Insulin-requiring diabetes in pregnancy: a randomized trial of active induction of labor and expectant management

Maternal and neonatal outcomes in electively induced low-risk term pregnancies

OBJECTIVE

Elective induction of labor has been discouraged over concerns regarding increased complications. We evaluated the mode of delivery and maternal and neonatal morbidities in low-risk patients whose labor was electively induced or expectantly managed at term.

STUDY DESIGN

This was a retrospective cross-sectional study from 12 US institutions (19 hospitals), 2002 through 2008 (Safe Labor Consortium). Healthy women with viable, vertex singleton pregnancies at 37-41 weeks of gestation were included. Women electively induced in each week were compared with women managed expectantly. The primary outcome was mode of delivery.

RESULTS

Of 131,243 low-risk deliveries, 13,242 (10.1%) were electively induced. The risk of cesarean delivery was lower at each week of gestation with elective induction vs expectant management regardless of parity and modified Bishop score (for unfavorable nulliparous patients at: 37 weeks = 18.6% vs 34.2%, adjusted odds ratio, 0.40; [95% confidence interval, 0.18-0.88]; 38 weeks = 28.4% vs 35.4%, 0.65 [0.49-0.85]; 39 weeks = 23.6% vs 38.5%, 0.47 [0.38-0.57]; 40 weeks = 32.3% vs 42.3%, 0.70 [0.59-0.81]). Maternal infections were significantly lower with elective inductions. Major, minor, and respiratory neonatal morbidity composites were lower with elective inductions at ≥38 weeks (for nulliparous patients at: 38 weeks = adjusted odds ratio, 0.43; [95% confidence interval, 0.26-0.72]; 39 weeks = 0.75 [0.61-0.92]; 40 weeks = 0.65 [0.54-0.80]).

CONCLUSION

Elective induction of labor at term is associated with decreased risks of cesarean delivery and other maternal and neonatal morbidities compared with expectant management regardless of parity or cervical status on admission.

Diabetes in pregnancy: timing and mode of delivery

Diabetes in pregnancy represents a risk condition for adverse maternal and feto-neonatal outcomes and many of these complications might occur during labor and delivery. In this context, the obstetrician managing women with pre-existing and gestational diabetes should consider (1) how these conditions might affect labor and delivery outcomes; (2) what are the current recommendations on management; and (3) which other factors should be considered to decide about the timing and mode of delivery. The analysis of the studies considered in this review leads to the conclusion that the decision to deliver should be primarily intended to reduce the risk of stillbirth, macrosomia, and shoulder dystocia. In this context, this review provides useful information for managing specific subgroups of diabetic women that may present overlapping risk factors, such as women with insulin-requiring diabetes and/or obesity and/or prenatal suspicion of macrosomic fetus. To date, the lack of definitive evidences and the complexity of the problem suggest that the "appropriate" clinical management should be customized according with the clinical condition, the type and mode of intervention, its consequences on outcomes, and considering the woman's consent and informed decisions.

Elective induction of labor in women with gestational diabetes mellitus: an intervention that modifies the risk of cesarean section

AIM

To evaluate the effect of elective induction at term for women with gestational diabetes mellitus (GDM) on the risk for cesarean delivery.

STUDY DESIGN

This is a retrospective case-control matched study, based on a single-center computerized database, 2005-2011. The medical records were reviewed for GDM management and glycemic control. For the study, two groups were defined: Group 1, women diagnosed with GDM with an estimated fetal weight <4,000 g, electively induced at term; Group 2, women induced due to Term-PROM, an indication for term induction in normoglycemic women with uncomplicated pregnancies, matched for age and parity (ratio 1:2). The primary outcome was cesarean delivery and secondary outcomes included other maternal and neonatal events. Descriptive analyses and multivariate analyses models were fitted.

RESULTS

GDM was diagnosed in 1,873 (2.6 %) women of 72,374 births; 227 (12.1 %) were eligible for inclusion in Group 1 and matched with 454 women in Group 2. GDM management included diet in 103 (45.4 %), insulin in 81 (35.7 %), and oral hypoglycemic agents in 43 (18.9 %).The cesarean delivery rate was significantly higher in Group 1, 17.1 vs. 11.2 % (p = 0.02). Three out of four births complicated by shoulder dystocia and BW <4,000 g, occurred in Group 1 (p = 0.076) and were associated with no glycemic control. Other obstetrical-related outcomes such as instrumental birth, severe perineal tears, early postpartum hemorrhage and peripartum transfusion were similar between groups.

CONCLUSION

Elective induction at term for women with GDM is associated with an increased risk for cesarean delivery as compared to other elective induction of labor.

Screening, diagnosis and management of gestational diabetes mellitus: A national survey

BACKGROUND AND METHODS

We conducted a National survey between February and June 2012 to evaluate the practices concerning screening, diagnosis and management of Gestational Diabetes (GDM) in England.

RESULTS

A total of 102/126 (80%) maternity units responded. The National Institute of Health and Clinical Excellence (NICE) recommended screening criteria were used by 83% of units. All the units performed 2 h 75 g oral glucose tolerance test (OGTT) between 24 and 28 weeks. There was a wide variation in the diagnostic blood glucose values used by different units. About 86% of units used a 2 h blood glucose value of ≥7.8 mmol/l and 45% of units used fasting value ≥6.1 mmol/l to diagnose GDM. Only 26% of units advised self-monitoring of blood glucose pre meal and 1 h post-meal, whereas 64% of units advised monitoring 2 h after the meal. Metformin was started when women did not respond to dietary measures in 101 units (99%). Regular growth scans every four weeks from 28 weeks onwards were performed by 99 units (97%). Women on metformin with no complications were offered induction of labour at 38 completed weeks in 97 units (95%). 84 maternity units (82.3%) offered OGTT six weeks postnatally.

CONCLUSION

Our survey has shown consistency in screening using the NICE criteria, use of 2 h 75 g OGTT at 24-28 weeks, in providing dietary support, use of metformin and ultrasound for fetal growth. But there is wide variation in the criteria used to diagnose GDM, self-monitoring of blood glucose, induction of labour and six weeks postnatal testing.

