Pregnancy outcome in obese and morbidly obese gestational diabetic women

Maternal and foetal complications of pregestational and gestational diabetes: a descriptive, retrospective cohort study

Gestational diabetes is characterized by hyperglycaemia diagnosed during pregnancy. Gestational and pregestational diabetes can have deleterious effects during pregnancy and perinatally. The baby's weight is frequently above average and might reach macrosomia (≥ 4 kg), which can reduce pregnancy time causing preterm births, and increase foetal-pelvic disproportion which often requires delivery by caesarean section. Foetal-pelvic disproportion due to the baby's weight can also cause foetal distress resulting in lower Apgar scores. To analyse the association between pregestational and gestational diabetes with maternal and foetal risk. We conducted a retrospective cohort study in women pregnant between 2012 and 2018 in the region of Lleida. Regression coefficients and 95% confidence intervals (CI) were used. The multivariate analysis showed statistically significant associations between pregestational diabetes and: prematurity (OR 2.4); caesarean section (OR 1.4); moderate (OR 1.3), high (OR 3.3) and very high (OR 1.7) risk pregnancies; and birth weight ≥ 4000 g (macrosomia) (OR 1.7). In getational diabetes the multivariate analysis show significant association with: caesarean section (OR 1.5); moderate (OR 1.7), high (OR 1.7) and very high (OR 1.8) risk pregnancies and lower 1-minuto Apgar score (OR 1.5). Pregestational and gestational diabetes increase: pregnancy risk, caesarean sections, prematurity, low Apgar scores, and macrosomia.

Refining the diagnosis of gestational diabetes mellitus: a systematic review and meta-analysis

BACKGROUND

Perinatal outcomes vary for women with gestational diabetes mellitus (GDM). The precise factors beyond glycemic status that may refine GDM diagnosis remain unclear. We conducted a systematic review and meta-analysis of potential precision markers for GDM.

METHODS

Systematic literature searches were performed in PubMed and EMBASE from inception to March 2022 for studies comparing perinatal outcomes among women with GDM. We searched for precision markers in the following categories: maternal anthropometrics, clinical/sociocultural factors, non-glycemic biochemical markers, genetics/genomics or other -omics, and fetal biometry. We conducted post-hoc meta-analyses of a subset of studies with data on the association of maternal body mass index (BMI, kg/m2) with offspring macrosomia or large-for-gestational age (LGA).

RESULTS

A total of 5905 titles/abstracts were screened, 775 full-texts reviewed, and 137 studies synthesized. Maternal anthropometrics were the most frequent risk marker. Meta-analysis demonstrated that women with GDM and overweight/obesity vs. GDM with normal range BMI are at higher risk of offspring macrosomia (13 studies [n = 28,763]; odds ratio [OR] 2.65; 95% Confidence Interval [CI] 1.91, 3.68), and LGA (10 studies [n = 20,070]; OR 2.23; 95% CI 2.00, 2.49). Lipids and insulin resistance/secretion indices were the most studied non-glycemic biochemical markers, with increased triglycerides and insulin resistance generally associated with greater risk of offspring macrosomia or LGA. Studies evaluating other markers had inconsistent findings as to whether they could be used as precision markers.

CONCLUSIONS

Maternal overweight/obesity is associated with greater risk of offspring macrosomia or LGA in women with GDM. Pregnancy insulin resistance or hypertriglyceridemia may be useful in GDM risk stratification. Future studies examining non-glycemic biochemical, genetic, other -omic, or sociocultural precision markers among women with GDM are warranted.

Combined Effect of Maternal Obesity and Diabetes on Excessive Fetal Growth: Pregnancy Risk Assessment Monitoring System (PRAMS), United States, 2012-2015

Introduction

Obesity and dysregulation in glucose metabolism are risk factors for excessive fetal growth, but their combined effects are not often examined in a single study.

Methods

Data from the Centers for Disease Control and Prevention's Pregnancy Risk Assessment Monitoring System Phase 7 (2012-2015) were used. Logistic regression was used to investigate the association between maternal prepregnancy BMI and pre-existing diabetes/gestational diabetes on the odds of delivering a large-for-gestational-age infant or an infant with macrosomia.

Results

Complete data for 128,199 singleton births were used. The proportions of large-for-gestational-age infants and infants with macrosomia increased with the degree of obesity (p<0.001) and were higher in women with diabetes than in those without (p<0.001). Compared with the AOR among normal-weight women, the AOR of delivering large-for-gestational-age infants and infants with macrosomia among women with morbid obesity (BMI≥40) were 2.82 (p<0.001) and 2.67 (p<0.001), respectively. Compared with the AOR among nondiabetic women, the AOR of delivering a large-for-gestational-age infant was 1.88 (p<0.001) among those with pre-existing diabetes and 1.49 (p<0.001) among those with gestational diabetes. Except for the underweight group, women with pre-existing diabetes were nearly twice as likely to deliver a large-for-gestational-age infant as those with similar BMI without diabetes. Women with morbid obesity and gestational diabetes were twice as likely to have a large-for-gestational-age infant and an infant with macrosomia as nondiabetic women with normal BMI.

Conclusions

We have shown that when maternal obesity and diabetes, particularly pre-existing diabetes, occur together, the risk of delivering large-for-gestational-age and macrosomia increases significantly. Our findings call for public health attention to address maternal obesity and diabetes to minimize suboptimal fetal growth.

Short-term neonatal outcomes in women with gestational diabetes treated using metformin versus insulin: a systematic review and meta-analysis of randomized controlled trials

AIMS

To expand the evidence base for the clinical use of metformin, we conducted a meta-analysis of randomized controlled trials (RCTs) comparing the efficacy and safety of metformin versus insulin with respect to short-term neonatal outcomes.

METHODS

A comprehensive search of electronic databases (PubMed, Embase, Cochrane Library, and Web of Science) was performed. Two reviewers extracted the data and calculated pooled estimates by use of a random-effects model. In total, 24 studies involving 4355 participants met the eligibility criteria and were included in the quantitative analyses.

RESULTS

Unlike insulin, metformin lowered neonatal birth weights (mean difference - 122.76 g; 95% confidence interval [CI] - 178.31, - 67.21; p < 0.0001), the risk of macrosomia (risk ratio [RR] 0.68; 95% CI 0.54, 0.86; p = 0.001), the incidence of neonatal intensive care unit admission (RR 0.73; 95% CI 0.61, 0.88; p = 0.0009), and the incidence of neonatal hypoglycemia (RR 0.65; 95% CI 0.52, 0.81; p = 0.0001). Subgroup analysis based on the maximum daily oral dose of metformin indicated that metformin-induced neonatal birth weight loss was independent of the oral dose.

CONCLUSIONS

Our meta-analysis provides further evidence that metformin is a safe oral antihyperglycemic drug and has some benefits over insulin when used for the treatment of gestational diabetes, without an increased risk of short-term neonatal adverse outcomes. Metformin may be particularly useful in women with gestational diabetes at high risk for neonatal hypoglycemia, women who want to limit maternal and fetal weight gain, and women with an inability to afford or use insulin safely.

