Use of umbilical artery Doppler velocimetry in the monitoring of pregnancy in women with pre-existing diabetes

An overview of diabetes mellitus in pregnant women with obesity

Rates of obesity are increasing world-wide with an estimated 1billion people projected to be obese by 2030 if current trends remain unchanged. Obesity currently considered one of the most significant associated factors of non-communicable diseases poses the greatest threat to health. Diabetes mellitus is an important metabolic disorder closely associated with obesity. It is therefore expected that with the increasing rates of obesity, the rates of diabetes in pregnancy will also be rising. This disorder may pre-date pregnancy (diagnosed or undiagnosed and diagnosed for the first time in pregnancy) or may be of onset in pregnancy. Irrespective of the timing of onset, diabetes in pregnancy is associated with both fetal and maternal complications. Outcomes are much better if control is maximised. Early diagnosis, multidisciplinary care and tailored management with optimum glycaemic control is associated with a significant reduction in not only pregnancy complications but long-term consequences on both the mother and offspring. This review brings together the current understanding of the pathogenesis of the endocrine derangements that are associated with diabetes in pregnancy how screening should be offered and management including pre-pregnancy care and the role of newer agents in management.

Prognostic Accuracy of Antenatal Doppler Ultrasound Measures in Predicting Adverse Perinatal Outcomes for Pregnancies Complicated by Diabetes: A Systematic Review

OBJECTIVE

This study aimed to assess the prognostic accuracies of Doppler ultrasound measures in predicting adverse perinatal outcomes for pregnancies complicated with preexisting or gestational diabetes mellitus.

DATA SOURCES

An online database search of MEDLINE, Cochrane, Embase, CINAHL, Scopus, and Emcare from inception to April 2022 was conducted.

STUDY ELIGIBILITY CRITERIA

Studies reporting singleton, nonanomalous fetuses of women with either preexisting (type 1 or 2 diabetes mellitus) or gestational diabetes mellitus during pregnancy were included. In addition, the included studies assessed cerebroplacental ratio and middle cerebral artery and/or umbilical artery pulsatility index in the prediction of either: preterm birth, cesarean delivery for fetal distress, APGAR (Appearance, Pulse, Grimace, Activity, and Respiration) score <7 at 5 minutes, neonatal intensive care unit admission (>24 hours), acute respiratory distress syndrome, jaundice, hypoglycemia, hypocalcemia, or neonatal death.

METHODS

The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed and 610 articles were identified, of which 15 were included. Two authors independently extracted prognostic data from each article and assessed the study applicability and risk of bias using the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies-2) scoring criteria.

RESULTS

A total of 15 studies were included in the review and comprised prospective (n=10; 66%) and retrospective (n=5; 33%) cohorts. Sensitivity and positive predictive values varied widely across each Doppler measurement. Umbilical artery sensitivities were higher than those of cerebroplacental ratio and middle cerebral artery for hypoglycemia, jaundice, neonatal intensive care unit admission, respiratory distress, and preterm birth. Cerebroplacental ratio was the most reported index test; however, prognostic accuracy was worse than that of umbilical artery and middle cerebral artery Doppler across all adverse perinatal outcomes. Significant risk of bias was present in 14 (94%) studies, with substantial heterogeneity observed across studies in terms of study design and outcomes assessed.

CONCLUSION

Abnormal umbilical artery pulsatility index may be of more clinical value in predicting adverse perinatal outcomes compared with cerebroplacental ratio and middle cerebral artery pulsatility index in diabetic pregnancies. Further evaluation of umbilical artery Doppler measurements in diabetic pregnancies using standardized variables across studies is required for broader clinical application. The significant association between abnormal Doppler measurement and hypoglycemia may warrant further investigation.

