Type 1 diabetes, diabetic nephropathy, and pregnancy: a systematic review and meta-study

BACKGROUND: In the last decade, significant improvements have been achieved in maternal-fetal and diabetic care which make pregnancy possible in an increasing number of type 1 diabetic women with end-organ damage. Optimal counseling is important to make the advancements available to the relevant patients and to ensure the safety of mother and child. A systematic review will help to provide a survey of the available methods and to promote optimal counseling. OBJECTIVES: To review the literature on diabetic nephropathy and pregnancy in type 1 diabetes. METHODS: Medline, Embase, and the Cochrane Library were scanned in November 2012 (MESH, Emtree, and free terms on pregnancy and diabetic nephropathy). Studies were selected that report on pregnancy outcomes in type 1 diabetic patients with diabetic nephropathy in 1980-2012 (i.e. since the detection of microalbuminuria). Case reports with less than 5 cases and reports on kidney grafts were excluded. Paper selection and data extraction were performed in duplicate and matched for consistency. As the relevant reports were highly heterogeneous, we decided to perform a narrative review, with discussions oriented towards the period of publication. RESULTS: Of the 1058 references considered, 34 fulfilled the selection criteria, and one was added from reference lists. The number of cases considered in the reports, which generally involved single-center studies, ranged from 5 to 311. The following issues were significant: (i) the evidence is scattered over many reports of differing format and involving small series (only 2 included over 100 patients), (ii) definitions are non-homogeneous, (iii) risks for pregnancy-related adverse events are increased (preterm delivery, caesarean section, perinatal death, and stillbirth) and do not substantially change over time, except for stillbirth (from over 10% to about 5%), (iv) the increase in risks with nephropathy progression needs confirmation in large homogeneous series, (v) the newly reported increase in malformations in diabetic nephropathy underlines the need for further studies. CONCLUSIONS: The heterogeneous evidence from studies on diabetic nephropathy in pregnancy emphasizes the need for further perspective studies on this issue

The role of antenatal education for the prevention of excessive weight gain during pregnancy

BACKGROUND: Excessive weight gain (EWG) during pregnancy is associated to adverse maternal-fetal outcomes. The aim of this study was to analyze the situation in a single high intensity care center in Eastern Piedmont, north of Italy. METHODS: This is a cohort study including 715 patients classified into four classes corresponding to pregestational BMI values. Based on the WHO's weight gain for each class, women were subdivided into three groups: Inadequate, adequate and excessive increase. RESULTS: EWG was significant in overweight (43.9%) and obese women (37.3%). There was a significant correlation with gestational diabetes (P=0.046), hypertension (P=0.0001), preterm birth (P=0.047), intake of antihypertensive drugs (P=0.0001), maternal study degree (P=0.005), profession (P=0.015), civil status (P=0.003), parity (P=0.039) and paternal ethnicity (P=0.027). Participation at antenatal education for childbirth (AEC) had a positive impact leading to an appropriate weight gain (P=0.004). CONCLUSIONS: If adequately counselled, women understand the consequences of excessive weight gain during pregnancy, comply more to therapy and modify their lifestyle

Preventing the human factor: organizational aspects linked to fetal asphyxia

BACKGROUND: Perinatal asphyxia can cause cerebral palsy and hypoxic-ischemic encephalopathy. They are public health problems because they cause permanent disability.METHODS: This is a retrospective, analytical, observational study. Overall, 162 cases of mothers whose children experienced fetal asphyxia were compared to 361 controls where this condition did not occur. The variables analyzed were classified as: prepartum, intrapartum and organizational.RESULTS: Assisted reproductive technology obtained pregnancies, smoking, maternal body mass index, lack of one-toone assistance during labor, birth on a day of high-volume activity increased the risk of fetal asphyxia, as well as other traditionally linked factors like shoulder dystocia or age over 35 years.CONCLUSIONS: Cerebral palsy cannot always be prevented because it is a syndrome with a multitude of potential causes. But a small number of cases is likely to be linked to acute intrapartum events that could be limited by changing organizational policies such as staff training and implementing teamwork and discussion. Our paper proposes strategies to try and modify organizational risk factors and therefore limit the incidence of fetal asphyxia