kitzmiller JL, Gavin LA, Gin GO, et al: Preconception care of diabetics. JAMA 265:731, 1991.) ceptional counseling, 8.3 percent had a fetus with a major congenital anomaly, and this compared with a rate of 2.7 percent in the 1599 women who did have counseling. Tripathi and coworkers (2010) compared outcomes in 588 women with pregestational diabetes in whom approximately half had preconceptional counseling. hose women who received counseling had improved glycemic control before pregnancy and in the first trimester. his group also had higher folate intake rates preconceptionally, and they experienced lower rates of adverse outcomes-deined as a perinatal death or major congenital anomaly. hese cited beneits are accompanied by reduced helth-care costs in diabetic women. From their review, Reece and Homko (2007) found that each $1 expended for a preconceptional care program saved between $1.86 and $5.19 in averted medical costs. Despite such beneits, the proportion of diabetic women receiving preconceptional care is suboptimal. In their study of approximately 300 diabetic women in a managed-care plan, Kim and colleagues (2005) found that only approximately one half had preconceptional counseling. Counseling rates are undoubtedly much lower among uninsured and indigent women.
Compared with unafected women, those with a seizure disorder carry an undisputed augmented risk of having neonates with structural anomalies (Chap. 12, p. 240). Some early reports indicated that epilepsy conferred an elevated a priori risk for congenital malformations that was independent of anticonvulsant treatment efects. Although more recent publications have largely failed to conirm this increased risk in untreated women, it is diicult to refute entirely because women who are controlled without medication generally have less severe disease (Cassina, 2013; Vajda, 2015). Fried and associates (2004) conducted a metaanalysis of studies comparing epileptic women, both treated and untreated, with controls. In this study, greater malformation rates could only be demonstrated in the ofspring of women who had been exposed to anticonvulsant therapy. Veiby and coworkers (2009) used the Medical Birth Registry of Norway and identiied an increased malformation risk only in women who were exposed to valproic acid (5.6 percent) or poly therapy (6.1 percent). Untreated women had anomaly rates that were similar to those of nonepileptic controls. Risks for miscarriage and stillbirths in exposed epileptic women do not appear elevated (Aghajanian, 2015; Bech, 2014).
Ideally, seizure control is optimized preconceptionlly. For example, Vajda and colleagues (2008) nalyzed data from the Australian Register of Antiepileptic Drugs in Pregnancy. hey found the seizure risk during pregnancy was 50-to 70-percent lower in women without a seizure in the year preceding pregnancy compared with a group experiencing seizures in this preceding year. No urther advantages accrued if the seizure-free period exceeded a year.