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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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Li X, Li TT, Tian RX, Fei JJ, Wang XX, Yu HH, Yin ZZ. Gestational diabetes mellitus: The optimal time of delivery. World J Diabetes 2023; 14:179-187. [PMID: 37035228 PMCID: PMC10075038 DOI: 10.4239/wjd.v14.i3.179] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Revised: 01/17/2023] [Accepted: 02/23/2023] [Indexed: 03/15/2023] Open
Abstract
Gestational diabetes mellitus (GDM) is a common pregnancy complication strongly associated with poor maternal-fetal outcomes. Its incidence and prevalence have been increasing in recent years. Women with GDM typically give birth through either vaginal delivery or cesarean section, and the maternal-fetal outcomes are related to several factors such as cervical level, fetal lung maturity, the level of glycemic control still present, and the mode of treatment for the condition. We categorized women with GDM based on the latter two factors. GDM that is managed without medication when it is responsive to nutrition- and exercise-based therapy is considered diet- and exercise-controlled GDM, or class A1 GDM, and GDM managed with medication to achieve adequate glycemic control is considered class A2 GDM. The remaining cases in which neither medical nor nutritional treatment can control glucose levels or patients who do not control their blood sugar are categorized as class A3 GDM. We investigated the optimal time of delivery for women with GDM according to the classification of the condition. This review aimed to address the benefits and harms of giving birth at different weeks of gestation for women with different classes of GDM and attempted to provide an analytical framework and clearer advice on the optimal time for labor.
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Affiliation(s)
- Xuan Li
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei 230022, Anhui Province, China
| | - Teng-Teng Li
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei 230022, Anhui Province, China
| | - Rui-Xian Tian
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei 230022, Anhui Province, China
| | - Jia-Jia Fei
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei 230022, Anhui Province, China
| | - Xing-Xing Wang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei 230022, Anhui Province, China
| | - Hui-Hui Yu
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei 230022, Anhui Province, China
| | - Zong-Zhi Yin
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei 230022, Anhui Province, China
- NHC Key Laboratory of the Study of Abnormal Gametes and the Reproductive Tract, Anhui Medical University, Hefei 230022, Anhui Province, China
- Key Laboratory of Population Health Across Life Cycle, Anhui Medical University, Hefei 230022, Anhui Province, China
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Witek K, Wydra K, Filip M. A High-Sugar Diet Consumption, Metabolism and Health Impacts with a Focus on the Development of Substance Use Disorder: A Narrative Review. Nutrients 2022; 14:nu14142940. [PMID: 35889898 PMCID: PMC9323357 DOI: 10.3390/nu14142940] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 07/13/2022] [Accepted: 07/15/2022] [Indexed: 01/01/2023] Open
Abstract
Carbohydrates are important macronutrients in human and rodent diet patterns that play a key role in crucial metabolic pathways and provide the necessary energy for proper body functioning. Sugar homeostasis and intake require complex hormonal and nervous control to proper body energy balance. Added sugar in processed food results in metabolic, cardiovascular, and nervous disorders. Epidemiological reports have shown enhanced consumption of sweet products in children and adults, especially in reproductive age and in pregnant women, which can lead to the susceptibility of offspring’s health to diseases in early life or in adulthood and proneness to mental disorders. In this review, we discuss the impacts of high-sugar diet (HSD) or sugar intake during the perinatal and/or postnatal periods on neural and behavioural disturbances as well as on the development of substance use disorder (SUD). Since several emotional behavioural disturbances are recognized as predictors of SUD, we also present how HSD enhances impulsive behaviour, stress, anxiety and depression. Apart from the influence of HSD on these mood disturbances, added sugar can render food addiction. Both food and addictive substances change the sensitivity of the brain rewarding neurotransmission signalling. The results of the collected studies could be important in assessing sugar intake, especially via maternal dietary patterns, from the clinical perspective of SUD prevention or pre-existing emotional disorders. Methodology: This narrative review focuses on the roles of a high-sugar diet (HSD) and added sugar in foods and on the impacts of glucose and fructose on the development of substance use disorder (SUD) and on the behavioural predictors of drugs abuse. The literature was reviewed by two authors independently according to the topic of the review. We searched the PubMed and Scopus databases and Multidisciplinary Digital Publishing Institute open access scientific journals using the following keyword search strategy depending on the theme of the chapter: “high-sugar diet” OR “high-carbohydrate diet” OR “sugar” OR “glucose” OR “fructose” OR “added sugar” AND keywords. We excluded inaccessible or pay-walled articles, abstracts, conference papers, editorials, letters, commentary, and short notes. Reviews, experimental studies, and epidemiological data, published since 1990s, were searched and collected depending on the chapter structure. After the search, all duplicates are thrown out and full texts were read, and findings were rescreened. After the selection process, appropriate papers were included to present in this review.
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5
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Carlson NS, Dunn Amore A, Ellis JA, Page K, Schafer R. American College of Nurse-Midwives Clinical Bulletin Number 18: Induction of Labor. J Midwifery Womens Health 2022; 67:140-149. [PMID: 35119782 DOI: 10.1111/jmwh.13337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 12/20/2021] [Indexed: 11/27/2022]
Abstract
Induction of labor is an increasingly common component of intrapartum care in the United States. This rise is fueled by a nationwide escalation in both medically indicated and elective inductions at or beyond term, supported by recent research showing some benefits of induction over expectant management. However, induction of labor medicalizes the birth experience and may lead to a complex cascade of interventions. The purpose of this Clinical Bulletin is twofold: (1) to guide clinicians on the use of person-centered decision-making when discussing induction of labor and (2) to review evidence-based practice recommendations for intrapartum midwifery care during labor induction.
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Affiliation(s)
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- American College of Nurse-Midwives, Silver Spring, Maryland
| | | | | | | | - Katie Page
- President, RMWC Alumnae and Randolph College Alumni Association; President, VA Affiliate of ACNM
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Kgosidialwa O, Bogdanet D, Egan A, Newman C, O'Shea PM, Biesty L, McDonagh C, O'Shea C, Devane D, Dunne F. A systematic review on outcome reporting in randomised controlled trials assessing treatment interventions in pregnant women with pregestational diabetes. BJOG 2021; 128:1894-1904. [PMID: 34258852 DOI: 10.1111/1471-0528.16842] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Pregestational diabetes mellitus (PGDM) is associated with adverse pregnancy outcomes. Studies assessing interventions to improve maternal and infant outcomes have increased exponentially over recent years. Several outcomes in this field of maternal diabetes are rare, making it difficult to synthesise evidence. OBJECTIVES To collect outcomes reported in studies assessing treatment interventions in pregnant women with PGDM. SEARCH STRATEGY CENTRAL, Web of Science, Medline, CINAHL, Embase and ClinicalTrials.gov from their inception until 27 January 2020. SELECTION CRITERIA Any randomised controlled trial assessing treatment interventions in pregnant women with PGDM reported in English. DATA COLLECTION AND ANALYSIS Two independent reviewers assessed the suitability of articles and retrieved the data. Outcomes extracted from the literature were broadly categorised into maternal, fetal/infant or other outcomes by the study advisory group. MAIN RESULTS Sixty-seven of the 1475 studies identified fulfilled the inclusion criteria. The median number of outcomes reported per study was 15 (range 1-46). The majority of studies were from North America and Europe. Insulin and metformin were the most commonly investigated pharmacological interventions. Glucose monitoring was the most assessed technological intervention. In all, 131 unique outcomes were extracted: maternal (n = 69), fetal/infant (n = 61) and other (n = 1). CONCLUSIONS Outcome reporting in treatment interventions trials of pregnant women with PGDM is varied, making it difficult to synthesise evidence, especially for rare outcomes. Systems are needed to standardise outcome reporting in future clinical trials and so facilitate evidence synthesis in this area of maternal diabetes. REGISTRATION The systematic review was registered prospectively with the International Prospective Register of Systematic Reviews (PROSPERO) database (Registration number CRD42020173549). TWEETABLE ABSTRACT Outcome reporting is heterogeneous in intervention trials of pregnant women with diabetes existing before pregnancy.
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Affiliation(s)
- O Kgosidialwa
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - D Bogdanet
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - A Egan
- Department of Endocrinology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - C Newman
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - P M O'Shea
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - L Biesty
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland.,Ireland HRB-Trials Methodology Research Network, National University of Ireland Galway, Galway, Ireland
| | - C McDonagh
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - C O'Shea
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - D Devane
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland.,Ireland HRB-Trials Methodology Research Network, National University of Ireland Galway, Galway, Ireland
| | - F Dunne
- School of Medicine, National University of Ireland Galway, Galway, Ireland
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7
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Kgosidialwa O, Bogdanet D, Egan AM, O'Shea PM, Newman C, Griffin TP, McDonagh C, O'Shea C, Carmody L, Cooray SD, Anastasiou E, Wender-Ozegowska E, Clarson C, Spadola A, Alvarado F, Noctor E, Dempsey E, Napoli A, Crowther C, Galjaard S, Loeken MR, Maresh M, Gillespie P, de Valk H, Agostini A, Biesty L, Devane D, Dunne F. A core outcome set for the treatment of pregnant women with pregestational diabetes: an international consensus study. BJOG 2021; 128:1855-1868. [PMID: 34218508 PMCID: PMC9311326 DOI: 10.1111/1471-0528.16825] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2021] [Indexed: 12/21/2022]
Abstract
Objective To develop a core outcome set (COS) for randomised controlled trials (RCTs) evaluating the effectiveness of interventions for the treatment of pregnant women with pregestational diabetes mellitus (PGDM). Design A consensus developmental study. Setting International. Population Two hundred and five stakeholders completed the first round. Methods The study consisted of three components. (1) A systematic review of the literature to produce a list of outcomes reported in RCTs assessing the effectiveness of interventions for the treatment of pregnant women with PGDM. (2) A three-round, online eDelphi survey to prioritise these outcomes by international stakeholders (including healthcare professionals, researchers and women with PGDM). (3) A consensus meeting where stakeholders from each group decided on the final COS. Main outcome measures All outcomes were extracted from the literature. Results We extracted 131 unique outcomes from 67 records meeting the full inclusion criteria. Of the 205 stakeholders who completed the first round, 174/205 (85%) and 165/174 (95%) completed rounds 2 and 3, respectively. Participants at the subsequent consensus meeting chose 19 outcomes for inclusion into the COS: trimester-specific haemoglobin A1c, maternal weight gain during pregnancy, severe maternal hypoglycaemia, diabetic ketoacidosis, miscarriage, pregnancy-induced hypertension, pre-eclampsia, maternal death, birthweight, large for gestational age, small for gestational age, gestational age at birth, preterm birth, mode of birth, shoulder dystocia, neonatal hypoglycaemia, congenital malformations, stillbirth and neonatal death. Conclusions This COS will enable better comparison between RCTs to produce robust evidence synthesis, improve trial reporting and optimise research efficiency in studies assessing treatment of pregnant women with PGDM. 165 key stakeholders have developed #Treatment #CoreOutcomes in pregnant women with #diabetes existing before pregnancy.
