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Rabachini Caetano AC, Machado Nardozza LM, Perez Zamarian AC, Silva Drumond LG, Chiaratti de Oliveira A, Dualib PM, Araujo Júnior E, Mattar R. Prediction of lung maturity through quantitative ultrasound analysis of fetal lung texture in women with diabetes during pregnancy. J Perinat Med 2023; 51:913-919. [PMID: 37097317 DOI: 10.1515/jpm-2023-0009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 04/01/2023] [Indexed: 04/26/2023]
Abstract
OBJECTIVES The present study aimed to evaluate the performance of QuantusFLM® software, which performs quantitative ultrasound analysis of fetal lung texture, in predicting lung maturity in fetuses of diabetic mothers. METHODS The patients included in this study were between 34 and 38 weeks and 6 days gestation and were divided into two groups: (1) patients with diabetes on medication and (2) control. The ultrasound images were performed up to 48 h prior to delivery and analyzed using QuantusFLM® software, which classified each fetus as high or low risk for neonatal respiratory morbidity based on lung maturity or immaturity. RESULTS A total of 111 patients were included in the study, being 55 in diabetes and 56 in control group. The pregnant women with diabetes had significantly higher body mass index (27.8 kg/m2 vs. 25.9 kg/m2, respectively, p=0.02), increased birth weight (3,135 g vs. 2,887 g, respectively, p=0.002), and a higher rate of labor induction (63.6 vs. 30.4 %, respectively, p<0.001) compared to the control group. QuantusFLM® software was able to predict lung maturity in diabetes group with 96.4 % accuracy, 96.4 % sensitivity and 100 % positive predictive value. Considering the total number of patients, the software demonstrated accuracy, sensitivity, specificity, positive predictive value and negative predictive value of 95.5 , 97.2, 33.3, 98.1 and 25 %, respectively. CONCLUSIONS QuantusFLM® was an accurate method for predicting lung maturity in normal and DM singleton pregnancies and has the potential to aid in deciding the timing of delivery for pregnant women with DM.
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Affiliation(s)
- Ana Carolina Rabachini Caetano
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
- Fetal Medicine Unit, Department of Perinatology, Albert Einstein Hospital, São Paulo, SP, Brazil
| | | | - Ana Cristina Perez Zamarian
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
| | - Luiza Grosso Silva Drumond
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
| | - Allan Chiaratti de Oliveira
- Department of Pediatrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
| | - Patricia Medici Dualib
- Department of Medical Clinic, Discipline of Endocrinology, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
| | - Edward Araujo Júnior
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
| | - Rosiane Mattar
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
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Luo R, Wen W, Corsi DJ, Fell DB, Taljaard M, Wen SW, Walker MC. Comparison of adverse maternal and perinatal outcomes between induction and expectant management among women with gestational diabetes mellitus at term pregnancy: a systematic review and meta-analysis. BMC Pregnancy Childbirth 2023; 23:509. [PMID: 37438706 DOI: 10.1186/s12884-023-05779-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 06/12/2023] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND Induction at 38-40 weeks of gestation has been broadly suggested for women with gestational diabetes mellitus (GDM), yet its benefits and risks remain unclear. This study aimed to systematically review and meta-analyze existing evidence on the effect of induction at term gestation among women with GDM. METHODS We searched MEDLINE, EMBASE, Cochrane Libraries, and Web of Science from inception to June 2021. We included randomized controlled trials (RCTs) and observational studies comparing induction with expectant management among GDM term pregnancies. Primary outcomes included caesarean section (CS) and macrosomia. All screening and extraction were conducted independently and in duplicates. Meta-analyses with random-effects models were conducted to generate the pooled odds ratios (ORs) and 95% confidence intervals (CIs) using the Mantel-Haenszel method. Methodological quality was assessed independently by two reviewers using the Cochrane Risk of Bias Tool for RCTs and the Newcastle-Ottawa Scale for observational studies. RESULTS Of the 4,791 citations, 11 studies were included (3 RCTs and 8 observational studies). Compared to expectant management, GDM women with induction had a significantly lower odds for macrosomia (RCTs 0.49 [0.30-0.81]); observational studies 0.64 [0.54-0.77]), but not for CS (RCTs 0.95 [0.64-1.43]); observational studies 1.03 [0.79-1.34]). Induction was associated with a lower odds of severe perineal lacerations in observational studies (0.59 [0.39-0.88]). No significant difference was observed for other maternal or neonatal morbidities, or perinatal mortality between groups. CONCLUSIONS For GDM women, induction may reduce the risk of macrosomia and severe perineal lacerations compared to expectant management. Further rigorous studies with large sample sizes are warranted to better inform clinical implications.
