Diabetes mellitus in pregnancy

Effectiveness of Insulin Analogs Compared with Human Insulins in Pregnant Women with Diabetes Mellitus: Systematic Review and Meta-analysis

Diabetes during pregnancy has been linked to unfavorable maternal-fetal outcomes. Human insulins are the first drug of choice because of the proven safety in their use. However, there are still questions about the use of insulin analogs during pregnancy. The objective of the present study was to determine the effectiveness of insulin analogs compared with human insulin in the treatment of pregnant women with diabetes through a systematic review with meta-analysis. The search comprised the period since the inception of each database until July 2017, and the following databases were used: MEDLINE, CINAHL, EMBASE, ISI Web of Science, LILACS, Scopus, SIGLE and Google Scholar. We have selected 29 original articles: 11 were randomized clinical trials and 18 were observational studies. We have explored data from 6,382 participants. All of the articles were classified as having an intermediate to high risk of bias. The variable that showed favorable results for the use of insulin analogs was gestational age, with a mean difference of - 0.26 (95 % confidence interval [CI]: 0.03-0.49; p = 0.02), but with significant heterogeneity (Higgins test [I2] = 38%; chi-squared test [χ2] = 16.24; degree of freedom [DF] = 10; p = 0.09). This result, in the clinical practice, does not compromise the fetal well-being, since all babies were born at term. There was publication bias in the gestational age and neonatal weight variables. To date, the evidence analyzed has a moderate-to-high risk of bias and does not allow the conclusion that insulin analogs are more effective when compared with human insulin to treat diabetic pregnant women.

Exercise for pregnant women with pre-existing diabetes for improving maternal and fetal outcomes

BACKGROUND

Pregnancies with pre-existing diabetes are high risk, with increased risk of poorer fetal, neonatal, and maternal outcomes. Identifying interventions to improving health outcomes for women with diabetes and their infants is a priority, as rates of diabetes continue to increase.Exercise has been shown to have benefits for non-pregnant individuals with pre-existing type 2 diabetes, such as improving glycaemic control, and reducing visceral adipose tissue and plasma triglycerides. For pregnant women with pre-existing diabetes, the effects of exercise interventions on the mother and her baby are unknown.An earlier Cochrane review on 'Exercise for pregnant women with diabetes' considered both pre-existing diabetes and gestational diabetes. That Cochrane review has now been split into two new reviews (following new protocols) - one on gestational diabetes and one on pre-existing diabetes (this review).

OBJECTIVES

To evaluate the effects of exercise interventions for improving maternal and fetal outcomes in women with pre-existing diabetes.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP) on 27 June 2017, and reference lists of retrieved studies.

SELECTION CRITERIA

We had planned to include published or unpublished randomised controlled trials (RCT) or cluster-randomised trials, in full text or abstract format that compared any type of exercise programme, added to standard care, targeted at women with known pre-gestational diabetes (type 1 or type 2 diabetes), at any stage of pregnancy, compared with 1) standard care alone or 2) standard care plus another exercise intervention. Quasi-randomised and cross-over trials were excluded. Conference abstracts were handled in the same way as full-text publications.Women with gestational diabetes mellitus were excluded, as they were covered in a separate Cochrane review.

DATA COLLECTION AND ANALYSIS

We had planned that two review authors would independently assess all the potential studies we identified as a result of the search strategy. For eligible studies, two review authors would have independently extracted the data using an agreed form. We had planned to resolve discrepancies through discussion, or by consulting a third person. We also had planned to assess the evidence using the GRADE approach.

MAIN RESULTS

We did not identify any randomised controlled trials.

AUTHORS' CONCLUSIONS

There was no evidence from RCTs that evaluated the effects of exercise interventions for improving maternal and fetal outcomes in women with pre-existing diabetes.Good quality, large randomised controlled trials are urgently needed to identify exercise interventions that are safe, and improve health outcomes for women with pre-existing diabetes and their babies. Future studies in this area could utilise the standardised outcomes in this review, in order to improve consistency between trials in this area, and aid future meta-analysis.