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Affiliation(s)
- O Kgosidialwa
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
| | - D Bogdanet
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
| | - A M Egan
- Division of Endocrinology, Mayo Clinic, Rochester, MN, USA
| | - P M O'Shea
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
| | - C Newman
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
| | - T P Griffin
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
| | - C McDonagh
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
| | - C O'Shea
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
| | - L Carmody
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
| | - S D Cooray
- Diabetes and Endocrinology Units, Monash Health, Clayton, Vic., Australia.,Monash Centre for Health Research and Implementation, Monash University, Clayton, Vic., Australia
| | - E Anastasiou
- Department Diabetes & Pregnancy Outpatients, Mitera Hospital, Athens, Greece
| | - E Wender-Ozegowska
- Department of Reproduction, Poznan University of Medical Sciences, Poznan, Poland
| | - C Clarson
- Department of Paediatrics, University of Western Ontario, London, ON, Canada.,Lawson Health Research Institute, London, ON, Canada
| | - A Spadola
- Mother Infant Research Institute, Tufts Medical Center, Boston, MA, USA
| | - F Alvarado
- Mother Infant Research Institute, Tufts Medical Center, Boston, MA, USA
| | - E Noctor
- Division of Endocrinology, University Hospital Limerick, Limerick, Ireland
| | - E Dempsey
- INFANT Centre and Department of Paediatrics & Child Health, University College Cork, Cork, Ireland
| | - A Napoli
- Department of Clinical and Molecular Medicine, Sant'Andrea University Hospital, Sapienza, University of Rome, Rome, Italy
| | - C Crowther
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - S Galjaard
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Prenatal Medicine, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - M R Loeken
- Section of Islet Cell and Regenerative Biology, Joslin Diabetes Center, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Mja Maresh
- Department of Obstetrics, St Mary's Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - P Gillespie
- Health Economics and Policy Analysis Centre (HEPAC), National University of Ireland, Galway, Ireland
| | - H de Valk
- Department of Internal Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - A Agostini
- A.S.LViterbo Distretto A, Consultorio Montefiascone, Rome, Italy
| | - L Biesty
- School of Nursing & Midwifery, National University of Ireland Galway, Galway, Ireland
| | - D Devane
- School of Nursing & Midwifery, National University of Ireland Galway, Galway, Ireland.,HRB-Trials Methodology Research Network, National University of Ireland Galway, Galway, Ireland
| | - F Dunne
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
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Diagnosis and Management of Gestational Diabetes Mellitus: An Overview of National and International Guidelines. Obstet Gynecol Surv 2021; 76:367-381. [PMID: 34192341 DOI: 10.1097/ogx.0000000000000899] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Importance Gestational diabetes mellitus (GDM) represents one of the most frequent complications of pregnancy and is associated with increased maternal and neonatal morbidity. Its incidence is rising, mostly due to an increase in maternal age and maternal obesity rate. Objective The aim of this study was to review and compare the recommendations of the most recently published guidelines on the diagnosis and management of this condition. Evidence Acquisition A descriptive review of guidelines from the National Institute for Health and Care Excellence (NICE), the International Federation of Gynecology and Obstetrics, the Australasian Diabetes in Pregnancy Society (ADIPS), the Society of Obstetricians and Gynecologists of Canada (SOGC), the American College of Obstetricians and Gynecologists (ACOG), the American Diabetes Association, and the Endocrine Society on gestational diabetes mellitus was carried out. Results The NICE guideline recommends targeted screening only for women with risk factors, whereas the International Federation of Gynecology and Obstetrics, ADIPS, SOGC, and the ACOG recommend screening for all pregnant women at 24 to 28 weeks of gestation in order to diagnose and effectively manage GDM; they also state that women with additional risk factors should be screened earlier (ie, in the first trimester) and retested at 24 to 28 weeks, if the initial test is negative. These guidelines describe similar risk factors for GDM and suggest the same thresholds for the diagnosis of GDM when using a 75-g 2-hour oral glucose tolerance test. Of note, the NICE only assesses the fasting and the 2-hour postprandial glucose levels for the diagnosis of GDM. Moreover, the SOGC and the ACOG do not recommend this test as the optimal screening method. The Endocrine Society alone, on the other hand, recommends the universal testing of all pregnant women for diabetes before 13 weeks of gestation or as soon as they attend the antenatal service and retesting at 24 to 28 weeks if the initial results are normal. In addition, there is a general consensus on the appropriate ultrasound surveillance of pregnancies complicated with GDM, and all the medical societies, except the ADIPS, recommend self-monitoring of capillary glucose to assess the glycemic control and set the same targets for fasting and postprandial glucose levels. There is also agreement that lifestyle modifications should be the first-line treatment; however, the reviewed guidelines disagree on the medical management of GDM. In addition, there are controversies regarding the timing of delivery, the utility of hemoglobin A1c measurement, and the postpartum and lifelong screening for persistent hyperglycemia and type 2 diabetes. However, all the guidelines state that all women in pregnancies complicated by GDM should undergo a glycemic test at around 6 to 12 weeks after delivery. Finally, there is a universal consensus on the importance of breastfeeding and preconception screening before future pregnancies. Conclusions As GDM is an increasingly common complication of pregnancy, it is of paramount importance that inconsistencies between national and international guidelines should encourage research to resolve the issues of controversy and allow uniform international protocols for the diagnosis and management of GDM, in order to safely guide clinical practice and subsequently improve perinatal and maternal outcomes.
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Morlando M, Savoia F, Conte A, Schiattarella A, La Verde M, Petrizzo M, Carpentieri M, Capristo C, Esposito K, Colacurci N. Maternal and Fetal Outcomes in Women with Diabetes in Pregnancy Treated before and after the Introduction of a Standardized Multidisciplinary Management Protocol. J Diabetes Res 2021; 2021:9959606. [PMID: 34805415 PMCID: PMC8604598 DOI: 10.1155/2021/9959606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 10/03/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Diabetes in pregnancy is associated with an increased risk to the woman and to the developing fetus. Currently, there is no consensus on the optimal management strategies for the follow-up and the timing of delivery of pregnancies affected by gestational and pregestational diabetes, with different international guidelines suggesting different management options. MATERIALS AND METHODS We conducted a retrospective cohort study from January 2017 to January 2021, to compare maternal and neonatal outcomes of pregnancies complicated by gestational and pregestational diabetes, followed-up and delivered in a third level referral center before and after the introduction of a standardized multidisciplinary management protocol including diagnostic, screening, and management criteria. RESULTS Of the 131 women included, 55 were managed before the introduction of the multidisciplinary management protocol and included in group 1 (preprotocol), while 76 were managed according to the newly introduced multidisciplinary protocol and included in group 2 (after protocol). We observed an increase in the rates of vaginal delivery, rising from 32.7% to 64.5% (<0.001), and the rate of successful induction of labor improved from 28.6% to 86.2% (P < 0.001). No differences were found in neonatal outcomes, and the only significant difference was demonstrated for the rates of fetal macrosomia (20% versus 5.3%, P: 0.012). Therefore, the improvements observed in the maternal outcomes did not impact negatively on fetal and neonatal outcomes. CONCLUSION The introduction of a standardized multidisciplinary management protocol led to an improvement in the rates of vaginal delivery and in the rate of successful induction of labor in our center. A strong cooperation between obstetricians, diabetologists, and neonatologists is crucial to obtain a successful outcome in women with diabetes in pregnancy.
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Affiliation(s)
- Maddalena Morlando
- Prenatal Diagnosis and High-Risk Pregnancy Unit, Department of Woman, Child, and General and Specialised Surgery, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Fabiana Savoia
- Prenatal Diagnosis and High-Risk Pregnancy Unit, Department of Woman, Child, and General and Specialised Surgery, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Anna Conte
- Prenatal Diagnosis and High-Risk Pregnancy Unit, Department of Woman, Child, and General and Specialised Surgery, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Antonio Schiattarella
- Prenatal Diagnosis and High-Risk Pregnancy Unit, Department of Woman, Child, and General and Specialised Surgery, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Marco La Verde
- Prenatal Diagnosis and High-Risk Pregnancy Unit, Department of Woman, Child, and General and Specialised Surgery, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Michela Petrizzo
- Unit of Diabetes, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Mauro Carpentieri
- Neonatal Intensive Care Unit, Department of Woman, Child, and General and Specialised Surgery, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Carlo Capristo
- Neonatal Care Unit, Department of Woman, Child, and General and Specialised Surgery, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Katherine Esposito
- Unit of Diabetes, Department of Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Nicola Colacurci
- Prenatal Diagnosis and High-Risk Pregnancy Unit, Department of Woman, Child, and General and Specialised Surgery, University of Campania “Luigi Vanvitelli”, Naples, Italy
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10
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Abstract
Background: The recommended gestational age to deliver pregnancies complicated by diabetes ranges from 34 to 39 weeks of gestation. The objective of this study was to determine the optimal gestational age for delivery of patients with diabetes to minimize perinatal death. Methods: We extracted a population-based cohort of singleton, nonanomalous infants of diabetic pregnancies from the Missouri birth registry for the period January 1, 1989 to December 31, 2005 and compared perinatal outcomes of planned deliveries at 37, 38, 39, and 40 weeks to expectant management. Planned deliveries were identified by induction or cesarean delivery without documented medical or obstetric indications. The primary outcome was perinatal death, defined as stillbirth or neonatal death within 28 days of birth. Secondary outcomes were independent stillbirth, independent neonatal death, and a composite adverse neonatal event of assisted ventilation >30 minutes, birth injury, seizures, or 5-minute Apgar score ≤3. Groups were compared using t test and chi-square as appropriate. Results: In 4,905 diabetic pregnancies reaching 37 weeks, 1,012 (20.6%) patients were insulin dependent. Overall, the risk of perinatal death at any gestational age examined was low (3/1,000 births or lower), as was the risk of the adverse perinatal outcome (<2%). When only patients who were insulin dependent were included in the analysis, the risk of perinatal death at any gestational age remained low at 6 per 1,000 births or fewer. Conclusion: Delivery as early as 37 weeks is reasonable for women who have diabetes, although the absolute risk of perinatal death is low at 37 to 39 weeks.
