Pre-existing diabetes mellitus and adverse pregnancy outcomes

Maternal and birth cohort studies in the Gulf Cooperation Council countries: protocol for a systematic review and narrative evaluation

INTRODUCTION

Cohort studies have revealed that genetic, socioeconomic, communicable and non-communicable diseases, and environmental exposures during pregnancy may influence the mother and her pregnancy, birth delivery and her offspring. Numerous studies have been conducted in the Gulf Cooperation Council (GCC) countries to examine maternal and birth health. The objectives of this protocol for a systematic review are to systematically review and characterise the exposures and outcomes that have been examined in the mother and birth cohort studies in the GCC region, and to summarise the strength of association between key maternal exposures during pregnancy (ie, body mass index) and different health-related outcomes (ie, mode of birth delivery). The review will then synthesise and characterise the consequent health implications and will serve as a platform to help identify areas that are overlooked, point out limitations of studies and provide recommendations for future cohort studies.

METHODS AND ANALYSIS

Medline, Embase, Cochrane Library and Web of Science electronic databases will be comprehensively searched. Two reviewers will independently screen each study for eligibility, and where discrepancies arise they will be discussed and resolved; otherwise a third reviewer will be consulted. The two reviewers will also independently extract data into a predefined Excel spreadsheet. The included studies will be categorised on the basis of whether the participant is a mother, infant or mother-infant dyad. Outcome variables will be divided along two distinctions: mother or infant. Exposure variables will be divided into six domains: psychosocial, biological, environmental, medical/medical services, maternal/reproductive and perinatal/child. Studies are expected to be of heterogeneous nature; therefore, quantitative syntheses might be limited.

ETHICS AND DISSEMINATION

There is no primary data collection; therefore, ethical review is not necessary. The findings of this review will be disseminated in a peer-reviewed journal and presented at relevant conferences.

PROSPERO REGISTRATION NUMBER

CRD42017068910.

Termination of pregnancy and sterilisation in women with childhood-onset type 1 diabetes

AIMS/HYPOTHESIS

The aim of this study was to explore the association between type 1 diabetes and reproductive health indicators in women, focusing on termination of pregnancy and sterilisation.

METHODS

We conducted a registry-based cohort study involving 2281 women with childhood-onset type 1 diabetes, matched for age and birthplace with women without diabetes: two control participants for each woman with diabetes. We compared the frequencies of termination of pregnancy and sterilisation over a 25 year period between women with type 1 diabetes and women without, and estimated standardised incidence ratios (SIRs). Smoothed age and period effects in the incidence of termination of pregnancy or sterilisation were tested statistically.

RESULTS

There were more terminations of pregnancy (SIR 1.67; 95% CI 1.51, 1.86) and sterilisations (SIR 1.69; 95% CI 1.56, 1.83) in women with diabetes than in control women. During recent years, sterilisations in women with diabetes have decreased and the difference compared with control women has vanished. The indications for both procedures showed a statistically highly significant difference: maternal medical indications were almost absent (< 1%) in procedures among control women, but comprised 23.6% of terminations of pregnancy and 22.9% of sterilisations in women with diabetes.

CONCLUSIONS/INTERPRETATION

The indications for termination of pregnancy and sterilisation are different in women with diabetes compared with other women. Pregnancies in women with type 1 diabetes are still terminated more often than in women without diabetes, but the difference in sterilisation rates has disappeared during recent years.

Diabetes and pre-eclampsia affecting pregnancy: a retrospective cross-sectional study

The interaction between pre-eclampsia and diabetes mellitus (DM) is far from being completely understood. In this study, we compared normal pregnancies with those complicated with pre-eclampsia, gestational DM, and/or pre-existing diabetes to assess the effects of hyperglycemia on placental development. AnInstitutional Review Board (IRB) approved retrospective cross-sectional study with 621 subjects was performed. Statistical analysis was performed using Duncan's post hoc test and analysis of variance. Regardless of diabetes status, patients with pre-eclampsia delivered prematurely. Patients in the group with pre-eclampsia and pregestational diabetes delivered much earlier, at 35.0±0.4 weeks, when compared with the patients that had pre-eclampsia with gestational diabetes and pre-eclampsia with no diabetes (*P<0.05 for each). Additionally, patients with pre-existing diabetes who developed pre-eclampsia delivered smaller babies than those with pre-existing diabetes without pre-eclampsia (1.00±0.03, P<0.05 for each). Pre-existing diabetes with added insult of pre-eclampsia led to fetal growth restriction. This outcome validates the understanding that elevated glucose earlier in pregnancy alters placentogenesis and leads to fetal growth restriction.