Prevalence of gestational diabetes mellitus according to the different criterias

OBJECTIVE

The two-step approach recommended by the National Diabetes Data Group (NDDG), Carpenter and Coustan (C&C), and O'Sullivan, and the single-step approach recommended by the International Association of Diabetes and Pregnancy Study Group (IADPSG) are used to diagnose gestational diabetes mellitus (GDM). We aimed to determine GDM prevalence and to compare the two-step and single-step approaches used in the southeastern region of Turkey.

MATERIALS AND METHODS

In total, 3048 records of pregnant women screened for GDM between 2008 and 2014 were retrospectively extracted from our laboratory information system. GDM was defined according to the criteria of NDDG, C&C, and O'Sullivan between in 2008 and 2011, and according to those of the IADPSG between 2012 and 2014. Demographic variables were compared using student's t-test. The linear trends in GDM prevalence with age were calculated using logistic regression.

RESULTS

GDM prevalence was found as 4.8%, 8%, and 13.4% using the NDDG, C&C, and O'Sullivan two-step approach, respectively, and 22.3% with the IADPSG single-step approach. GDM prevalence increased with increasing age in both approaches.

CONCLUSION

GDM prevalence was higher using the single-step approach than with the two-step approach. There was a significant increase in GDM prevalence using the IADPSG criteria.

Different intensities of glycaemic control for pregnant women with pre-existing diabetes

BACKGROUND

The optimal glycaemic control target in pregnant women with pre-existing diabetes is unclear, although there is a clear link between high glucose concentrations and adverse birth outcomes.

OBJECTIVES

To assess the effects of different intensities of glycaemic control in pregnant women with pre-existing type 1 or type 2 diabetes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2016) and planned to search reference lists of retrieved studies.

SELECTION CRITERIA

We included randomised controlled trials comparing different glycaemic control targets in pregnant women with pre-existing diabetes.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion, conducted data extraction, assessed risk of bias and checked for accuracy. We assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

We included three trials, all in women with type 1 diabetes (223 women and babies). All three trials were at high risk of bias due to lack of blinding, unclear methods of randomisation and selective reporting of outcomes. Two trials compared very tight (3.33 to 5.0 mmol/L fasting blood glucose (FBG)) with tight-moderate (4.45 to 6.38 mmol/L) glycaemic control targets, with one trial of 22 babies reporting no perinatal deaths orserious perinatal morbidity (evidence graded low for both outcomes). In the same trial, there were two congenital anomalies in the very tight, and none in the tight-moderate group, with no significant differences in caesarean section between groups (risk ratio (RR) 0.92, 95% confidence interval (CI) 0.49 to 1.73; evidence graded very low). In these two trials, glycaemic control was not significantly different between the very tight and tight-moderate groups by the third trimester, although one trial of 22 women found significantly less maternal hypoglycaemia in the tight-moderate group.In a trial of 60 women and babies comparing tight (≤ 5.6 mmol/L FBG); moderate (5.6 to 6.7 mmol/L); and loose (6.7 to 8.9 mmol/L) glycaemic control targets, there were two neonatal deaths in the loose and none in the tight or moderate groups (evidence graded very low). There were significantly fewer women with pre-eclampsia (evidence graded low), fewer caesarean sections (evidence graded low) and fewer babies with birthweights greater than 90th centile (evidence graded low) in the combined tight-moderate compared with the loose group.The quality of the evidence was graded low or very low for important outcomes, because of design limitations to the studies, the small numbers of women included, and wide confidence intervals crossing the line of no effect. Many of the important outcomes were not reported in these studies.

AUTHORS' CONCLUSIONS

In a very limited body of evidence, few differences in outcomes were seen between very tight and tight-moderate glycaemic control targets in pregnant women with pre-existing type 1 diabetes, including actual glycaemic control achieved. There is evidence of harm (increased pre-eclampsia, caesareans and birthweights greater than 90th centile) for 'loose' control (FBG above 7 mmol/L). Future trials comparing interventions, rather than glycaemic control targets, may be more feasible. Trials in pregnant women with pre-existing type 2 diabetes are required.

IADPSG criteria for diagnosing gestational diabetes mellitus and predicting adverse pregnancy outcomes

OBJECTIVE

To evaluate the International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria versus the American Diabetes Association (ADA) criteria for diagnosing gestational diabetes mellitus (GDM) in China.

