Obstetric and Perinatal Outcomes in Type 1 Diabetic Pregnancies: A large, population-based study

The aim of this epidemiological study was to elucidate whether in recent years, obstetric and perinatal outcomes in pregnancies complicated by type 1 diabetes (T1DM) have improved or not. The objective was also to identify possible risk factors for adverse outcome for the mother, fetus and the newborn. All studies (Ι-ΙV) included in this thesis were based on national data from the Swedish Medical Birth Registry, during the time period 1991-2007. In 5,089 type 1 diabetic pregnancies and 1.2 million controls we found significantly increased risks of all adverse outcomes in women with T1DM: adjusted odds ratios: severe preeclampsia: 4.47 (3.77-5.31), Caesarean delivery: 5.31 (4.97-5.69), stillbirth: 3.34 (2.46- 4.55), perinatal mortality: 3.29 (2.50-4.33), major malformations: 2.50 (2.13-2.94) and large for gestational age: LGA (birth weight ≥ +2 SD): 11.45 (10.61-12.36) (study Ι). The markedly elevated odds of an LGA outcome inspired us to characterize in more detail the distribution of birth size in a large national cohort of T1DM offspring (study ΙΙ n=3,705) and to investigate if disproportionate body composition was associated with increased risk of perinatal complications (study ΙΙΙ n=3,517). Percentiles for birth weight (BW), birth length (BL) and head circumference (HC) were formed based on data from non-diabetic pregnancies and standard deviation scores (SDS) were calculated for BW, BL and HC. The ponderal index (PI: BW in grams/(BL in cm) ³ was used as a proxy for body proportionality and fat mass and we defined disproportionate/overweight LGA as infants with a BW and PI ≥90th percentile for gestational age and gender. The distributions of BW, BL and HC were all unimodal but significantly shifted to the right of the normal reference. The distribution for BW was most markedly shifted to the right. 47% were LGA with a BW ≥90th adjusted percentile. The mean ponderal index (PI) was significantly increased and 46% of LGA infants were disproportionate with a PI ≥90th percentile and thus overweight at birth. A novel and unexpected finding was that fetal macrosomia was more pronounced in preterm and female infants (study ΙΙ). Surprisingly, neonatal outcome was independent of body proportionality in appropriate for gestational age (AGA) and LGA infants. The risk of adverse outcome was significantly increased in LGA compared with AGA infants born at term (study ΙΙΙ). There was a significant interaction between gestational age and body weight with prematurity overriding LGA as a risk factor for neonatal morbidity in moderately preterm infants. In study ΙV, we examined the risk of adverse outcome in relation to pre-pregnancy body mass index in a national cohort of 3,457 T1DM pregnancies compared to 764,498 non-diabetic pregnancies. Maternal overweight/obesity increases the risk of adverse outcome in both women with and without T1DM. Within the T1DM cohort, obesity was associated with increased odds of major malformations adjusted OR: 1.77 (1.18-2.65) and preeclampsia adjusted OR: 1.74 (1.35-2.25). T1DM was a significant effect modifier of the association between BMI and major malformations, preeclampsia, LGA and neonatal overweight. Conclusion: In spite of major improvements in the management of type 1 diabetic pregnancies over the years, the present findings clearly demonstrate that T1DM pregnancies still are associated with significantly increased risk of adverse outcomes. An important observation is the rising incidence of LGA infants, which partly can be attributed to a concomitant increase in maternal BMI. This development is worrying as LGA infants face an excess risk of both perinatal and future complications as compared to normal sized infants. The novel and unexpected finding of a gender difference in fetal macrosomia requires further investigations

Does cardiotocography have a role in the antenatal management of pregnancy complicated by gestational diabetes mellitus?

Background: Controversy surrounds the role of fetal cardiotocography (CTG) in the antenatal management of pregnancy complicated with gestational diabetes mellitus (GDM). Aim: The aim was to investigate whether antenatal CTG aids the management in pregnancy complicated by GDM. Materials and Methods: A prospective audit of 1404 consecutive antenatal CTGs in women diagnosed with GDM. Outcomes for all CTGs were audited to determine if the CTGs altered pregnancy management. Results: In women requiring combination therapy (diet and medication), 43 CTGs were required to change management of a pregnancy. In women managed by diet alone with a secondary pregnancy complication, 161 CTGs were required to change management. In women managed by diet alone with no secondary pregnancy complication, CTGs did not change management. Conclusions: Antenatal CTGs are not recommended in women with GDM managed by diet alone with no secondary pregnancy complication. Antenatal CTGs are recommended in women with GDM who require combination therapy (diet and medication). The role of CTG in women managed by diet alone with a secondary pregnancy complication should be based upon the nature of the complication