Use of labour induction and risk of cesarean delivery: a systematic review and meta-analysis

BACKGROUND

Induction of labour is common, and cesarean delivery is regarded as its major complication. We conducted a systematic review and meta-analysis to investigate whether the risk of cesarean delivery is higher or lower following labour induction compared with expectant management.

METHODS

We searched 6 electronic databases for relevant articles published through April 2012 to identify randomized controlled trials (RCTs) in which labour induction was compared with placebo or expectant management among women with a viable singleton pregnancy. We assessed risk of bias and obtained data on rates of cesarean delivery. We used regression analysis techniques to explore the effect of patient characteristics, induction methods and study quality on risk of cesarean delivery.

RESULTS

We identified 157 eligible RCTs (n = 31,085). Overall, the risk of cesarean delivery was 12% lower with labour induction than with expectant management (pooled relative risk [RR] 0.88, 95% confidence interval [CI] 0.84-0.93; I(2) = 0%). The effect was significant in term and post-term gestations but not in preterm gestations. Meta-regression analysis showed that initial cervical score, indication for induction and method of induction did not alter the main result. There was a reduced risk of fetal death (RR 0.50, 95% CI 0.25-0.99; I(2) = 0%) and admission to a neonatal intensive care unit (RR 0.86, 95% CI 0.79-0.94), and no impact on maternal death (RR 1.00, 95% CI 0.10-9.57; I(2) = 0%) with labour induction.

INTERPRETATION

The risk of cesarean delivery was lower among women whose labour was induced than among those managed expectantly in term and post-term gestations. There were benefits for the fetus and no increased risk of maternal death.

Timing of delivery in women with diabetes in pregnancy

The incidence of both gestational and pre-gestational diabetes is increasing worldwide. The main cause of this increase is likely the concomitant increase in the incidence of global obesity, but in the case of gestational diabetes, changes in the diagnostic criteria are also a contributing factor. The adverse outcomes associated with pre-gestational diabetes are well known and have led clinicians to implement various strategies that include increased fetal surveillance and induction of labour at various gestational ages. In many cases these same strategies have been applied in clinical practice also to women with gestational diabetes despite there being differences in the type and magnitude of perinatal complications associated with this diagnosis. Despite the widespread application of these clinical practices, there is a paucity of quality data in the medical literature to guide the clinician in choosing a strategy for fetal surveillance and timing of delivery in both gestational diabetes and pre-gestational diabetes pregnancies. In the following review, we will discuss the rationale and consequences of planned delivery in gestational diabetes and pre-gestational diabetes, the evidence supporting different strategies for delivery and finally highlight future targets for research in this area.

Does induction of labour increase the risk of caesarean section? A systematic review and meta-analysis of trials in women with intact membranes

BACKGROUND

Recent literature on the effect of induction of labour (compared with expectant management) has provided conflicting results. Reviews of observational studies generally report an increase in the rate of caesarean section, whereas reviews of post-dates and term prelabour rupture of membrane (PROM trials suggest either no difference or a reduction in risk.

OBJECTIVE

To evaluate with a systematic review and meta-analysis of randomised controlled trials (RCTs) whether or not the induction of labour increases the risk of caesarean section in women with intact membranes.

SEARCH STRATEGY

Literature search using electronic databases: MEDLINE, EMBASE, and the Cochrane Database of Clinical Trials.

SELECTION CRITERIA

RCTs comparing a policy of induction of labour with expectant management in women with intact membranes.

DATA COLLECTION AND ANALYSIS

A total of 37 trials were identified and reviewed. Quantitative analyses with fixed- and random-effects models were performed with revman 5.1.

MAIN RESULTS

Of the 37 RCTs, 27 were trials of uncomplicated pregnancies at 37-42 weeks of gestation. The remaining ten evaluated induction versus expectant management in pregnancies with suspected macrosomia (two), diabetes in pregnancy (one), oligohydramnios (one), twins (two), intrauterine growth restriction (IUGR) (two), mild pregnancy-induced hypertension (PIH) (one), and women with a high-risk score for caesarean section (one). Meta-analysis of 31 trials determined that a policy of induction was associated with a reduction in the risk of caesarean section compared with expectant management (OR 0.83, 95% CI 0.76-0.92).

AUTHOR'S CONCLUSIONS

Induction of labour in women with intact membranes reduces the risk of caesarean section. Review of the trials suggests that this effect may arise from non-treatment effects, and that additional trials are needed.

Gestational diabetes mellitus

Gestational diabetes mellitus is one of the most common medical problems that results from an increase in the insulin resistance as well as an impairment of the compensatory increase in insulin secretion from the beta cells of the pancreas. It serves as a metabolic stress test that uncovers underlying insulin resistance and beta-cell dysfunction. Gestational diabetes is associated with a variety of maternal and fetal complications, most notably macrosomia. Controversy surrounds the ideal approach for detecting gestational diabetes, andthe approaches recommended for screening and diagnosis are largely based on expert opinion. Controlling maternal glycemia with Medical Nutrition Therapy, close monitoring of blood glucose levels and treatment with insulin if blood glucose levels are not at goal has been shown to decrease fetal and maternal morbidities. Other treatment modalities, such as oral agents, need further study to validate their safety and efficacy. Finally, postpartum management of women with Gestational diabetes is critical because of their markedly increased risk of Type 2 diabetes in the future. Efforts should be made to prevent gestational diabetes in subsequent pregnancies. Because body fat and diet contribute to the risk of gestational diabetes mellitus, patients who lose weight before pregnancy and follow an appropriate diet may lower their risk of gestational diabetes mellitus.

Gestational diabetes mellitus

Gestational diabetes mellitus (GDM) represents a heterogeneous group of metabolic disorders, which result in varying degrees of maternal hyperglycemia and pregnancy-associated risk. The frequency of GDM is rising globally and may also increase further as less-stringent criteria for the diagnosis are potentially adopted. The additional burden placed on the health care system by increasing cases of GDM requires consideration of diagnostic approaches and currently used treatment strategies. Debate continues to surround both the diagnosis and treatment of GDM despite several recent large-scale studies addressing these controversial issues. As many now have come to reassess their approach to the management of GDM, we provide information in this review to help guide this process. The goal for each health care practitioner should continue to be to provide optimum care for women discovered to have carbohydrate intolerance during pregnancy.