Demographic profile and pregnancy outcomes of adolescents and older mothers in Saudi Arabia: analysis from Riyadh Mother (RAHMA) and Baby cohort study

OBJECTIVES

To investigate the impact of maternal age on pregnancy outcomes with special emphasis on adolescents and older mothers and to investigate the differences in demographic profile between adolescents and older mothers.

METHODS

This study is a secondary analysis of pregnancy outcomes of women in Riyadh Mother and Baby cohort study according to maternal age. The study population was grouped according to maternal age into five subgroups; <20, 20-29, 30-34, 35-39 and 40+years. The age group 20-29 years was considered as a reference group. Investigation of maternal age impact on maternal and neonatal outcomes was conducted with adjustment of confounders using regression models.

RESULTS

All mothers were married when conceived with the index pregnancy. Young mothers were less likely to be illiterate, more likely to achieve higher education and be employed compared with mothers ≥ 40 years. Compared with the reference group, adolescents were more likely to have vaginal delivery (and least likely to deliver by caesarean section (CS); OR=0.6, 95% CI 0.4 to 0.9, while women ≥40 years, were more likely to deliver by CS; OR 2.9, 95% CI 2.3 to 3.7. Maternal age was a risk factor for gestational diabetes in women ≥40 years; OR 1.7, 95% CI 1.3 to 2.1. Adolescents had increased risk of preterm delivery; OR 1.5, 95% CI 1.1 to 2.1 and women ≥40 years had similar risk; OR, 1.3, 95% CI 1.1 to 1.6.

CONCLUSION

Adverse pregnancy outcomes show a continuum with the advancement of maternal age. Adolescents mother are more likely to have vaginal delivery; however, they are at increased risk of preterm delivery. Advanced maternal age is associated with increased risk of preterm delivery, gestational diabetes and CS.

Prevalence and Complications of Pregestational and Gestational Diabetes in Saudi Women: Analysis from Riyadh Mother and Baby Cohort Study (RAHMA)

The objectives of this study were to estimate the burden of diabetes and to explore the adverse pregnancy outcomes associated with pregestational diabetes mellitus (pre-GDM) and gestational diabetes mellitus (GDM) among the Saudi pregnant population. In this subcohort, we compared the maternal and the neonatal outcomes of diabetic women with pre-GDM and GDM to the outcomes of nondiabetic mothers who delivered during the same period. From the total cohort, 9723 women participated in this study. Of the participants, 24.2% had GDM, 4.3% had pre-GDM, and 6951 were nondiabetic. After adjustment for confounders, women with GDM had increased odds of delivering a macrosomic baby (OR: 1.6; 95% CI: 1.2–2.1). Women with pre-GDM were more likely to deliver by Cesarean section (OR: 1.65; CI: 1.32–2.07) and to have preterm delivery < 37 weeks (OR: 2.1; CI: 1.5–2.8). Neonates of mothers with pre-GDM were at increased risk of being stillbirth (OR: 3.66; CI: 1.98–6.72), at increased risk of admission to NICU (OR: 2.21; CI: 1.5–3.27), and at increased risk for being macrosomic (OR: 2.40; CI: 1.50–3.8). The prevalence of GDM and pre-GDM in the Saudi pregnant population is among the highest in the world. The conditions are associated with high maternal and neonatal morbidities and mortalities.

Maternal-Foetal Diabetes Modifies Neonatal Fc Receptor Expression on Human Leucocytes