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Affiliation(s)
- Rong Luo
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Wendy Wen
- McLaughlin Centre for Population Health Risk Assessment, University of Ottawa, Ottawa, Canada
| | - Daniel J Corsi
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Deshayne B Fell
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Shi Wu Wen
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada.
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada.
- Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, Canada.
- Department of Obstetrics, Gynecology & Newborn Care, The Ottawa Hospital, Ottawa, Canada.
| | - Mark C Walker
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada.
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada.
- Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, Canada.
- Department of Obstetrics, Gynecology & Newborn Care, The Ottawa Hospital, Ottawa, Canada.
- International and Global Health Office, University of Ottawa, Ottawa, Canada.
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McElwee ER, Oliver EA, McFarling K, Haney A, Cuff R, Head B, Karanchi H, Loftley A, Finneran MM. Risk of Stillbirth in Pregnancies Complicated by Diabetes, Stratified by Fetal Growth. Obstet Gynecol 2023; 141:801-809. [PMID: 36897128 DOI: 10.1097/aog.0000000000005102] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 12/12/2022] [Indexed: 03/11/2023]
Abstract
OBJECTIVE To compare stillbirth rates per week of expectant management stratified by birth weight in pregnancies complicated by gestational diabetes mellitus (GDM) or pregestational diabetes mellitus. METHODS A national population-based retrospective cohort study of singleton, nonanomalous pregnancies complicated by pregestational diabetes or GDM was performed using national birth and death certificate data from 2014 to 2017. Stillbirth rates per 10,000 patients (stillbirth incidence at gestational age week/ongoing pregnancies-[0.5×live births at gestational age week]) were determined for each week of pregnancy from 34 to 39 completed weeks of gestation. Pregnancies were stratified by birth weight, categorized as having small-for-gestational-age (SGA), appropriate-for-gestational-age (AGA), or large-for-gestational-age (LGA) fetuses, assigned by sex-based Fenton criteria. Relative risk (RR) and 95% CI for stillbirth were calculated for each gestational age week compared with the GDM-related AGA group. RESULTS We included 834,631 pregnancies complicated by either GDM (86.9%) or pregestational diabetes (13.1%) in the analysis, with a total of 3,033 stillbirths. Stillbirth rates increased with advancing gestational age for pregnancies complicated by both GDM and pregestational diabetes regardless of birth weight. Compared with pregnancies with AGA fetuses, those with both SGA and LGA fetuses were significantly associated with an increased risk of stillbirth at all gestational ages. Ongoing pregnancies at 37 weeks of gestation complicated by pregestational diabetes with LGA or SGA fetuses had respective stillbirth rates of 64.9 and 40.1 per 10,000 patients. Pregnancies complicated by pregestational diabetes had an RR of stillbirth of 21.8 (95% CI 17.4-27.2) for LGA fetuses and 13.5 (95% CI 8.5-21.2) for SGA fetuses compared with GDM-related AGA at 37 weeks of gestation. The greatest absolute risk of stillbirth was in pregnancies complicated by pregestational diabetes at 39 weeks of gestation with LGA fetuses (97/10,000). CONCLUSION Pregnancies complicated by both GDM and pregestational diabetes affected by pathologic fetal growth have an increased risk of stillbirth with advancing gestational age. This risk is significantly higher with pregestational diabetes, especially pregestational diabetes with LGA fetuses.