[Prediction, prevention and management of shoulder dystocia]

Shoulder dystocia is one of the most tragic, fatal and unexpected obstetrical events, which is mostly unpredictable and unpreventable. This clinical picture is defined as a delivery that requires additional obstetric maneuvers to release the shoulders after gentle downward traction has failed. Shoulder dystocia occurs when the fetal shoulder impacts on the maternal symphysis or sacral promontory. The incidence of shoulder dystocia is 0.2-0.6%. High perinatal mortality and morbidity is associated with the condition, even when it is managed appropriately. Obstetricians should be aware of the existing risk factors, but should always be alert to the possibility of shoulder dystocia in all labors. Maternal morbidity is also increased, particularly postpartum hemorrhage, rupture of the uterus, injury of the bladder, urethra and the bowels and fourth-degree perineal tears. Complications of the newborn include asphyxia, perinatal mortality, fracture of the clavicula and the humerus. Brachial plexus injuries are one of the most important fetal complications of shoulder dystocia, complicating 4-16% of such deliveries. The purpose of this article is to review the current evidence regarding the possible prediction, prevention and management of shoulder dystocia.

Failed induction of labor: strategies to improve the success rates

The rates of induction of labor (IOL) are rising all over the world. In developed countries, one of every 4 babies is born after IOL at term. The recent World Health Organization guidelines on IOL recommend that failure of induction does not necessitate cesarean delivery [WHO recommendations for induction of labor. World Health Organization, 2011]. These guidelines come when there are concerns that failed primary inductions in nulliparous women, which have led to escalation of the cesarean delivery rates. Obstetricians must recognize the risks associated with IOL (including failure and need for cesarean delivery) and avoid inductions for borderline indications, which are not evidence based. The issue of "failed induction of labor" is topical, and there is a need to define this entity and offer alternatives to cesarean delivery in the management of this group of women. Research is required to develop a test to accurately identify those fetuses most at risk of morbidity or stillbirth who would truly benefit from an early IOL and assess the cost-effectiveness of policies of routine IOL. In this review, we summarized the current recommendations for best practice in the area of IOL, defined "failed induction," and described options to improve the success rate after "failed primary induction of labor."

TARGET AUDIENCE

Obstetricians & Gynecologists and Family Physicians.

LEARNING OBJECTIVES

After the completing the CME activity, physicians should be better able to classify the factors determining success or failure of induction of labor, counsel women about risks and benefits of various methods of induction of labor, and compare the options of management available after failed primary induction of labor.

The risk of stillbirth and infant death stratified by gestational age in women with gestational diabetes

OBJECTIVE

We sought to compare the different mortality risks between delivery and expectant management in women with gestational diabetes mellitus (GDM).

STUDY DESIGN

This is a retrospective cohort study that included singleton pregnancies of women diagnosed with GDM delivering at 36-42 weeks' gestational age in California from 1997 through 2006. A composite mortality rate was developed to estimate the risk of expectant management at each gestational age incorporating the stillbirth risk during the week of continuing pregnancy plus the infant mortality risk at the gestational age 1 week hence.

RESULTS

In women with GDM, the risk of expectant management is lower than the risk of delivery at 36 weeks (17.4 vs 19.3/10,000), but at 39 weeks, the risk of expectant management exceeds that of delivery (relative risk, 1.8; 95% confidence interval, 1.2-2.6).

CONCLUSION

In women with GDM, infant mortality rates at 39 weeks are lower than the overall mortality risk of expectant management for 1 week; absolute risks of stillbirth and infant death are low.

Diagnosis and treatment of hyperglycemia in pregnancy

Hyperglycemia in pregnancy is an opportunity for women at risk for complications during pregnancy and beyond to change their life course to improve outcomes for themselves and their offspring. Providers of diabetes care during pregnancy complicated by hyperglycemia in pregnancy have the unique opportunity to make a significant difference.

Timing of indicated late preterm and early-term birth in chronic medical complications: diabetes

The number of pregnant women who have type 2 diabetes and the number found to have gestational diabetes are progressively increasing. In the future, as many as 20% of pregnant women may be diagnosed with diabetes. Although there is consensus regarding many issues in the treatment of pregnant women with diabetes, there are few evidenced-based studies upon which to base the timing of delivery. There must be a balance between increased neonatal morbidity of late preterm and early-term delivery and fetal mortality. Potential adverse outcomes associated with late preterm and early-term delivery include respiratory problems as well as other metabolic dysfunctions characteristic of the preterm infant of a mother with diabetes. Delivery at term increases the risk of fetal demise, fetal overgrowth, and birth injury. Even among diabetic women who practice good glycemic control, the risk of intrauterine fetal demise in third trimester appears greater than that of neonatal death. Additional prospective data are urgently needed to better understand the short and long-term risks and benefits of the timing of delivery in this very common obstetrical dilemma.

"GINEXMAL RCT: Induction of labour versus expectant management in gestational diabetes pregnancies"

BACKGROUND

Gestational diabetes (GDM) is one of the most common complications of pregnancies affecting around 7% of women. This clinical condition is associated with an increased risk of developing fetal macrosomia and is related to a higher incidence of caesarean section in comparison to the general population. Strong evidence indicating the best management between induction of labour at term and expectant monitoring are missing.