A proposed fetal risk scoring system for gestational diabetes to assist in optimising timing of delivery

Background. The pathophysiology of gestational diabetes, which is related to abnormal gluocose tolerance and hyperinsulinaemia, renders standard fetal monitoring models ineffective, insufficient and inappropriate, as these models revolve around detecting and prognosticating on placenta-mediated disease rather than increased metabolic rates due to hyperinsulinaemia, functional hypoxia and ischaemic trophoblastic thresholds. To improve perinatal morbidity and mortality in gestational diabetes, there is therefore a need to introduce new prognostic parameters and scoring systems. Objectives. A proposed risk scoring system has been developed, based on our previous studies, to risk-categorise patients with gestational diabetes in terms of fetal outcome in view of the fact that the pathophysiology of gestational diabetes is not recognised by standard monitoring models, which revolve around placental insufficiency rather than metabolic anomalies.Methods. Patients with diabetes from four case-control studies were combined to form a total sample of 159 cases for validation of the risk scoring system. Univariate logistic regression analysis was used to assess the effect of individual risk factors with proposed cut-offs on adverse pregnancy outcome. The diagnostic accuracy of the total summative score was assessed by computing the area under the receiver operating characteristic (ROC) curve. Results. Four potential parameters were identified to risk-categorise fetuses in a pregnancy complicated by gestational diabetes, i.e. the myocardial performance index (MPI), the E/A ratio (early diastolic filling/late diastolic filling, a marker of diastolic dysfunction), increasing fetal weight (macrosomia), and an increased amniotic fluid index. The total score, obtained by summation of the composite scores for these parameters, ranged from 0 to 11. The total score performed as an excellent predictor of adverse outcome, evidenced by an ROC area under the curve of 0.94. A cut-point of 6 on the score confers a sensitivity of 84.2% and specificity of 90.2% for predicting adverse outcome. Conclusion. To our knowledge, this is the first gestational diabetes scoring system proposed to predict an adverse outcome.

Fetoplacental oxygen homeostasis in pregnancies with maternal diabetes mellitus and obesity

Despite improvements in clinical management, pregnancies complicated by pre-existing diabetes mellitus, gestational diabetes mellitus or obesity carry substantial risks for parent and offspring. Some of the endocrine and metabolic changes in parent and fetus in diabetes mellitus and obesity lead to fetal oxygen deficit, mostly due to insulin-induced accelerated fetal metabolism. The human fetus deals with reduced oxygenation through a wide range of adaptive responses that act at various levels in the placenta as well as the fetus. These responses ensure adequate oxygen delivery to the fetus, increase the oxygen transport capacity of fetal blood and redistribute oxygen-rich blood to vital organs such as the brain and heart. The liver has a central role in adapting to reduced oxygenation by increasing its oxygen extraction and stimulating erythropoietin synthesis to increase haematocrit. The type of adaptive response depends on the onset and duration of hypoxia and the severity of the metabolic disturbance. In pregnancies characterized by diabetes mellitus or obesity, these adaptive systems come under additional strain owing to the increased maternal supply of glucose and resultant fetal hyperinsulinaemia, both of which stimulate oxidative metabolism. In the rare situation that the adaptive responses are overwhelmed, stillbirth can ensue.

The relationship between falling insulin requirements and serial ultrasound measurements in women with preexisting diabetes: a prospective cohort study

INTRODUCTION

A large fall in insulin requirements (FIR) in women with diabetes is associated with adverse clinical outcomes but previous studies have not examined its relation with serial ultrasound parameters.

OBJECTIVE

To determine whether FIR is associated with alteration in umbilical artery Doppler parameters and fetal growth restriction (FGR) in women with preexisting diabetes.

METHODS

Serial obstetric Doppler ultrasounds were conducted 2 weekly from 28 weeks gestation in women with Type 1 and Type 2 diabetes who were being treated with insulin. Estimated fetal weight (EFW), head circumference:abdominal circumference (HC:AC) ratio and umbilical artery doppler parameters (SD ratio) and pulsatility index (PI) were measured. Information on insulin dose was collected prospectively throughout pregnancy and women with FIR ≥ 15% were considered cases. Linear mixed effect models were used to assess the association between FIR and ultrasound parameters.

RESULTS

One hundred and forty two women were included in the study (type 1 diabetes n = 41, type 2 diabetes n = 101). Thirty women demonstrated FIR ≥ 15%. There was no significant difference in the change of S/D ratio or PI over the third trimester in cases with FIR ≥ 15%, compared to the rest of the cohort, before or after adjusting for type of diabetes. Likewise there was no difference in EFW and HC:AC ratio with advancing gestation before or after adjusting for variables known to influence fetal growth. FGR rates (3.3 vs 8% p = 0.298) and high S/D ratio > 95% (13.3 vs 8%, p = 0.296) were similar between the two groups.