STUDY DESIGN

Overall, 3083 women with a singleton pregnancy underwent a 75-g, 2-h oral glucose tolerance test between 24 and 28 weeks of pregnancy, and both IADPSG and ADA criteria were used for GDM diagnosis. Adverse pregnancy outcomes (APOs), including preterm birth, required Cesarean section, preeclampsia, macrosomia and low birth weight, were recorded and analyzed.

RESULT

IADPSG and ADA criteria diagnosed 19.9% and 7.98% of women with GDM, respectively (P<0.001). IADPSG criteria has a stronger capacity of predicting APOs than ADA criteria (odds ratio (OR)=1.84, 95% confidence interval (CI): 1.52-2.25 for IADPSG, and OR=1.54, 95% CI: 1.16-2.05 for ADA).

CONCLUSION

IADPSG criteria increase GDM diagnosis by almost twofold. GDM diagnosed by IADPSG criteria is more associated with APOs, although the economic impact needs further evaluation.

Effect of pregnancy for females born small on later life metabolic disease risk

There is a strong inverse relationship between a females own birth weight and her subsequent risk for gestational diabetes with increased risk of developing diabetes later in life. We have shown that growth restricted females develop loss of glucose tolerance during late pregnancy with normal pancreatic function. The aim of this study was to determine whether growth restricted females develop long-term impairment of metabolic control after an adverse pregnancy adaptation. Uteroplacental insufficiency was induced by bilateral uterine vessel ligation (Restricted) or sham surgery (Control) in late pregnancy (E18) in F0 female rats. F1 Control and Restricted female offspring were mated with normal males and allowed to deliver (termed Ex-Pregnant). Age-matched Control and Restricted Virgins were also studied and glucose tolerance and insulin secretion were determined. Pancreatic morphology and hepatic glycogen and triacylglycerol content were quantified respectively. Restricted females were born lighter than Control and remained lighter at all time points studied (p<0.05). Glucose tolerance, first phase insulin secretion and liver glycogen and triacylglycerol content were not different across groups, with no changes in β-cell mass. Second phase insulin secretion was reduced in Restricted Virgins (-34%, p<0.05) compared to Control Virgins, suggestive of enhanced peripheral insulin sensitivity but this was lost after pregnancy. Growth restriction was associated with enhanced basal hepatic insulin sensitivity, which may provide compensatory benefits to prevent adverse metabolic outcomes often associated with being born small. A prior pregnancy was associated with reduced hepatic insulin sensitivity with effects more pronounced in Controls than Restricted. Our data suggests that pregnancy ameliorates the enhanced peripheral insulin sensitivity in growth restricted females and has deleterious effects for hepatic insulin sensitivity, regardless of maternal birth weight.

Different intensities of glycaemic control for pregnant women with pre-existing diabetes

BACKGROUND

The optimal glycaemic control target in pregnant women with pre-existing diabetes is unclear, although there is a clear link between high glucose concentrations and adverse birth outcomes.

OBJECTIVES

To assess the effects of different intensities of glycaemic control in pregnant women with pre-existing type 1 or type 2 diabetes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 April 2012).

SELECTION CRITERIA

We included randomised controlled trials comparing different glycaemic control targets in pregnant women with pre-existing diabetes.

DATA COLLECTION AND ANALYSIS

Two review authors assessed trial eligibility and risk of bias, and extracted data.

MAIN RESULTS

We included three trials all in women with type 1 diabetes (223 women and babies), and all with a high risk of bias. Two trials compared very tight (3.33 to 5.0 mmol/L fasting blood glucose (FBG)) with tight-moderate (4.45 to 6.38) glycaemic control targets, with one trial of 22 babies reporting no perinatal deaths or serious perinatal morbidity. In the same trial, there were two birth defects in the very tight and none in the tight-moderate group with no significant differences in caesarean section between groups (risk ratio 0.92, 95% confidence interval (CI) 0.49 to 1.73). In these two trials glycaemic control was not significantly different between the very tight and tight-moderate groups by the third trimester, although one trial of 22 women found significantly less maternal hypoglycaemia in the tight-moderate group.In a trial of 60 women and babies comparing tight (≤ 5.6 mmol/L FBG); moderate (5.6 to 6.7); and loose (6.7 to 8.9) glycaemic control targets, there were two neonatal deaths in the loose and none in the tight or moderate groups. There were significantly fewer women with pre-eclampsia, fewer caesareans and fewer birthweights greater than 90th centile in the combined tight-moderate compared with the loose group.