METHODS/DESIGN

Pregnant women with singleton pregnancy in vertex presentation previously diagnosed with gestational diabetes will be asked to participate in a multicenter open-label randomized controlled trial between 38+0 and 39+0 gestational weeks. Women will be recruited in the third trimester in the outpatient clinic or in the Day Assessment Unit according to local protocols. Women who opt to take part will be randomized according to induction of labour or expectant management for spontaneous delivery. Patients allocated to the induction group will be admitted to the obstetric ward and offered induction of labour via use of prostaglandins, Foley catheter or oxytocin (depending on clinical conditions). Women assigned to the expectant arm will be sent to their domicile where they will be followed up until delivery, through maternal and fetal wellbeing monitoring twice weekly. The primary study outcome is the Caesarean section (C-section) rate, whilst secondary measurements are maternal and neonatal outcomes. A total sample of 1760 women (880 each arm) will be recruited to identify a relative difference between the two arms equal to 20% in favour of induction, with concerns to C-section rate. Data will be collected until mothers and newborns discharge from the hospital. Analysis of the outcome measures will be carried out by intention to treat.

DISCUSSION

The present trial will provide evidence as to whether or not, in women affected by gestational diabetes, induction of labour between 38+0 and 39+0 weeks is an effective management to ameliorate maternal and neonatal outcomes. The primary objective is to determine whether caesarean section rate could be reduced among women undergoing induction of labour, in comparison to patients allocated to expectant monitoring. The secondary objective consists of the assessment and comparison of maternal and neonatal outcomes in the two study arms. .

Intravenous oxytocin alone for cervical ripening and induction of labour

BACKGROUND

Oxytocin is the commonest induction agent used worldwide. It has been used alone, in combination with amniotomy or following cervical ripening with other pharmacological or non-pharmacological methods.

OBJECTIVES

To determine the effects of oxytocin alone for third trimester cervical ripening and induction of labour in comparison with other methods of induction of labour or placebo/no treatment.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (January 2009) and bibliographies of relevant papers.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing intravenous oxytocin with placebo or no treatment, or with prostaglandins (vaginal or intracervical) for third trimester cervical ripening or labour induction.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility and carried out data extraction.

MAIN RESULTS

Sixty-one trials (12,819 women) are included.When oxytocin inductions were compared with expectant management, fewer women failed to deliver vaginally within 24 hours (8.4% versus 53.8%, risk ratio (RR) 0.16, 95% confidence interval (CI) 0.10 to 0.25). There was a significant increase in the number of women requiring epidural analgesia (RR 1.10, 95% CI 1.04 to 1.17). Fewer women were dissatisfied with oxytocin induction in the one trial reporting this outcome (5.9% versus 13.7%, RR 0.43, 95% CI 0.33 to 0.56).Compared with vaginal prostaglandins, oxytocin increased unsuccessful vaginal delivery within 24 hours in the two trials reporting this outcome (70% versus 21%, RR 3.33, 95% CI 1.61 to 6.89). There was a small increase in epidurals when oxytocin alone was used (RR 1.09, 95% CI 1.01 to 1.17).Most of the studies included women with ruptured membranes, and there was some evidence that vaginal prostaglandin increased infection in mothers (chorioamnionitis RR 0.66, 95% CI 0.47 to 0.92) and babies (use of antibiotics RR 0.68, 95% CI 0.53 to 0.87). These data should be interpreted cautiously as infection was not pre-specified in the original review protocol.When oxytocin was compared with intracervical prostaglandins, there was an increase in unsuccessful vaginal delivery within 24 hours (50.4% versus 34.6%, RR 1.47, 95% CI 1.10 to 1.96) and an increase in caesarean sections (19.1% versus 13.7%, RR 1.37, 95% CI 1.08 to 1.74) in the oxytocin group.

AUTHORS' CONCLUSIONS

Comparison of oxytocin with either intravaginal or intracervical PGE2 reveals that the prostaglandin agents probably increase the chances of achieving vaginal birth within 24 hours. Oxytocin induction may increase the rate of interventions in labour.A suggestion that for women with prelabour rupture of membranes induction with vaginal prostaglandin may increase risk of infection for mother and baby warrants further study.

Independent predictors of Cesarean delivery in women with diabetes

OBJECTIVES

To identify independent risk factors for Cesarean delivery in women with pregnancy complicated by diabetes.

METHODS

Retrospective analysis of pregnancies from 5735 diabetic women delivering liveborn infants. Maternal demographic, medical, obstetric historical factors and index pregnancy obstetric, glycemic and neonatal outcome parameters were evaluated for association with Cesarean delivery after a trial of labor. Individual risk factors were analyzed for association by chi2 and ANOVA. Independent predictors of Cesarean delivery and adjusted relative risk (RR) were identified by stepwise logistic regression.

RESULTS

Trial of labor was permitted in 90.8% and 59.4% of women without (n = 4643) and with prior Cesarean delivery (n = 1092) and was successful in 85.2% and 56.9%, respectively. Eleven independent predictors were found. Five were related to obstetric history and maternal age: prior Cesarean delivery (RR 5.34, 95% CI 3.94-7.25), no prior live birth (RR 3.17, 95% CI 1.98-5.07), no prior vaginal delivery (RR 2.28, 95% CI 1.50-3.44), prior stillbirth (RR 1.71, 95% CI 1.09-2.68%) and maternal age > or = 35 years (RR 1.53, 95% CI 1.20-1.93). Two were related to the severity of diabetes at entry to diabetes care: requiring insulin (RR 1.53, 95% CI 1.20-1.93) and highest fasting plasma glucose level (RR 1.04, 95% CI 1.01-1.07). Two were related to obstetric factors: pre-eclampsia/hypertension (RR 2.56, 95% CI 2.00-3.27) and labor induction (RR 3.32, 95% CI 2.70-4.10). The remaining two were birth weight (per 250 g, RR 1.12, 95% CI 1.09-1.17) and pre-delivery body mass index (RR, 1.03, 95% CI 1.00-1.05).

CONCLUSION

The majority of predictors were not modifiable, relating to obstetric history, maternal age and diabetes severity. Possible modifiable interventions to avoid/improve labor induction, and decrease birth weight and maternal weight gain might decrease risk of Cesarean delivery. Future studies must address these multiple predictors.

Consequences of routine delivery at 38 weeks for A-2 gestational diabetes

OBJECTIVE

To report our intrapartum experience with routine delivery at 38 weeks of gestation of A-2 diabetic pregnancies requiring primarily oral hypoglycemic therapy.