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11
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Abstract
Full-term deliveries are defined as occurring between 39 weeks and 40 weeks and 6 days. Because contemporary research suggests improved outcomes with delivery in the term period compared with the early term period, nonindicated delivery should be pursued no earlier than 39 weeks. There are, however, multiple medical, obstetric, and fetal indications for delivery before 39 weeks, and the obstetric provider must weigh the risks and benefits of delivery versus expectant management on both the mother and fetus. This review serves to provide a basic framework of evidentiary support toward optimizing the term delivery.
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Affiliation(s)
- Timothy Wen
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, CA 94158, USA
| | - Amy L Turitz
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, 622 West 168th Street, New York, NY 10032, USA.
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12
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Gortazar L, Goday A, Flores-Le Roux JA, Sarsanedas E, Payà A, Mañé L, Pedro-Botet J, Benaiges D. Trends in prevalence of pre-existing diabetes and perinatal outcomes: a large, population-based study in Catalonia, Spain, 2006-2015. BMJ Open Diabetes Res Care 2020; 8:8/1/e001254. [PMID: 33106331 PMCID: PMC7592254 DOI: 10.1136/bmjdrc-2020-001254] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 06/17/2020] [Accepted: 07/13/2020] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION This study aims to assess trends in the prevalence of pre-existing diabetes and whether the risk of adverse perinatal outcomes decreased in women between 2006 and 2015 in Catalonia, Spain. RESEARCH DESIGN AND METHODS A population-based study of 743 762 singleton deliveries between 2006 and 2015 in Catalonia, Spain, was conducted using data from the Spanish Minimum Basic Data Set. Cases of type 1 diabetes (T1DM) and 'type 2 diabetes and other pre-existing diabetes' ('T2DM and other PGD') were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes. Crude and age-adjusted annual prevalences were calculated. Poisson regression model was used to assess trends in prevalence and perinatal outcomes during the study period. RESULTS Overall prevalences of pre-existing diabetes, T1DM and 'T2DM and other PGD' were 0.52% (95% CI 0.51 to 0.54), 0.17% (95% CI 0.17 to 0.18) and 0.35% (95% CI 0.33 to 0.36), respectively. From 2006 to 2015, rates increased for pre-existing diabetes (from 0.43 (95% CI 0.39 to 0.48) to 0.56% (0.50 to 0.62), p<0.001), T1DM (from 0.14 (0.11 to 0.17) to 0.20% (0.17 to 0.23), p<0.001) and 'T2DM and other PGD' (from 0.29 (0.25 to 0.33) to 0.36% (0.31 to 0.40), p<0.001). Pre-eclampsia rose in women with pre-existing diabetes (from 4.38% to 8.97%, adjusted p<0.001), T1DM (from 3.85% to 12.88%, p=0.005) and 'T2DM and other PGD' (from 4.63% to 6.78%, adjusted p=0.01). Prevalence of prematurity, cesarean section and small for gestational age remained stable in all diabetes groups. However, the prevalence of macrosomia fell in women with pre-existing diabetes (from 18.18% to 11.9%, adjusted p=0.011) and 'T2DM and other PGD' (from 14.71% to 11.06%, non-adjusted p=0.022, adjusted p=0.305) and large for gestational age decreased in all diabetes groups (from 39.73% to 30.25% in pre-existing diabetes, adjusted p=0.004). CONCLUSIONS The prevalence of pre-existing diabetes increased significantly in Catalonia between 2006 and 2015. Despite improvements in outcomes related to excessive birth weight, pre-eclampsia rates are rising and overall perinatal outcomes in women with pre-existing diabetes continue to be markedly worse than in the population without diabetes.
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Affiliation(s)
- Lucia Gortazar
- Department of Endocrinology and Nutrition, Hospital del Mar, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Albert Goday
- Department of Endocrinology and Nutrition, Hospital del Mar, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
- Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
| | - Juana Antonia Flores-Le Roux
- Department of Endocrinology and Nutrition, Hospital del Mar, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
- Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
| | - Eugènia Sarsanedas
- Health Information Management Department, Hospital del Mar, Barcelona, Spain
| | - Antonio Payà
- Department of Gynaecology and Obstetrics, Hospital del Mar, Barcelona, Spain
| | - Laura Mañé
- Department of Endocrinology and Nutrition, Hospital del Mar, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Juan Pedro-Botet
- Department of Endocrinology and Nutrition, Hospital del Mar, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
- Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
| | - David Benaiges
- Department of Endocrinology and Nutrition, Hospital del Mar, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
- Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
- Consorci Sanitari de l'Alt Penedès Garraf, Vilafranca del Penedès, Spain
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13
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Helman S, James-Todd TM, Wang Z, Bellavia A, Wyckoff JA, Serdy S, Halprin E, O'Brien K, Takoudes T, Gupta M, McElrath TF, Brown FM. Time trends in pregnancy-related outcomes among women with type 1 diabetes mellitus, 2004-2017. J Perinatol 2020; 40:1145-1153. [PMID: 32488037 PMCID: PMC7375951 DOI: 10.1038/s41372-020-0698-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 04/15/2020] [Accepted: 05/19/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To examine time trends in US pregnant women with type 1 diabetes mellitus for maternal characteristics and pregnancy outcomes. STUDY DESIGN We abstracted clinical data from the medical records of 700 pregnant women from 2004 to 2017. For each time period, means and percentages were calculated. P values for trend were calculated using linear and logistic regression. RESULTS HbA1c in each trimester was unchanged across the analysis period. The prevalence of nephropathy decreased from 4.8% to 0% (P = 0.002). Excessive gestational weight gain increased (P = 0.01). Gestation length also increased (P = 0.01), as did vaginal deliveries (P = 0.03). There were no change in birthweight over time (P = 0.07) and the percentage of neonates with macrosomia and large for gestational age (LGA) neonates also remained unchanged. CONCLUSION Obstetric guideline changes may have improved gestation length and mode of delivery; however, other outcomes need more attention, including excessive gestational weight gain, macrosomia, and LGA.
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Affiliation(s)
| | - Tamarra M James-Todd
- Department of Environmental health, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Zifan Wang
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Andrea Bellavia
- Department of Environmental health, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | | | | | - Karen O'Brien
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Hospital, Boston, MA, USA
| | - Tamara Takoudes
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Hospital, Boston, MA, USA
| | - Munish Gupta
- Department of Neonatology, Beth Israel Deaconess Hospital, Boston, MA, USA
| | - Thomas F McElrath
- Division of Maternal Fetal Medicine, Brigham and Women's Hospital, Boston, MA, USA
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14
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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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15
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Abstract
The review presents some renewed data on the problem of optimal time and modes of delivery for women with various types of diabetes mellitus (DM 1 and 2, gestational diabetes). The necessity of making the universal delivery strategy algorithm for women with DM comes out of adverse outcomes high frequency, where the main cases are fetal macrosomia, fetal shoulder dystocia and perinatal mortality. Despite significant interest for this issue, there is still no common delivery tactics in the world for pregnant women with carbohydrate metabolism disorders. The main obstacle is evidence-based tests and meta-analysis insufficiency. So far, further studies are necessary to obtain high quality data concerning optimal terms and modes of delivery for women with DM.
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Affiliation(s)
- Roman Kapustin
- Department of Obstetrics, Division of Maternal-Fetal Medicine, D.O. Ott Research Institute of Obstetrics, Gynecology and Reproductive Medicine, St. Petersburg, Russia
- Department of Obstetrics, Gynecology and Reproduction, Faculty of Medicine, St. Petersburg State University, St. Petersburg, Russia
| | - Olga Arzhanova
- Department of Obstetrics, Division of Maternal-Fetal Medicine, D.O. Ott Research Institute of Obstetrics, Gynecology and Reproductive Medicine, St. Petersburg, Russia
- Department of Obstetrics, Gynecology and Reproduction, Faculty of Medicine, St. Petersburg State University, St. Petersburg, Russia
| | - Elena Alekseenkova
- Department of Obstetrics, Gynecology and Reproduction, Faculty of Medicine, St. Petersburg State University, St. Petersburg, Russia
| | - Adrey Glotov
- Department of Genetics, D.O. Ott Research Institute of Obstetrics, Gynecology and Reproductive Medicine, St. Petersburg, Russia
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16
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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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17
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Directive clinique N° 393 - Le diabète pendant la grossesse. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 41:1826-1839.e1. [DOI: 10.1016/j.jogc.2019.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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18
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Berger H, Gagnon R, Sermer M. Guideline No. 393-Diabetes in Pregnancy. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 41:1814-1825.e1. [PMID: 31785800 DOI: 10.1016/j.jogc.2019.03.008] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVES This guideline reviews the evidence relating to the diagnosis and obstetrical management of diabetes in pregnancy. OUTCOMES The outcomes evaluated were short and long-term maternal outcomes including pre-eclampsia, Caesarean section, future diabetes and other cardiovascular complications; and fetal outcomes including congenital anomalies, stillbirth, macrosomia, birth trauma, hypoglycemia and long-term effects. EVIDENCE Published literature was retrieved through searches of PubMed and The Cochrane Library using appropriate controlled vocabulary (MeSH terms "diabetes" and "pregnancy"). Where appropriate, results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date limits but results were limited to English or French language materials. VALUES The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. SUMMARY STATEMENTS RECOMMENDATIONS.