AUTHORS' CONCLUSIONS

In a very limited body of evidence, few differences in outcomes were seen between very tight and tight-moderate glycaemic control targets in pregnant women with pre-existing type 1 diabetes, including actual glycaemic control achieved. There is evidence of harm (increased pre-eclampsia, caesareans and birthweights greater than 90th centile) for 'loose' control (FBG above 7 mmol/L). Future trials comparing interventions, rather than glycaemic control targets, may be more feasible particularly for pregnant women with type 2 diabetes.

Barriers to managing diabetes during pregnancy: the perceptions of health care practitioners

BACKGROUND

Uncontrolled pregestational diabetes in pregnancy is associated with an increased risk for a major birth defect and additional adverse pregnancy outcomes. The study objective was to investigate the concerns of health care practitioners who care for women with a history of diabetes during pregnancy and their perceptions of attitudes and barriers to achieving good glycemic control.

METHODS

Focus groups were conducted with physicians, midlevel practitioners, and certified diabetes educators in Atlanta, Georgia. Practitioners were eligible if they actively practiced, primarily in outpatient facilities in Atlanta, and were neither students nor interns. Six focus groups, two of each practitioner type, were conducted.

RESULTS

Practitioners stated that few of their patients planned their pregnancies. Practitioners perceived that pregnant women were concerned primarily about their babies and might not be aware of complications with their personal health. Their perceptions of the greatest barriers to glycemic control for women involved lack of knowledge, lack of access, and attitude.

CONCLUSIONS

Educating women with diabetes about the importance of using effective birth control until they have achieved good glycemic control can help reduce the risk for adverse pregnancy outcomes. Motivators and barriers for a woman with diabetes to achieve glycemic control before, during, and after pregnancy should be considered when developing approaches to improve outcomes. Helping practitioners know what and how to address the needs of childbearing women with or at risk for diabetes can be beneficial. Additional efforts to increase women's knowledge about diabetes and pregnancy and to develop effective strategies to encourage women's achievement and maintenance of glycemic control before, during, and after pregnancy are needed.

Evaluating the extent of pregravid risk factors of gestational diabetes mellitus in women in tehran

BACKGROUND

Gestational diabetes mellitus (GDM) is associated with maternal and fetal complications. Specific outcomes in previous pregnancies are considered as risk factors for GDM in the consecutive pregnancies. The aim of this study was to evaluate the pregravid risk factors of GDM in multigravid women.

METHODS

We conducted a retrospective cross sectional study on 114 multigravid women with GDM without previous history of diabetes and compared them with non-diabetic controls. We used modified criteria of Carpenter and Coustan for screening. Risk factors were obtained from medical records of individuals.

RESULTS

We found that women of 26 years and older who had previous neonates with birth weight more than 3800 gram and those affected with hypothyroidism or chronic hypertension were at risk for GDM. The difference of the number of preterm birth in GDM women and healthy controls was statistically significant (p=0.05). There was no significant difference between the numbers of pregnancies, parity, previous fetal and neonatal death and abortion number between patients and the control group.

CONCLUSION

Our results show that maternal age over 26 years, birth weight of previous neonate more than 3800 g, hypothyroidism, chronic hypertension and probably history of preterm birth are significant risk factors for GDM.

Gestational diabetes and gestational impaired glucose tolerance in 1653 teenage pregnancies: prevalence, risk factors and pregnancy outcomes

STUDY OBJECTIVE

The aim of this study was to determine the prevalence of gestational diabetes mellitus (GDM) and gestational impaired glucose tolerance (GIGT) in adolescent pregnancies, associated risk factors, and pregnancy complications.

DESIGN

Retrospective study.

SETTINGS

Community-based teaching hospital.

PARTICIPANTS

Results of 1653 pregnant women age ≤ 19 years in 2005-2007 were reviewed.

INTERVENTION

All pregnant women screened with 50-g glucose challenge test (GCT) and patients with a GCT result ≥ 140 mg/dl underwent a 3-hour 100-g oral glucose tolerance test (OGTT).