Influence of Pre-Pregnancy Underweight Body Mass Index on Fetal Abdominal Circumference, Estimated Weight, and Pregnancy Outcomes in Gestational Diabetes Mellitus

This study aimed to determine the influence of pre-pregnancy body mass index on pregnancy outcomes in gestational diabetes mellitus (GDM), comparing underweight patients with GDM with normal weight patients with GDM. Maternal baseline characteristics, ultrasonographic results, and pregnancy and neonatal outcomes were reviewed in 946 women with GDM with singleton pregnancies. Underweight patients with GDM showed a benign course in most aspects during pregnancy, except for developing a higher risk of giving birth to small for gestational age neonates. Underweight women with GDM required less insulin treatment, had a higher rate of vaginal delivery, and had a lower rate of cesarean delivery. In addition, their neonates were more likely to have fetal abdominal circumference and estimated fetal weight below the 10th percentile both at the time of GDM diagnosis and before delivery. Notably, their risk for preeclampsia and macrosomia were lower. Collectively, our data suggest that underweight women with GDM may require a different approach in terms of diagnosis and management throughout their pregnancy.

The dynamic changes in the pattern of liver function tests in pregnant obese women

Obesity is an important problem in healthcare regarding gestating women. The objective of the present study was to highlight the impact that obesity has on the hepatic function in pregnant women by comparing the functional tests used in current practice. In addition, the aim was to identify possible predictors of liver damage by analyzing specific anthropometric data. The present study was descriptive, observational, retrospective, and based on the observation sheets found in the database of the Institute for the Health of the Mother and Child, the Obstetrics Gynecology Department of Polizu Hospital. Patients who presented for consultation in each trimester of pregnancy were included in the study. Demographic data taken into account included age, body mass index (BMI), provenance environment, anthropometric data: Abdominal circumference and the complete set of paraclinical data from which we extracted these specific liver tests: Aspartate aminotransferase (AST), alanine transferase (ALT), direct bilirubin (BD), serum albumin and gamma-glutamyl transferase (GGT). The present study included 157 patients divided into two groups, distributed as follows: Group A: 66 obese pregnant women (BMI >25 kg/m2) and group B: 91 patients with normal weight (BMI <25 kg/m2). Measurement of serum ALT and AST were the most useful tests for routine diagnosis of liver disease. The effects of pregnancy on serum levels of ALT and AST are controversial. In some studies, there was a slight increase in ALT and AST during the second and third trimesters, a fact confirmed by our study, albeit the result was not statistically significant Most published studies claim that serum ALT and AST levels do not change during pregnancy. In conclusion, obesity during pregnancy does not drastically influence liver function. However, patients with greater abdominal circumference are prone to developing minor hepatic cytolysis syndrome during the gestation period. The liver functional tests described in the aforementioned groups agree with the results provided by the specialized studies.

Effects of omega-7 palmitoleic acids on skeletal muscle differentiation in a hyperglycemic condition

Maternal obesity and diabetes are known to be involved in fetal myogenesis, but the later stages of myogenesis are not well understood. In this study, we investigated the influence of a hyperglycemic environment on L6 skeletal myoblast differentiation and the function of omega-7 palmitoleic acids. Exposure to a high concentration of glucose (25 mM) in high-glucose culture medium (HG) increased the expression of myogenic genes (MyoD, Myogenin, MRF4, Myhc2x, and Myhc2a) and the synthesis of myosin. HG also activated the PI3K/AKT pathway revealed muscle cell differentiation. Furthermore, the levels of reactive oxygen species (ROS) and an inflammatory cytokine (Tnfaip3; tumor necrosis factor alpha-induced protein 3), which are crucial for the growth and differentiation of skeletal muscle, were increased by HG. Palmitoleic acids suppressed the expression levels of myogenic regulatory genes and increased the expression level of a cell proliferation-related gene (Pax3). Trans-palmitoleic acid and eicosapentaenoic acid (TPA and EPA) increased the phosphorylation level of MAPK/ERK1/2 and downregulated ROS generation and Tnfaip3 expression. In contrast, cis-palmitoleic acid inactivated MAPK/ERK1/2, leading to increased ROS generation. In conclusion, a hyperglycemic environment mediated by HG induced excessive muscle differentiation. Palmitoleic acids inhibited myoblast differentiation by downregulating muscle-specific genes. Moreover, trans-palmitoleic acids may have beneficial antioxidant and/or anti-inflammatory effects in cells.

Effects of pre-gestational diabetes mellitus and gestational diabetes mellitus on macrosomia and birth defects in Upstate New York

AIMS

To evaluate the effects of pre-gestational diabetes mellitus (PGDM) and gestational diabetes mellitus (GDM) on macrosomia and birth defects.

METHODS

Existing birth registry data from the Perinatal Data System in Upstate New York was analysed. 650,914 women with a singleton term pregnancy (≥37 weeks) aged 18-55 years from 2004 to 2016 were included.

RESULTS

The prevalence of macrosomia in infants born to women with PGDM and GDM were 26.0% and 16.4%, respectively, higher than that in the controls (11.2%). Compared with the controls (0.8%), the PGDM and GDM groups had higher prevalence of any birth defect (1.8% and 1.0%). The PGDM group had the highest prevalence of cyanotic heart disease (0.6%). Moreover, the PGDM group had higher prevalence of cleft lip and palate, cleft palate alone, hypospadias and limb reduction defect compared to the GDM and control groups (p < 0.05). However, these birth defects in the GDM group were similar to those in the controls. Both the PGDM and GDM groups had significantly elevated odds of macrosomia, cyanotic heart disease and any birth defect than controls. The PGDM group had higher odds of cleft lip and palate, cleft palate alone, hypospadias and limb reduction defect.

CONCLUSIONS

Using the Perinatal Data System database, PGDM and GDM, especially PGDM, was associated with higher prevalence of macrosomia, cyanotic heart disease and any birth defect in singleton term pregnancy in Upstate New York. PGDM, not GDM had higher prevalence of cleft lip and palate, cleft palate alone, hypospadias and limb reduction defect.

Gestational diabetes mellitus and macrosomia predispose to diabetes in the Lebanese population

AIMS

The Middle East has the fastest rising rate of Type 2 Diabetes Mellitus (T2DM) worldwide, with Lebanon having 15.8% of its population affected. This study aims at studying Polycystic Ovarian Syndrome (PCOS), Gestational Diabetes Mellitus (GDM), and macrosomia as risk factors of T2DM in Lebanon. Such epidemiological and statistical study has never been conducted before in the Middle East region and would be useful for clinical diagnosis.

METHODS

Our cohort is comprised of 1453 Lebanese individuals, with 897 controls and 556 patients. We tested the correlation between T2DM and the covariates GDM, PCOS, and macrosomia independently. We conducted multinomial logistic regression and cross tabulations with T2DM as an outcome.