METHODS

This retrospective study consisted of 143 consecutive women with gestational diabetes not controlled with diet alone (A-2). Each underwent a routine trial of labor at 38 weeks of gestation. The preinduction condition of the cervix, need for oxytocin, and primary cesarean rates were primary endpoints. For comparison, a control group during that same period consisted of 137 consecutive diet-controlled diabetic (A-1) pregnancies with the same eligibility criteria who underwent expectant management at 38 weeks.

RESULTS

The study group was more likely to have an unfavorable cervix (75% versus 45%; p < 0.001) and to require oxytocin (76% versus 56%; p < 0.001). Early onset meconium was less common in the study group (3.5% versus 13.1%; p < 0.01). Primary cesarean rates were low and not different between the study and control groups (12.7% versus 11.7%; p < 0.8). The only stillbirth was in the control group and was associated with a tight double nuchal cord encirclement. Mean birth weights and the frequency of birth weights > 4000 g were not different between groups. Shoulder dystocia, low Apgar scores, and admissions to the special care nursery were infrequent in either group. No respiratory difficulties requiring resuscitation or prolonged nursery care were encountered.

CONCLUSION

Routine delivery at 38 weeks in an A-2 diabetic population is not associated with additional intrapartum morbidity or a greater need for cesarean delivery.

Weekly compared with daily blood glucose monitoring in women with diet-treated gestational diabetes

OBJECTIVE

To estimate whether daily blood glucose self-monitoring reduces macrosomia when compared with weekly office testing in women with gestational diabetes.

METHODS

Between January 1991 and December 1997, standard treatment at our hospital for women with diet-treated gestational diabetes included routine office monitoring of fasting blood glucose. Beginning in January 1998, blood glucose self-monitoring (four times daily) became the standard management. Women with diet-treated gestational diabetes who underwent routine office-based monitoring of fasting glucose values were compared with similar women who used blood glucose self-monitoring. The outcomes of interest were birthweight at or above 4,000 g and large for gestational age (LGA) in relation to the method of blood glucose self-monitoring.

RESULTS

A total of 315 women used daily blood glucose self-monitoring, and they were compared with 675 women with weekly office-based glucose testing. Women with daily blood glucose self-monitoring had fewer macrosomic (29.5% compared with 21.9%, P=.013) and LGA neonates (34.4% compared with 23.1%, P < or = .001) and gained significantly less weight (median 0.56, interquartile range 0.22-1.08 lb per week compared with 0.74, interquartile range 0.33-1.17 lb per week, P=.009).

CONCLUSION

Daily blood glucose self-monitoring, compared with weekly office-based testing, is associated with a reduction in the incidence of macrosomia.

LEVEL OF EVIDENCE

II.

Reducing stillbirths: interventions during labour

BACKGROUND

Approximately one million stillbirths occur annually during labour; most of these stillbirths occur in low and middle-income countries and are associated with absent, inadequate, or delayed obstetric care. The low proportion of intrapartum stillbirths in high-income countries suggests that intrapartum stillbirths are largely preventable with quality intrapartum care, including prompt recognition and management of intrapartum complications. The evidence for impact of intrapartum interventions on stillbirth and perinatal mortality outcomes has not yet been systematically examined.

METHODS

We undertook a systematic review of the published literature, searching PubMed and the Cochrane Library, of trials and reviews (N = 230) that reported stillbirth or perinatal mortality outcomes for eight interventions delivered during labour. Where eligible randomised controlled trials had been published after the most recent Cochrane review on any given intervention, we incorporated these new trial findings into a new meta-analysis with the Cochrane included studies.

RESULTS

We found a paucity of studies reporting statistically significant evidence of impact on perinatal mortality, especially on stillbirths. Available evidence suggests that operative delivery, especially Caesarean section, contributes to decreased stillbirth rates. Induction of labour rather than expectant management in post-term pregnancies showed strong evidence of impact, though there was not enough evidence to suggest superior safety for the fetus of any given drug or drugs for induction of labour. Planned Caesarean section for term breech presentation has been shown in a large randomised trial to reduce stillbirths, but the feasibility and consequences of implementing this intervention routinely in low-/middle-income countries add caveats to recommending its use. Magnesium sulphate for pre-eclampsia and eclampsia is effective in preventing eclamptic seizures, but studies have not demonstrated impact on perinatal mortality. There was limited evidence of impact for maternal hyperoxygenation, and concerns remain about maternal safety. Transcervical amnioinfusion for meconium staining appears promising for low/middle income-country application according to the findings of many small studies, but a large randomised trial of the intervention had no significant impact on perinatal mortality, suggesting that further studies are needed.

CONCLUSION

Although the global appeal to prioritise access to emergency obstetric care, especially vacuum extraction and Caesarean section, rests largely on observational and population-based data, these interventions are clearly life-saving in many cases of fetal compromise. Safe, comprehensive essential and emergency obstetric care is particularly needed, and can make the greatest impact on stillbirth rates, in low-resource settings. Other advanced interventions such as amnioinfusion and hyperoxygenation may reduce perinatal mortality, but concerns about safety and effectiveness require further study before they can be routinely included in programs.

Gestational diabetes mellitus: developments in diagnosis and treatment

After many years of uncertainty regarding the true pathological nature of mild gestational diabetes and the possible benefits of treatment, the situation appears to have been resolved by the publication of the Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS). It is now appropriate for obstetric units to review their treatment and screening programs for gestational diabetes mellitus. Furthermore, with the publication of the Metformin in Gestational Diabetes (MiG) trial, consideration should be given as to whether metformin should be the first choice when diet fails to maintain glycemic control.

Active compared with expectant delivery management in women with gestational diabetes: a systematic review

OBJECTIVE

We conducted a systematic review to estimate benefits and harms of the choice of timing of induction or elective cesarean delivery based on estimated fetal weight or gestational age in women with gestational diabetes mellitus (GDM).

DATA SOURCES

An electronic literature search was performed using MEDLINE, EMBASE, the Cumulative Index to Nursing and Allied Health Literature, and The Cochrane Central Register of Controlled Trials from inception to January 2007.

