Spontaneous abortion in patients with insulin-dependent diabetes mellitus: the effect of preconceptional diabetic control

Systematic review and meta-analysis of the effectiveness of pre-pregnancy care for women with diabetes for improving maternal and perinatal outcomes

Background

Pre-gestational diabetes mellitus is associated with increased risk of maternal and perinatal adverse outcomes. This systematic review was conducted to evaluate the effectiveness and safety of pre-conception care (PCC) in improving maternal and perinatal outcomes.

Methods

Databases from MEDLINE, EMBASE, WEB OF SCIENCE, and Cochrane Library were searched, including the CENTRAL register of controlled trials, and CINHAL up until March 2019, without any language restrictions, for any pre-pregnancy care aiming at health promotion, glycemic control, and screening and treatment of diabetes complications in women with type I or type II pre-gestational diabetes. Trials and observational studies were included in the review. Newcastle-Ottawa scale and the Cochrane collaboration methodology for data synthesis and analysis were used, along with the GRADE tool to evaluate the body of evidence.

Results

The search identified 8500 potentially relevant citations of which 40 reports of 36 studies were included. The meta-analysis results show that PCC reduced congenital malformations risk by 71%, (Risk ratio (RR) 0.29; 95% CI: 0.21–0.40, 25 studies; 5903 women; high-certainty evidence). The results also show that PCC may lower HbA1c in the first trimester of pregnancy by an average of 1.27% (Mean difference (MD) 1.27; 95% CI: 1.33–1.22; 4927 women; 24 studies, moderate-certainty evidence). Furthermore, the results suggest that PCC may lead to a slight reduction in the risk of preterm delivery of 15%, (RR 0.85; 95% CI: 0.73–0.99; nine studies, 2414 women; moderate-certainty evidence). Moreover, PCC may result in risk reduction of perinatal mortality by 54%, (RR 0.46; 95% CI: 0.30–0.73; ten studies; 3071 women; moderate-certainty evidence). There is uncertainty about the effects of PCC on the early booking for antenatal care (MD 1.31; 95% CI: 1.40–1.23; five studies, 1081 women; very low-certainty evidence) and maternal hypoglycemia in the first trimester, (RR 1.38; 95% CI: 1.07–1.79; three studies; 686 women; very low- certainty evidence). In addition, results of the meta-analysis indicate that PCC may lead to 48% reduction in the risk of small for gestational age (SGA) (RR 0.52; 95% CI: 0.37–0.75; six studies, 2261 women; moderate-certainty evidence). PCC may reduce the risk of neonatal admission to intensive care unit (NICU) by 25% (RR 0.75; 95% CI: 0.67–0.84; four studies; 1322 women; moderate-certainty evidence). However, PCC may have little or no effect in reducing the cesarean section rate (RR 1.02; 95% CI: 0.96–1.07; 14 studies; 3641 women; low-certainty evidence); miscarriage rate (RR 0.86; 95% CI: 0.70–1.06; 11 studies; 2698 women; low-certainty evidence); macrosomia rate (RR 1.06; 95% CI: 0.97–1.15; nine studies; 2787 women, low-certainty evidence); neonatal hypoglycemia (RR 0.93; 95% CI: 0.74–1.18; five studies; 880 women; low-certainty evidence); respiratory distress syndrome (RR 0.78; 95% CI: 0.47–1.29; four studies; 466 women; very low-certainty evidence); or shoulder dystocia (RR 0.28; 95% CI: 0.07–1.12; 2 studies; 530 women; very low-certainty evidence).

Conclusion

PCC for women with pre-gestational type 1 or type 2 diabetes mellitus is effective in improving rates of congenital malformations. In addition, it may improve the risk of preterm delivery and admission to NICU. PCC probably reduces maternal HbA1C in the first trimester of pregnancy, perinatal mortality and SGA. There is uncertainty regarding the effects of PCC on early booking for antenatal care or maternal hypoglycemia during the first trimester of pregnancy. PCC has little or no effect on other maternal and perinatal outcomes.

Health care and risk of adverse pregnancy outcomes among diabetic women: an updated meta-analysis

PURPOSE

Diabetic women appear to have adverse pregnancy outcomes. Although there were two meta-analyzes that examined the association between health care and adverse pregnancy outcomes, their results were limited because they only included congenital anomaly and perinatal mortality, and they did not clarify the detailed situations of diabetes and health care. This meta-analysis aims to completely evaluate the effects of health care in improving adverse pregnancy outcomes among diabetic mothers.