RESULTS

The results showed a significant association of the independent factors GDM and macrosomia with T2DM. The risk of having T2DM was increased by 4.192 times with the GDM, and by 2.315 times with macrosomia respectively.

CONCLUSION

In conclusion, GDM and macrosomia, but not PCOS, are significant risk factors for T2DM in our Lebanese cohort. Our results, reported for the first time in the Middle East, present insights into risk factors management and disease prevention.

Maternal overweight is not an independent risk factor for increased birth weight, leptin and insulin in newborns of gestational diabetic women: observations from the prospective 'EaCH' cohort study

BACKGROUND

Both gestational diabetes mellitus (GDM) as well as overweight/obesity during pregnancy are risk factors for detrimental anthropometric and hormonal neonatal outcomes, identified to 'program' adverse health predispositions later on. While overweight/obesity are major determinants of GDM, independent effects on critical birth outcomes remain unclear. Thus, the aim of the present study was to evaluate, in women with GDM, the relative/independent impact of overweight/obesity vs. altered glucose metabolism on newborn parameters.

METHODS

The prospective observational 'Early CHARITÉ (EaCH)' cohort study primarily focuses on early developmental origins of unfavorable health outcomes through pre- and/or early postnatal exposure to a 'diabetogenic/adipogenic' environment. It includes 205 mother-child dyads, recruited between 2007 and 2010, from women with treated GDM and delivery at the Clinic of Obstetrics, Charité - Universitätsmedizin Berlin, Germany. Recruitment, therapy, metabolite/hormone analyses, and data evaluation were performed according to standardized guidelines and protocols. This report specifically aimed to identify maternal anthropometric and metabolic determinants of anthropometric and critical hormonal birth outcomes in 'EaCH'.

RESULTS

Group comparisons, Spearman's correlations and unadjusted linear regression analyses initially confirmed that increased maternal prepregnancy body-mass-index (BMI) is a significant factor for elevated birth weight, cord-blood insulin and leptin (all P < 0.05). However, consideration of and adjustment for maternal glucose during late pregnancy showed that no maternal anthropometric parameter (weight, BMI, gestational weight gain) remained significant (all n.s.). In contrast, even after adjustment for maternal anthropometrics, third trimester glucose values (fasting and postprandial glucose at 32nd and 36th weeks' gestation, HbA1c in 3rd trimester and at delivery), were clearly positively associated with critical birth outcomes (all P < 0.05).

CONCLUSIONS

Neither overweight/obesity nor gestational weight gain appear to be independent determinants of increased birth weight, insulin and leptin. Rather, 3rd trimester glycemia seems to be crucial for respective neonatal outcomes. Thus, gestational care and future research studies should greatly consider late pregnancy glucose in overweight/obese women with or without GDM, for evaluation of critical causes and interventional strategies against 'perinatal programming of diabesity' in the offspring.

Optimal Gestational Weight Gain for Women with Gestational Diabetes and Morbid Obesity

OBJECTIVES

Our aim was to investigate the greatest gestational weight gain (GWG) without adverse pregnancy complications in women with gestational diabetes mellitus (GDM) and morbid obesity.

METHODS

An observational retrospective study including 3284 patients with single pregnancies and GDM was completed. Of the patients, 131 (4.0%) were classified as having pre-pregnancy morbid obesity (BMI ≥ 35 kg/m²). Perinatal complications were compared among BMI groups. In the group with morbid obesity, GWG threshold values to predict outcomes were examined based on sensitivity and specificity values under the receiver operating characteristic curve.

RESULTS

GWG was higher in mothers with morbid obesity and macrosomic neonates: 11.3 (4.4-15.7) versus 4.8 (1.5-8.2) kg (p = 0.033). The GWG and neonatal ponderal index were positively correlated (r = 0.305, p = 0.001). The GWG was 7.0 (2.9-11.6) kg in women with hypertensive disorder versus 4.5 (1.0-7.5) kg in normotensive women (p = 0.017). A GWG above 5 kg was a risk factor for macrosomia (87.8% sensitivity, 54.7% specificity) and hypertensive disorder (70.0% sensitivity, 48.4% specificity). GWG associations were maintained after controlling for glycemic control, maternal and gestational age, parity, smoking and neonatal sex.

CONCLUSIONS FOR PRACTICE

A GWG below 5 kg is recommended for women with GDM and morbid obesity. In these women, adequate GWG may prevent macrosomia, fetal overgrowth and hypertensive disorder.

Population-Based Risk Factors for Shoulder Dystocia

OBJECTIVE

To re-examine the risk factors for shoulder dystocia given the increasing rates of obesity and diabetes in pregnant women.

DESIGN

Retrospective observational study.

SETTING

Five hospitals located in Wisconsin, Florida, Maryland, Michigan, and Alabama.

PARTICIPANTS

We evaluated 19,236 births that occurred between April 1, 2011, and July 25, 2013.

METHODS

Data were collected from electronic medical records and used to evaluate the risk of shoulder dystocia. Data were analyzed using a generalized linear mixed model, which controlled for clustering due to site.

RESULTS

When insulin was prescribed, gestational diabetes was associated with an increased risk of shoulder dystocia (odds ratio = 2.10, 95% confidence interval [1.01, 4.37]); however, no similar association was found with regard to gestational diabetes treated with glycemic agents or through diet. Use of epidural anesthesia was associated with an increased risk for shoulder dystocia (odds ratio = 3.47, 95% confidence interval [2.72, 4.42]). Being Black or Hispanic, being covered by Medicaid or having no insurance, infant gestational age of 41 weeks or greater, and chronic diabetes were other significant risk factors.

CONCLUSION

With the changing characteristics of pregnant women, labor and birth clinicians care for more pregnant women who have an increased risk for shoulder dystocia. Our findings may help prospectively identify women with the greatest risk.

Maternal Habitual Midday Napping Duration and Frequency are Associated with High Birthweight

Habitual midday napping is a common habit in China, especially for pregnant women. The purpose of this study was to examine whether duration and frequency of maternal habitual midday napping were associated with high birthweight (HBW). A total of 10,482 participants from Healthy Baby Cohort were include in our analysis. The information of the mothers and their infants were abstracted from medical records, or obtained from questionnaire. Logistic regression models were used to calculate the odds ratios (ORs) and 95% confidence intervals (CIs) of habitual midday napping duration and frequency with HBW. Of the participants, 8,705 (83.0%) reported having habitual midday napping. Duration and frequency of napping had a positive association with HBW without adjustment. After controlling for potential confounders, increasing risk of HBW was observed in participants who napped 1.5–2 hours (OR, 1.50, 95% CI, 1.14, 1.98), and ≥2 hours (OR, 1.35, 95% CI, 1.03, 1.78) compared with no habitual midday napping. Participants who took naps ≥5 days/week had a higher risk of HBW (OR, 1.37, 95% CI, 1.07, 1.77) compared with the women without naps. This suggests that longer (≥1.5 hours) and more frequent (≥5 days/week) maternal habitual midday napping were associated with an increased risk of HBW.