CONCLUSIONS

FIR ≥ 15% was not associated with changes in placental flow or FGR however larger studies are needed to evaluate this further.

Assessment of the Fetal Myocardial Performance Index in Well-Controlled Gestational Diabetics and to Determine Whether It Is Predictive of Adverse Perinatal Outcome

This study was aimed at determining if the myocardial performance index (MPI) is altered in well-controlled gestational diabetics and if so whether it is predictive of adverse perinatal outcome. In a prospective cross-sectional study, 54 consecutive women with well-controlled gestational diabetes controlled on insulin or metformin in the third trimester were recruited and matched with 54 women with normal pregnancies (control group). Using Doppler echocardiography, the MPI was calculated. Sonographic biophysical and placental resistance Doppler markers in both groups were also determined. An abnormal outcome was defined as any of the following: stillbirth; neonatal death; neonatal intensive care admissions; tachypnea with pulmonary edema; neonatal cord pH < 7.15; 5-min Apgar score < 7, polycythemia; and nucleated red blood cells > 10/100 white blood cell counts, hypoglycemia. The MPI was significantly higher in the diabetic group compared to controls (p < 0.0001). Rate of adverse outcome was 22% in the diabetic group. The diabetic group with adverse outcomes had significantly elevated MPI values compared to the diabetic group with normal outcomes. There were 26 diabetics controlled on metformin and 28 controlled on insulin. The adverse outcome rate was slightly higher in the IDDM group compared to the non-insulin-dependent group but was not statistically significant. The main adverse outcomes were low Apgars (18%), hypoglycemia (22%), polycythemia (13%) and low pH in 7%. All control births had normal outcomes. MPI served as an independent predictor of adverse outcome. The MPI z-score had a good diagnostic accuracy as evidenced by the area under the ROC curve of 0.83. An MPI z-score exceeding 4.55 conferred a 90% sensitivity and 74% specificity, with 77% of outcomes correctly classified with a likelihood ratio of 3.5. The MPI is impaired in fetuses in well-controlled gestational diabetes, with fetuses with an adverse outcome having significantly higher MPI values compared to the fetuses with normal outcome in the diabetic group. MPI has the potential to improve fetal surveillance in gestational diabetes.

Optimal Obstetric Management for Women with Diabetes: the Benefits and Costs of Fetal Surveillance

PURPOSE OF REVIEW

To elaborate on the risks and benefits associated with antenatal fetal surveillance for stillbirth prevention in women with diabetes.

RECENT FINDINGS

Women with pregestational diabetes have a 3- to 5-fold increased odds of stillbirth compared to women without diabetes. The stillbirth risk in women with gestational diabetes (GDM) is more controversial; while recent data suggest the odds for stillbirth are approximately 50% higher in women with GDM at term (37 weeks and beyond) than in those without GDM, it is unclear if this risk is seen in women with optimal glycemic control. Current professional society guidelines are broad with respect to fetal testing strategies and delivery timing in women with diabetes. The data supporting strategies to reduce the risk of stillbirth in women with diabetes are limited. Antepartum fetal surveillance should be performed to reduce stillbirth rates; however, the optimal test, frequency of testing, and delivery timing are not yet clear. Future studies of obstetric management for women with diabetes should consider not just individual but also system level costs and benefits associated with antenatal surveillance.

Maternal diabetes alters the development of ductus venosus shunting in the fetus

INTRODUCTION

Despite adequate glycemic control, the risks of fetal macrosomia and perinatal complications are increased in diabetic pregnancies. Adjustments of the umbilical venous distribution, including increased ductus venosus shunting, can be important fetal compensatory mechanisms, but the impact of pregestational diabetes on umbilical venous and ductus venosus flow is not known.