Effectiveness of a Regional Prepregnancy Care Program in Women With Type 1 and Type 2 Diabetes: Benefits beyond glycemic control

OBJECTIVE: To implement and evaluate a regional prepregnancy care program in women with type 1 and type 2 diabetes. RESEARCH DESIGN AND METHODS: Prepregnancy care was promoted among patients and health professionals and delivered across 10 regional maternity units. A prospective cohort study of 680 pregnancies in women with type 1 and type 2 diabetes was performed. Primary outcomes were adverse pregnancy outcome (congenital malformation, stillbirth, or neonatal death), congenital malformation, and indicators of pregnancy preparation (5 mg folic acid, gestational age, and A1C). Comparisons were made with a historical cohort (n = 613 pregnancies) from the same units during 1999-2004. RESULTS: A total of 181 (27%) women attended, and 499 women (73%) did not attend prepregnancy care. Women with prepregnancy care presented earlier (6.7 vs. 7.7 weeks; P < 0.001), were more likely to take 5 mg preconception folic acid (88.2 vs. 26.7%; P < 0.0001) and had lower A1C levels (A1C 6.9 vs. 7.6%; P < 0.0001). They had fewer adverse pregnancy outcomes (1.3 vs. 7.8%; P = 0.009). Multivariate logistic regression confirmed that in addition to glycemic control, lack of prepregnancy care was independently associated with adverse outcome (odds ratio 0.2 [95% CI 0.05-0.89]; P = 0.03). Compared with 1999-2004, folic acid supplementation increased (40.7 vs. 32.5%; P = 0.006) and congenital malformations decreased (4.3 vs. 7.3%; P = 0.04). CONCLUSIONS: Regional prepregnancy care was associated with improved pregnancy preparation and reduced risk of adverse pregnancy outcome in type 1 and type 2 diabetes. Prepregnancy care had benefits beyond improved glycemic control and was a stronger predictor of pregnancy outcome than maternal obesity, ethnicity, or social disadvantage

Preconception care of women with diabetes: a review of current guideline recommendations

<p>Abstract</p> <p>Background</p> <p>The prevalence of type 2 diabetes mellitus (T2DM) continues to rise worldwide. More women from developing countries who are in the reproductive age group have diabetes resulting in more pregnancies complicated by T2DM, and placing both mother and foetus at higher risk. Management of these risks is best achieved through comprehensive preconception care and glycaemic control, both prior to, and during pregnancy. The aim of this review was to compare the quality and content of current guidelines concerned with the preconception care of women with diabetes and to develop a summary of recommendations to assist in the management of diabetic women contemplating pregnancy.</p> <p>Methods</p> <p>Relevant clinical guidelines were identified through a search of several databases (MEDLINE, SCOPUS and The Cochrane Library) and relevant websites. Five guidelines were identified. Each guideline was assessed for quality using the AGREE instrument. Guideline recommendations were extracted, compared and contrasted.</p> <p>Results</p> <p>All guidelines were assessed as being of high quality and strongly recommended for use in practice. All were consistent in counselling about the risk of congenital malformation related to uncontrolled blood sugar preconceptionally, ensuring adequate contraception until glycaemic control is achieved, use of HBA1C to monitor metabolic control, when to commence insulin and switching from ACE inhibitors to other antihypertensives. Major differences were in the targets recommended for optimal metabolic control and opinion regarding the usage of metformin as an adjunct or alternative treatment before or during pregnancy.</p> <p>Conclusions</p> <p>International guidelines for the care of women with diabetes who are contemplating pregnancy are consistent in their recommendations; however some are more comprehensive than others. Having established current standards for the preconception care of diabetic women, there is now a need to focus on guideline implementation through an examination of the barriers and enablers to successful implementation, and the applicability of the recommendations in the local setting.</p

Screening of postpartum diabetes in women with gestational diabetes: high-risk subgroups and areas for improvements-the strong observational study