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Affiliation(s)
- Eliza R McElwee
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, and the Division of Endocrinology, Department of Internal Medicine, Medical University of South Carolina, Charleston, South Carolina; and the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
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Malaza N, Masete M, Adam S, Dias S, Nyawo T, Pheiffer C. A Systematic Review to Compare Adverse Pregnancy Outcomes in Women with Pregestational Diabetes and Gestational Diabetes. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph191710846. [PMID: 36078559 PMCID: PMC9517767 DOI: 10.3390/ijerph191710846] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 08/15/2022] [Accepted: 08/22/2022] [Indexed: 05/14/2023]
Abstract
Pregestational type 1 (T1DM) and type 2 (T2DM) diabetes mellitus and gestational diabetes mellitus (GDM) are associated with increased rates of adverse maternal and neonatal outcomes. Adverse outcomes are more common in women with pregestational diabetes compared to GDM; although, conflicting results have been reported. This systematic review aims to summarise and synthesise studies that have compared adverse pregnancy outcomes in pregnancies complicated by pregestational diabetes and GDM. Three databases, Pubmed, EBSCOhost and Scopus were searched to identify studies that compared adverse outcomes in pregnancies complicated by pregestational T1DM and T2DM, and GDM. A total of 20 studies met the inclusion criteria and are included in this systematic review. Thirteen pregnancy outcomes including caesarean section, preterm birth, congenital anomalies, pre-eclampsia, neonatal hypoglycaemia, macrosomia, neonatal intensive care unit admission, stillbirth, Apgar score, large for gestational age, induction of labour, respiratory distress syndrome and miscarriages were compared. Findings from this review confirm that pregestational diabetes is associated with more frequent pregnancy complications than GDM. Taken together, this review highlights the risks posed by all types of maternal diabetes and the need to improve care and educate women on the importance of maintaining optimal glycaemic control to mitigate these risks.
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Affiliation(s)
- Nompumelelo Malaza
- Biomedical Research and Innovation Platform (BRIP), South African Medical Research Council, Tygerberg, Cape Town 7505, South Africa
- Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of Pretoria, Pretoria 0001, South Africa
| | - Matladi Masete
- Biomedical Research and Innovation Platform (BRIP), South African Medical Research Council, Tygerberg, Cape Town 7505, South Africa
- Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of Pretoria, Pretoria 0001, South Africa
| | - Sumaiya Adam
- Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of Pretoria, Pretoria 0001, South Africa
- Diabetes Research Centre, Faculty of Health Sciences, University of Pretoria, Pretoria 0001, South Africa
| | - Stephanie Dias
- Biomedical Research and Innovation Platform (BRIP), South African Medical Research Council, Tygerberg, Cape Town 7505, South Africa
| | - Thembeka Nyawo
- Biomedical Research and Innovation Platform (BRIP), South African Medical Research Council, Tygerberg, Cape Town 7505, South Africa
- Centre for Cardio-Metabolic Research in Africa, Division of Medical Physiology, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, Cape Town 7505, South Africa
| | - Carmen Pheiffer
- Biomedical Research and Innovation Platform (BRIP), South African Medical Research Council, Tygerberg, Cape Town 7505, South Africa
- Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of Pretoria, Pretoria 0001, South Africa
- Centre for Cardio-Metabolic Research in Africa, Division of Medical Physiology, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, Cape Town 7505, South Africa
- Correspondence:
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Coates D, Makris A, Catling C, Henry A, Scarf V, Watts N, Fox D, Thirukumar P, Wong V, Russell H, Homer C. A systematic scoping review of clinical indications for induction of labour. PLoS One 2020; 15:e0228196. [PMID: 31995603 PMCID: PMC6988952 DOI: 10.1371/journal.pone.0228196] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 01/10/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The proportion of women undergoing induction of labour (IOL) has risen in recent decades, with significant variation within countries and between hospitals. The aim of this study was to review research supporting indications for IOL and determine which indications are supported by evidence and where knowledge gaps exist. METHODS A systematic scoping review of quantitative studies of common indications for IOL. For each indication, we included systematic reviews/meta-analyses, randomised controlled trials (RCTs), cohort studies and case control studies that compared maternal and neonatal outcomes for different modes or timing of birth. Studies were identified via the databases PubMed, Maternity and Infant Care, CINAHL, EMBASE, and ClinicalTrials.gov from between April 2008 and November 2019, and also from reference lists of included studies. We identified 2554 abstracts and reviewed 300 full text articles. The quality of included studies was assessed using the RoB 2.0, the ROBINS-I and the ROBIN tool. RESULTS 68 studies were included which related to post-term pregnancy (15), hypertension/pre-eclampsia (15), diabetes (9), prelabour rupture of membranes (5), twin pregnancy (5), suspected fetal compromise (4), maternal elevated body mass index (BMI) (4), intrahepatic cholestasis of pregnancy (3), suspected macrosomia (3), fetal gastroschisis (2), maternal age (2), and maternal cardiac disease (1). Available evidence supports IOL for women with post-term pregnancy, although the evidence is weak regarding the timing (41 versus 42 weeks), and for women with hypertension/preeclampsia in terms of improved maternal outcomes. For women with preterm premature rupture of membranes (24-37 weeks), high-quality evidence supports expectant management rather than IOL/early birth. Evidence is weakly supportive for IOL in women with term rupture of membranes. For all other indications, there were conflicting findings and/or insufficient power to provide definitive evidence. CONCLUSIONS While for some indications, IOL is clearly recommended, a number of common indications for IOL do not have strong supporting evidence. Overall, few RCTs have evaluated the various indications for IOL. For conditions where clinical equipoise regarding timing of birth may still exist, such as suspected macrosomia and elevated BMI, researchers and funding agencies should prioritise studies of sufficient power that can provide quality evidence to guide care in these situations.