MATERIAL AND METHODS

In this prospective study, 49 women with pregestational diabetes mellitus underwent monthly ultrasound examinations from gestational week 20 to 36. The blood velocity and the mean diameters of the umbilical vein and ductus venosus were used for calculating blood flow volumes. The development of the umbilical venous flow, ductus venosus flow and ductus venosus shunt fraction (% of umbilical venous blood shunted through the ductus venosus) was compared with a reference population, and the effect of HbA_1c on the ductus venosus flow was assessed.

RESULTS

The umbilical venous flow was larger in pregnancies with pregestational diabetes mellitus than in low-risk pregnancies (p < 0.001) but smaller when normalized for fetal weight (p = 0.036). The distributional pattern of the ductus venosus flow developed differently in diabetic pregnancies, particularly during the third trimester, being smaller (p = 0.007), also when normalized for fetal weight (p < 0.001). Correspondingly, the ductus venosus shunt fraction was reduced (p < 0.0001), most prominently at 36 weeks. There were negative relations between the maternal HbA_1c and the ductus venosus flow velocity, flow volume and shunt fraction.

CONCLUSIONS

In pregnancies with pregestational diabetes mellitus, prioritized umbilical venous distribution to the fetal liver and lower ductus venosus shunt capacity reduce the compensatory capability of the fetus and may represent an augmented risk during hypoxic challenges during late pregnancy and birth.

Determination of the fetal myocardial performance index in women with gestational impaired glucose tolerance and to assess whether this parameter is a possible prognostic indicator of adverse fetal outcome

AIM

The aim of this study was to investigate if the myocardial performance index (MPI) is altered in fetuses in women with gestational impaired glucose tolerance (GIGT), controlled on diet and whether this parameter is also predictive of adverse outcome in this group, as in poorly controlled gestational diabetes.

METHODS

In a prospective cross-sectional study, 32 women with GIGT on diet in the 3rd trimester were recruited and matched with 32 women with normal pregnancies (control group). Using Doppler echocardiography, the MPI was calculated. Placental resistance Doppler markers in both groups were also determined. An abnormal outcome was defined as any of the following: stillbirth, neonatal death, neonatal intensive care unit (NICU) admissions, tachypnea with pulmonary oedema, neonatal cord pH <7.15, five minute Apgar score <7, and cardiomyopathy.

RESULTS

The cases had a significantly higher median MPI compared to controls, p value <.0001. There were eight abnormal outcomes recorded in the 32 fetuses in the study group, corresponding to an adverse outcome rate of 25%. Fetuses with an adverse outcome had significantly higher MPI measurements compared to the GIGT fetuses with normal outcome. The MPI served as an excellent predictor of adverse outcome in the GIGT fetuses, with a total area under the ROC curve of 0.96. An MPI z-score greater than 4.0 conferred a sensitivity of 100% and specificity of 80%. No abnormal outcomes were noted in the control group.

CONCLUSIONS

The MPI is impaired in fetuses in GIGT women, with fetuses with an adverse outcome having significantly higher MPI measurements compared to the fetuses with normal outcome in the GIGT group. MPI has the potential to improve fetal surveillance in gestational diabetes.

Falling insulin requirements are associated with adverse obstetric outcomes in women with preexisting diabetes

OBJECTIVE

To investigate the clinical significance of falling insulin requirements in women with preexisting or overt diabetes in pregnancy.

RESEARCH DESIGN AND METHODS

A retrospective review of 139 pregnancies was conducted in women, with preexisting diabetes, delivering between January 2010 and January 2013. Women with falling insulin requirements of 15% or more from the peak total daily dose in late pregnancy were considered case subjects (n = 35). The primary outcome consisted of a composite of clinical markers of placental dysfunction, including preeclampsia, small for gestational age (SGA, ≤5th percentile for gestational age), stillbirth (>20 weeks), and premature delivery (≤30 weeks).