METHODS

CNKI, EMBASE, Web of Science, and PubMed databases were searched for eligible studies up to December 2017, without any restrictions. Relevant cohort studies characterizing the relationship between health care and adverse pregnancy outcomes were selected for inclusion in the meta-analysis. We also screened the reference list of relevant studies. The fixed-effect models or random-effect models were used to calculate the risk estimates. The potential sources of heterogeneity were explored by stratified and sensitivity analyzes.

RESULTS

Twenty-one studies with 6685 cases were included in our analysis. Health care was associated with significantly decreased risk of congenital anomaly (RR 0.237; 95% CI 0.166-0.338), perinatal death (RR 0.457; 95% CI 0.294-0.712), large for gestational age (LGA) (RR 0.794; 95% CI 0.640-0.986), and neonatal hypoglycemia (RR 0.672; 95% CI 0.486-0.929). Publication bias was not found in most results, with the exception of congenital anomaly and small for gestational age (SGA).

CONCLUSION

Health care is associated with decreased risk of congenital anomaly, perinatal death, LGA, neonatal hypoglycemia.

Continuous glucose monitoring during diabetic pregnancy (GlucoMOMS): A multicentre randomized controlled trial

AIM

Diabetes is associated with a high risk of adverse pregnancy outcomes. Optimal glycaemic control is fundamental and is traditionally monitored with self-measured glucose profiles and periodic HbA1c measurements. We investigated the effectiveness of additional use of retrospective continuous glucose monitoring (CGM) in diabetic pregnancies.

MATERIAL AND METHODS

We performed a nationwide multicentre, open label, randomized, controlled trial to study pregnant women with type 1 or type 2 diabetes who were undergoing insulin therapy at gestational age < 16 weeks, or women who were undergoing insulin treatment for gestational diabetes at gestational age < 30 weeks. Women were randomly allocated (1:1) to intermittent use of retrospective CGM or to standard treatment. Glycaemic control was assessed by CGM for 5-7 days every 6 weeks in the CGM group, while self-monitoring of blood glucose and HbA1c measurements were applied in both groups. Primary outcome was macrosomia, defined as birth weight above the 90th percentile. Secondary outcomes were glycaemic control and maternal and neonatal complications.

RESULTS

Between July 2011 and September 2015, we randomized 300 pregnant women with type 1 (n = 109), type 2 (n = 82) or with gestational (n = 109) diabetes to either CGM (n = 147) or standard treatment (n = 153). The incidence of macrosomia was 31.0% in the CGM group and 28.4% in the standard treatment group (relative risk [RR], 1.06; 95% CI, 0.83-1.37). HbA1c levels were similar between treatment groups.

CONCLUSIONS

In diabetic pregnancy, use of intermittent retrospective CGM did not reduce the risk of macrosomia. CGM provides detailed information concerning glycaemic fluctuations but, as a treatment strategy, does not translate into improved pregnancy outcome.

Pathways of association between maternal haemoglobin and stillbirth: path-analysis of maternity data from two hospitals in England

OBJECTIVE

To investigate the mechanisms that link maternal haemoglobin concentration with stillbirth.

DESIGN

A retrospective cohort analysis using anonymised maternity data from two hospitals in England.

SETTING

The Royal Wolverhampton NHS Trust and Guy's and St Thomas' NHS Foundation Trust.

STUDY POPULATION

12 636 women with singleton pregnancies ≥24 weeks of gestation giving birth in the two hospitals during 2013-2015.

METHOD

A conceptual framework of hypothesised pathways through birth weight-for-gestational age and maternal infection including potential confounders and other risk factors was developed and examined using path-analysis. Path-analysis was performed by fitting a set of regression equations using weighted least squares adjusted for mean and variance. Goodness-of-fit indices were estimated.

MAIN OUTCOME MEASURES

Coefficient of association (β) for relationship between each parameter, and direct, indirect and total effects via the postulated pathways.