This study investigated the expression of the neonatal Fc receptor (FcRn) in maternal blood, cord blood and placental cells and determined IgG levels in maternal blood and cord blood from diabetic mothers. Peripheral blood, cord blood and placenta samples were collected from 26 mothers with normoglycaemia (non-diabetic, ND group) and 52 with hyperglycaemia (26 with mild gestational hyperglycaemia, MGH group, and 26 with type 2 diabetes mellitus, DM-2 group). Cells expressing CD19(+) and FcRn were identified by flow cytometry. Total IgG and its subclasses were quantified by ELISA. Maternal blood from DM-2 and cord blood from MGH exhibited a higher proportion of CD19(+) expression by B cells. DM-2 showed a lower proportion of CD19(+) cells in placenta. FcRn expression increased in cells from cord blood and placenta from MGH. Maternal blood, cord blood and placenta cells from DM-2 showed lower FcRn expression. Blood IgG levels were lower in DM-2, and cord blood IgG levels were higher in MGH. The highest levels of IgG4 were detected in the blood of hyperglycaemic mothers. The highest IgG3 and IgG4 levels in cord blood were detected in MGH, and the lowest IgG2 and IgG3 levels in DM-2. Maternal hyperglycaemia compromised placental transfer of IgG1, IgG3 and IgG4. The results suggest that regardless of hyperglycaemia degree, it decreases FcRn expression in placenta and blood cells and compromises the production and transfer of antibodies from maternal blood to newborns.

Maternal glucose intolerance reduces offspring nephron endowment and increases glomerular volume in adult offspring

BACKGROUND

Animal studies report a nephron deficit in offspring exposed to maternal diabetes, yet are limited to models of severe hyperglycaemia which do not reflect the typical clinical condition and which are associated with foetal growth restriction that may confound nephron endowment. We aimed to assess renal morphology and function in offspring of leptin receptor deficient mice (Lepr^db /+) and hypothesized that exposure to impaired maternal glucose tolerance (IGT) would be detrimental to the developing kidney.

METHODS

Nephron endowment was assessed in offspring of C57BKS/J Lepr^db /+ and +/+ mice at embryonic day (E)18 and postnatal day (PN)21 using design-based stereology. Transcutaneous measurement of renal function and total glomerular volume were assessed in 6-month-old offspring. Only +/+ offspring of Lepr^db /+ dams were analysed.

RESULTS

Compared with +/+ dams, Lepr^db /+ dams had a 20% and 35% decrease in glucose tolerance prior to pregnancy and at E17.5 respectively. Offspring of IGT Lepr^db /+ dams had approximately 15% fewer nephrons at E18.5 and PN21 than offspring of +/+ dams. There was no difference in offspring bodyweight. Despite normal renal function, total glomerular volume was 13% greater in 6-month-old offspring of IGT Lepr^db /+ dams than in +/+ offspring.

CONCLUSIONS

IGT throughout gestation resulted in a nephron deficit that was established early in renal development. Maternal IGT was associated with glomerular hypertrophy in adult offspring, likely a compensatory response to maintain normal renal function. Given the increasing prevalence of IGT, monitoring glucose from early in gestation may be important to prevent altered kidney morphology. Copyright © 2016 John Wiley & Sons, Ltd.

The associations of maternal body mass index with birthweight and placental weight. Does maternal diabetes matter? A population study of 106 191 pregnancies

INTRODUCTION

The aim of this study was to study whether the associations of maternal body mass index with offspring birthweight and placental weight differ by maternal diabetes status.

MATERIAL AND METHODS

We performed a population study of 106 191 singleton pregnancies by using data from the years 2009-2012 in the Medical Birth Registry of Norway. We estimated changes in birthweight and in placental weight (in grams) by maternal body mass index by linear regression analysis.

RESULTS

In pregnancies of women without diabetes, birthweight increased by 14.7 g (95% confidence interval 14.1-15.2) per unit increase in maternal body mass index, and the increase in placental weight was 4.2 g (95% confidence interval 4.0-4.4). In pregnancies of women with gestational diabetes, the corresponding figures were 11.8 g (95% confidence interval 8.3-15.4) and 2.9 g (95% confidence interval 1.7-4.0). In pregnancies of women with type 1 diabetes we found no significant changes in birthweight or in placental weight by maternal body mass index. Overall, mean birthweight was 513.9 g (95% confidence interval 475.6-552.1) higher in pregnancies involving type 1 diabetes than in pregnancies of women without diabetes. Mean placental weight was 102.1 g (95% confidence interval 89.3-114.9) higher. Also, in pregnancies of women with gestational diabetes, both birthweight and placental weight were higher than in women without diabetes (168.2 g and 46.5 g, respectively). Adjustments were made for maternal body mass index and gestational age at birth.

CONCLUSIONS

Birthweight and placental weight increased with increasing maternal body mass index in pregnancies of women without diabetes and in pregnancies of women with gestational diabetes, but not in pregnancies of women with type 1 diabetes. Independent of body mass index, mean birthweight and mean placental weight were highest in pregnancies of women with type 1 diabetes.