RESULTS

A total of 25.2% of women had >15% fall in insulin requirements with nulliparity as the only predictor at baseline (odds ratio [OR] 2.5 [95% CI 1.1-5.7], P = 0.03). Falling insulin requirements were associated with an increased risk of preeclampsia (OR 3.5 [1.1-10.7], P < 0.05) and the composite of clinical markers of placental dysfunction (4.4 [1.73-11.26], P = 0.002). Although falling insulin requirements were associated with higher rates of SGA (3.4 [1.0-11.3], P = 0.048), they were not associated with other adverse neonatal outcomes. However, there was a higher incidence of neonatal intensive care unit admission (15.5 [3.1-77.6], P = 0.001) and earlier delivery in this group (median 37.7 weeks [IQR 34.3-38.4] vs. 38.3 weeks [37.4-38.9], P = 0.014).

CONCLUSIONS

Falling insulin requirements, in women with preexisting diabetes, are associated with an increased risk of complications related to placental dysfunction. Further prospective studies are needed to guide clinical management.

Role of fetal echocardiography in the evaluation of structure and function of fetal heart in diabetic pregnancies

OBJECTIVE

To detect the structural and functional changes of fetal hearts in diabetic pregnancies by using Doppler echocardiography.

METHODS

This prospective study included 119 pregnant women divided into three groups. Group 1 included 47 pregnant patients with pre-existing diabetes mellitus (DM), group 2 included 40 patients with gestational diabetes and group 3 included 32 non-diabetic pregnant women. M-mode echocardiography was used to measure the thickness of the fetal ventricular walls and interventricular septum. The mitral and tricuspid early (E) and late (A) diastolic velocities and the ventricular shortening fraction were measured.

RESULTS

HbA1c % was significantly lower in gestational diabetes group compared with the pre-existing diabetes group. The interventricular septum was significantly thicker in the pre-existing diabetes group compared with other groups. Tricuspid and mitral E/A ratios were significantly lower in the pre-existing diabetes group compared with gestational diabetes and control groups. Moreover, there were no significant differences in the tricuspid and mitral E/A ratios between gestational diabetes group and the control group. The right and left ventricular shortening fractions were similar in the three groups.

CONCLUSION

Fetuses of women with well-controlled gestational diabetes lack the diastolic dysfunction that is present in fetuses of women with pre-existing diabetes.

Sonographic evaluation and the pregnancy complicated by diabetes

Sonography is a fundamental tool in the management of pregnancies affected by maternal diabetes. Purposeful use of ultrasound in each trimester provides an invaluable amount of information about the developing fetus including gestational age and growth patterns, anatomical structure and function, assessment of fetal well-being, and prediction of adverse outcome. There are great ongoing research efforts in this field of prenatal diagnosis and management, yet even more are needed.

Stillbirth in diabetic pregnancies

Pregnancy in women with pregestational diabetes is associated with high perinatal morbidity and mortality. Stillbirth accounts for the majority of cases with perinatal death. Intrauterine growth restriction, pre-eclampsia, foetal hypoxia and congenital malformations may be contributing factors, but more than 50% of stillbirths are unexplained. Majority of stillbirths are characterised by suboptimal glycaemic control during pregnancy. Foetal hypoxia and cardiac dysfunction secondary to poor glycaemic control are probably the most important pathogenic factors in stillbirths among pregnant diabetic women. There is thus a need for new strategies for improving glycaemic control to near-normal levels throughout pregnancy and for preventing and treating hypertensive disorders in pregnancy. Antenatal surveillance tests including ultrasound examinations of the foetal growth rate, kick counting and non-stress testing of foetal cardiac function are widely used. However, future research should establish better antenatal surveillance tests to identify the infants susceptible to stillbirth before it happens.

[Obstetrical care in gestational diabetes and management of preterm labor]

OBJECTIVES

Search for data necessary to elaborate recommendations for obstetrical care in gestational diabetes and management of preterm labor.

METHODS

Systematic review of the literature and levels of evidence.