RESULTS

The path-model showed a significant adjusted indirect negative effect of maternal haemoglobin on stillbirth mediated via birth weight-for-gestational age (standardised estimate (SE)=-0.01; 95% CI=-0.01 to -0.001; P=0.028). The effect through maternal infection was not significant at P<0.05 (SE=0.001; 95% CI=-0.004 to 0.01; P=0.610). There was a residual direct negative effect of maternal haemoglobin on stillbirth (SE=-0.12; 95% CI -0.23 to -0.02; P=0.020) after accounting for the two pathways. Total indirect SE=-0.004; 95% CI -0.01 to 0.003; P=0.267; total direct and indirect SE=-0.13; 95% CI -0.23 to -0.02; P=0.016. The goodness-of-fit indices showed a good fit between the model and the data.

CONCLUSION

While some of the influence on risk of stillbirth acts through low birth weight-for-gestational age, the majority does not. Several new mechanisms have been suggested for how haemoglobin may be exerting its influence on the risk of stillbirth possibly involving genetic, epigenetic and/or alternative obstetric and nutritional pathologies, but much more research is needed.

Preconception care: screening and management of chronic disease and promoting psychological health

INTRODUCTION

A large proportion of women around the world suffer from chronic diseases including mental health diseases. In the United States alone, over 12% of women of reproductive age suffer from a chronic medical condition, especially diabetes and hypertension. Chronic diseases significantly increase the odds for poor maternal and newborn outcomes in pregnant women.

METHODS

A systematic review and meta-analysis of the evidence was conducted to ascertain the possible impact of preconception care for preventing and managing chronic diseases and promoting psychological health on maternal, newborn and child health outcomes. A comprehensive strategy was used to search electronic reference libraries, and both observational and clinical controlled trials were included. Cross-referencing and a separate search strategy for each preconception risk and intervention ensured wider study capture.

RESULTS

Maternal prepregnancy diabetic care is a significant intervention that reduces the occurrence of congenital malformations by 70% (95% Confidence Interval (CI): 59-78%) and perinatal mortality by 69% (95% CI: 47-81%). Furthermore, preconception management of epilepsy and phenylketonuria are essential and can optimize maternal, fetal and neonatal outcomes if given before conception. Ideally changes in antiepileptic drug therapy should be made at least 6 months before planned conception. Interventions specifically targeting women of reproductive age suffering from a psychiatric condition show that group-counseling and interventions leading to empowerment of women have reported non-significant reduction in depression (economic skill building: Mean Difference (MD) -7.53; 95% CI: -17.24, 2.18; counseling: MD-2.92; 95% CI: -13.17, 7.33).

CONCLUSION

While prevention and management of the chronic diseases like diabetes and hypertension, through counseling, and other dietary and pharmacological intervention, is important, delivering solutions to prevent and respond to women's psychological health problems are urgently needed to combat this leading cause of morbidity.

Preconception care: delivery strategies and packages for care

The notion of preconception care aims to target the existing risks before pregnancy, whereby resources may be used to improve reproductive health and optimize knowledge before conceiving. The preconception period provides an opportunity to intervene earlier to optimize the health of potential mothers (and fathers) and to prevent harmful exposures from affecting the developing fetus. These interventions include birth spacing and preventing teenage pregnancy, promotion of contraceptive use, optimization of weight and micronutrient status, prevention and management of infectious diseases, and screening for and managing chronic conditions. Given existing interventions and the need to organize services to optimize delivery of care in a logical and effective manner, interventions are frequently co-packaged or bundled together. This paper highlights packages of preconception interventions that can be combined and co-delivered to women through various delivery channels and provides a logical framework for development of such packages in varying contexts.

Diabetes and pregnancy: an endocrine society clinical practice guideline

OBJECTIVE

Our objective was to formulate a clinical practice guideline for the management of the pregnant woman with diabetes.

PARTICIPANTS

The Task Force was composed of a chair, selected by the Clinical Guidelines Subcommittee of The Endocrine Society, 5 additional experts, a methodologist, and a medical writer.

EVIDENCE

This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe both the strength of recommendations and the quality of evidence.

CONSENSUS PROCESS

One group meeting, several conference calls, and innumerable e-mail communications enabled consensus for all recommendations save one with a majority decision being employed for this single exception.