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19
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Vitner D, Hiersch L, Ashwal E, Shmueli A, Yogev Y, Aviram A. Induction of labor versus expectant management for gestational diabetes mellitus at term. Arch Gynecol Obstet 2019; 300:79-86. [PMID: 31065804 DOI: 10.1007/s00404-019-05171-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 04/24/2019] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate whether induction of labor (IOL), as compared with expectant management, in gestational diabetes mellitus (GDM) mothers at term (between 370/7 and 406/7), decreases caesarean section (CS) rate and the rate of adverse composite neonatal outcomes. METHODS A retrospective cohort study, of all women with GDM and a singleton gestation who delivered at term in a single, tertiary, university-affiliated medical center (2007-2014). We compared outcomes of women who underwent IOL at each week of gestation between 370/7 and 406/7 weeks with women who were managed expectantly. The primary outcome was CS rate. RESULTS Overall, 2472 GDM patients included in the study, of which 880 women had IOL. CS rate was not found to be significantly different between the groups at any gestational age. IOL at 37 weeks was associated with adverse composite neonatal outcome (aOR 2.2, 95% CI 1.4-3.6) and NICU admission (aOR 2.5, 95% CI 1.4-4.4). At 38 weeks, with NICU admission (aOR 2.0, 95% CI 1.4-2.9), and at 39 weeks with fracture of the clavicle. In a sub-analysis of nulliparous women, IOL at 37 weeks had higher odds of NICU admission and adverse composite neonatal outcomes, at 38 weeks with CS and at 39 weeks with fracture of the clavicle. CONCLUSIONS IOL in GDM mothers at term does not reduce CS rate and may be associated with increased CS rate among nulliparous women at 38 weeks. It is also associated with increased risk for adverse composite neonatal outcome or NICU admission when done prior to 390/7 weeks.
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Affiliation(s)
- Dana Vitner
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, affiliated to the Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.
| | - Liran Hiersch
- Lis Maternity and Women's Hospital, Tel-Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Eran Ashwal
- Lis Maternity and Women's Hospital, Tel-Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Anat Shmueli
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach-Tikva, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Yariv Yogev
- Lis Maternity and Women's Hospital, Tel-Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Amir Aviram
- Lis Maternity and Women's Hospital, Tel-Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
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20
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Perinatal outcome following induction of labor in patients with good glycemic controlled gestational diabetes: does timing matter? Arch Gynecol Obstet 2019; 300:299-303. [DOI: 10.1007/s00404-019-05183-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 04/24/2019] [Indexed: 10/26/2022]
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Worda K, Bancher-Todesca D, Husslein P, Worda C, Leipold H. Randomized controlled trial of induction at 38 weeks versus 40 weeks gestation on maternal and infant outcomes in women with insulin-controlled gestational diabetes. Wien Klin Wochenschr 2019; 129:618-624. [PMID: 28168363 DOI: 10.1007/s00508-017-1172-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare the impact of induction of labor at 38 weeks of gestation with the induction of labor at 40 weeks of gestation in women with insulin-treated gestational diabetes on maternal and fetal outcome. STUDY DESIGN In this study 100 pregnant women with insulin-treated gestational diabetes were randomized to either induction of labor at 38 (group I) or 40 weeks (group II) to evaluate the rate of large for gestational age newborns, neonatal hypoglycemia, success rate of deliveries within 48 h and cesarean section rate after induction in both groups. RESULTS The difference of large for gestational age newborns was not significant between the two groups (6.8% vs. 12.8%, p = 0.49), 16 (36.4%) newborns in group I and 8 (17.0%) newborns in group II developed hypoglycemia <35 mg/dl (p = 0.04). The success rate for deliveries within 48 h after induction of labor for groups I and II was 77.3% and 92.3%, respectively (p = 0.25). The cesarean section rate after induction of labor was not significantly different between the two groups (24.1% vs. 18.7%, p = 0.49). CONCLUSION In a cohort of women with insulin-treated gestational diabetes, induction of labor at 38 weeks did not significantly reduce the rate of large for gestational age newborns compared to induction at 40 weeks but seems to increase the rate of neonatal hypoglycemia.
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MESH Headings
- Adult
- Bilirubin/blood
- Blood Glucose/metabolism
- Diabetes Mellitus, Type 1/blood
- Diabetes Mellitus, Type 1/drug therapy
- Diabetes, Gestational/blood
- Diabetes, Gestational/drug therapy
- Female
- Fetal Macrosomia/blood
- Fetal Macrosomia/etiology
- Gestational Age
- Glycated Hemoglobin/metabolism
- Humans
- Infant, Newborn
- Infant, Newborn, Diseases/blood
- Infant, Newborn, Diseases/etiology
- Insulin/therapeutic use
- Intensive Care Units, Neonatal
- Labor, Induced
- Patient Admission
- Patient Outcome Assessment
- Pregnancy
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Affiliation(s)
- Katharina Worda
- Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria
| | | | - Peter Husslein
- Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria
| | - Christof Worda
- Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria
| | - Heinz Leipold
- Department of Obstetrics and Gynecology, General Hospital of Klagenfurt, St. Veiterstraße 47, 9020, Klagenfurt, Austria.
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23
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Abstract
Gestational diabetes mellitus (GDM) is one of the most common medical complications of pregnancy. However, debate continues to surround the diagnosis and treatment of GDM despite several recent large-scale studies addressing these issues. The purposes of this document are the following: 1) provide a brief overview of the understanding of GDM, 2) review management guidelines that have been validated by appropriately conducted clinical research, and 3) identify gaps in current knowledge toward which future research can be directed.
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24
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Foetal Macrosomia and Foetal-Maternal Outcomes at Birth. J Pregnancy 2018; 2018:4790136. [PMID: 30174954 PMCID: PMC6106949 DOI: 10.1155/2018/4790136] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 07/16/2018] [Accepted: 07/24/2018] [Indexed: 11/18/2022] Open
Abstract
To investigate how macrosomia affects foetal-maternal birth outcomes, we conducted a retrospective cohort study of singleton pregnant women who gave birth at gestational age ≥37+0 weeks. The patients were divided into three groups according to birth weight: “macrosomia” group, ≥4500 g, n=285; “upper-normal” group, 3500–4499 g, n=593; and “normal” group, 2500–3499 g, n=495. Foetal-maternal and delivery outcomes were compared among the three groups after adjustment for confounders. Caesarean section was more frequent in the macrosomia group than in upper-normal and normal groups. The duration of labour (p < 0.05) and postpartum care at the hospital (p < 0.001) were the highest in the macrosomia group. Increased birth weight was associated with higher risks of shoulder dystocia (p < 0.001), increased bleeding volume (p < 0.001), and perineal tear (p < 0.05). The Apgar score at 5 minutes (p < 0.05), arterial cord pH (p < 0.001), and partial pressure of O2 (p < 0.05) were lower, while the arterial cord partial pressure of CO2 was higher (p < 0.001), in the macrosomia group. Macrosomia has potentially serious impacts for neonate and mother as a result of a complicated and occasionally traumatic delivery.
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Abstract
Elective induction of labor (ie, without a maternal or fetal indication) is common in the United States. When using the correct comparison group (elective induction vs expectant management) induction is not associated with an increased risk of cesarean delivery. Moreover, elective induction after 39 weeks seems to have maternal benefits (eg, lower infection rates) as well as a reduction in neonatal morbidity and the potential for a decrease in term stillbirth. However, these risks, especially stillbirth, are low in a healthy cohort and there are potential negative impacts on maternal satisfaction, breastfeeding, and cost/resource use that must be considered.