METHODS OF STUDY SELECTION

Two investigators independently reviewed titles and abstracts, assessed article quality, and abstracted data. Maternal outcomes included cesarean delivery and operative vaginal delivery. Neonatal outcomes included birth weight, macrosomia, large for gestational age, shoulder dystocia, birth trauma, neonatal intensive care admissions, and perinatal mortality.

TABULATION, INTEGRATION, AND RESULTS

Five studies met our inclusion criteria: one randomized controlled trial (RCT) and four observational studies. The RCT (n=200) compared the effect of labor induction at term with expectant management. The proportion of newborns with birth weight greater than the 90th percentile was significantly greater in the expectant-management group (23% compared with 10% with active induction, P=.02); there were no significant differences in rates of cesarean delivery, shoulder dystocia, neonatal hypoglycemia, or perinatal deaths. The four observational studies suggest a potential reduction in macrosomia and shoulder dystocia with labor induction and cesarean delivery for estimated fetal weight indications, but there was insufficient evidence to assess other clinical outcomes.

CONCLUSION

Active rather than expectant management of labor at term for women with GDM may reduce rates of macrosomia and related complications. Further RCTs and observational studies with a broader range of outcomes are needed for sufficient evidence to inform clinical practice.

Indications for induction of labour: a best-evidence review

BACKGROUND

Rates of labour induction are increasing.

OBJECTIVES

To review the evidence supporting indications for induction.

SEARCH STRATEGY

We listed indications for labour induction and then reviewed the evidence. We searched MEDLINE and the Cochrane Library between 1980 and April 2008 using several terms and combinations, including induction of labour, premature rupture of membranes, post-term pregnancy, preterm prelabour rupture of membranes (PROM), multiple gestation, suspected macrosomia, diabetes, gestational diabetes mellitus, cardiac disease, fetal anomalies, systemic lupus erythematosis, oligohydramnios, alloimmunization, rhesus disease, intrahepatic cholestasis of pregnancy (IHCP), and intrauterine growth restriction (IUGR). We performed a review of the literature supporting each indication.

SELECTION CRITERIA

We identified 1387 abstracts and reviewed 418 full text articles. We preferentially included high-quality systematic reviews or large randomised trials. Where no such studies existed, we included the best evidence available from smaller randomised trials and observational studies.

MAIN RESULTS

We included 34 full text articles. For each indication, we assigned levels of evidence and grades of recommendation based upon the GRADE system. Recommendations for induction of labour for post-term gestation, PROM at term, and premature rupture of membranes near term with pulmonary maturity are supported by the evidence. Induction for IUGR before term reduces intrauterine fetal death, but increases caesarean deliveries and neonatal deaths. Evidence is insufficient to support induction for women with insulin-requiring diabetes, twin gestation, fetal macrosomia, oligohydramnios, cholestasis of pregnancy, maternal cardiac disease and fetal gastroschisis.

AUTHORS' CONCLUSIONS

Research is needed to determine risks and benefits of induction for many commonly advocated clinical indications.

Gestational diabetes: diagnosis and management

PURPOSE

To review the diagnosis and management of gestational diabetes.

EPIDEMIOLOGY

In the United States, approximately 2 to 5% of all pregnant women have gestational diabetes. Those women with a family history of type 2 diabetes mellitus, Asian or native American race, Latina ethnicity or obesity are at higher risk for developing gestational diabetes.

CONCLUSION

Women with gestational diabetes who are treated appropriately can achieve good outcomes in the majority of pregnancies. Frequent blood glucose monitoring, nutrition counseling and frequent physician contact allow for individualized care to achieve optimal outcomes. Such treatment includes diet, exercise and insulin. The use of oral hypoglycemic agents is controversial and there is some concern about worse maternal and neonatal outcomes as compared to treatment with insulin. Evolving technologies promise to provide more therapeutic options.

GESTATIONAL DIABETES MELLITUS

Gestational diabetes (GDM) is defined as “carbohydrate intolerance of variable severity with onset or first recognition during pregnancy.” The definition is applicable regardless of whether insulin is used for treatment or the condition persists after pregnancy. It does not exclude the possibility that unrecognized glucose intolerance may have antedated the pregnancy”. GDM complicates 3–15% of all pregnancies and is a major cause of perinatal morbidity and mortality, as well as maternal long term morbidity. Of all types of diabetes, gestational diabetes (GDM) accounts for approximately 90–95% of all cases of diabetes in pregnancy.

The impact of the active management of risk in pregnancy at term on birth outcomes: a randomized clinical trial

OBJECTIVE

The purpose of this study was to compare birth outcomes that result from the active management of risk in pregnancy at term (AMOR-IPAT) to those outcomes that result from standard management.

STUDY DESIGN

This was a randomized clinical trial with 270 women of mixed parity. AMOR-IPAT used preventive labor induction to ensure delivery before the end of an estimated optimal time of delivery. Rates of 4 adverse obstetric events and 2 composite measures were used to evaluate birth outcomes.

RESULTS

The AMOR-IPAT-exposed group had a similar cesarean delivery rate (10.3% vs 14.9%; P = .25), but a lower neonatal intensive care unit admission rate (1.5% vs 6.7%; P = .03), a higher uncomplicated vaginal birth rate (73.5% vs 62.8%; P = .046), and a lower mean Adverse Outcome Index score (1.4 vs 8.6; P = .03).

CONCLUSION

AMOR-IPAT exposure improved the pattern of birth outcomes. Larger randomized clinical trials are needed to explore further the impact of AMOR-IPAT on birth outcomes and to determine the best methods of preventive labor induction.

Diabetes in pregnancy: a review of current evidence

PURPOSE OF REVIEW

There is controversy about the best approach to screening and management for gestational diabetes. In the recent Confidential Enquiry in Maternal and Child Health (CEMACH) the outcome of women with diabetes compared with women without diabetes. The results were exceptionally poor, suggesting the need for a new management approach. The aim of this review is to address these findings and our suggested care pathways.