Maternal Obesity and its Short- and Long-Term Maternal and Infantile Effects

Obesity, in childhood or in adulthood, remains to be a global health problem. The worldwide prevalence of obesity has increased in the last few decades, and consequently, the women of our time suffer more gestational problems than women in the past. The prevalence of obesity is greater in older women than in younger ones and in women with low educational level than in their counterparts with a higher level of education. Maternal obesity during pregnancy may increase congenital malformations and neonatal morbidity and mortality. Maternal obesity is associated with a decreased intention to breastfeed, decreased initiation of breastfeeding, and decreased duration of breastfeeding. We discuss the current epidemiological evidence for the association of maternal obesity with congenital structural neural tube and cardiac defects, fetal macrosomia that predisposes infants to birth injuries and to problems with physiological and metabolic transition, as well as potential for long-term complications secondary to prenatal and neonatal programming effects compounded by a reduction in sustained breastfeeding.

Bariatric Surgery and the Pregnancy Complicated by Gestational Diabetes

Gestational diabetes mellitus (GDM) is an increasingly common obstetrical problem. Due to the global escalation in the prevalence of obesity, as many as 15 % of pregnant women may soon be classified as having GDM. While often not diagnosed until late gestation, GDM is now recognized as a disorder of glucose and lipid metabolism, systemic inflammation, and insulin resistance that begins early in pregnancy. Recent large randomized trials have clarified the risk of maternal and neonatal complications caused by GDM, as well as the potential to ameliorate these risks. There is significant interest in the potential to reduce the risk for developing GDM in obese women through the performance of bariatric surgery (BS) before pregnancy. BS significantly reduces the risk for GDM, preeclampsia, and large neonates. However, it seems that the risk for small neonates and preterm delivery is increased. No significant differences are observed in regard to cesarean section, postpartum hemorrhage, or perinatal mortality. In this article, we address the effects of GDM on the mother and child, and explore the risks and benefits of BS in the obstetrical population.

Antepartum Care of the Obese Patient

In the United States, roughly half of women are either overweight (24.5%) or obese (21.4%) when they become pregnant. Women who are obese before pregnancy are at increased risk for a number of pregnancy complications relative to normal-weight women. Specifically, obesity is associated with significantly increased maternal risks, including gestational diabetes mellitus, hypertensive disorders of pregnancy, and sleep disordered breathing. Maternal obesity is also associated with increased risks of adverse fetal outcomes, including prematurity, stillbirth, congenital anomalies, and abnormal fetal growth. In this review, we will discuss the implications of obesity with respect to antepartum care.

Treatment With Diet and Exercise for Women With Gestational Diabetes Mellitus Diagnosed Using IADPSG Criteria

CONTEXT

Prevalence of gestational diabetes mellitus (GDM) and obesity continue to increase.

OBJECTIVE

This study aimed to ascertain whether diet and exercise is a successful intervention for women with GDM and whether a subset of these women have comparable outcomes to those with normal glucose tolerance (NGT).

DESIGN, SETTING, AND PARTICIPANTS

This was a retrospective cohort study of five antenatal centers along the Irish Atlantic seaboard of 567 women diagnosed with GDM and 2499 women with NGT during pregnancy.

INTERVENTION

Diet and exercise therapy on diagnosis of GDM were prescribed and multiple maternal and neonatal outcomes were examined.

RESULTS

Infants of women with GDM were more likely to be hypoglycemic (adjusted odds ratio [aOR], 7.25; 95% confidence interval [CI], 2.94-17.9) at birth. They were more likely to be admitted to the neonatal intensive care unit (aOR, 2.16; 95% CI, 1.60-2.91). Macrosomia and large-for-gestational-age rates were lower in the GDM group (aOR, 0.48; 95% CI, 0.37-0.64 and aOR, 0.61; 95% CI, 0.46-0.82, respectively). There was no increase in small for gestational age among offspring of women with GDM (aOR, 0.81; 95% CI, 0.49-1.34). Women with diet-treated GDM and body mass index (BMI) < 25 kg/m(2) had similar outcomes to those with NGT of the same BMI group. Obesity increased risk for poor pregnancy outcomes regardless of diabetes status.

CONCLUSION

Medical nutritional therapy and exercise for women with GDM may be successful in lowering rates of large for gestational age and macrosomia without increasing small-for-gestational-age rates. Women with GDM and a BMI less than 25 kg/m(2) had outcomes similar to those with NGT suggesting that these women could potentially be treated in a less resource intensive setting.

[Epidemiology of shoulder dystocia]

OBJECTIVES

To synthetize the available evidence regarding the incidence and risk factors of shoulder dystocia (SD).

METHODS

Consultation of the Medline database, and of national guidelines.

RESULTS

Shoulder dystocia is defined as a vaginal delivery that requires additional obstetric manoeuvres to deliver the foetus after the head has delivered and gentle traction has failed. With this definition, the incidence of SD in population-based studies is about 0.5-1% of vaginal deliveries. Many risk factors have been described but most associations are not independent, or have not been constantly found. The 2 characteristics consistently found as independent risk factors for SD in the literature are previous SD (incidence of SD of about 10% in parturients with previous SD) and foetal macrosomia. Maternal diabetes and obesity also are associated with a higher risk of SD (2 to 4 folds) but these associations may be completely explained by foetal macrosomia. However, even factors independently and constantly associated with SD do not allow a valid prediction of SD because they are not discriminant; 50 to 70% of SD cases occur in their absence, and the great majority of deliveries when they are present is not associated with SD.

CONCLUSION

Shoulder dystocia is defined by the need for additional obstetric manoeuvres to deliver the foetus after the head has delivered and gentle traction has failed, and complicates 0.5-1% of vaginal deliveries. Its main risk factors are previous SD and macrosomia, but they are poorly predictive. SD remains a non-predictable obstetrics emergency. Knowledge of SD risk factors should increase the vigilance of clinicians in at-risk contexts.

Can we predict the need for pharmacological treatment according to demographic and clinical characteristics in gestational diabetes?

OBJECTIVE

To determine the ability to predict the need for pharmacological treatment in gestational diabetes mellitus (GDM).

METHOD

A retrospective cohort study. Data were collected from medical records of 1324 GDM patients including demographic data, family history of diabetes, obstetrical history, laboratory results, treatment modality and level of glycemic control. Patients who were identified as pre-gestational diabetes were excluded.

RESULTS

Overall, 143 (10.8%) GDM patients required pharmacological therapy. Of women who had GDM in their previous pregnancy; only 11.65% achieved desired glycemic control solely by diet treatment. Moreover, 62.5% of patients requiring pharmacological therapy in their previous pregnancy achieved desired level of glycemic control only by diet. Of patients who achieved desired level of glycemic control on diet until the second antenatal visit, 95% continued to maintain desired level glycemic control throughout pregnancy. Pre-pregnancy BMI >30, fasting plasma glucose >95 mg/dL and maternal age above 30 were associated with increase need for pharmacological treatment. One abnormal value in the OGTT and GCT result >2 mg/dL did not predict the need for pharmacological therapy. Primigravida and family history of GDM were not found to be predictors for treatment modality.