CONCLUSIONS

Using an evidence-based approach, this Diabetes and Pregnancy Clinical Practice Guideline addresses important clinical issues in the contemporary management of women with type 1 or type 2 diabetes preconceptionally, during pregnancy, and in the postpartum setting and in the diagnosis and management of women with gestational diabetes during and after pregnancy.

Pregnancy in diabetes and kidney disease

With appropriate multi-disciplinary team care, most women with diabetic nephropathy will have successful pregnancy outcomes; however, pregnancy complications are increased compared to non-diabetic individuals, particularly in those with poor glycaemic control. Women with more severe renal impairment, especially those with hypertension and proteinuria at are highest risk of worse pregnancy outcomes and deterioration in pre-existing renal function. Pre-pregnancy counselling should be offered to all women with diabetes in order to optimise diabetic care, and inform women of potential complications. Pregnancy is an indicator of long-term health, and may indicate important issues for the future management of women with diabetic nephropathy.

Preconception care for women with diabetes: is it effective and who should provide it?

The association between hyperglycaemia and congenital malformations was first recognised over 40 years ago and was followed by the development of preconception clinics for women with diabetes. A fresh look at preconception care is needed as many studies were conducted during the late 1970s and early 1980s, before the introduction of regular home blood glucose monitoring and glycosylated haemoglobin assays, and when many patients with diabetes had microvascular complications. Recent observational studies and a meta-analysis suggest preconception care is effective with an approximately threefold reduction in the risk of malformations. There is now a worldwide epidemic of type 2 diabetes, but only few studies of preconception care have included women with type 2 diabetes. Furthermore, few studies have addressed the relationship between preconception care and perinatal morbidity. This article will review the evidence for preconception care in women with diabetes, evaluate different models of preconception care and discuss future strategies.

Preconception care for diabetic women for improving maternal and fetal outcomes: a systematic review and meta-analysis

Background

Preexisting diabetes mellitus is associated with increased risk for maternal and fetal adverse outcomes. Despite improvement in the access and quality of antenatal care recent population based studies demonstrating increased congenital abnormalities and perinatal mortality in diabetic mothers as compared to the background population. This systematic review was carried out to evaluate the effectiveness and safety of preconception care in improving maternal and fetal outcomes for women with preexisting diabetes mellitus.

Methods

We searched the following databases, MEDLINE, EMBASE, WEB OF SCIENCE, Cochrane Library, including the CENTRAL register of controlled trials and CINHAL up to December 2009, without language restriction, for any preconception care aiming at health promotion, glycemic control and screening and treatment of diabetes complications in women of reproductive age group with type I or type II diabetes. Study design were trials (randomized and non-randomized), cohort and case-control studies. Of the 1612 title scanned 44 full papers were retrieved of those 24 were included in this review. Twelve cohort studies at low and medium risk of bias, with 2502 women, were included in the meta-analysis.

Results

Meta-analysis suggested that preconception care is effective in reducing congenital malformation, RR 0.25 (95% CI 0.15-0.42), NNT17 (95% CI 14-24), preterm delivery, RR 0.70 (95% CI 0.55-0.90), NNT = 8 (95% CI 5-23) and perinatal mortality RR 0.35 (95% CI 0.15-0.82), NNT = 32 (95% CI 19-109). Preconception care lowers HbA1c in the first trimester of pregnancy by an average of 2.43% (95% CI 2.27-2.58). Women who received preconception care booked earlier for antenatal care by an average of 1.32 weeks (95% CI 1.23-1.40).

Conclusion

Preconception care is effective in reducing diabetes related congenital malformations, preterm delivery and maternal hyperglycemia in the first trimester of pregnancy.

The association between depression and diabetes in the perinatal period

Both depression and diabetes are common in the perinatal period and result in serious consequences for mother and fetus. Although the association between depression and diabetes is well established, few studies have examined the association between these disorders during the perinatal period, when the etiology of depression and diabetes may differ from other periods over the life course. This article reviews the four most relevant epidemiologic papers that examined the association between depression and diabetes in the perinatal period and makes recommendations for future studies about how best to examine the association between these disorders during the perinatal period.

Pre-conception health awareness in infertility patients

OBJECTIVE

Pre-conception counselling is important, as most pregnancies are unplanned. There are few published studies examining women's attitudes and knowledge in this area. As part of our ongoing education quality improvement program we evaluated the pre-conception knowledge and attitudes of women at an infertility clinic.