RECENT FINDINGS

The CEMACH report showed the congenital malformation rate was four to 10-fold higher, the perinatal mortality rate was four to seven-fold higher, stillbirth was five times more common, and babies were three times more likely to die in the first 3 months of life. Only 39% of women with established diabetes took folic acid and only 37% had some documentation of glycaemic control before pregnancy. Overall, less than a fifth of NHS trusts in the UK had any kind of multidisciplinary preconception services. The results for women with type 2 diabetes were as bad as those for type 1. Caesarean delivery rates were very high (67%).

SUMMARY

Prepregnancy counselling and multidisciplinary team management is the key in achieving good pregnancy outcomes. There is emerging evidence about the safety and efficacy of oral hypoglycaemics like metformin in pregnancy.

Antepartum fetal surveillance and timing of delivery in the pregnancy complicated by diabetes mellitus

Pregnancies complicated by diabetes mellitus are associated with an increased risk of fetal and neonatal risks compared with pregnancies in the healthy gravida. Data suggest that stillbirth and perinatal mortality may be increased as much as 5 times for patients with insulin-dependent diabetes than in the general population. Pregnancies complicated by preexisting diabetes should undergo twice weekly surveillance with nonstress test or biophysical profile or a combination of both. Doppler studies should be reserved for those patients with vascular disease, intrauterine growth restriction, or hypertensive disorders.

Labor and delivery management for women with diabetes

Diabetes in pregnancy confers a number of risks for both the mother and her baby, and many of these risks are encountered in the labor and delivery unit. The obstetric provider caring for women with diabetes should be alert to the risk of hypertension and the potential for difficult delivery due to an overgrown fetus. Women with preexisting diabetes or poor glycemic control are at increased risk for poor obstetrical outcomes such as stillbirth or delivery of a malformed infant. Meticulous attention to avoiding maternal hyperglycemia during labor can prevent neonatal hypoglycemia.

Measuring perinatal complications: methodologic issues related to gestational age

BACKGROUND

Perinatal outcomes differ by week of gestational age. However, it appears that how measures to examine these outcomes vary among various studies. The current paper explores how perinatal complications are reported and how they might differ when different denominators, numerators, and comparison groups are utilized.

CONCLUSION

One issue that can clearly affect absolute rates and trends is how groups of women are categorized by their gestational age. Since most perinatal outcomes can only occur in women and neonates who have delivered, using the number of pregnancies delivered (PD) as the denominator of outcomes is appropriate. However, for an outcome such as antepartum stillbirth, all women who are pregnant at a particular gestational age are at risk. Thus, the denominator should include all ongoing pregnancies (OP). When gestational age is used by week this means using both deliveries during a particular week plus those women who deliver beyond the particular week of gestation in the denominator. Researchers should be careful to make sure they are utilizing the appropriate measure of perinatal complications so they do not report findings that would be misleading to clinicians, patients, and policy makers.

Effects on perinatal outcome of treating women with 1 elevated glucose tolerance test value

OBJECTIVE

This study was undertaken to determine whether medical nutrition therapy and home glucose monitoring can reduce complications in pregnancies with 1 elevated oral glucose tolerance test value.

STUDY DESIGN

This was a retrospective case-control study with historical controls. Medical records of women with one elevated oral glucose tolerance test value between January 2001 and June 2006 were reviewed; routine medical nutrition therapy and self-blood glucose monitoring for this group of women was initiated in April 2004. Women before (untreated group) and after (treated group) the initiation of therapy were compared. Baseline characteristics, as well pregnancy weight gain, birthweight greater than 4000 g, incidence of shoulder dystocia, cesarean delivery rate, and neonatal metabolic complications were compared. Student t test, Mann-Whitney U test, and chi2 test were used as appropriate, with P < .05 considered significant.

RESULTS

Fifty-seven women comprised the untreated group, and 69 were in the treated group. Except for greater prepregnancy weight in the treated group, maternal characteristics did not differ significantly between the 2 groups. Mean birthweight was similar between untreated and treated subjects (3385 g vs 3476 g, P = .45). Number of subjects with birthweights greater than 4000 g, shoulder dystocia, and unplanned cesarean deliveries were similar between the 2 groups.

CONCLUSION

In our patient population, women with 1 elevated oral glucose tolerance test value did not benefit from a structured program of medical nutritional therapy and self-blood glucose monitoring.

Women with gestational diabetes mellitus in the ACHOIS trial: risk factors for shoulder dystocia

BACKGROUND

Gestational diabetes mellitus (GDM) is associated with increased risk of fetal macrosomia and shoulder dystocia. However, not all women with GDM and fetal macrosomia have shoulder dystocia.

AIMS

To identify the risk factors for shoulder dystocia in women with gestational diabetes using data from women recruited into the routine care group of the ACHOIS trial.

METHODS

A secondary analysis was performed on data collected from women enrolled in the ACHOIS trial. Bivariate analyses were performed using the Fisher exact test. Variables found to be significantly associated with shoulder dystocia and previously identified risk factors were used as explanatory variables in multivariate analyses.

RESULTS

A positive relationship was found between the severity of maternal fasting hyperglycaemia and the risk of shoulder dystocia, with a 1 mmol increase in fasting oral glucose-tolerance test leading to a relative risk (RR) of 2.09 (95% CI 1.03-4.25). Shoulder dystocia occurred more often in births requiring operative vaginal delivery (RR 9.58, 95% CI 3.70-24.81, P < 0.001). Macrosomic and large-for-gestational-age infants were more likely to have births complicated by shoulder dystocia (RR 6.27, 95% CI 2.33-16.88, P < 0.001 and RR 4.57, 95% CI 1.74-12.01, P < 0.005, respectively). Fetal macrosomia was the only variable to maintain its significance in all multivariate analyses.

CONCLUSIONS

Fetal macrosomia is the strongest independent risk factor for shoulder dystocia. Effective preventative strategies are needed.

Intrapartum interventions for preventing shoulder dystocia

BACKGROUND

The early management of shoulder dystocia involves the administration of various manoeuvres which aim to relieve the dystocia by manipulating the fetal shoulders and increasing the functional size of the maternal pelvis.