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Affiliation(s)
- Dominiek Coates
- Centre for Midwifery and Child and Family Health, Faculty of Health, University of Technology Sydney, Australia
| | - Angela Makris
- Department of Medicine, Western Sydney University, Sydney, Australia
- Women’s Health Initiative Translational Unit (WHITU), Liverpool Hospital, Liverpool, Australia
| | - Christine Catling
- Centre for Midwifery and Child and Family Health, Faculty of Health, University of Technology Sydney, Australia
| | - Amanda Henry
- School of Women’s and Children’s Health, UNSW Medicine, University of New South Wales, Sydney, Australia
- Department of Women’s and Children’s Health, St George Hospital, Sydney, Australia
- The George Institute for Global Health, UNSW Medicine, Sydney, Australia
| | - Vanessa Scarf
- Centre for Midwifery and Child and Family Health, Faculty of Health, University of Technology Sydney, Australia
| | - Nicole Watts
- Centre for Midwifery and Child and Family Health, Faculty of Health, University of Technology Sydney, Australia
| | - Deborah Fox
- Centre for Midwifery and Child and Family Health, Faculty of Health, University of Technology Sydney, Australia
| | - Purshaiyna Thirukumar
- School of Women’s and Children’s Health, UNSW Medicine, University of New South Wales, Sydney, Australia
| | - Vincent Wong
- Liverpool Diabetes Collaborative Research Unit, Ingham Institute of Applied Research Science, University of New South Wales, Liverpool, Australia
| | - Hamish Russell
- South Western Sydney Local Health District, Sydney, Australia
| | - Caroline Homer
- Centre for Midwifery and Child and Family Health, Faculty of Health, University of Technology Sydney, Australia
- Maternal and Child Health Program, Burnet Institute, Victoria, Australia
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6
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Metcalfe A, Hutcheon JA, Sabr Y, Lyons J, Burrows J, Donovan LE, Joseph KS. Timing of delivery in women with diabetes: A population-based study. Acta Obstet Gynecol Scand 2019; 99:341-349. [PMID: 31654401 PMCID: PMC7065101 DOI: 10.1111/aogs.13761] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 10/21/2019] [Accepted: 10/22/2019] [Indexed: 12/14/2022]
Abstract
Introduction Women with diabetes, and their infants, have an increased risk of adverse events due to excess fetal growth. Earlier delivery, when fetuses are smaller, may reduce these risks. This study aimed to evaluate the week‐specific risks of maternal and neonatal morbidity/mortality to assist with obstetrical decision making. Material and methods In this population‐based cohort study, women with type 1 diabetes (n = 5889), type 2 diabetes (n = 9422) and gestational diabetes (n = 138 917) and a comparison group without diabetes (n = 2 553 243) who delivered a singleton infant at ≥36 completed weeks of gestation between 2004 and 2014 were identified from the Canadian Institute of Health Information Discharge Abstract Database. Multivariate logistic regression was used to determine the week‐specific rates of severe maternal and neonatal morbidity/mortality among women delivered iatrogenically vs those undergoing expectant management. Results For all women, the absolute risk of severe maternal morbidity/mortality was low, typically impacting less than 1% of women, and there was no significant difference in gestational age‐specific severe maternal morbidity/mortality between iatrogenic delivery and expectant management among women with any form of diabetes. Among women with gestational diabetes, iatrogenic delivery was associated with an increased risk of neonatal morbidity/mortality compared with expectant management at 36 and 37 weeks’ gestation (76.7 and 27.8 excess cases per 1000 deliveries, respectively) and a lower risk of neonatal morbidity/mortality at 38, 39 and 40 weeks’ gestation (7.9, 27.3 and 15.9 fewer cases per 1000 deliveries, respectively). Increased risks of severe neonatal morbidity following iatrogenic delivery compared with expectant management were also observed for women with type 1 diabetes at 36 (98.3 excess cases per 1000 deliveries) and 37 weeks’ gestation (44.5 excess cases per 1000 deliveries) and for women with type 2 diabetes at 36 weeks’ gestation (77.9 excess cases per 1000 deliveries) weeks. Conclusions The clinical decision regarding timing of delivery is complex and contingent on maternal‐fetal wellbeing, including adequate glycemic control. This study suggests that delivery at 38, 39 or 40 weeks’ gestation may optimize neonatal outcomes among women with diabetes.