METHODS

Women who presented for initial assessment to a university-affiliated infertility clinic completed a knowledge survey prior to the first physician consultation.

RESULTS

Four hundred surveys were appropriately completed for data analysis. Patients were well informed about health optimization, folic acid consumption, infectious disease exposure, medication use, partner abuse, smoking, and recreational drug use. Patients were not well informed about the risks of daily alcohol consumption, advanced maternal age, exercise, cat litter exposure, and consumption of fish and certain other foods. They were uncertain about the importance of rubella immunization and family history. Nulliparous women were less knowledgeable about the significance of rubella immunization, exercise, recreational drug use, cat litter exposure, and fish consumption. Women who were more educated had more knowledge about the effects of the mother's age, exercise, alcohol exposure, and smoking on pregnancy.

CONCLUSIONS

There are gaps in knowledge, even in the highly motivated population of infertile women who are planning to be pregnant. The results of this survey suggest that women need and want their physicians to educate them about optimal pre-pregnancy lifestyle. We will revise our education programs to account for these gaps. Larger population-based studies are needed to assess knowledge in the general population, so that appropriate health promotion and education programs can be implemented.

TYPE 1 DIABETES IN PREGNANCY; INFLUENCES ON MOTHER AND FETUS

Type 1 diabetes complicates around 1 in 200 to 300 pregnancies in the United Kingdom. Historically maternal type 1 diabetes carried very high risks for mother and child. Introduction of insulin led to an immediate, marked decline in the previously very high rates of maternal mortality; in contrast an improvement in perinatal outcomes occurred more slowly but was nevertheless dramatic. This is strikingly demonstrated by the temporal decline in perinatal mortality in offspring of mothers with type 1 diabetes which was virtually universal before use of insulin in the 1920's, likely remained in excess of 20% even in the 1960's and fell to under 4% by the 1990's. The reasons for this more gradual improvement in perinatal outcomes cannot be defined with precision but will have been influenced by improved glycaemic management with use of intensive, multiple dose insulin treatment and home glucose monitoring; improvements in obstetric and neonatal management, and better management of complications of diabetes before and during pregnancy. In 1989 the St Vincent declaration proposed that pregnancy outcomes in women with type 1 diabetes should approximate those of the non-diabetic population. While the long term improvements in fetal outcomes have been dramatic, contemporary surveys confirm a persistent doubling or more of rates of congenital anomaly and a three to four fold increase in perinatal mortality in the UK and other European countries which will require further clinical innovation to overcome.

Insulin resistance increases the risk of spontaneous abortion after assisted reproduction technology treatment

OBJECTIVE

This study aims to examine the impact of insulin resistance (IR) on the risk of spontaneous abortion in patients who received infertility treatment.

PATIENTS AND METHODS

This is a cohort study of 107 patients who achieved their first pregnancy after infertility treatment in a tertiary medical center. A homeostasis model assessment of IR (HOMA-IR) was carried out. Patient demographic characteristics and pregnancy outcome were also recorded. Statistical comparison was made between patients with and without IR. Logistical regression analysis was used to assess the effect of IR and several other factors simultaneously on the risk of spontaneous abortion.

RESULTS

The incidence of spontaneous abortion was 17.8%. The association of IR with the risk of spontaneous abortion was significant after adjusting for other risk factors. The effect of overweight/obesity and polycystic ovarian syndrome was not statistically significant in the multivariate model.

DISCUSSION AND CONCLUSION

This study suggested that IR was an independent risk factor for spontaneous abortion. Because of the high prevalence of IR in obese or polycystic ovarian syndrome patients, the risk of spontaneous abortion in these patients can be raised. Patients with IR should be advised to improve their insulin sensitivity through lifestyle change or medical intervention before infertility treatment to reduce their risk of spontaneous abortion.

Do we practice what we preach? A review of actual clinical practice with regards to preconception care guidelines

OBJECTIVES

To review what past studies have found with regard to existing clinical practices and approaches to providing preconception care.

METHODS

A literature review between 1966 and September 2005 was performed using Medline. Key words included preconception care, preconception counseling, preconception surveys, practice patterns, pregnancy outcomes, prepregnancy planning, and prepregnancy surveys.