RESULTS

In case of gestational diabetes and in the absence of disease or other risk factor associated, there is no evidence to support a systematic rate of clinical follow up different from other pregnancy. The relevance of ultrasound estimates of fetal weight is limited. No formula is superior to others or to the simple measurement of abdominal circumference for the prediction of macrosomia (EL3). The usefulness of the research septal hypertrophy is not demonstrated (EL4). The systematic application of umbilical Doppler has no proven benefits in the absence of growth restriction or hypertension associated (EL4). Monthly ultrasound monitoring of the fetus can be proposed for diabetics on insulin or poorly controlled. In cases of gestational diabetes controlled by diet, cardiotocography of fetal heart rate has not proven useful. In poorly controlled diabetes and/or on insulin, the registration may be discussed taking into account other risk factors associated (EL4). A weekly recording of fetal heart rate is often recommended in case of type 2 diabetes discovered during pregnancy. In case of preterm labor, calcium channel blockers and oxytocin antagonists can be used without specific precautions. The risk of using beta-adrenergic outweighs the benefit. Administration of corticosteroid can be done under glycemic control, with insulin therapy if necessary. Screening test for gestational diabetes should not be performed within few days after last steroid injection.

Influence of polyhydramnios on perinatal outcome in pregestational diabetic pregnancies

OBJECTIVE

This study was carried out to evaluate the perinatal outcomes of pregnancy with pregestational diabetes mellitus complicated by polyhydramnios.

METHODS

This was a retrospective study of singleton pregnancies, with an antepartum diagnosis of polyhydramnios, seen at the maternal fetal medicine department of Mater Mothers' Hospital, a tertiary-level facility. All pregnancies in women with pregestational diabetes with a singleton pregnancy beyond 24 weeks of gestation, from 1996 to 2006, were reviewed (n = 314), and pregnancies complicated by polyhydramnios were identified (n = 59). Pregnancy outcomes of women whose pregnancy was complicated with polyhydramnios were compared to those without this complication.

RESULTS

The incidence of polyhydramnios in the study population was 18.8%. Women with polyhydramnios had increased hemoglobin A1c (HbA1c) levels throughout the pregnancy, and the difference was significant during the prepregnancy period and in the third trimester (P = 0.003 and P = 0.025, respectively). Significantly more mothers in the polyhydramnios group delivered preterm (54.2% vs. 33.3%, P = 0.004), the majority of which were iatrogenic preterm deliveries (44.1%). More pregnancies with polyhydramnios were delivered by Cesarean section (83.0% vs. 62%; P = 0.006), with the majority being performed electively in both groups (79.6% and 70.3%, respectively). Regardless, there were no significant differences in perinatal mortality rates, congenital abnormality rates, the incidences of low Apgar score, acidemia, hypoglycemia requiring intravenous therapy, phototherapy and ventilatory needs between the babies of the two groups.

CONCLUSION

Pregestational diabetic pregnancy with polyhydramnios is associated with poor diabetic control. Despite this, there is no significant increase in adverse perinatal outcome in these pregnancies, apart from a higher iatrogenic preterm birth rate.

Ductus venosus velocimetry in monitoring pregnancy in women with pregestational diabetes mellitus

OBJECTIVE

The purpose of this research was to assess the ability of ductus venosus (DV) Doppler velocimetry to predict adverse perinatal outcome in pregnancies complicated by pre-existing diabetes mellitus.

METHODS

This was a prospective study conducted at a tertiary referral obstetric facility in Brisbane, Australia. The study group included women with pregestational diabetes mellitus who delivered in the hospital between 1 January 1995 and 31 December 2006. The DV Doppler index was defined as abnormal if the DV peak velocity index for veins (PVIV) was equal to or greater than the 95(th) percentile for gestation. Adverse perinatal outcome included one or more of the following criteria: small-for-gestational-age infant; Cesarean section for non-reassuring fetal status; fetal acidemia at delivery; a 1-min Apgar score of <or= 3; a 5-min Apgar score of < 7; hypoxic ischemic encephalopathy; and stillbirth or neonatal death. The maternal characteristics and perinatal outcomes of pregnancies with normal or abnormal DV Doppler indices were compared.

RESULTS

Eighty-two pregestational diabetic pregnancies were studied and an abnormal DV-PVIV was identified in 25 (30.5%). Adverse perinatal outcome was identified in eight of 25 (32.0%) pregnancies with an abnormal DV-PVIV compared to seven of 57 (12.3%) pregnancies with a normal DV-PVIV (P < 0.05). The sensitivity of the DV-PVIV in predicting adverse perinatal outcomes in pregestational diabetic pregnancies was 53.3%, the specificity was 74.6%, the positive predictive value was 32.0% and the negative predictive value was 87.7%.