The Association Between Diabetes Mellitus Among American Indian/Alaska Native Populations with Preterm Birth in Eight US States from 2004-2011

OBJECTIVES

Assess risk of preterm birth associated with diabetes mellitus (DM) among American Indian and Alaska Natives (AI/AN), a population with increased risk of DM and preterm birth, and examine whether this association differed by state of residence.

METHODS

We used surveillance data from the Pregnancy Risk Assessment Monitoring System from 12,400 AI/AN respondents with singleton births in Alaska, Minnesota, Nebraska, New Mexico, Oklahoma, Oregon, Utah, and Washington from 2004-2011. We conducted multivariable logistic regression models to estimate the odds ratio adjusted for maternal age and prepregnancy BMI with all observations and then stratified by state.

RESULTS

DM was reported in 5.92 % of the study population and preterm birth occurred in 8.95 % of births. Women with DM had 1.92 times higher odds of having a preterm birth than women without DM [95 % confidence interval (CI) 1.21-2.78]. After stratifying on state, women with DM in Nebraska had the greatest odds of preterm birth [aOR 6.63, (95 % CI 3.80-11.6)] while women in Alaska saw a protective effect from DM [aOR 0.17, (95 % CI 0.07-0.42)] compared to women without DM.

CONCLUSION

Overall, AI/AN women with DM had significantly greater odds of preterm birth compared to AI/AN women without DM across states. Substantial differences in this association between states calls for increased public health efforts in high-risk areas as well as further research to assess whether differences are attributable to diagnosis, reporting, tribal, healthcare or lifestyle factors.

Ambient air pollution and adverse birth outcomes: Differences by maternal comorbidities

BACKGROUND

Prenatal exposure to ambient air pollution has been associated with adverse birth outcomes, but the potential modifying effect of maternal comorbidities remains understudied. Our objective was to investigate whether associations between prenatal air pollution exposures and birth outcomes differ by maternal comorbidities.

METHODS

A total of 818,400 singleton live births were identified in the province of Ontario, Canada from 2005 to 2012. We assigned exposures to fine particulate matter (PM2.5), nitrogen dioxide (NO2) and ozone (O3) to maternal residences during pregnancy. We evaluated potential effect modification by maternal comorbidities (i.e. asthma, hypertension, pre-existing diabetes mellitus, heart disease, gestational diabetes and preeclampsia) on the associations between prenatal air pollution and preterm birth, term low birth weight and small for gestational age.

RESULTS

Interquartile range (IQR) increases in PM2.5 (2μg/m(3)), NO2 (9ppb) and O3 (5ppb) over the entire pregnancy were associated with a 4% (95% CI: 2.4-5.6%), 8.4% (95% CI: 5.5-10.3%) and 2% (95% CI: 0.5-4.1%) increase in the odds of preterm birth, respectively. Increases of 10.6% (95% CI: 0.2-2.1%) and 23.8% (95% CI: 5.5-44.8%) in the odds of preterm birth were observed among women with pre-existing diabetes while the increases were of 3.8% (95% CI: 2.2-5.4%) and 6.5% (95% CI: 3.7-8.4%) among women without this condition for pregnancy exposure to PM2.5 and NO2, respectively (Pint<0.01). The increase in the odds of preterm birth for exposure to PM2.5 during pregnancy was higher among women with preeclampsia (8.3%, 95% CI: 0.8-16.4%) than among women without (3.6%, 95% CI: 1.8-5.3%) (Pint=0.04). A stronger increase in the odds of preterm birth was found for exposure to O3 during pregnancy among asthmatic women (12.0%, 95% CI: 3.5-21.1%) compared to non-asthmatic women (2.0%, 95% CI: 0.1-3.5%) (Pint<0.01). We did not find statistically significant effect modification for the other outcomes investigated.

CONCLUSIONS

Findings of this study suggest that associations of ambient air pollution with preterm birth are stronger among women with pre-existing diabetes, asthma, and preeclampsia.

Preconception care in Saudi women with diabetes mellitus

BACKGROUND

The rate of preexisting diabetes mellitus (DM) in Saudi Arabia is one of the highest in the world. The role of preconception care (PCC) is well-established as a means of improving pregnancy outcomes in DM.

OBJECTIVES

To assess the rate of preconception counseling, the level of PCC knowledge, and the rate of unplanned pregnancies in Saudi women with DM.