RESULTS

There are no current national recommendations that fully address preconception care; as a result, there is wide variability in what is provided clinically under the rubric of preconception care.

CONCLUSIONS

In 2005, the Centers for Disease Control and Prevention sponsored a national summit regarding preconception care and efforts are underway to develop a uniform set of national recommendations and guidelines for preconception care. Understanding how preconception care is presently incorporated and manifested in current medical practices should help in the development of these national guidelines. Knowing where, how, and why some specific preconception recommendations have been successfully adopted and translated into clinical practice, as well as barriers to implementation of other recommendations or guidelines, is vitally important in developing an overarching set of national guidelines. Ultimately, the success of these recommendations rests on their ability to influence and shape women's health policy.

Prepregnancy care and pregnancy outcomes in women with type 1 diabetes

OBJECTIVE

The objective of this study was to examine the relationship between prepregnancy care, glycemic control, maternal hypoglycemia, and pregnancy outcomes in women with type 1 diabetes.

RESEARCH DESIGN AND METHODS

This was a prospective observational cohort study of women with type 1 diabetes who delivered from 1991 to 2002. Outcome measures were attendance at a clinic for prepregnancy care, maternal HbA(1c) (A1C) throughout pregnancy, maternal severe hypoglycemic episodes, macrosomia, preeclampsia, premature delivery (delivery before 37 weeks), very premature delivery (delivery before 34 weeks), spontaneous abortion, and adverse pregnancy outcome (defined as major malformation, stillbirth, and neonatal death).

RESULTS

There were 290 pregnancies, in which 110 (38%) women had prepregnancy care. The prepregnancy care group contained more primiparous women (54.7 vs. 40.6%; P = 0.021) and fewer smokers (9.4 vs. 28.7%; P < 0.0001). They registered earlier (6.6 vs. 8.3 weeks, P < 0.0001) and had a lower A1C at the initial visit (6.5% vs. 7.6%; P < 0.0001). Adverse pregnancy outcomes and very premature deliveries were significantly lower in women who received prepregnancy care (2.9 vs. 10.2%; P = 0.03 and 5.0 vs. 14.2%; P = 0.02, respectively). In contrast, between groups, there was no difference in A1C after 24 weeks or in the rates of macrosomia, preeclampsia, or maternal severe hypoglycemic episodes.

CONCLUSIONS

Prepregnancy care was associated with improved glycemic control in early pregnancy and significant reductions in adverse pregnancy outcome (malformation, stillbirth, and neonatal death) and very premature delivery. However, prepregnancy care failed to have an impact on glycemic control in later pregnancy or to reduce the risk of macrosomia and preeclampsia.

Impaired fertility caused by endocrine dysfunction in women

Infertility can be frustrating for patients and physicians. Endocrine dysfunction can impair fertility and alter pregnancy outcome. Once the diagnosis is secured, most endocrine disorders are reversible or can be adequately managed to restore fertility and decrease associated pregnancy complications. Improved understanding of the subtleties and intricacies of mechanisms by which endocrinopathies can hinder fertility and influence the course of a pregnancy is vital, more so in the era of assisted reproductive technology, because pregnancy in an abnormal endocrine environment can be disastrous. The role of autoimmunity in infertility and pregnancy loss is less clear; in this context, there are limited management options to improve fertility and overall pregnancy outcomes.

The Art and Science of Maintenance of Normoglycemia in Pregnancies complicated by Insulin-Dependent Diabetes Mellitus

OBJECTIVE

To provide a "how-to" manual for achieving and maintaining normoglycemia in pregnant women with insulin-dependent diabetes.

METHODS

We describe a detailed program that has successfully maintained normoglycemia before, during, and after diabetes-complicated pregnancies. Insulin and glucose requirements throughout pregnancy, during labor, and in the postpartum period are outlined.

RESULTS

With preconception planning and careful dietary and blood glucose management during pregnancy, complications can be minimized and an optimal outcome of pregnancy can be achieved in women with diabetes.

CONCLUSION

Women with type I, insulin-dependent diabetes can now have the same chances as women without diabetes to have a healthy infant. The reduction of risks associated with pregnancies complicated by diabetes can be ensured if normoglycemia is achieved before and during the pregnancy.