CONCLUSION

Using clinical and demographical data can predict the need for pharmacological treatment for GDM.

Gestational diabetes mellitus and macrosomia: a literature review

BACKGROUND

Fetal macrosomia, defined as a birth weight ≥ 4,000 g, may affect 12% of newborns of normal women and 15-45% of newborns of women with gestational diabetes mellitus (GDM). The increased risk of macrosomia in GDM is mainly due to the increased insulin resistance of the mother. In GDM, a higher amount of blood glucose passes through the placenta into the fetal circulation. As a result, extra glucose in the fetus is stored as body fat causing macrosomia, which is also called 'large for gestational age'. This paper reviews studies that explored the impact of GDM and fetal macrosomia as well as macrosomia-related complications on birth outcomes and offers an evaluation of maternal and fetal health.

SUMMARY

Fetal macrosomia is a common adverse infant outcome of GDM if unrecognized and untreated in time. For the infant, macrosomia increases the risk of shoulder dystocia, clavicle fractures and brachial plexus injury and increases the rate of admissions to the neonatal intensive care unit. For the mother, the risks associated with macrosomia are cesarean delivery, postpartum hemorrhage and vaginal lacerations. Infants of women with GDM are at an increased risk of becoming overweight or obese at a young age (during adolescence) and are more likely to develop type II diabetes later in life. Besides, the findings of several studies that epigenetic alterations of different genes of the fetus of a GDM mother in utero could result in the transgenerational transmission of GDM and type II diabetes are of concern.

Maternal obesity and occurrence of fetal macrosomia: a systematic review and meta-analysis

OBJECTIVE

To determine a precise estimate for the contribution of maternal obesity to macrosomia.

DATA SOURCES

The search strategy included database searches in 2011 of PubMed, Medline (In-Process & Other Non-Indexed Citations and Ovid Medline, 1950-2011), and EMBASE Classic + EMBASE. Appropriate search terms were used for each database. Reference lists of retrieved articles and review articles were cross-referenced.

METHODS OF STUDY SELECTION

All studies that examined the relationship between maternal obesity (BMI ≥30 kg/m(2)) (pregravid or at 1st prenatal visit) and fetal macrosomia (birth weight ≥4000 g, ≥4500 g, or ≥90th percentile) were considered for inclusion.

TABULATION, INTEGRATION, AND RESULTS

Data regarding the outcomes of interest and study quality were independently extracted by two reviewers. Results from the meta-analysis showed that maternal obesity is associated with fetal overgrowth, defined as birth weight ≥ 4000 g (OR 2.17, 95% CI 1.92, 2.45), birth weight ≥4500 g (OR 2.77,95% CI 2.22, 3.45), and birth weight ≥90% ile for gestational age (OR 2.42, 95% CI 2.16, 2.72).

CONCLUSION

Maternal obesity appears to play a significant role in the development of fetal overgrowth. There is a critical need for effective personal and public health initiatives designed to decrease prepregnancy weight and optimize gestational weight gain.

Shoulder dystocia: risk factors, predictability, and preventability

Shoulder dystocia remains an unpredictable obstetric emergency, striking fear in the hearts of obstetricians both novice and experienced. While outcomes that lead to permanent injury are rare, almost all obstetricians with enough years of practice have participated in a birth with a severe shoulder dystocia and are at least aware of cases that have resulted in significant neurologic injury or even neonatal death. This is despite many years of research trying to understand the risk factors associated with it, all in an attempt primarily to characterize when the risk is high enough to avoid vaginal delivery altogether and prevent a shoulder dystocia, whose attendant morbidities are estimated to be at a rate as high as 16-48%. The study of shoulder dystocia remains challenging due to its generally retrospective nature, as well as dependence on proper identification and documentation. As a result, the prediction of shoulder dystocia remains elusive, and the cost of trying to prevent one by performing a cesarean delivery remains high. While ultimately it is the injury that is the key concern, rather than the shoulder dystocia itself, it is in the presence of an identified shoulder dystocia that occurrence of injury is most common. The majority of shoulder dystocia cases occur without major risk factors. Moreover, even the best antenatal predictors have a low positive predictive value. Shoulder dystocia therefore cannot be reliably predicted, and the only preventative measure is cesarean delivery.

The effect of maternal body mass index on perinatal outcomes in women with diabetes

OBJECTIVE

To determine the effect of increasing maternal obesity, including superobesity (body mass index [BMI] ≥ 50 kg/m2), on perinatal outcomes in women with diabetes.

STUDY DESIGN

Retrospective cohort study of birth records for all live-born nonanomalous singleton infants ≥ 37 weeks' gestation born to Missouri residents with diabetes from 2000 to 2006. Women with either pregestational or gestational diabetes were included.

RESULTS

There were 14,595 births to women with diabetes meeting study criteria, including 7,082 women with a BMI > 30 kg/m2 (48.5%). Compared with normal-weight women with diabetes, increasing BMI category, especially superobesity, was associated with a significantly increased risk for preeclampsia (adjusted relative risk [aRR] 3.6, 95% confidence interval [CI] 2.5, 5.2) and macrosomia (aRR 3.0, 95% CI 1.8, 5.40). The majority of nulliparous obese women with diabetes delivered via cesarean including 50.5% of obese, 61.4% of morbidly obese, and 69.8% of superobese women. The incidence of primary elective cesarean among nulliparous women with diabetes increased significantly with increasing maternal BMI with over 33% of morbidly obese and 39% of superobese women with diabetes delivering electively by cesarean.

CONCLUSION

Increasing maternal obesity in women with diabetes is significantly associated with higher risks of perinatal complications, especially cesarean delivery.

Prevalence of obesity among Bangladeshi pregnant women at their first trimester of pregnancy

BACKGROUND

Paradoxically, the escalating global epidemic of maternal obesity coexists with malnutrion in many areas of Bangladesh. This proves a major challenge to obstetric practice from preconception to postpartum due to related comorbid conditions including: maternal death or severe morbidity, gestational diabetes and hypertension, increased risk of early and recurrent miscarriage, pre-eclampsia, thromboembolism, post-caesarean wound infection, postpartum haemorrhage, and low breastfeeding rates. A dramatic increase in birth defects and other pregnancy-induced disorders related to maternal obesity has added millions of dollars to health care costs leading great economical loss to the country.

OBJECTIVE

The study was designed to determine the prevalence of obesity among Bangladeshi pregnant women in their 1st trimester of pregnancy.

STUDY DESIGN

426 pregnant women presenting to the antenatal care until of Azimpur maternity hospital of Dhaka, Bangladesh were randomly selected for this cross sectional study to determine their weight status using body mass index (BMI, kg/m2).