MATERIALS AND METHODS

A cross-sectional study was conducted among 355 Saudi women aged 18-49 years with self-reported DM. The study questionnaire contained variables about the provision of preconception counseling, knowledge of PCC facts, and the number of unplanned pregnancies after developing DM. The level of PCC knowledge was evaluated using a modified Likert scale. Statistical Package for Social Sciences 20 was used for statistical analysis. Descriptive statistics, mean and standard deviation, and percentages were calculated; t-test was used for statistical significance.

RESULTS

About one-third of the participants had received preconception counseling after being diagnosed with DM. Counseling on PCC for older and married participants was significantly less. Of the 355 participants, 42.8% had little or no PCC knowledge. All pregnancies that occurred after developing DM were unplanned.

CONCLUSIONS

The rate of preconception counseling, the level of PCC knowledge in the studied Saudi women with DM is suboptimal, and none of the pregnancies that occurred after developing DM was planned. The study highlights the need for PCC programs that target all Saudi women of child-bearing age with DM, and their families starting at the age of puberty and at diagnosis of type 2DM, to optimize women's health and improve pregnancy outcomes.

Riyadh Mother and Baby Multicenter Cohort Study: The Cohort Profile

OBJECTIVES

To assess the effects of non-communicable diseases, such as diabetes, hypertension and obesity, on the mother and the infant.

METHODS

A multicentre cohort study was conducted in three hospitals in the city of Riyadh in Saudi Arabia. All Saudi women and their babies who delivered in participating hospitals were eligible for recruitment. Data on socio-demographic characteristics in addition to the maternal and neonatal outcomes of pregnancy were collected. The cohort demographic profile was recorded and the prevalence of maternal conditions including gestational diabetes, pre-gestational diabetes, hypertensive disorders in pregnancy and obesity were estimated.

FINDINGS

The total number of women who delivered in participating hospitals during the study period was 16,012 of which 14,568 women participated in the study. The mean age of the participants was 29 ± 5.9 years and over 40% were university graduates. Most of the participants were housewives, 70% were high or middle income and 22% were exposed to secondhand smoke. Of the total cohort, 24% were married to a first cousin. More than 68% of the participants were either overweight or obese. The preterm delivery rate was 9%, while 1.5% of the deliveries were postdate. The stillbirth rate was 13/1000 live birth. The prevalence of gestational diabetes was 24% and that of pre-gestational diabetes was 4.3%. The preeclampsia prevalence was 1.1%. The labour induction rate was 15.5% and the cesarean section rate was 25%.

CONCLUSION

Pregnant women in Saudi Arabia have a unique demographic profile. The prevalence of obesity and diabetes in pregnancy are among the highest in the world.

Outcomes of singleton and twin pregnancies complicated by pre-existing diabetes and gestational diabetes: A population-based study in Alberta, Canada, 2005-11

BACKGROUND

We assessed the prevalence and pregnancy outcomes of pre-existing diabetes mellitus (pre-DM) and gestational diabetes mellitus (GDM) in Alberta, Canada, 2005-11.

METHODS

327 198 singleton and 5552 twin pregnancies resulting in live births or stillbirths were included. The odds ratios of adverse outcomes were evaluated comparing pre-DM with no diabetes and GDM with no diabetes, controlling for maternal characteristics.

RESULTS

Diabetes complicated 6.3% of pregnancies, with 88% being GDM. In singleton pregnancies, pre-DM and GDM were associated with increased risks of pre-eclampsia (adjusted odds ratio [aOR] = 3.38 and 1.83, respectively), cesarean delivery (aOR 2.53, 1.55), spontaneous preterm (aOR 4.20, 1.71), and labor-induced preterm (aOR 3.82, 2.00) in the mother, and macrosomia (aOR 2.11, 1.30), shoulder dystocia (aOR 1.54, 1.32), congenital anomalies (aOR 1.61, 1.20), and neonatal intensive care unit (NICU) admissions (aOR 3.81, 1.60) in the infants. In addition, pre-DM was associated with an increased likelihood of stillbirth (aOR 3.73) and neonatal death (aOR 2.00) compared with non-diabetic pregnancies. In twin pregnancies, pre-DM was associated with increased risks of spontaneous (aOR 3.54) and labor-induced (aOR 3.57) preterm births, large for gestational age (LGA) infants (aOR 3.73), congenital anomalies (aOR 3.05) and NICU admissions (aOR 2.91); GDM was associated with an increased risk of pre-eclampsia (aOR 1.54), cesarean delivery (aOR 1.57), and LGA infants (aOR 1.63).