CONCLUSION

It may be useful to include DV-PVIV in the antenatal screening of pregnancies complicated by pregestational diabetes.

Obstetric problems in diabetic pregnancy - The role of fetal hypoxia

Perinatal mortality has not decreased over the last two decades in pregestational diabetic pregnancies. Stillbirth rate is 4-6 times and neonatal mortality 2-4 times higher in diabetic than in non-diabetic pregnancies despite modern electronic fetal surveillance methods. Majority of late stillbirths are "unexplained", many of which are presumably caused by fetal hypoxia. Both experimental and clinical studies have shown that fetal hyperglycaemia and hyperinsulinaemia can independently cause fetal hypoxia, which ultimately can lead to fetal death. Poor glycaemic control is associated with perinatal complications. Sharp increases in amniotic fluid erythropoietin levels indicate fetal hypoxia in diabetic pregnancy. Fetal erythropoietin concentrations correlate directly with maternal HbA(1c) levels. It is therefore important to maintain near-normal glycaemic level throughout pregnancy. Measurement of amniotic fluid erythropoietin level is a new way to detect fetal hypoxia antenatally. Sufficiently large controlled studies are needed before definitive answer of the clinical utility of amniotic fluid erythropoietin measurements in diabetic pregnancies can be determined.

Antepartum fetal surveillance and timing of delivery in the pregnancy complicated by diabetes mellitus

Pregnancies complicated by diabetes mellitus are associated with an increased risk of fetal and neonatal risks compared with pregnancies in the healthy gravida. Data suggest that stillbirth and perinatal mortality may be increased as much as 5 times for patients with insulin-dependent diabetes than in the general population. Pregnancies complicated by preexisting diabetes should undergo twice weekly surveillance with nonstress test or biophysical profile or a combination of both. Doppler studies should be reserved for those patients with vascular disease, intrauterine growth restriction, or hypertensive disorders.

Diabetic-associated stillbirth: incidence, pathophysiology, and prevention

All forms of diabetes during pregnancy are associated with an increased risk for stillbirth, defined as fetal death at greater than 20 weeks. The incidence of stillbirth in women who have diabetes has decreased dramatically with improved diabetes care. Diabetic-associated stillbirth is associated with hyperglycemia, resulting in fetal anaerobic metabolism with hypoxia and acidosis. Prevention of stillbirth in women who have diabetes hinges on intensive multidisciplinary prenatal care with control of blood sugars and appropriate fetal surveillance.

Diabetic-associated stillbirth: incidence, pathophysiology, and prevention

All forms of diabetes during pregnancy are associated with an increased risk for stillbirth, defined as fetal death at greater than 20 weeks. The incidence of stillbirth in women who have diabetes has decreased dramatically with improved diabetes care. Diabetic-associated stillbirth is associated with hyperglycemia, resulting in fetal anaerobic metabolism with hypoxia and acidosis. Prevention of stillbirth in women who have diabetes hinges on intensive multidisciplinary prenatal care with control of blood sugars and appropriate fetal surveillance.

Pulsatility index of temporal and renal arteries as an early finding of arteriopathy in diabetic patients

The objective of this study was to investigate the relationship between alterations in the elasticity of the temporal and the renal arteries and the grade of arteriopathy, using the pulsatility index in type II diabetic patients and healthy volunteers. All individuals were divided into groups. Group A consisted of 15 patients without risk factors (hyperlipidemia, hypertension, obesity, and smoking) and had well-controlled diabetes mellitus as demonstrated by normal values of HbA1c. Group B had 20 patients with two risk factors (hyperlipidemia and hypertension) and normal HbA1c. Group C (25 patients) had four risk factors and high values of HbA1c, and group D consisted of 20 healthy individuals. All patients were examined by use of color Doppler ultrasonography. Pulsatility index values were measured in the temporal and renal arteries. Pulsatility indices of temporal arteries were higher in group C than in groups A and B, whereas for the renal arteries, no significant difference was detected between the four groups. In our study there seems to be strong correlation between increased values of pulsatility index, mainly in the temporal arteries, and grade of arteriopathy in type II diabetic patients.