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Affiliation(s)
- Sarah E Little
- Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
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Feig DS, Berger H, Donovan L, Godbout A, Kader T, Keely E, Sanghera R. Diabetes and Pregnancy. Can J Diabetes 2018; 42 Suppl 1:S255-S282. [DOI: 10.1016/j.jcjd.2017.10.038] [Citation(s) in RCA: 108] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Biesty LM, Egan AM, Dunne F, Smith V, Meskell P, Dempsey E, Ni Bhuinneain GM, Devane D. Planned birth at or near term for improving health outcomes for pregnant women with pre-existing diabetes and their infants. Cochrane Database Syst Rev 2018; 2:CD012948. [PMID: 29423911 PMCID: PMC6491338 DOI: 10.1002/14651858.cd012948] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Pregnant women with pre-existing diabetes (Type 1 or Type 2) have increased rates of adverse maternal and neonatal outcomes. Current clinical guidelines support elective birth, at or near term, because of increased perinatal mortality during the third trimester of pregnancy.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 pre-existing diabetes (Type 1 or Type 2) and a sister review focuses on women with gestational diabetes. OBJECTIVES To assess the effect of planned birth (either by induction of labour or caesarean birth) at or near term gestation (37 to 40 weeks' gestation) compared with an expectant approach, for improving health outcomes for pregnant women with pre-existing 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, the WHO International Clinical Trials Registry Platform (ICTRP) (15 August 2017), and reference lists of retrieved studies. SELECTION CRITERIA We planned to include randomised trials (including those using a cluster-randomised design) and non-randomised trials (e.g. quasi-randomised trials using alternate allocation) which compared planned birth, at or near term, with an expectant approach for pregnant women with pre-existing diabetes. DATA COLLECTION AND ANALYSIS Two of the review authors independently assessed study eligibility. In future updates of this review, at least two of the review authors will extract data and assess the risk of bias in included studies. We will also assess the quality of the evidence using the GRADE approach. MAIN RESULTS We identified no eligible published trials for inclusion in this review.We did identify one randomised trial which examined whether expectant management reduced the incidence of caesarean birth in uncomplicated pregnancies of women with gestational diabetes (requiring insulin) and with pre-existing diabetes. However, published data from this trial does not differentiate between pre-existing and gestational diabetes, and therefore we excluded this trial. AUTHORS' CONCLUSIONS In the absence of evidence, we are unable to reach any conclusions about the health outcomes associated with planned birth, at or near term, compared with an expectant approach for pregnant women with pre-existing diabetes.This review demonstrates the urgent need for high-quality trials evaluating the effectiveness of planned birth at or near term gestation for pregnant women with pre-existing (Type 1 or Type 2) 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
| | | | - Valerie Smith
- Trinity College DublinSchool of Nursing and Midwifery24 D'Olier StreetDublinIreland2
| | - Pauline Meskell
- University of LimerickDepartment of Nursing and MidwiferyHealth Sciences BuildingUniversity of LimerickLimerickIreland
| | - Eugene Dempsey
- Cork University Maternity HospitalNeonatologyWiltonCorkIreland
| | - 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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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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Wiggs KK, Rickert ME, Hernandez-Diaz S, Bateman BT, Almqvist C, Larsson H, Lichtenstein P, Oberg AS, D'Onofrio BM. A Family-Based Study of the Association Between Labor Induction and Offspring Attention-Deficit Hyperactivity Disorder and Low Academic Achievement. Behav Genet 2017; 47:383-393. [PMID: 28551761 DOI: 10.1007/s10519-017-9852-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 05/09/2017] [Indexed: 12/01/2022]
Abstract
The current study examined associations between labor induction and both (1) offspring attention-deficit hyperactivity disorder (ADHD) diagnosis in a Swedish birth cohort born 1992-2005 (n = 1,085,008) and (2) indices of offspring low academic achievement in a sub-cohort born 1992-1997 (n = 489,196). Associations were examined in the entire sample (i.e., related and unrelated individuals) with adjustment for measured covariates and, in order to account for unmeasured confounders shared within families, within differentially exposed cousins and siblings. We observed an association between labor induction and offspring ADHD diagnosis and low academic achievement in the population. However, these associations were fully attenuated after adjusting for measured covariates and unmeasured factors that cousins and siblings share. The results suggest that observed associations between labor induction and ADHD and low academic achievement may be due to genetic and/or shared environmental factors that influence both mothers' risk of labor induction and offspring neurodevelopment.
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Affiliation(s)
- Kelsey K Wiggs
- Department of Psychological and Brain Sciences, Indiana University, 1101 E. 10th St., Bloomington, IN, 47405, USA.
| | - Martin E Rickert
- Department of Psychological and Brain Sciences, Indiana University, 1101 E. 10th St., Bloomington, IN, 47405, USA
| | - Sonia Hernandez-Diaz
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, USA
| | - Brian T Bateman
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine at Brigham and Women's Hospital, Harvard Medical School, Boston, USA.,Department of Anesthesia, Critical Care, and Pain Medicine at Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Catarina Almqvist
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Pediatric Allergy and Pulmonology Unit at Astrid Lindgren Children's Hospital, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Henrik Larsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Paul Lichtenstein
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Anna Sara Oberg
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, USA.,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Brian M D'Onofrio
- Department of Psychological and Brain Sciences, Indiana University, 1101 E. 10th St., Bloomington, IN, 47405, USA
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Nugent R, de Costa C, Vangaveti V. Caesarean risk in obese women at term: A retrospective cohort analysis. Aust N Z J Obstet Gynaecol 2017; 57:440-445. [PMID: 28338231 DOI: 10.1111/ajo.12616] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 01/16/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Obesity in pregnancy is a growing health problem conferring higher risk to both the woman and her infant. Internationally, peak bodies offer little guidance regarding the method and timing of delivery in these patients. Our hypothesis is that induction of labour (IOL) at term will not increase the caesarean section (CS) rate when compared to expectant management. AIMS To compare perinatal outcomes between IOL and expectant management in obese women at term. METHODS A retrospective cohort study of all term, singleton, vertex deliveries at the Townsville Hospital and Health Service from January 2011 to June 2015 in women with a body mass index (BMI) ≥ 35. Women undergoing IOL at 37 weeks were compared with women expectantly managed at that gestational age. Similar comparisons were made at 38, 39 and 40 weeks. χ2 tests and binary logistic regression were used for statistical comparison. The primary outcome measure was mode of delivery, with secondary measures of perinatal morbidity also considered. RESULTS There was no difference in outcome of CS, or other maternal secondary outcomes. There was no difference in rates of neonatal nursery admission. Expectant management at 38 weeks was associated with lower odds of post-partum haemorrhage (odds ratio 0.371; 95% confidence interval 0.163-0.845). CONCLUSIONS In women with a BMI ≥ 35, IOL does not affect the CS rate, or the risk of neonatal adverse events, but may increase the rate of postpartum haemorrhage when compared with expectant management.
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Affiliation(s)
- Rachael Nugent
- Department of Obstetrics and Gynaecology, The Townsville Hospital, Douglas, Queensland, Australia
| | - Caroline de Costa
- Department of Obstetrics and Gynaecology, James Cook University, College of Medicine, Cairns Clinical School, Cairns Hospital, Cairns City, Queensland, Australia
| | - Venkat Vangaveti
- School of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
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Alberico S, Erenbourg A, Hod M, Yogev Y, Hadar E, Neri F, Ronfani L, Maso G. Immediate delivery or expectant management in gestational diabetes at term: the GINEXMAL randomised controlled trial. BJOG 2016; 124:669-677. [DOI: 10.1111/1471-0528.14389] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2016] [Indexed: 11/30/2022]
Affiliation(s)
- S Alberico
- Department of Obstetrics and Gynaecology; Institute for Maternal and Child Health - IRCCS Burlo Garofolo; Trieste Italy
| | - A Erenbourg
- Department of Obstetrics and Gynaecology; Institute for Maternal and Child Health - IRCCS Burlo Garofolo; Trieste Italy
| | - M Hod
- Department of Obstetrics and Gynaecology; The Helen Schneider Hospital for Women at Rabin Medical Center; Petah-Tiqva Israel
| | - Y Yogev
- Department of Obstetrics and Gynaecology; The Helen Schneider Hospital for Women at Rabin Medical Center; Petah-Tiqva Israel
| | - E Hadar
- Department of Obstetrics and Gynaecology; The Helen Schneider Hospital for Women at Rabin Medical Center; Petah-Tiqva Israel
| | - F Neri
- Department of Obstetrics and Gynaecology; Hospital Angelo Zelarino di Mestre; Mestre-Venezia Italy
| | - L Ronfani
- Clinical Epidemiology and Public Health Research Unit; Institute for Maternal and Child Health - IRCCS Burlo Garofolo; Trieste Italy
| | - G Maso
- Department of Obstetrics and Gynaecology; The Helen Schneider Hospital for Women at Rabin Medical Center; Petah-Tiqva Israel
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Feghali MN, Caritis SN, Catov JM, Scifres CM. Timing of delivery and pregnancy outcomes in women with gestational diabetes. Am J Obstet Gynecol 2016; 215:243.e1-7. [PMID: 26976558 PMCID: PMC4967397 DOI: 10.1016/j.ajog.2016.03.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 02/22/2016] [Accepted: 03/07/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Women with gestational diabetes mellitus (GDM) commonly undergo induction of labor (IOL) at term, but the risks and benefits of IOL are incompletely understood. OBJECTIVE We examined the relationship among gestational age, IOL, and the rate of cesarean delivery (CD) in women with GDM. STUDY DESIGN We identified 863 women with GDM who underwent either IOL or spontaneous labor ≥37 0/7 weeks. Demographic, cervical favorability, and outcome data were abstracted from the medical record. We compared the CD rate in women undergoing IOL at each week of gestation with expectant management to a later gestational age. RESULTS When compared to women who were expectantly managed, IOL at 37 weeks (adjusted odds ratio [aOR], 1.53; 95% confidence interval [CI], 0.76-3.06; P = .23), 38 weeks (aOR, 2.07; 95% CI, 0.89-4.80; P = .09), and 39 weeks (aOR, 0.79; 95% CI, 0.44-1.42; P = .43)) was associated with similar risk for CD as expectant management after adjustment for nulliparity, body mass index, baseline simplified Bishop score, and maternal age. CD rates were higher in nulliparous women, but did not differ significantly in those undergoing IOL or expectant management. In multiparous women, IOL was significantly associated with an increased risk for CD at 38 weeks (aOR, 7.47; 95% CI, 1.6-34.8; P = .01) and rates of CD (17.39% vs 2.2%, P = .001) were significantly higher in multiparous women with an unfavorable Bishop score induced <39 weeks. Neonatal morbidity was similar across gestational ages after adjustment for maternal body mass index and maternal glycemic control. CONCLUSION IOL results in similar risk for CD as expectant management between 37-40 weeks of gestation. Rates of CD differed based on cervical exam and parity. These findings suggest that gestational age alone does not significantly impact maternal and neonatal outcomes, but that decisions regarding delivery in women with GDM should take into account cervical exam and parity.
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Affiliation(s)
- Maisa N Feghali
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Research Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA.
| | - Steve N Caritis
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Research Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Janet M Catov
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Research Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Christina M Scifres
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, OK
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Berger H, Gagnon R, Sermer M. Archivée: Le diabète pendant la grossesse. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2016; 38:680-694.e2. [DOI: 10.1016/j.jogc.2016.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Sinnott SJ, Layte R, Brick A, Turner MJ. Variation in induction of labour rates across Irish hospitals; a cross-sectional study. Eur J Public Health 2016; 26:753-760. [PMID: 27267615 DOI: 10.1093/eurpub/ckw060] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND In developed countries, rates of induction of labour (IOL) have increased and vary between hospitals. We aimed to identify whether national variations could be explained by sociodemographic, clinical and organisational differences. METHODS Two national databases in Ireland that routinely collect clinical and administrative data, the National Perinatal Reporting System and the Hospital Inpatient Enquiry Scheme, were used to analyse data for all women with singleton births weighing ≥500 g in 2009. We used logistic multilevel models to examine variation between hospitals, and to determine how much variation was due to individual level sociodemographic, clinical and organisational variables. Analyses were stratified for nulliparas, multiparas without prior caesarean section (CS) and multiparas with prior CS. RESULTS Of 69 304 eligible births, the rate of IOL nationally was 25.0% (range 14.5-33.2%).In nulliparas, the mean rate was 30.9% (range 18.6-45.7%). The rate was 24.8% (13.5-33.3%) and 3.8% (0.0-10.2%) for multiparas without and with prior CS, respectively. In nulliparas and multiparas without prior CS IOL was predicted by maternal birth in Ireland, increasing birthweight, antepartum complications, giving birth on a weekday and the model of obstetric care. Even after adjusting for known sociodemographic and clinical variables, variation between hospitals remained. CONCLUSION We found that clinical, sociodemographic and organisational factors all contributed to variation. However, unexplained variation persisted possibly due to organisational factors such as hospital-specific policies on IOL. The results indicate that the prevalence of antenatal complications, changing immigration patterns and policies on IOL after previous CS are factors likely to influence future IOL rates.