RESULT

90 (21.2%) pregnant women were reported as obese with pregnancy BMI of >30 kg/m2. 171 (40.1%) and 140 (32.8%) pregnant women were reported as overweight and healthy with pregnancy BMI of 25-29.9 kg/m2 and 18.5-24.9 kg/ m2, respectively. Statistical analysis revealed obesity and overweight status were found to be significantly associated with age; women aged 31 or above were more likely to be obese (OR=2.5; 95% CI 1.53-3.96) and overweight (OR=3.3; 95% CI 2.15-4.99).

CONCLUSION

This study provides evidence of increasing trends in obesity among Bangladeshi pregnant women, which poses possible health risks both for mother and child. The findings of this study may act as baseline data for monitoring the effectiveness of national programs for the prevention and control of maternal obesity.

Macrophage infiltration and stress-signaling in omental and subcutaneous adipose tissue in diabetic pregnancies

OBJECTIVE

To examine if, as in obesity, pregnancies complicated by gestational diabetes mellitus (GDM) exhibit increased macrophage infiltration and activated MAP-kinases in omental adipose tissue.

METHODS

Paired omental (OM) and abdominal subcutaneous (SC) fat samples were collected from 11 GDM and 20 normal pregnancies during cesarean delivery. Tissues were stained to detect macrophages, and analyzed to assess MAP-kinases.

RESULTS

OM had higher macrophage counts than SC in GDM (6.10 ± 2.20 versus 2.53 ± 1.45, p = 0.04), but not in normal pregnancies (p = 0.346). GDM pregnancies had more macrophages than normal pregnancies in OM (6.10 ± 2.20 versus 1.29 ± 0.55, p = 0.01), while only a trend was observed in SC fat (p = 0.08). Significant correlation (R = 0.619, p = 0.005) was observed between OM-macrophage infiltration and insulin resistance. Using multivariate analysis, only obesity independently associated with GDM. Expression of total p38MAP-kinase was higher in OM versus SC in both normal and GDM pregnancies, without significant differences between these groups. However, expression of activated p-p38MAP-kinase, and its upstream kinase MKK4, was comparable between fat depots.

CONCLUSION

GDM pregnancies demonstrate increased macrophage infiltration to OM fat, correlating with higher insulin resistance. As in non-pregnant-patients obesity and OM macrophage infiltration may be on the same causal pathway, leading to GDM. Yet, this occurs without activation of p38MAP-kinase signaling.

Female obesity: short- and long-term consequences on the offspring

The worldwide prevalence of obesity has risen over the past few decades and women are currently more likely than ever to enter pregnancy obese. Pre-pregnancy obesity and excessive gestational weight gain increase miscarriage rates and obstetric and neonatal complications, which result in a lower healthy live birth rate. In addition to its negative consequences for the mother, obesity has been shown to be an important risk factor for chronic illnesses, such as cardiovascular disease, metabolic syndrome and type 2 diabetes in the adolescence and adulthood of the offspring. Moreover, maternal obesity causes psychological problems, physical disabilities and higher healthcare costs. Fetal programming of metabolic function induced by obesity, through physiological and/or epigenetic mechanisms, may have an intergenerational effect and could, thus, perpetuate obesity in the next generation. In order to break this vicious circle and avoid serious short- and long-term negative outcomes for both mothers and fetuses, the prevention and adequate management of obesity and gestational weight gain are essential.

Bariatric surgery: impact on pregnancy outcomes

The dramatic increase in the prevalence of obesity in women of reproductive age has resulted in approximately 1 in 5 women being obese when they conceive. Bariatric surgery has been shown to be the most effective long-term weight loss strategy in obese women in this age group. Clinicians should be aware of the effects of bariatric surgery on fertility and future pregnancies. Regarding certain complications, pregnancy after bariatric surgery appears to be safer than pregnancy in the obese. In patients where nutrition is properly maintained and monitored, the risks for obesity-related obstetric complications, such as gestational diabetes mellitus and hypertension, are significantly reduced, but possibly at the expense of an increase in neonates born small-for-gestational-age. At the present, definitive conclusions cannot be drawn concerning the risk for Caesarian delivery, differences in type of bariatric procedure, or the optimal surgery-to-conception interval.

The obese woman with gestational diabetes: effects of body mass index and weight gain in pregnancy on obstetric and glycaemic outcomes

BACKGROUND

Obese women with gestational diabetes mellitus (GDM) represent a high-risk group in pregnancy, although the effects of increasing degrees of obesity and weight gain in pregnancy in this group is poorly defined.

METHODS

We performed a retrospective analysis of 375 singleton pregnancies complicated by maternal obesity and GDM. Women with a body mass index (BMI) of 30-35 kg/m(2) were compared with those with a BMI of ≥ 35 kg/m(2). Additionally, women were categorized according to weight gain in pregnancy: Group A (<0.18 kg/week), Group B (0.18-0.27 kg/week), Group C (>0.27 kg/week).

RESULTS

Obstetric outcomes did not differ between the groups; however, postpartum dysglycaemia was more likely in women with a BMI ≥ 35 kg/m(2) (odds ratio [OR] 3.2, 95% confidence interval [CI]: 1.2-8.9). Group B and Group C had higher odds of LGA (OR 3.8, 95% CI: 1.3-11.3; OR 5.0, 95% CI: 2.0-12.1, respectively) compared with Group A. Group C also had a lower risk of SGA (OR 0.4, 95% CI: 0.2-1.0) and a higher risk of postpartum dysglycaemia (OR 6.8, 95% CI: 1.7-26.9) compared with Group A.

CONCLUSION

Greater degrees of obesity are associated with higher risk of abnormal metabolic outcomes after pregnancy. Excessive weight gain in pregnancy in obese women increases adverse obstetric and glycaemic outcomes. Our findings suggest that targets for weight gain in pregnancy for obese women should be reduced from current recommendations.

Pre-pregnancy body mass index and the risk of adverse outcome in type 1 diabetic pregnancies: a population-based cohort study

OBJECTIVE

To assess the risk of perinatal complications in overweight and obese women with and without type 1 diabetes (T1DM).

DESIGN

Prospective population-based cohort study.

SETTING

This study was based on data from the Swedish Medical Birth Registry from 1998 to 2007.

PARTICIPANTS

3457 T1DM and 764 498 non-diabetic pregnancies were included. T1DM was identified based on ICD code O24.0. Mothers were categorised according to pre-pregnancy body mass index (BMI: weight in kilograms per height in square metres) as normal weight (BMI 18.5-24.9), overweight (BMI 25-29.9) or obese (BMI ≥30). Only women with singleton pregnancies and with data on BMI were included. PRIMARY/SECONDARY OUTCOMES: The primary outcome was large for gestational age (LGA: birth weight >90th percentile) infants. Secondary outcomes were major malformations, pre-eclampsia (PE), preterm delivery, perinatal mortality, delivery by Caesarean section and neonatal overweight. Logistic regression analysis was performed with normal weight non-diabetic women as the reference category and also within the diabetic cohort with normal weight type 1 diabetic women as the reference. The ORs were adjusted for ethnicity, maternal age, height, parity, smoking and chronic hypertension.