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Affiliation(s)
- Amy Metcalfe
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, Alberta, Canada.,Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Jennifer A Hutcheon
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, British Columbia, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Yasser Sabr
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, British Columbia, Canada.,Department of Obstetrics and Gynecology, King Saud University, Riyadh, Saudi Arabia
| | - Janet Lyons
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jason Burrows
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lois E Donovan
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, Alberta, Canada.,Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - K S Joseph
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, British Columbia, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
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Abstract
The rate of labor induction is steadily increasing and, in industrialized countries, approximately one out of four pregnant women has their labor induced. Induction of labor should be considered when the benefits of prompt vaginal delivery outweigh the maternal and/or fetal risks of waiting for the spontaneous onset of labor. However, this procedure is not free of risks, which include an increase in operative vaginal or caesarean delivery and excessive uterine activity with risk of fetal heart rate abnormalities. A search for "Induction of Labor" retrieves more than 18,000 citations from 1844 to the present day. The aim of this review is to summarize the controversies concerning the indications, the methods, and the tools for evaluating the success of the procedure, with an emphasis on the scientific evidence behind each.
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Affiliation(s)
- Anna Maria Marconi
- Department of Health Sciences, San Paolo Hospital Medical School, University of Milano, Milano, Italy
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8
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Biesty LM, Egan AM, Dunne F, Dempsey E, Meskell P, Smith V, Ni Bhuinneain GM, Devane D. Planned birth at or near term for improving health outcomes for pregnant women with gestational diabetes and their infants. Cochrane Database Syst Rev 2018; 1:CD012910. [PMID: 29303230 PMCID: PMC6491311 DOI: 10.1002/14651858.cd012910] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Gestational diabetes is a type of diabetes that occurs during pregnancy. Women with gestational diabetes are more likely to experience adverse health outcomes such as pre-eclampsia or polyhydramnios (excess amniotic fluid). Their babies are also more likely to have health complications such as macrosomia (birthweight > 4000 g) and being large-for-gestational age (birthweight above the 90th percentile for gestational age). Current clinical guidelines support elective birth, at or near term in women with gestational diabetes to minimise perinatal complications, especially those related to macrosomia.This review replaces a review previously published in 2001 that included "diabetic pregnant women", which has now been split into two reviews. This current review focuses on pregnant women with gestational diabetes and a sister review focuses on women with pre-existing diabetes (Type 1 or Type 2). OBJECTIVES To assess the effect of planned birth (either by induction of labour or caesarean birth), at or near term (37 to 40 weeks' gestation) compared with an expectant approach for improving health outcomes for women with gestational diabetes and their infants. The primary outcomes relate to maternal and perinatal mortality and morbidity. SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (15 August 2017), and reference lists of retrieved studies. SELECTION CRITERIA We included randomised trials comparing planned birth, at or near term (37 to 40 weeks' gestation), with an expectant approach, for women with gestational diabetes. Cluster-randomised and non-randomised trials (e.g. quasi-randomised trials using alternate allocation) were also eligible for inclusion but none were identified. DATA COLLECTION AND ANALYSIS Two of the review authors independently assessed study eligibility, extracted data and assessed the risk of bias of the included study. The quality of the evidence was assessed using the GRADE approach. MAIN RESULTS The findings of this review are based on a single trial involving 425 women with gestational diabetes. The trial compared