In vitro fertilization and embryo transfer in well-controlled, insulin-dependent diabetics

Five IDD patients achieved strict preconception glycemic control and then underwent nine IVF-ET cycles. All patients had high E2 response with an adequate number of preovulatory oocytes retrieved and normal fertilization and cleavage rates; one conceived. Follicular fluid analysis revealed similar E2, P, A, hCG, PRL, and IGF-I levels to non-IDD controls. The source of the insulin detected in the FF of IDD patients was probably from the insulin doses administered intensively during the tight diabetes management; insulin was absent in non-IDD participants. It seems that patients with IDD have conventional responses to gonadotropin stimulation for IVF and their follicular milieu resembles that of non-IDD patients. Nevertheless, in view of the significant advantages of preconceptional diabetes control in regard to pregnancy outcome, they should be allowed to participate in IVF programs only after tight preconception metabolic control has been obtained.

Progression of diabetic retinopathy in pregnancy: association with hypertension in pregnancy

OBJECTIVE

To test the hypothesis that women with insulin-dependent diabetes and chronic or pregnancy-induced hypertensive disorders are at increased risk for developing retinopathic complications during pregnancy.

STUDY DESIGN

One hundred fifty-four women with insulin-dependent diabetes were prospectively followed in an intensive program of diabetes in pregnancy. Ophthalmologic evaluations were obtained through pregnancy and at 6 to 12 weeks post partum, and findings were graded by a standard scale. Association of retinopathic progression with risk factors was tested with chi 2 and multiple logistic regression analysis.

RESULTS

Fifty-one women had progression of retinopathy during pregnancy; postpartum regression was observed in 13 women. Changes in glycemic control early in pregnancy, chronic hypertension, and pregnancy-induced hypertension were significantly associated with progression of retinopathy.

CONCLUSION

Women with insulin-dependent diabetes who have hypertensive disorders in pregnancy are at increased risk for progression of retinopathy.

Spontaneous abortion and congenital malformations in diabetes

The first few weeks after conception are a critical period for the embryo of a diabetic mother. If the mother is in good glycaemic control during this time, the risk of spontaneous abortion or major congenital malformation is low. Otherwise, the risk increases in proportion to the degree of blood glucose elevation. Glycohaemoglobin determination in the first trimester can be useful in retrospectively evaluating the degree of glycaemic control present around the time of conception and in roughly estimating the risk of spontaneous abortion or major malformation. For women with high risk, early prenatal diagnosis of congenital anomalies is warranted using detailed ultrasound examination, fetal echocardiography and alpha-fetoprotein determinations. Encouraging diabetic women to achieve strict control prior to conception should virtually eliminate the excess risk of spontaneous abortion or major malformation.

Experimental diabetes impairs rat embryo development during the preimplantation period

Congenital malformations and early fetal losses are still the main complications of diabetic pregnancy. Whether the diabetic state affects the early embryo development during the preimplantation period is not known. To understand better the early steps of embryo growth, we collected the embryonic structures from the uterine horns of pregnant diabetic rats on day 5 of pregnancy. Diabetes was induced by streptozotocin (50 mg/kg) injection, 7, 14 or 21 days before mating. The morphological analysis revealed a lower rate of blastocysts (72% of all structures) and an increased rate of morulae (19.5%) in diabetic rats, compared to control animals (86.7 and 7.9% respectively). Hence, diabetic rats had fewer blastocysts (5.5 +/- 2.9 per rat) and more morulae (1.5 +/- 1.7) than control animals (7.2 +/- 2.7 and 0.66 +/- 1.2 respectively). Moreover, blastocysts from diabetic rats had fewer nuclei (26.9 +/- 7.3 per blastocyst) than blastocysts from control animals (31 +/- 6.1). In another set of experiments, subdiabetogenic doses of streptozotocin were administered. In rats injected with 25 mg/kg, neither the glycaemia, nor the morphological aspects of the embryos, nor the number of blastocyst nuclei differed from the control animals. In the animals receiving 35 mg/kg, the glycaemia was increased to approximately twice the control group value. However, the embryonic morphology and the nuclei counting of the blastocysts were similar to those of the fully diabetic group injected with 50 mg of streptozotocin. These results show that experimentally induced diabetes, even of a rather mild degree, affects the embryo development during the preimplantation period. The recovered embryos appear less mature and less developed.(ABSTRACT TRUNCATED AT 250 WORDS)