RESULTS

35% of women with T1DM were overweight and 18% were obese, as compared with 26% and 11%, respectively, in non-diabetic pregnancies. The incidences of adverse outcome increased with greater BMI category. As compared with non-diabetic normal weight women, the adjusted OR for obese T1DM for LGA was 13.26 (95% CI 11.27 to 15.59), major malformations 4.11 (95% CI 2.99 to 5.65) and PE 14.19 (95% CI 11.50 to 17.50). T1DM was a significant effect modifier of the association between BMI and LGA, major malformations and PE (p<0.001).

CONCLUSION

High pre-pregnancy BMI is an important risk factor for adverse outcome in type 1 diabetic pregnancies. The combined effect of both T1DM and overweight or obesity constitutes the greatest risk. It seems prudent to strive towards normal pre-pregnancy BMI in women with T1DM.

Reducing the risk of shoulder dystocia and associated brachial plexus injury

Despite persisting controversy over shoulder dystocia prediction, prevention, and injury causation, the authors find considerable evidence in recent research in the field to recommend additional guidelines beyond the current American College of Obstetricians and Gynecologists and Royal College of Obstetricians and Gynecologists guidelines to improve clinical practice in managing patients at risk for experiencing shoulder dystocia. In this article, the authors offer health care providers information, practical direction, and advice on how to limit shoulder dystocia risk and, more importantly, to reduce adverse outcome risk.

Metformin for gestational diabetes in routine clinical practice

AIMS

To compare maternal and neonatal outcomes in women with gestational diabetes treated with diet, metformin and/or insulin in routine clinical practice in a single centre.

METHODS

We analysed prospectively collected data from the National Women's Health database for all women with gestational diabetes who delivered between January 2007 and December 2009. Since June 2007, women requiring medication have been given a choice of either metformin or insulin treatment, except women with a fetal abdominal circumference less than the 10th percentile, who were not offered metformin.

RESULTS

There were 1269 women with gestational diabetes; treatment was diet in 371, insulin in 399 and metformin in 465 (249 metformin alone, 216 metformin and insulin). Women treated with metformin and/or insulin had significantly higher BMIs compared with those in the diet group (P < 0.001) and had a higher fasting glucose at diagnosis (p < 0.001). Women treated with insulin had higher rates of Caesarean delivery (45.6% insulin, 37% metformin, 34% diet, P = 0.02) than women treated with metformin or diet. They also had higher rates of preterm births (19.2% insulin, 12.5% metformin, 12.1% diet, P = 0.005), customized large-for-gestational-age infants (18.5% insulin, 12.5% metformin, 12.4% diet, P = 0.02), neonatal admissions (18.7% insulin, 12.7% metformin, 14.0% diet, P = 0.04) and neonatal intravenous dextrose use (11.1% insulin, 5.1% metformin, 7.4% diet, P = 0.004). Neonatal outcomes were similar between diet- and metformin-treated women.

CONCLUSIONS

In routine practice, use of metformin in gestational diabetes was associated with fewer adverse outcomes compared with insulin, but baseline differences between treatment groups may have contributed to this.

Maternal outcome of gestational diabetes mellitus

OBJECTIVE

To estimate maternal outcome of treated or untreated gestational diabetes mellitus (GDM).

METHODS

French and English publications were searched using PubMed and the Cochrane library.

RESULTS

The diagnosis of GDM includes a high risk population for preeclampsia and Caesarean sections (EL3). The risks are positively correlated with the level of hyperglycaemia in a linear way (EL2). Intensive treatment of mild GDM compared with routine care reduces the risk of pregnancy-induced hypertension (preeclampsia, gestational hypertension). Moreover, it does not increase the risk of operative vaginal delivery, Caesarean section and postpartum haemorrhage (EL1). Being overweight, obesity and maternal hyperglycaemia are independent risk factors for preeclampsia (EL2). Their association with GDM increases the risk of preeclampsia and Caesarean section compared to diabetic women with a normal body mass index (EL3). The association of several risk factors (such as advanced maternal age, pre-existing chronic hypertension, pre-existing nephropathy, obesity, suboptimal glycaemic control) increases the risk of preeclampsia. In that case, the classic follow-up (blood pressure measurement, proteinuria) should be more frequent than monthly (professional consensus). The risk of Caesarean section is increased by macrosomia, whether suspected prenatally or not, but this increased risk remains whatever the birth weight (EL3). Diagnosis and treatment of GDM do not reduce the risk of severe perineal lesions, operative vaginal delivery and postpartum haemorrhage (EL2). Some psychological symptoms, such as anxiety and alteration of self-perception, can occur upon diagnosis of GDM (EL3). The treatment of GDM appears to reduce the risk of postpartum depression symptoms (EL2).

CONCLUSION

Most of the information published on GDM covers the risks of preeclampsia and Caesarean section; intensive care of GDM reduces these risks. Pregnancy care should be adjusted to the risk factors.

Maternal high fat diet is associated with decreased plasma n-3 fatty acids and fetal hepatic apoptosis in nonhuman primates

To begin to understand the contributions of maternal obesity and over-nutrition to human development and the early origins of obesity, we utilized a non-human primate model to investigate the effects of maternal high-fat feeding and obesity on breast milk, maternal and fetal plasma fatty acid composition and fetal hepatic development. While the high-fat diet (HFD) contained equivalent levels of n-3 fatty acids (FA's) and higher levels of n-6 FA's than the control diet (CTR), we found significant decreases in docosahexaenoic acid (DHA) and total n-3 FA's in HFD maternal and fetal plasma. Furthermore, the HFD fetal plasma n-6∶n-3 ratio was elevated and was significantly correlated to the maternal plasma n-6∶n-3 ratio and maternal hyperinsulinemia. Hepatic apoptosis was also increased in the HFD fetal liver. Switching HFD females to a CTR diet during a subsequent pregnancy normalized fetal DHA, n-3 FA's and fetal hepatic apoptosis to CTR levels. Breast milk from HFD dams contained lower levels of eicosopentanoic acid (EPA) and DHA and lower levels of total protein than CTR breast milk. This study links chronic maternal consumption of a HFD with fetal hepatic apoptosis and suggests that a potentially pathological maternal fatty acid milieu is replicated in the developing fetal circulation in the nonhuman primate.

Pregnancy outcome of patients who conceive during or after the first year following bariatric surgery

OBJECTIVE

We sought to compare pregnancy outcome of patients who conceived during or after the first year postbariatric surgery.

STUDY DESIGN

A retrospective study comparing pregnancy outcome between patients who conceived during or after the first postoperative year was conducted.

RESULTS

The study included 104 pregnancies of patients who conceived during and 385 who conceived after the first postoperative year. Prepregnancy and predelivery body mass index were comparable between the groups. No significant differences were noted regarding hypertensive disorders (15.4% in the early vs 11.2% in the late postoperative pregnancy; P = .392); diabetes mellitus (11.5% vs 7.3%; P = .392); perinatal outcomes, such as congenital malformations (1.9% vs 1.3%; P = .485); or bariatric complications (6.7% vs 7.0%; P = .392) between the groups. Using multiple logistic regression models, controlling for confounders, the interval (in months) was not associated with pregnancy complications.