induction of labour with expectant management (waiting for the spontaneous onset of labour in the absence of any maternal or fetal issues that may necessitate birth) in pregnant women with gestational diabetes at term. We assessed the overall risk of bias as being low for most domains, apart from performance, detection and attrition bias (for outcome perineum intact), which we assessed as being at high risk. It was an open-label trial, and women and healthcare professionals were not blinded.There were no clear differences between women randomised to induction of labour and women randomised to expectant management for maternal mortality or serious maternal morbidity (risk ratio (RR) 1.48, 95% confidence interval (CI) 0.25 to 8.76, one trial, 425 women); caesarean section (RR 1.06, 95% CI 0.64 to 1.77, one trial, 425 women); or instrumental vaginal birth (RR 0.81, 95% CI 0.45 to 1.46, one trial, 425 women). For the primary outcome of maternal mortality or serious maternal morbidity, there were no deaths in either group and serious maternal morbidity related to admissions to intensive care unit. The quality of the evidence contributing to these outcomes was assessed as very low, mainly due to the study having high risk of bias for some domains and because of the imprecision of effect estimates.In relation to primary neonatal outcomes, there were no perinatal deaths in either group. The quality of evidence for this outcome was judged as very low, mainly due to high risk of bias and imprecision of effect estimates. There were no clear differences in infant outcomes between women randomised to induction of labour and women randomised to expectant management: shoulder dystocia (RR 2.96, 95% CI 0.31 to 28.21, one trial, 425 infants, very low-quality evidence); large-for-gestational age (RR 0.53, 95% CI 0.28 to 1.02, one trial, 425 infants, low-quality evidence).There were no clear differences between women randomised to induction of labour and women randomised to expectant management for postpartum haemorrhage (RR 1.17, 95% CI 0.53 to 2.54, one trial, 425 women); admission to intensive care unit (RR 1.48, 95% CI 0.25 to 8.76, one trial, 425 women); and intact perineum (RR 1.02, 95% CI 0.73 to 1.43, one trial, 425 women). No infant experienced a birth trauma, therefore, we could not draw conclusions about the effect of the intervention on the outcomes of brachial plexus injury and bone fracture at birth. Infants of women in the induction-of-labour group had higher incidences of neonatal hyperbilirubinaemia (jaundice) when compared to infants of women in the expectant-management group (RR 2.46, 95% CI 1.11 to 5.46, one trial, 425 women).We found no data on the following prespecified outcomes of this review: postnatal depression, maternal satisfaction, length of postnatal stay (mother), acidaemia, intracranial haemorrhage, hypoxia ischaemic encephalopathy, small-for-gestational age, length of postnatal stay (baby) and cost.The authors of this trial acknowledge that it is underpowered for their primary outcome of caesarean section. The authors of the trial and of this review note that the CIs demonstrate a wide range, therefore making it inappropriate to draw definite conclusions. AUTHORS' CONCLUSIONS There is limited evidence to inform implications for practice. The available data are not of high quality and lack power to detect possible important differences in either benefit or harm. There is an urgent need for high-quality trials evaluating the effectiveness of planned birth at or near term gestation for women with gestational diabetes compared with an expectant approach.
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Affiliation(s)
- Linda M Biesty
- National University of Ireland GalwaySchool of Nursing and MidwiferyAras MoyolaGalwayIreland
| | - Aoife M Egan
- National University of Ireland Galway/University Hospital GalwayGalway Diabetes Research CentreNewcastle RoadGalwayIreland
| | | | - Eugene Dempsey
- Cork University Maternity HospitalNeonatologyWiltonCorkIreland
| | - Pauline Meskell
- University of LimerickDepartment of Nursing and MidwiferyHealth Sciences BuildingUniversity of LimerickLimerickIreland
| | - Valerie Smith
- Trinity College DublinSchool of Nursing and Midwifery24 D'Olier StreetDublinIreland2
| | - G Meabh Ni Bhuinneain
- Mayo University Hospital, SaoltaDepartment of Obstetrics and GynaecologyWestport RoadCastlebarMayoIreland
| | - Declan Devane
- National University of Ireland GalwaySchool of Nursing and MidwiferyAras MoyolaGalwayIreland
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