CONCLUSIONS

Pre-existing diabetes confers higher risks than GDM. Diabetes is associated with adverse outcomes in singleton and twin pregnancies, and the increased risks are generally similar or less in twins, probably due to their higher "baseline" risks and closer clinical monitoring.

Role of HbA1c in predicting risk for congenital malformations

AIMS

Association between conventionally identified hyperglycemias and rates of congenital abnormalities is known; however there is less information about role of HbA1c in determining gestational hyperglycemias and associated risks. This study tried to explore the association between HbA1c in women without known diabetes at first antenatal visit and risk of congenital malformations (CM) among Saudi women living at Al-Madinah Al-Monawarah.

METHODS

Eleven hundred and eighty (1180), healthy, first-trimester pregnant Saudi females without known diabetes, were selected from various antenatal care clinics of Al-Madinah Al-Monawarah city. General clinical and biochemical data was collected for this study by researchers at first visit and the time of delivery.

RESULTS

Nearly one fifth (19.6%) of mothers had above normal HbA1c (>5.7) at first visit. Rates of CM had significant positive association with level of HbA1c. Rate of CM among those who had HbA1c in diabetes range, pre-diabetes range or normal range was 27.8%, 9.8% and 3.0%, respectively. The difference was significant between normal and pre-diabetes at the level P=0.000 and between pre-diabetes and diabetes at level P=0.038.

CONCLUSION

In this study HbA1c is found to be a valuable predictor of risk of congenital malformations. This observation calls for further studies and establishment of policies for care of pregnant mothers having higher than normal HbA1c at first visit.

Insulin Glulisine in Pregnancy - Experience from Clinical Trials and Post-marketing Surveillance

Pregnancies complicated by gestational diabetes or pre-existing type 1 or type 2 diabetes mellitus are associated with a higher rate of adverse outcomes compared with pregnancies in the background population. These outcomes include miscarriage, pre-term delivery, pre-eclampsia, perinatal mortality and congenital malformations. Insulin glulisine (Apidra^®, Sanofi) is a rapid-acting insulin analogue indicated for the treatment of adults, adolescents and children 6 years or older with diabetes mellitus where treatment with insulin is required. Here, all post-marketing and clinical trials safety data with insulin glulisine in pregnancy available to Sanofi up to June 2014 are summarised together with the findings of a comprehensive literature search. Cumulatively, a total of 303 pregnancy exposures to insulin glulisine were received. Of these 303 pregnancy exposures, there were 116 live births, 12 spontaneous abortions, two late foetal intra-uterine deaths (>28 weeks), three elective abortions and 170 cases without a known pregnancy outcome. There were six cases of congenital malformations; of these, there were five live births; in the other case a live birth was not confirmed. The congenital malformations reported to date do not reveal a pattern of defects. In conclusion, the evidence to date does not suggest a causal association between insulin glulisine and an increased risk of pregnancy complications or congenital malformations.

Comparing type 1 and type 2 diabetes in pregnancy- similar conditions or is a separate approach required?

BACKGROUND

Pregnancy in women with type 1 (T1DM) or type 2 diabetes (T2DM) is associated with increased risk. These conditions are managed similarly during pregnancy, and compared directly in analyses, however they affect women of different age, body mass index and ethnicity.

METHODS

We assess if differences exist in pregnancy outcomes between T1DM and T2DM by comparing them directly and with matched controls. We also analyze the effect of glycemic control on pregnancy outcomes and analyze predictive variables for poor outcome.

RESULTS

We include 323 women with diabetes and 660 glucose-tolerant controls. T2DM women had higher BMI, age and parity with a shorter duration of diabetes and better glycemic control. Preeclampsia occurred more in women with T1DM only. Rates of elective cesarean section were similar between groups but greater than in controls, emergency cesarean section was increased in women with type 1 diabetes. Maternal morbidity in T1DM was double that of matched controls but T2DM was similar to controls. Babies of mothers with diabetes were more likely to be delivered prematurely. Neonatal hypoglycemia occurred more in T1DM than T2DM and contributed to a higher rate of admission to neonatal intensive care for both groups. Adverse neonatal outcomes including stillbirths and congenital abnormalities were seen in both groups but were more common in T1DM pregnancies. HbA1C values at which these poor outcomes occurred differed between T1 and T2DM.