OBJECTIVES

To assess the effects of prophylactic manoeuvres in preventing shoulder dystocia.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 June 2006).

SELECTION CRITERIA

Randomised controlled trials comparing the prophylactic implementation of manoeuvres and maternal positioning with routine or standard care.

DATA COLLECTION AND ANALYSIS

Two review authors independently applied exclusion criteria, assessed trial quality and extracted data.

MAIN RESULTS

Two trials were included; one comparing the McRobert's manoeuvre and suprapubic pressure with no prophylactic manoeuvres in 185 women likely to give birth to a large baby and one trial comparing the use of the McRobert's manoeuvre versus lithotomy positioning in 40 women. We decided not to pool the results of the two trials. One study reported fifteen cases of shoulder dystocia in the therapeutic (control) group compared to five in the prophylactic group (relative risk (RR) 0.44, 95% confidence interval (CI) 0.17 to 1.14) and the other study reported one episode of shoulder dystocia in both prophylactic and lithotomy groups. In the first study, there were significantly more caesarean sections in the prophylactic group and when these were included in the results, significantly fewer instances of shoulder dystocia were seen in the prophylactic group (RR 0.33, 95% CI 0.12 to 0.86). In this study, thirteen women in the control group required therapeutic manoeuvres after delivery of the fetal head compared to three in the treatment group (RR 0.31, 95% CI 0.09 to 1.02). One study reported no birth injuries or low Apgar scores recorded. In the other study, one infant in the control group had a brachial plexus injury (RR 0.44, 95% CI 0.02 to 10.61), and one infant had a five-minute Apgar score less than seven (RR 0.44, 95% CI 0.02 to 10.61).

AUTHORS' CONCLUSIONS

There are no clear findings to support or refute the use of prophylactic manoeuvres to prevent shoulder dystocia, although one study showed an increased rate of caesareans in the prophylactic group. Both included studies failed to address important maternal outcomes such as maternal injury, psychological outcomes and satisfaction with birth. Due to the low incidence of shoulder dystocia, trials with larger sample sizes investigating the use of such manoeuvres are required.

Induction of labor and cesarean delivery by gestational age

OBJECTIVE

Studies of cesarean delivery (CD) rates among women undergoing induction of labor (IOL) often compare such women to women experiencing spontaneous labor at similar gestational ages. We sought to examine the association between IOL at various gestational ages and CD, accounting for the effect of increased gestational age among the comparison group who were managed expectantly.

STUDY DESIGN

We conducted a retrospective cohort study of all term, singleton, cephalic presentation pregnancies delivered at our institution over 15 years excluding cesarean deliveries before labor. For each gestational age of induction, we created a comparison group of women who were undelivered at that gestational age, and who experienced labor at some future gestational age.

RESULTS

In women undergoing IOL at 38 weeks gestation, the CD rate was 11.9% as compared to 13.3% (P = .42) of women beyond 38 weeks gestation. The CD rate for induction of labor compared to ongoing pregnancy was 14.3% versus 15.0% (P = .62) at 39 weeks, 20.4% versus 19.0% (P = .41) at 40 weeks, and 24.3% versus 26.0% (P = .39) at 41 weeks. When controlling for potential confounding, there was a higher rate of CD among women with expectant management beyond 38 weeks (adjusted odds ratio [AOR] 1.80; 95% CI 1.29-2.53), 39 weeks (1.39; 95% CI 1.08-1.80), and 40 weeks (AOR 1.27; 95% CI 1.00-1.62).

CONCLUSION

Our findings suggest that IOL may not increase a woman's risk of CD when compared to expectant management. While this question has been addressed prospectively at 41 weeks gestation, it requires further examination at earlier gestations and among various subgroups.

The impact of the interaction between increasing gestational age and obstetrical risk on birth outcomes: evidence of a varying optimal time of delivery

OBJECTIVE

To estimate the gestational age ranges that result in optimal birth outcomes for each of four risk-defined groups.

STUDY DESIGN

Retrospective cohort study of singleton late third-trimester deliveries at a large urban teaching hospital between July 1995 and September 2003. Low-risk, advanced maternal age, hypertensive and diabetic patients were identified and grouped. Rates, by day of gestation at delivery, of cesarean delivery, major maternal perineal trauma, low 5-min APGAR score and NICU admission were determined for each study group.

RESULTS

Each study group had meaningful changes in rates of obstetric outcomes as a function of gestational age at delivery and these patterns differed from group to group. A unique optimal time of delivery (OTD) was estimated for each group. The low-risk group OTD was calculated to be 37 weeks 1 day to 41 weeks 0 day; the advanced maternal age group OTD was 38 weeks 5 days to 39 weeks 6 days; the hypertension group OTD was 39 weeks 2 days to 40 weeks 1 day; and the diabetes mellitus group OTD was 40 weeks 3 days to 41 weeks 1 day.

CONCLUSIONS

The OTD varied based on obstetrical risk. Strategies to increase the proportion of deliveries that occur within the OTD for specific risk-defined groups could theoretically improve birth outcomes.

Comparison of international and New Zealand guidelines for the care of pregnant women with diabetes

OBJECTIVE

To compare international guidelines for the care of women with diabetes and pregnancy with reported current practice among New Zealand tertiary centres.

RESEARCH DESIGN AND METHODS

A literature review of national and international guidelines for the care of women with diabetes in pregnancy was undertaken. Guideline activities were placed within nine facets of care, from preconception advice, through pregnancy from screening to follow-up. New Zealand tertiary centres guidelines were obtained and placed in the same framework.

RESULTS

International guideline consensus was inconsistent across most facets of care. Those for the detection and diagnosis of gestational diabetes mellitus (GDM) were particularly discordant internationally, although intranational agreement has occurred.

CONCLUSIONS

International guidelines for the care of women with diabetes in pregnancy remain fragmented. The development of one set of guidelines based on the consensus of international best practice could overcome many of the misconceptions associated with diabetes in pregnancy.