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Affiliation(s)
- Sarah-Jo Sinnott
- Economic and Social Research Institute, Whitaker Square, Sir John Rogerson's Quay, Dublin 2, Ireland
| | - Richard Layte
- Department of Sociology, Trinity College Dublin, Dublin 2, Ireland.,Economic and Social Research Institute, Whitaker Square, Sir John Rogerson's Quay, Dublin 2, Ireland
| | - Aoife Brick
- Economic and Social Research Institute, Whitaker Square, Sir John Rogerson's Quay, Dublin 2, Ireland.,Trinity College Dublin, Dublin 2, Ireland
| | - Michael J Turner
- UCD Centre for Human Reproduction, Coombe Women and Infants University Hospital, Dublin 8, Ireland
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Berger H, Gagnon R, Sermer M, Basso M, Bos H, Brown RN, Bujold E, Cooper SL, Gagnon R, Gouin K, McLeod NL, Menticoglou SM, Mundle WR, Roggensack A, Sanderson FL, Walsh JD. Diabetes in Pregnancy. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2016; 38:667-679.e1. [PMID: 27591352 DOI: 10.1016/j.jogc.2016.04.002] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE This guideline reviews the evidence relating to the diagnosis and obstetrical management of diabetes in pregnancy. OUTCOMES The outcomes evaluated were short- and long-term maternal outcomes, including preeclampsia, Caesarean section, future diabetes, and other cardiovascular complications, and fetal outcomes, including congenital anomalies, stillbirth, macrosomia, birth trauma, hypoglycemia, and long-term effects. EVIDENCE Published literature was retrieved through searches of PubMed and the Cochrane Library using appropriate controlled vocabulary (MeSH terms "diabetes" and "pregnancy"). Where appropriate, results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date limits, but results were limited to English or French language materials. VALUES The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). SUMMARY STATEMENTS Recommendations It is recognized that the use of different diagnostic thresholds for the "preferred" and "alternative" strategies could cause confusion in certain settings. Despite this, the committee has identified the importance of remaining aligned with the current Canadian Diabetes Association 2013 guidelines as being a priority. It is thus recommended that each care centre strategically align with 1 of the 2 strategies and implement protocols to ensure consistent and uniform reporting of test results.
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Zhang L, Zhang H, Zhang J, Zhang JW, Ye JF, Branch DW. Preventive induction of labor for non-urgent indications at term and maternal and neonatal outcomes. Reprod Health 2016; 13:46. [PMID: 27103111 PMCID: PMC4839063 DOI: 10.1186/s12978-016-0165-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2015] [Accepted: 04/13/2016] [Indexed: 11/26/2022] Open
Abstract
Background Induction of labor (IOL) is a common practice in many parts of the world. However, the benefits and risks of preventive IOL for the mother and baby have yet to be critically assessed. This study is to investigate the effects of preventive IOL for non-urgent indications at term on maternal and neonatal outcomes. Methods In this study, we applied a propensity score model to mimic a randomized clinical trial. Maternal and neonatal outcomes were compared between women with preventive IOL at 37–39 weeks of gestation and women with ongoing pregnancy (expectant management). The subjects were from the Consortium on Safe Labor, a study of over 200,000 births from 19 hospitals across the US from 2002 to 2008. Results Both nulliparous and multiparous women induced preventively for non-urgent indications at 37–38 weeks’ gestation had lower rates of cesarean delivery compared to those delivered at later gestational weeks. However, preventive IOL was associated with increased risks of adverse neonatal outcomes (adjusted odds ratio [aOR] = 1.68, 95 % confidence interval [CI], 0.97–2.92 for nulliparas; aOR = 2.22, 1.32–3.74 for multiparas) and admission to NICU (aOR = 1.48, 0.99–2.20 for nulliparas; aOR = 2.08, 1.47–2.96 for multiparas) at 37 weeks’ gestation. A longer maternal hospital stay was found among all women with preventive IOL. Conclusions Preventive IOL for non-urgent indications may be associated with a decreased risk of cesarean delivery at early term but increased risks of adverse neonatal outcomes at 37 weeks. It also results in a longer hospital stay than expectant management.
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Affiliation(s)
- Lin Zhang
- Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, 1665 Kongjiang Road, Shanghai, 200092, China
| | - Hao Zhang
- Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, 1665 Kongjiang Road, Shanghai, 200092, China
| | - Jun Zhang
- Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, 1665 Kongjiang Road, Shanghai, 200092, China.
| | - Jin Wen Zhang
- Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, 1665 Kongjiang Road, Shanghai, 200092, China
| | - Jiang Feng Ye
- Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, 1665 Kongjiang Road, Shanghai, 200092, China
| | - D Ware Branch
- Intermountain HealthCare and University of Utah, Salt Lake City, UT, USA
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38
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Ten Eikelder MLG, Oude Rengerink K, Jozwiak M, de Leeuw JW, de Graaf IM, van Pampus MG, Holswilder M, Oudijk MA, van Baaren GJ, Pernet PJM, Bax C, van Unnik GA, Martens G, Porath M, van Vliet H, Rijnders RJP, Feitsma AH, Roumen FJME, van Loon AJ, Versendaal H, Weinans MJN, Woiski M, van Beek E, Hermsen B, Mol BW, Bloemenkamp KWM. Induction of labour at term with oral misoprostol versus a Foley catheter (PROBAAT-II): a multicentre randomised controlled non-inferiority trial. Lancet 2016; 387:1619-28. [PMID: 26850983 DOI: 10.1016/s0140-6736(16)00084-2] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Labour is induced in 20-30% of all pregnancies. In women with an unfavourable cervix, both oral misoprostol and Foley catheter are equally effective compared with dinoprostone in establishing vaginal birth, but each has a better safety profile. We did a trial to directly compare oral misoprostol with Foley catheter alone. METHODS We did an open-label randomised non-inferiority trial in 29 hospitals in the Netherlands. Women with a term singleton pregnancy in cephalic presentation, an unfavourable cervix, intact membranes, and without a previous caesarean section who were scheduled for induction of labour were randomly allocated to cervical ripening with 50 μg oral misoprostol once every 4 h or to a 30 mL transcervical Foley catheter. The primary outcome was a composite of asphyxia (pH ≤7·05 or 5-min Apgar score <7) or post-partum haemorrhage (≥1000 mL). The non-inferiority margin was 5%. The trial is registered with the Netherlands Trial Register, NTR3466. FINDINGS Between July, 2012, and October, 2013, we randomly assigned 932 women to oral misoprostol and 927 women to Foley catheter. The composite primary outcome occurred in 113 (12·2%) of 924 participants in the misoprostol group versus 106 (11·5%) of 921 in the Foley catheter group (adjusted relative risk 1·06, 90% CI 0·86-1·31). Caesarean section occurred in 155 (16·8%) women versus 185 (20·1%; relative risk 0·84, 95% CI 0·69-1·02, p=0·067). 27 adverse events were reported in the misoprostol group versus 25 in the Foley catheter group. None were directly related to the study procedure. INTERPRETATION In women with an unfavourable cervix at term, induction of labour with oral misoprostol and Foley catheter has similar safety and effectiveness. FUNDING FondsNutsOhra.