CONCLUSIONS

Pregnancy outcomes in T1DM and T2DM are different and occur at different levels of glycemia. This should be considered when planning and managing pregnancy and when counseling women.

Medically complex pregnancies and early breastfeeding behaviors: a retrospective analysis

BACKGROUND

Breastfeeding is beneficial for women and infants, and medical contraindications are rare. Prenatal and labor-related complications may hinder breastfeeding, but supportive hospital practices may encourage women who intend to breastfeed. We measured the relationship between having a complex pregnancy (entering pregnancy with hypertension, diabetes, or obesity) and early infant feeding, accounting for breastfeeding intentions and supportive hospital practices.

METHODS

We performed a retrospective analysis of data from a nationally-representative survey of women who gave birth in 2011-2012 in a US hospital (N = 2400). We used logistic regression to examine the relationship between pregnancy complexity and breastfeeding. Self-reported prepregnancy diabetes or hypertension, gestational diabetes, or obesity indicated a complex pregnancy. The outcome was feeding status 1 week postpartum; any breastfeeding was evaluated among women intending to breastfeed (N = 1990), and exclusive breastfeeding among women who intended to exclusively breastfeed (N = 1418). We also tested whether breastfeeding intentions or supportive hospital practices mediated the relationship between pregnancy complexity and infant feeding status.

RESULTS

More than 33% of women had a complex pregnancy; these women had 30% lower odds of intending to breastfeed (AOR = 0.71; 95% CI, 0.52-0.98). Rates of intention to exclusively breastfeed were similar for women with and without complex pregnancies. Women who intended to breastfeed had similar rates of any breastfeeding 1 week postpartum regardless of pregnancy complexity, but complexity was associated with >30% lower odds of exclusive breastfeeding 1 week among women who intended to exclusively breastfeed (AOR = 0.68; 95% CI, 0.47-0.98). Supportive hospital practices were strongly associated with higher odds of any or exclusive breastfeeding 1 week postpartum (AOR = 4.03; 95% CI, 1.81-8.94; and AOR = 2.68; 95% CI, 1.70-4.23, respectively).

CONCLUSIONS

Improving clinical and hospital support for women with complex pregnancies may increase breastfeeding rates and the benefits of breastfeeding for women and infants.

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.

The independent effects of maternal obesity and gestational diabetes on the pregnancy outcomes

BACKGROUND

Obesity and gestational diabetes (GDM) in pregnancy are recognized risk factors for adverse outcomes, including cesarean section (CS), macrosomia and preeclampsia. The aim of this study was to investigate the independent effect of GDM and obesity on the adverse pregnancy outcomes at term.

METHODS

A retrospective cohort of postpartum women, in King Khalid University Hospital, were stratified according to body mass index (obese ≥30 kg/m2, non-obese <30 kg/m2) and the results of GDM screening into the following groups, women with no obesity and no GDM (reference group), women with no obesity but with GDM, women with obesity but no GDM and women with both GDM and obesity. Adverse pregnancy outcomes included high birth weight, macrosomia, CS delivery and preeclampsia. Multiple logistic regression used to examine independent associations of GDM and obesity with macrosomia and CS.

RESULTS

2701 women were included, 44% of them were obese and 15% had GDM. 63% of the women with GDM were obese. There was significant increase in the percentage of macrosomia, P < 0.001, high birth weight, P < 0.001, CS, P < 0.001 and preeclampsia, P < 0.001 in women with GDM and obesity compared to the reference group. Obesity increased the estimated risk of CS delivery, odds ratio (OR) 2.16, confidence intervals (CI) 1.74-2.67. The combination of GDM and obesity increased the risk of macrosomia OR 3.45, CI 2.05-5.81 and the risk of CS delivery OR 2.26, CI 1.65-3.11.

CONCLUSION

Maternal obesity and GDM were independently associated with adverse pregnancy outcomes. The combination of both conditions further increase the risk.

The IDF Diabetes Atlas methodology for estimating global prevalence of hyperglycaemia in pregnancy

INTRODUCTION

Hyperglycaemia is one of the most prevalent metabolic disorders occurring during pregnancy. Limited data are available on the global prevalence of hyperglycaemia in pregnancy. The International Diabetes Federation (IDF) has developed a methodology for generating estimates of the prevalence of hyperglycaemia in pregnancy, including hyperglycaemia first detected in pregnancy and live births to women with known diabetes, among women of childbearing age (20-49 years).