CONCLUSION

Patients who conceived during the first postoperative year had comparable short-term perinatal outcome compared with patients who conceived after the first postoperative year.

Glycemia and its relationship to outcomes in the metformin in gestational diabetes trial

OBJECTIVE

To determine how glucose control in women with GDM treated with metformin and/or insulin influenced pregnancy outcomes.

RESEARCH DESIGN AND METHODS

Women randomly assigned to metformin or insulin treatment in the Metformin in Gestational Diabetes (MiG) trial had baseline glucose tolerance test (OGTT) results and A1C documented, together with all capillary glucose measurements during treatment. In the 724 women who had glucose data for analysis, tertiles of baseline glucose values and A1C and of mean capillary glucose values during treatment were calculated. The relationships between maternal factors, glucose values, and outcomes (including a composite of neonatal complications, preeclampsia, and large-for-gestational-age [LGA] and small-for-gestational-age infants) were examined with bivariable and multivariate models.

RESULTS

Baseline OGTT did not predict outcomes, but A1C predicted LGA infants (P = 0.003). During treatment, fasting capillary glucose predicted neonatal complications (P < 0.001) and postprandial glucose predicted preeclampsia (P = 0.016) and LGA infants (P = 0.001). Obesity did not influence outcomes, and there was no interaction between glycemic control, randomized treatment, or maternal BMI in predicting outcomes. The lowest risk of complications was seen when fasting capillary glucose was <4.9 mmol/l (mean +/- SD 4.6 +/- 0.3 mmol/l) compared with 4.9-5.3 mmol/l or higher and when 2-h postprandial glucose was 5.9-6.4 mmol/l (6.2 +/- 0.2 mmol/l) or lower.

CONCLUSIONS

Glucose control in women with gestational diabetes mellitus treated with metformin and/or insulin is strongly related to outcomes. Obesity is not related to outcomes in this group. Targets for fasting and postprandial capillary glucose may need to be lower than currently recommended.

Pregnancy outcome in patients following different types of bariatric surgeries

BACKGROUND

The objective of this study was to investigate pregnancy outcome of patients following different types of bariatric surgery.

METHODS

A population-based study includes all pregnancies of patients with bariatric surgeries delivered during 1988-2008. Pregnancy outcome was compared between the different types of surgeries.

RESULTS

This retrospective study included 449 deliveries: 394 deliveries following pure restrictive operations-laparoscopic gastric banding (LAGB; n = 202), silastic ring vertical gastroplasty (SRVG; n = 136), and vertical-banded gastroplasty (VBG; n = 56)-and 55 deliveries following restrictive and malabsorptive Roux-en-Y gastric bypass (RGB). While no significant differences were noted between the groups regarding body mass index (BMI) before the bariatric operations or prepregnancy BMI, patients following LAGB had significantly higher BMI before delivery (36.8 +/- 5.9 kg compared to the SRVG 33.4 +/- 6.0, VBG 34.2 +/- 5.4, and RGB 34.9 +/- 6.8 groups; p < 0.001). Following LAGB, patients had higher weight gain during pregnancy (13.1 +/- 9.6 kg) compared to the SRVG (8.8 +/- 7.4), VBG (8.5 +/- 8.0), and RGB (11.6 +/- 9.6; p < 0.001) groups. The interval between operation and pregnancy was shorter in the LAGB group (22.8 months) compared to the SRVG (41.0) and the VBG (42.1) groups and was significantly higher in the RGB group (57.4; p < 0.001). Birth weight was significantly higher among newborns of patients following RBG (3,332.8 +/- 475.5 g) compared to the restrictive procedures (3,104.3 +/- 578.7 in the LAGB, 3,086.7 +/- 533.1 in the SRVG, and 3,199.2 +/- 427.2 in the VBG groups). No significant differences in low birth weight (<2,500 g) or macrosomia (>4,000 g), or low Apgar scores or perinatal mortality were noted between the groups.

CONCLUSION

There is no difference in the affect on pregnancy outcome among the different forms of bariatric surgeries; all procedures have basically comparable perinatal outcome.

Obesity, gestational diabetes and pregnancy outcome

The prevalence of both obesity and gestational diabetes mellitus (GDM) is rising worldwide. The complications of diabetes affecting the mother and fetus are well known. Maternal complications include preterm labor, pre-eclampsia, nephropathy, birth trauma, cesarean section, and postoperative wound complications, among others. Fetal complications include fetal wastage from early pregnancy loss or congenital anomalies, macrosomia, shoulder dystocia, stillbirth, growth restriction, and hypoglycemia, among others. The presence of obesity among diabetic patients compounds these complications. The above-mentioned short-term complications can be mediated by achieving the desired level of glycemic control during pregnancy. However, GDM during pregnancy is associated with increased risk of early obesity, type 2 diabetes during adolescence and the development of metabolic syndrome in early childhood. Additionally, GDM is a marker for the development of overt type 2 diabetes and metabolic syndrome for the mother in the early future.

Benefits and risks of oral diabetes agents compared with insulin in women with gestational diabetes: a systematic review

OBJECTIVE

Little is known about the comparative risks and benefits of medical treatments for gestational diabetes mellitus (GDM). We conducted a systematic review of randomized controlled trials and observational studies of maternal and neonatal outcomes in women with GDM treated with oral diabetes agents compared with all types of insulin.

DATA SOURCES

We searched four electronic databases from inception through January 2007. Terms for GDM, insulins, and oral hypoglycemic agents were used in the search. Two investigators independently reviewed titles and abstracts, performed data abstraction on full articles, and assessed study quality.

METHOD OF STUDY SELECTION

Articles were excluded if they had no comparison group or did not use a standard diagnosis of GDM (3-hour, 100-g oral glucose tolerance test or 2-hour, 75-g oral glucose tolerance test). Nine studies met our inclusion criteria, four randomized controlled trials (n=1,229 participants) and five observational studies (n=831 participants). Data were abstracted on study characteristics, gestational age at treatment, medication dosage, and length of follow-up. Outcomes included glycemic control, infant birth weight, neonatal hypoglycemia, and congenital anomalies.

TABULATION, INTEGRATION, AND RESULTS

Two trials compared insulin to glyburide; one trial compared insulin, glyburide, and acarbose; and one trial compared insulin to metformin. No significant differences were found in maternal glycemic control or cesarean delivery rates between the insulin and glyburide groups. A meta-analysis showed similar infant birth weights between women treated with glyburide and women treated with insulin (mean difference -93 g) (95% confidence interval -191 to 5 g). There was a higher proportion of infants with neonatal hypoglycemia in the insulin group (8.1%) compared with the metformin group (3.3%) (P=.008). The rate of congenital malformations did not differ between pregnancies treated with insulin and those treated with oral agents. Observational studies were limited by selection bias and confounding.

CONCLUSION

No substantial maternal or neonatal outcome differences were found with the use of glyburide or metformin compared with use of insulin in women with GDM.