MAIN OUTCOME MEASURES

GDM was diagnosed with at least two abnormal results and GIGT was diagnosed with one abnormal result. GDM and GIGT cases were evaluated for the presence of any associated risk factors and effects of presence of risk factors on pregnancy outcomes.

RESULTS

The prevalence of GDM was 0.85% (95% CI, 0.41-1.29), GIGT was 0.5% (95% CI, 0.15-0.81) and GDM+GIGT was 1.35% (95% CI, 0.78-1.88) by Carpenter and Coustan criteria. 68% of patients had at least one of the risk factors including body mass index ≥ 25, family history of diabetes and polycystic ovary syndrome (PCOS). Only 9.1% (n = 2) of them required insulin for glucose regulation during pregnancy with 9.1% (n = 2) macrosomia rate. All patients were primiparous and cesarean delivery rate was 27.3% (n = 6). We could not find any effect of presence of risk factors on pregnancy outcomes in GDM and GIGT cases.

CONCLUSION

We demonstrated that GDM and GIGT are strongly associated with high BMI before pregnancy, PCOS, and family history of diabetes. Since GDM is a state of prediabetes, it is important to diagnose in adolescent pregnancies considering their life expectancy to take preventive measures to avoid diabetes mellitus.

Glycosylated hemoglobin level in the second trimester predicts birth weight and amniotic fluid volume in non-diabetic pregnancies with abnormal screening test

OBJECTIVE

To investigate relationship between glycemic control in first half of pregnancy by measuring mid-pregnancy HbA1c and neonatal birth weight and amniotic fluid volume.

METHODS

We prospectively enrolled 220 pregnant women who received oral glucose tolerance test (OGTT) after positive gestational diabetes mellitus screening. We included 102 women with normal OGTT results into final analysis. We measured birth weight and amniotic fluid index (AFI) at 32-34 weeks.

RESULTS

Mean birth weight was 3313±426 g, and 15.7% of neonates were classified as large-for-gestational age (LGA). Mean Hb1Ac was 4.96±0.28%. Median AFI was 145 mm, and polyhydramnios rate was 2.9%. Birth weight was positively correlated with HbA1c level (r=0.373, p<0.001) and pre-pregnancy body mass index (BMI; r=0.351, p<0.001). Linear regression analysis showed that HbA1c and pre-pregnancy BMI were positive independent determinants of neonatal birth weight, and HbA1c was positive independent determinant of AFI. Receiver operating characteristics curve identified HbA1c level of 4.99 as optimal threshold for prediction of LGA with 93.8% sensitivity, 61.6% specificity and positive likelihood ratio (+LR) of 2.45 and pre-pregnancy BMI value of 25.2 as optimal threshold for prediction of LGA with 81.3% sensitivity, 57% specificity and +LR of 1.9.

CONCLUSION

In non-diabetic pregnant women with abnormal screening test, mid-pregnancy HbA1c level and pre-pregnancy BMI may predict neonatal birth weight. AFI in 32-34 weeks of gestation is related with mid-pregnancy HbA1c level.

Different intensities of glycaemic control for pregnant women with pre-existing diabetes

BACKGROUND

The optimal glycaemic control target in pregnant women with pre-existing diabetes is unclear, although there is a clear link between high glucose concentrations and adverse birth outcomes.

OBJECTIVES

To assess the effects of different intensities of glycaemic control in pregnant women with pre-existing type 1 or type 2 diabetes.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (7 May 2010).

SELECTION CRITERIA

We included randomised controlled trials comparing different glycaemic control targets in pregnant women with pre-existing diabetes.

DATA COLLECTION AND ANALYSIS

Two review authors assessed trial eligibility and risk of bias, and extracted data.