AIMS: To assess the proportion of women with gestational diabetes (GDM) by performing postpartum Oral Glucose Tolerance Test (OGTT) and to identify GDM phenotypes at high-risk of postpartum dysglycemia (PPD).METHODS: Observational, retrospective, multicenter study involving consecutive GDM women. Recursive partitioning (RECPAM) analysis was used to identify distinct and homogeneous subgroups of women at different PPD risk.RESULTS: From a sample of 2,736 women, OGTT was performed in 941 (34.4%) women, of whom 217 (23.0%) developed PPD. Insulin-treated women having family history of diabetes represented the subgroup with the highest PPD risk (OR 5.57, 95% CI 3.60-8.63) compared to the reference class (women on diet with pre-pregnancy BMI&lt;=28.1kg/m2). Insulin-treated women without family diabetes history and women on diet with pre-pregnancy BMI&gt;28.1kg/m2 showed a two-fold PPD risk. Previous GDM and socioeconomic status represent additional predictors. Fasting more than post-prandial glycemia plays a predictive role, with values of 81-87mg/dl (4.5-4.8mmol/l) (lower than the current diagnostic GDM threshold) being associated with PPD risk.CONCLUSIONS: Increasing compliance to postpartum OGTT to prevent/delay PPD is a priority. Easily available characteristics identify subgroups of women more likely to benefit from preventive strategies. Fasting BG values during pregnancy lower than those usually considered deserve attention

Evaluation of the impact of universal testing for gestational diabetes mellitus on maternal and neonatal health outcomes: a retrospective analysis

Background: Gestational diabetes (GDM) affects a substantial proportion of women in pregnancy and is associated with increased risk of adverse perinatal and long term outcomes. Treatment seems to improve perinatal outcomes, the relative effectiveness of different strategies for identifying women with GDM however is less clear. This paper describes an evaluation of the impact of a change in policy from selective risk factor based offering, to universal offering of an oral glucose tolerance test (OGTT) to identify women with GDM on maternal and neonatal outcomes. Methods: Retrospective six year analysis of 35,674 births at the Women’s and Newborn unit, Bradford Royal Infirmary, United Kingdom. Results: The proportion of the whole obstetric population diagnosed with GDM increased almost fourfold following universal offering of an OGTT compared to selective offering of an OGTT; Rate Ratio (RR) 3.75 (95% CI 3.28 to 4.29), the proportion identified with severe hyperglycaemia doubled following the policy change; 1.96 (1.50 to 2.58). The case detection rate however, for GDM in the whole population and severe hyperglycaemia in those with GDM reduced by 50-60%; 0.40 (0.35 to 0.46) and 0.51 (0.39 to 0.67) respectively. Universally offering an OGTT was associated with an increased induction of labour rate in the whole obstetric population and in women with GDM; 1.43 (1.35 to 1.50) and 1.21 (1.00 to1.49) respectively. Caesarean section, macrosomia and perinatal mortality rates in the whole population were similar. For women with GDM, rate of caesarean section; 0.70 (0.57 to 0.87), macrosomia; 0.22 (0.15 to 0.34) and perinatal mortality 0.12 (0.03 to 0.46) decreased following the policy change. Conclusions: Universally offering an OGTT was associated with increased identification of women with GDM and severe hyperglycaemia and with neonatal benefits for those with GDM. There was no evidence of benefit or adverse effects in neonatal outcomes in the whole obstetric population

Preconception Care in International Settings

Objectives: This literature review briefly describes international programs, policies, and activities related to preconception care and resulting pregnancy outcomes. Methods: Electronic databases were searched and findings supplemented with secondary references cited in the original articles as well as textbook chapters, declarations, reports, and recommendations. Results: Forty-two articles, book chapters, declarations, and other published materials were reviewed. Policies, programs, and recommendations related to preconceptional health promotion exist worldwide and comprise a readily identifiable component of historic and modern initiatives pertaining to women's health, reproductive freedom, and child survival. Conclusions: The integration of preconception care services within a larger maternal and child health continuum of care is well aligned with a prevention-based approach to enhancing global health

Dysglycemias in pregnancy: from diagnosis to treatment. Brazilian consensus statement

There is an urgent need to find consensus on screening, diagnosing and treating all degrees of DYSGLYCEMIA that may occur during pregnancies in Brazil, considering that many cases of DYSGLYCEMIA in pregnant women are currently not diagnosed, leading to maternal and fetal complications. For this reason the Brazilian Diabetes Society (SBD) and the Brazilian Federation of Gynecology and Obstetrics Societies (FEBRASGO), got together to introduce this proposal. We present here a joint consensus regarding the standardization of clinical management for pregnant women with any degree of Dysglycemia, on the basis of current information, to improve medical assistance and to avoid related complications of Dysglycemia in pregnancy to the mother and the fetus. This consensus aims to standardize the diagnosis among general practitioners, endocrinologists and obstetricians allowing the dissemination of information in basic health units, public and private services, that are responsible for screening, diagnosing and treating disglycemic pregnant patients