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Affiliation(s)
| | - Katrien Oude Rengerink
- Department of Obstetrics and Gynaecology, Academic Medical Centre, Amsterdam, Netherlands
| | - Marta Jozwiak
- Department of Obstetrics, Leiden University Medical Centre, Leiden, Netherlands
| | - Jan W de Leeuw
- Department of Obstetrics and Gynaecology, Ikazia Hospital, Rotterdam, Netherlands
| | - Irene M de Graaf
- Department of Obstetrics and Gynaecology, Academic Medical Centre, Amsterdam, Netherlands
| | - Mariëlle G van Pampus
- Department of Obstetrics and Gynaecology, Onze Lieve Vrouwen Gasthuis, Amsterdam, Netherlands
| | - Marloes Holswilder
- Department of Obstetrics and Gynaecology, University Medical Centre Groningen, Groningen, Netherlands
| | - Martijn A Oudijk
- Department of Obstetrics and Gynaecology, Academic Medical Centre, Amsterdam, Netherlands
| | - Gert-Jan van Baaren
- Department of Obstetrics and Gynaecology, Academic Medical Centre, Amsterdam, Netherlands
| | - Paula J M Pernet
- Department of Obstetrics and Gynaecology, Kennemer Gasthuis, Haarlem, Netherlands
| | - Caroline Bax
- Department of Obstetrics and Gynaecology, Vrije University Medical Centre, Amsterdam, Netherlands
| | - Gijs A van Unnik
- Department of Obstetrics and Gynaecology, Diaconessenhuis, Leiden, Netherlands
| | - Gratia Martens
- Department of Obstetrics and Gynaecology, Zuwe Hofpoort, Woerden, Netherlands
| | - Martina Porath
- Department of Obstetrics and Gynaecology, Maxima Medical Centre, Veldhoven, Netherlands
| | - Huib van Vliet
- Department of Obstetrics and Gynaecology, Catharina Hospital, Eindhoven, Netherlands
| | - Robbert J P Rijnders
- Department of Obstetrics and Gynaecology, Jeroen Bosch Hospital, 's-Hertogenbosch, Netherlands
| | - A Hanneke Feitsma
- Department of Obstetrics and Gynaecology, HAGA Hospital, Den Haag, Netherlands
| | - Frans J M E Roumen
- Department of Obstetrics and Gynaecology, Atrium Medical Centre, Heerlen, Netherlands
| | - Aren J van Loon
- Department of Obstetrics and Gynaecology, Martini Hospital, Groningen, Netherlands
| | - Hans Versendaal
- Department of Obstetrics and Gynaecology, Maasstad Hospital, Rotterdam, Netherlands
| | - Martin J N Weinans
- Department of Obstetrics and Gynaecology, Gelderse Vallei Hospital, Ede, Netherlands
| | - Mallory Woiski
- Department of Obstetrics and Gynaecology, University Medical Centre Nijmegen, Nijmegen, Netherlands
| | - Erik van Beek
- Department of Obstetrics and Gynaecology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Brenda Hermsen
- Department of Obstetrics and Gynaecology, St Lucas Andreas Hospital, Amsterdam, Netherlands
| | - Ben Willem Mol
- The Robinson Research Institute, School of Paediatrics and Reproductive Health, University of Adelaide, Adelaide, SA, Australia; The South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Kitty W M Bloemenkamp
- Department of Obstetrics, Leiden University Medical Centre, Leiden, Netherlands; Wilhelmina Children's Hospital Birth Centre, University Medical Centre Utrecht, Utrecht, Netherlands
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Walker KF, Bugg GJ, Macpherson M, McCormick C, Grace N, Wildsmith C, Bradshaw L, Smith GCS, Thornton JG. Randomized Trial of Labor Induction in Women 35 Years of Age or Older. N Engl J Med 2016; 374:813-22. [PMID: 26962902 DOI: 10.1056/nejmoa1509117] [Citation(s) in RCA: 148] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The risk of antepartum stillbirth at term is higher among women 35 years of age or older than among younger women. Labor induction may reduce the risk of stillbirth, but it also may increase the risk of cesarean delivery, which already is common in this older age group. METHODS We conducted a randomized, controlled trial involving primigravid women who were 35 years of age or older. Women were randomly assigned to labor induction between 39 weeks 0 days and 39 weeks 6 days of gestation or to expectant management (i.e., waiting until the spontaneous onset of labor or until the development of a medical problem that mandated induction). The primary outcome was cesarean delivery. The trial was not designed or powered to assess the effects of labor induction on stillbirth. RESULTS A total of 619 women underwent randomization. In an intention-to-treat analysis, there were no significant between-group differences in the percentage of women who underwent a cesarean section (98 of 304 women in the induction group [32%] and 103 of 314 women in the expectant-management group [33%]; relative risk, 0.99; 95% confidence interval [CI], 0.87 to 1.14) or in the percentage of women who had a vaginal delivery with the use of forceps or vacuum (115 of 304 women [38%] and 104 of 314 women [33%], respectively; relative risk, 1.30; 95% CI, 0.96 to 1.77). There were no maternal or infant deaths and no significant between-group differences in the women's experience of childbirth or in the frequency of adverse maternal or neonatal outcomes. CONCLUSIONS Among women of advanced maternal age, induction of labor at 39 weeks of gestation, as compared with expectant management, had no significant effect on the rate of cesarean section and no adverse short-term effects on maternal or neonatal outcomes. (Funded by the Research for Patient Benefit Programme of the National Institute for Health Research; Current Controlled Trials number, ISRCTN11517275.).
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Affiliation(s)
- Kate F Walker
- From the Division of Child Health, Obstetrics and Gynaecology, School of Clinical Sciences (K.F.W., M.M., C.M., J.G.T.), and Nottingham Clinical Trials Unit (L.B.), and the University of Nottingham, the Division of Obstetrics and Gynaecology, Nottingham University Hospitals NHS Trust (G.J.B., N.G.), Nottingham, Stillbirth and Neonatal Death Charity, London (C.W.), and the Department of Obstetrics and Gynaecology and National Institute for Health Research Biomedical Research Centre, Cambridge University, Cambridge (G.C.S.S.) - all in the United Kingdom
| | - George J Bugg
- From the Division of Child Health, Obstetrics and Gynaecology, School of Clinical Sciences (K.F.W., M.M., C.M., J.G.T.), and Nottingham Clinical Trials Unit (L.B.), and the University of Nottingham, the Division of Obstetrics and Gynaecology, Nottingham University Hospitals NHS Trust (G.J.B., N.G.), Nottingham, Stillbirth and Neonatal Death Charity, London (C.W.), and the Department of Obstetrics and Gynaecology and National Institute for Health Research Biomedical Research Centre, Cambridge University, Cambridge (G.C.S.S.) - all in the United Kingdom
| | - Marion Macpherson
- From the Division of Child Health, Obstetrics and Gynaecology, School of Clinical Sciences (K.F.W., M.M., C.M., J.G.T.), and Nottingham Clinical Trials Unit (L.B.), and the University of Nottingham, the Division of Obstetrics and Gynaecology, Nottingham University Hospitals NHS Trust (G.J.B., N.G.), Nottingham, Stillbirth and Neonatal Death Charity, London (C.W.), and the Department of Obstetrics and Gynaecology and National Institute for Health Research Biomedical Research Centre, Cambridge University, Cambridge (G.C.S.S.) - all in the United Kingdom
| | - Carol McCormick
- From the Division of Child Health, Obstetrics and Gynaecology, School of Clinical Sciences (K.F.W., M.M., C.M., J.G.T.), and Nottingham Clinical Trials Unit (L.B.), and the University of Nottingham, the Division of Obstetrics and Gynaecology, Nottingham University Hospitals NHS Trust (G.J.B., N.G.), Nottingham, Stillbirth and Neonatal Death Charity, London (C.W.), and the Department of Obstetrics and Gynaecology and National Institute for Health Research Biomedical Research Centre, Cambridge University, Cambridge (G.C.S.S.) - all in the United Kingdom
| | - Nicky Grace
- From the Division of Child Health, Obstetrics and Gynaecology, School of Clinical Sciences (K.F.W., M.M., C.M., J.G.T.), and Nottingham Clinical Trials Unit (L.B.), and the University of Nottingham, the Division of Obstetrics and Gynaecology, Nottingham University Hospitals NHS Trust (G.J.B., N.G.), Nottingham, Stillbirth and Neonatal Death Charity, London (C.W.), and the Department of Obstetrics and Gynaecology and National Institute for Health Research Biomedical Research Centre, Cambridge University, Cambridge (G.C.S.S.) - all in the United Kingdom
| | - Chris Wildsmith
- From the Division of Child Health, Obstetrics and Gynaecology, School of Clinical Sciences (K.F.W., M.M., C.M., J.G.T.), and Nottingham Clinical Trials Unit (L.B.), and the University of Nottingham, the Division of Obstetrics and Gynaecology, Nottingham University Hospitals NHS Trust (G.J.B., N.G.), Nottingham, Stillbirth and Neonatal Death Charity, London (C.W.), and the Department of Obstetrics and Gynaecology and National Institute for Health Research Biomedical Research Centre, Cambridge University, Cambridge (G.C.S.S.) - all in the United Kingdom
| | - Lucy Bradshaw
- From the Division of Child Health, Obstetrics and Gynaecology, School of Clinical Sciences (K.F.W., M.M., C.M., J.G.T.), and Nottingham Clinical Trials Unit (L.B.), and the University of Nottingham, the Division of Obstetrics and Gynaecology, Nottingham University Hospitals NHS Trust (G.J.B., N.G.), Nottingham, Stillbirth and Neonatal Death Charity, London (C.W.), and the Department of Obstetrics and Gynaecology and National Institute for Health Research Biomedical Research Centre, Cambridge University, Cambridge (G.C.S.S.) - all in the United Kingdom
| | - Gordon C S Smith
- From the Division of Child Health, Obstetrics and Gynaecology, School of Clinical Sciences (K.F.W., M.M., C.M., J.G.T.), and Nottingham Clinical Trials Unit (L.B.), and the University of Nottingham, the Division of Obstetrics and Gynaecology, Nottingham University Hospitals NHS Trust (G.J.B., N.G.), Nottingham, Stillbirth and Neonatal Death Charity, London (C.W.), and the Department of Obstetrics and Gynaecology and National Institute for Health Research Biomedical Research Centre, Cambridge University, Cambridge (G.C.S.S.) - all in the United Kingdom
| | - James G Thornton
- From the Division of Child Health, Obstetrics and Gynaecology, School of Clinical Sciences (K.F.W., M.M., C.M., J.G.T.), and Nottingham Clinical Trials Unit (L.B.), and the University of Nottingham, the Division of Obstetrics and Gynaecology, Nottingham University Hospitals NHS Trust (G.J.B., N.G.), Nottingham, Stillbirth and Neonatal Death Charity, London (C.W.), and the Department of Obstetrics and Gynaecology and National Institute for Health Research Biomedical Research Centre, Cambridge University, Cambridge (G.C.S.S.) - all in the United Kingdom
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40
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Melamed N, Ray JG, Geary M, Bedard D, Yang C, Sprague A, Murray-Davis B, Barrett J, Berger H. Induction of labor before 40 weeks is associated with lower rate of cesarean delivery in women with gestational diabetes mellitus. Am J Obstet Gynecol 2016; 214:364.e1-8. [PMID: 26928149 DOI: 10.1016/j.ajog.2015.12.021] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Revised: 12/09/2015] [Accepted: 12/16/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND In women with gestational diabetes mellitus, it is not clear whether routine induction of labor at <40 weeks of gestation is beneficial to mother and newborn infant. OBJECTIVE The purpose of this study was to compare outcomes among women with gestational diabetes mellitus who had induction of labor at either 38 or 39 weeks with those whose pregnancy was managed expectantly. STUDY DESIGN We included all women in Ontario, Canada, with diagnosed gestational diabetes mellitus who had a singleton hospital birth at ≥38 + 0 weeks of gestation between April 2012 and March 2014. Data were obtained from the Better Outcomes Registry & Network Ontario, which is a province-wide registry of all births in Ontario, Canada. Women who underwent induction of labor at 38 + 0 to 38 + 6 weeks of gestation (38-IOL; n = 1188) were compared with those who remained undelivered until 39 + 0 weeks of gestation (38-Expectant; n = 5229). Separately, those women who underwent induction of labor at 39 + 0 to 39 + 6 weeks of gestation (39-IOL; n = 1036) were compared with women who remained undelivered until 40 + 0 weeks of gestation (39-Expectant; n = 2162). Odds ratios and 95% confidence intervals were adjusted for maternal age, parity, insulin treatment, and prepregnancy body mass index. RESULTS Of 281,480 women who gave birth during the study period, 14,600 women (5.2%) had gestational diabetes mellitus; of these, 8392 women (57.5%) met all inclusion criteria. Compared with the 38-Expectant group, those women in the 38-IOL group had lower odds for cesarean delivery (adjusted odds ratio, 0.73; 95% confidence interval, 0.52-0.90), higher odds for neonatal intensive care unit admission (adjusted odds ratio, 1.36; 95% confidence interval, 1.09-1.69), and no difference in other maternal-newborn infant outcomes. Compared with the 39-Expectant group, women in the 39-IOL group likewise had lower odds for cesarean delivery (adjusted odds ratio, 0.73; 95% confidence interval, 0.58-0.93) but no difference in neonatal intensive care unit admission (adjusted odds ratio, 0.83; 95% confidence interval, 0.61-1.11). CONCLUSION In women with gestational diabetes mellitus, the routine induction of labor at 38 or 39 weeks is associated with a lower risk of cesarean delivery compared with expectant management but may increase the risk of neonatal intensive care unit admission when done at <39 weeks of gestation.