MAIN RESULTS

We included three trials all in women with type 1 diabetes (223 women and babies), and all with a high risk of bias. Two trials compared very tight (3.33 to 5.0 mmol/L fasting blood glucose (FBG)) with tight-moderate (4.45 to 6.38) glycaemic control targets, with one trial of 22 babies reporting no perinatal deaths or serious perinatal morbidity. In the same trial, there were two birth defects in the very tight and none in the tight-moderate group with no significant differences in caesarean section between groups (risk ratio 0.92, 95% confidence interval (CI) 0.49 to 1.73). In these two trials glycaemic control was not significantly different between the very tight and tight-moderate groups by the third trimester, although one trial of 22 women found significantly less maternal hypoglycaemia in the tight-moderate group.In a trial of 60 women and babies comparing tight (</= 5.6 mmol/L FBG); moderate (5.6 to 6.7); and loose (6.7 to 8.9) glycaemic control targets, there were two neonatal deaths in the loose and none in the tight or moderate groups. There were significantly fewer women with pre-eclampsia, fewer caesareans and fewer birthweights greater than 90th centile in the combined tight-moderate compared with the loose group.

AUTHORS' CONCLUSIONS

In a very limited body of evidence, few differences in outcomes were seen between very tight and tight-moderate glycaemic control targets in pregnant women with pre-existing type 1 diabetes, including actual glycaemic control achieved. There is evidence of harm (increased pre-eclampsia, caesareans and birthweights greater than 90th centile) for 'loose' control (FBG above 7 mmol/L). Future trials comparing interventions, rather than glycaemic control targets, may be more feasible particularly for pregnant women with type 2 diabetes.

Prevalence of gestational diabetes mellitus and gestational impaired glucose tolerance in pregnant women evaluated by National Diabetes Data Group and Carpenter and Coustan criteria

OBJECTIVE

To determine the prevalence of gestational diabetes mellitus (GDM) and gestational impaired glucose tolerance (GIGT) using National Diabetes Data Group (NDDG), and Carpenter and Coustan (CC) criteria.

METHOD

Retrospective study of the prevalence of GDM and GIGT in 21531 pregnant women screened for GDM between 2005 and 2007 using NDDG and CC criteria. Linear trends in prevalence of GDM and GIGT by age were calculated using logistic regression.

RESULTS

Mean prevalence rates for GDM were 3.17% (95% CI, 3.05-3.29; n=683) and 4.48% (95% CI, 4.36-4.6; n=964) according to NDDG and CC criteria, respectively. Mean prevalence rates for GIGT were 1.97% (95% CI, 1.85-2.09; n=426) and 2.46% (95% CI, 2.34-2.58; n=529) according to NDDG and CC criteria, respectively. Prevalence of GDM and GIGT increased with increasing age with both criteria (P<0.001). The prevalence of GDM increased by 41.1% and GIGT increased by 24.2% using the CC criteria compared with the NDDG criteria.

CONCLUSION

The prevalence of GDM and GIGT was higher when CC criteria were used compared with NDDG criteria, particularly in younger age groups. The prevalence of both GIGT and GDM increased with increasing age with both criteria.

Neonatal Care and Data

Neonatology encompasses the care of all infants: from term newborns to extremely premature infants, from healthy infants to those suffering from severe infections or genetic disorders. While the management of infants can vary greatly, there are essential core data and knowledge that is needed to care for them.

Infants of diabetic mothers: the effects of hyperglycemia on the fetus and neonate

News that a woman with diabetes is about to deliver brings up images of a macrosomic infant. This infant may experience birth injuries, asphyxia, respiratory distress, hypoglycemia, hypocalcemia, hyperbilirubinemia, polycvthemia/hyperviscosity syndrome, asymmetric sepral hypertrophy, and other congenital malformations. Uncontrolled diabetes has profound effects on embryogenesis, organogenesis, and fetal and neonatal growth, and evidence increasingly indicates that some of these effects are lifelong and may contribute to adult obesity. Preconception control of diabetes and monitoring throughout pregnancy are important in reducing the impact of diabetes on the fetus and newborn.

Comparison of Guidelines Available in the United States for Diagnosis and Management of Diabetes before, during, and after Pregnancy

Women with preexisting diabetes are at increased risk of adverse pregnancy outcomes and birth defects. Women with gestational diabetes are at increased risk for adverse outcomes, including neonatal hypoglycemia, hyperbilirubinemia, macrosomia, increased risk of obesity and diabetes in the offspring later in life, and increased risk for other maternal comorbidities. Studies have shown that tight glycemic control before and during pregnancy can decrease the risk for adverse outcomes, congenital malformations, and maternal complications resulting from maternal preexisting diabetes. It is important to identify women with gestational diabetes and provide interconception care to minimize the risk of a future pregnancy complicated by type 2 diabetes. To reduce the risk of adverse consequences for both the woman and her baby, it is important to effectively manage diabetes before, during, and after pregnancy. Several professional organizations have developed guidelines in an effort to establish some consistency in the diagnosis and treatment of diabetes and to decrease the risk of adverse outcomes. The objectives of this paper are to (1) compare the guidelines for women with preexisting (types 1 and 2) and gestational diabetes available to healthcare providers in the United States, highlighting the similarities and differences among them, and (2) discuss how differences among the guidelines might affect efforts to address the challenges of controlling and preventing diabetes and resulting complications during pregnancy.