METHODS

A systematic review of the literature for studies reporting the prevalence of gestational diabetes was conducted. Studies were evaluated and scored to favour those that were representative of a large population, conducted recently, reported age-specific estimates, and case identification was based on blood test. Age-specific prevalence data from studies were entered to produce estimates for five-year age groups using logistic regression to smooth curves, with age as the independent variable. The derived age-specific prevalence was adjusted for differences in diagnostic criteria in the underlying data. Cases of hyperglycaemia in pregnancy were derived from age-specific estimates of fertility and age-specific population estimates. Country-specific estimates were generated for countries with available data. Regional and global estimates were generated based on aggregation and extrapolation for 219 countries and territories. Available fertility rates and diabetes prevalence estimates were used to estimate the proportion of hyperglycaemia in pregnancy that may be due to total diabetes in pregnancy - pregnancy in women with known diabetes and diabetes first detected in pregnancy.

RESULTS

The literature review identified 199 studies that were eligible for characterisation and selection. After scoring and exclusion requirements, 46 studies were selected representing 34 countries. More than 50% of selected studies came from Europe and North America and Caribbean. The smallest number of identified studies came from sub-Saharan Africa. The majority of studies were for high-income countries, although low- and middle-income countries were also represented.

CONCLUSION

Prevalence estimates of hyperglycaemia in pregnancy are sensitive to the data from which they are derived. The IDF methodology is a transparent, reproducible, and modifiable method for estimating the burden of hyperglycaemia in pregnancy. More data are needed, in particular from developing countries, to strengthen the methodology.

Effects of secondhand smoke on the birth weight of term infants and the demographic profile of Saudi exposed women

BACKGROUND

Maternal exposure to tobacco smoke during pregnancy is associated with detrimental effects on the mother and the fetus including; impaired fetal growth, low birth weight and preterm delivery. In utero exposure to tobacco is implicated in the etiology of many adults' diseases including obesity, diabetes and hypertension.The objectives of this study were to evaluate the effects of Secondhand Tobacco Smoke (SHS) exposure on newborns' anthropometric measurements and to compare the demographic profile of the women exposed to SHS to those who were not.

METHOD

This is a retrospective cohort study investigating the effects of SHS during pregnancy on newborns' anthropometry. Women who self-reported SHS exposure were compared with those not exposed. The primary outcomes were birth weight, newborn length and head circumference. Univariate analysis and multivariate regression analysis were performed. Adjusted differences with 95% confidence intervals were calculated.

RESULTS

Mothers exposed to SHS constituted 31% of the cohort. The mean birth weight of infants of exposed mothers was significantly lower by 35 g, 95% CI: 2-68 g, (P = 0.037) and the mean length was shorter by 0.261 cm, 95% CI 0.058-0.464 cm, (P = 0.012) compared to the infants of unexposed mothers. Women exposed to SHS, were younger, of lower parity and more likely to be illiterate than those who were not exposed in addition, exposed women were less likely to be primiparous.

CONCLUSION

The prevalence of exposure of Saudi pregnant women to SHS is high at 31% and it is associated with reduced birth weight, and shorter length of the newborn.

The Role of Ultrasound in the Diagnosis of Complications Associated with Maternal Diabetes

Gestational diabetes mellitus (GDM) is defined as glucose intolerance that begins or is first recognized during pregnancy. Numerous clinical factors are associated with an increased likelihood of GDM, such as increasing age, obesity, ethnicity, family history of diabetes and past obstetric history. There is a well-documented relationship between maternal hyperglycemia and increased rate of macrosomia, cesarean section, stillbirth, fetal congenital malformations, shoulder dystocia, hypoglycemia, hyperbilirubinemia, pre-eclampsia, preterm delivery, childhood obesity, and increased risk of maternal development of type 2 DM later on in her life. This case-based review is designed to provide health care workers a framework on using various ultrasound imaging modalities in early detection of the effects of gestational diabetes, and the specific conditions and/or anomalies seen in diabetic pregnancies.

How to cite this article

Appleton K, Barnard J, Jantz AK, Pooh R, Comas-Gabriel C, Kupesic-Plavsic S. The Role of Ultrasound in the Diagnosis of Complications Associated with Maternal Diabetes. Donald School J Ultrasound Obstet Gynecol 2013;7(4):506-515.