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Abstract
Shoulder dystocia is a complication of vaginal delivery and the primary factor associated with brachial plexus injury. In this review, we discuss the risk factors for shoulder dystocia and propose a framework for the prediction and prevention of the complication. A recommended approach to management when shoulder dystocia occurs is outlined, with review of the maneuvers used to relieve the obstruction with minimal risk of fetal and maternal injury.
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Affiliation(s)
- Meghan G Hill
- Department of Obstetrics & Gynecology, University of Arizona College of Medicine, Tuscon, AZ 85724, USA
| | - Wayne R Cohen
- Department of Obstetrics & Gynecology, University of Arizona College of Medicine, Tuscon, AZ 85724, USA
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Au CPY, Raynes-Greenow CH, Turner RM, Carberry AE, Jeffery HE. Antenatal management of gestational diabetes mellitus can improve neonatal outcomes. Midwifery 2016; 34:66-71. [PMID: 26821975 DOI: 10.1016/j.midw.2016.01.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Revised: 11/19/2015] [Accepted: 01/06/2016] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Pregnancies complicated with gestational diabetes mellitus (GDM) are at a higher risk for caesarean and instrumental deliveries as well as adverse neonatal outcomes such as fetal overgrowth, hypoglycaemia and neonatal intensive care admission. Our primary objective was to describe neonatal outcomes in a sample that included term infants of both GDM mothers and mothers with normal glucose tolerance (NGT). DESIGN AND SETTING this cross-sectional study included 599 term babies born between September and October 2010 at Royal Prince Alfred Hospital, Sydney, Australia. Maternal and neonatal data were collected from medical records and a questionnaire. Glycaemic control data was based on third trimester HbA1c levels and self-monitoring blood glucose levels (BGL). Univariate associations between GDM status and maternal demographic factors, as well as pregnancy outcomes, were estimated using χ(2) tests and t-tests, as appropriate. FINDINGS of 599 babies, 67(11%) were born to GDM mothers. GDM mothers were more likely to be overweight/obese and of Asian ethnicity. Good glycaemic control was achieved in most GDM mothers. GDM babies were more likely to have been induced (p=0.013) and delivered earlier than non-GDM mothers (p<0.001), and they were also more likely to be breastfed within one hour of birth. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE in this study, GDM infants were more likely to be induced and delivered earlier but otherwise they did not have significantly different neonatal outcomes compared to infants of NGT mothers. This can be attributed to the good GDM control by lifestyle modification and insulin if necessary. The role of labour induction in GDM pregnancies should be further investigated. Midwives have an important role in maternal education during pregnancy and in the postnatal period.
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Affiliation(s)
| | | | - Robin M Turner
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
| | | | - Heather E Jeffery
- School of Public Health, University of Sydney, Sydney, Australia; Newborn Care, Royal Prince Alfred Hospital, Sydney, Australia
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Affiliation(s)
- Seong Yeon Hong
- Department of Obstetrics and Gynecology, Catholic University of Daegu College of Medicine, Daegu, Korea
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Ashwal E, Hod M. Gestational diabetes mellitus: Where are we now? Clin Chim Acta 2015; 451:14-20. [DOI: 10.1016/j.cca.2015.01.021] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2014] [Revised: 01/24/2015] [Accepted: 01/24/2015] [Indexed: 01/17/2023]
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Vilchez GA, Dai J, Hoyos LR, Gill N, Bahado-Singh R, Sokol RJ. Labor and neonatal outcomes after term induction of labor in gestational diabetes. J Perinatol 2015; 35:924-9. [PMID: 26313053 DOI: 10.1038/jp.2015.103] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 07/11/2015] [Accepted: 07/22/2015] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To identify the optimal gestational age (GA) for induction of labor (IOL) at term among patients with gestational diabetes (GDMA) according to perinatal outcomes. STUDY DESIGN The US Natality Database from 2007 to 2010 was reviewed. Inclusion criteria were singleton delivery, IOL at 37 to 42 weeks and GDMA. Exclusion criteria included congenital anomalies, pre-gestational diabetes, hypertensive disorders, previous cesarean, breech presentation and rupture of membranes. Controls were non-GDMA cases delivered in geographic and temporal proximity. Delivery mode, macrosomia and perinatal complications were analyzed. Logistic regression adjusted for confounders was used to calculate odds ratios by GA using 39 weeks non-GDMA as reference. RESULTS In all, 96,964 cases and 176,079 controls were included. Increased risk for all adverse outcomes among GDMA cases was found. The nadir for intrapartum and neonatal complications was 38 and 40 weeks, respectively, whereas for cesarean and macrosomia was 39 weeks. CONCLUSION The optimal timing for IOL at term in GDMA appears to be 39 to 40 weeks.
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Affiliation(s)
- G A Vilchez
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, MI, USA
| | - J Dai
- C.S Mott Center for Human Growth and Development, Wayne State University, Detroit, MI, USA
| | - L R Hoyos
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, MI, USA
| | - N Gill
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, MI, USA
| | - R Bahado-Singh
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - R J Sokol
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, MI, USA
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Hod M, Kapur A, Sacks DA, Hadar E, Agarwal M, Di Renzo GC, Roura LC, McIntyre HD, Morris JL, Divakar H. The International Federation of Gynecology and Obstetrics (FIGO) Initiative on gestational diabetes mellitus: A pragmatic guide for diagnosis, management, and care . Int J Gynaecol Obstet 2015; 131 Suppl 3:S173-S211. [PMID: 29644654 DOI: 10.1016/s0020-7292(15)30033-3] [Citation(s) in RCA: 516] [Impact Index Per Article: 57.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Moshe Hod
- Division of Maternal Fetal Medicine, Rabin Medical Center, Tel Aviv University, Petah Tikva, Israel
| | - Anil Kapur
- World Diabetes Foundation, Gentofte, Denmark
| | - David A Sacks
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Eran Hadar
- Helen Schneider Hospital for Women, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mukesh Agarwal
- Department of Pathology, UAE University, Al Ain, United Arab Emirates
| | - Gian Carlo Di Renzo
- Centre of Perinatal and Reproductive Medicine, Department of Obstetrics and Gynecology, University of Perugia, Perugia, Italy
| | - Luis Cabero Roura
- Maternal Fetal Medicine Unit, Vall d'Hebron University Hospital, Barcelona, Spain
| | | | - Jessica L Morris
- International Federation of Gynecology and Obstetrics, London, UK
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Abstract
Determining the optimal timing for induction of labor is critical in minimizing the risks to maternal and fetal health. While data are available to guide us in some clinical situations, such as hypertension and diabetes, many gaps in knowledge still exist in others, including cholestasis of pregnancy, fetal anomalies, and placental abruption. This review of the currently available literature assesses the risks and benefits of preterm and early term induction in a wide variety of maternal and fetal conditions.
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Affiliation(s)
- Stephen J Bacak
- Department of Obstetrics and Gynecology, University of Rochester, Elmwood Ave, Box 668, Rochester, NY 14642
| | - Courtney Olson-Chen
- Department of Obstetrics and Gynecology, University of Rochester, Elmwood Ave, Box 668, Rochester, NY 14642
| | - Eva Pressman
- Department of Obstetrics and Gynecology, University of Rochester, Elmwood Ave, Box 668, Rochester, NY 14642.
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Abstract
Ideally, all pregnant women would enter labor spontaneously at the safest time to yield the best health outcomes for both themselves and their newborns. Unfortunately, this does not always happen and leaves obstetric providers weighing the maternal and fetal risks of continued expectant management versus labor induction. Several elements have been reported to affect the success rate of an induction, including the Bishop score, maternal parity, body mass index (BMI), age, medical comorbidities, fetal gestational age, and estimated weight, as well as the hospital site and provider practice. Recent data suggest that the decision to induce or continue expectant management in anticipation of labor is an important variable in determining whether a woman has a safe and successful delivery.
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Affiliation(s)
- Kelly S Gibson
- Department of Obstetrics and Gynecology, MetroHealth Medical Center-Case Western Reserve University, 2500 Metrohealth Dr, Cleveland, OH 44109.
| | - Thaddeus P Waters
- Department of Obstetrics and Gynecology, Loyola University Medical Center, Maywood, IL
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