Audit of Pregnancies Complicated by Diabetes from One Center Five Years Apart with Selective versus Universal Screening

The article compares the effect of selective and universal screening on detection rate and outcomes of pregnancies complicated by diabetes mellitus (DM) in a multiethnic population. The method used was to review the pregnancy and delivery of two 18-month periods, 5 years apart. In the year 1996-1997 when selective screening was used 315 (5.7%) of 5506 delivered women had diabetes during pregnancy. The rates of diabetes in the different ethnic groups were: UAE (4.4%), Peninsula Arabs (4.0%), Chami Arabs (4.5%), North African Arabs (6.7%), Indian subcontinent (7.5%), and Somalis and Sudanese (9.7%). The rate of diabetes among the different ethnic groups for the year 2001-2002 when screening was universal but diagnosis made by the same criteria were 590 (9.7%) of 6232 delivered women, UAE (9.2%), Peninsula Arabs (8.4%), Chami Arabs (8.2%), North African Arabs (9.6%), Indian Subcontinent (11.0%), Somalis and Sudanese (11.3%). The outcome indicators and their rates in the years 1996-1997 and 2001-2002 were respectively: gestational diabetes, 86.3%, 89.0%; requirement of insulin treatment, 74.3% 82.5%; vaginal delivery, 68.2%, 75.3%; cesarean section, 30.3%, 19.8%; macrosomia, 22.2%, 6.7%; intrauterine fetal death, 2.9%, 1.1%; and preterm delivery, 22.5%, 17.5%. This article confirms the influence of ethnic background on the prevalence of gestational diabetes in a multiethnic and multicultural society. Over a period of 5 years, there was a 66.7% increase in the incidence of gestational diabetes, which was probably due to a combination of increased detection by change in screening policy and an increase in the incidence of gestational diabetes. The indicators of disease severity and control, such as insulin requirement, rates of abdominal delivery, macrosomia, and structural congenital malformations, were significantly better in a cohort identified by universal screening compared with that identified by selective screening. Universal screening seems to be a more appropriate strategy for screening in this environment.

Obstetric hospitalizations in the United States for women with systemic lupus erythematosus and rheumatoid arthritis

OBJECTIVE

To estimate the national occurrence of pregnancies in women with systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) and to compare pregnancy outcomes in these patients with those in women with pregestational diabetes mellitus (DM) and with the general obstetric population.

METHODS

We studied the 2002 Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project to estimate the number of obstetric hospitalizations, deliveries, and cesarean deliveries in women with SLE, RA, pregestational DM, and the general obstetric population. Pregnancy outcomes included length of hospital stay, hypertensive disorders including preeclampsia, premature rupture of membranes, and intrauterine growth restriction.

RESULTS

Of an estimated 4.04 million deliveries, 3,264 occurred in women with SLE, 1,425 in women with RA, and 13,574 in women with pregestational DM. Women with SLE, RA, and pregestational DM had significantly increased rates of hypertensive disorders compared with the general obstetric population (23.2%, 11.1%, 27.4%, and 7.8%, respectively), longer hospital stays, and significantly higher risk of cesarean delivery. Although women with SLE, RA, and pregestational DM were significantly older than women in the general obstetric population, disparities in the risk of adverse outcomes of pregnancy remained statistically significant after adjustment for maternal age.

CONCLUSION

To our knowledge, this is the first study to examine national data on pregnancy outcomes in women with common rheumatic diseases. As with underlying pregestational DM, women with SLE and RA appear to have a higher age-adjusted risk of adverse outcomes of pregnancy and longer hospital stays than do pregnant women in the general population, and careful antenatal monitoring should be performed.