Choosing route of delivery for the macrosomic infant of a diabetic mother: Cesarean section versus vaginal delivery

Timing of delivery in women with diabetes: A population-based study

INTRODUCTION

Women with diabetes, and their infants, have an increased risk of adverse events due to excess fetal growth. Earlier delivery, when fetuses are smaller, may reduce these risks. This study aimed to evaluate the week-specific risks of maternal and neonatal morbidity/mortality to assist with obstetrical decision making.

MATERIAL AND METHODS

In this population-based cohort study, women with type 1 diabetes (n = 5889), type 2 diabetes (n = 9422) and gestational diabetes (n = 138 917) and a comparison group without diabetes (n = 2 553 243) who delivered a singleton infant at ≥36 completed weeks of gestation between 2004 and 2014 were identified from the Canadian Institute of Health Information Discharge Abstract Database. Multivariate logistic regression was used to determine the week-specific rates of severe maternal and neonatal morbidity/mortality among women delivered iatrogenically vs those undergoing expectant management.

RESULTS

For all women, the absolute risk of severe maternal morbidity/mortality was low, typically impacting less than 1% of women, and there was no significant difference in gestational age-specific severe maternal morbidity/mortality between iatrogenic delivery and expectant management among women with any form of diabetes. Among women with gestational diabetes, iatrogenic delivery was associated with an increased risk of neonatal morbidity/mortality compared with expectant management at 36 and 37 weeks' gestation (76.7 and 27.8 excess cases per 1000 deliveries, respectively) and a lower risk of neonatal morbidity/mortality at 38, 39 and 40 weeks' gestation (7.9, 27.3 and 15.9 fewer cases per 1000 deliveries, respectively). Increased risks of severe neonatal morbidity following iatrogenic delivery compared with expectant management were also observed for women with type 1 diabetes at 36 (98.3 excess cases per 1000 deliveries) and 37 weeks' gestation (44.5 excess cases per 1000 deliveries) and for women with type 2 diabetes at 36 weeks' gestation (77.9 excess cases per 1000 deliveries) weeks.

CONCLUSIONS

The clinical decision regarding timing of delivery is complex and contingent on maternal-fetal wellbeing, including adequate glycemic control. This study suggests that delivery at 38, 39 or 40 weeks' gestation may optimize neonatal outcomes among women with diabetes.

Time and mode of delivery in diabetic pregnancy: a review

The review presents some renewed data on the problem of optimal time and modes of delivery for women with various types of diabetes mellitus (DM 1 and 2, gestational diabetes). The necessity of making the universal delivery strategy algorithm for women with DM comes out of adverse outcomes high frequency, where the main cases are fetal macrosomia, fetal shoulder dystocia and perinatal mortality. Despite significant interest for this issue, there is still no common delivery tactics in the world for pregnant women with carbohydrate metabolism disorders. The main obstacle is evidence-based tests and meta-analysis insufficiency. So far, further studies are necessary to obtain high quality data concerning optimal terms and modes of delivery for women with DM.

Obstetric and neonatal characteristics of pregnancy and delivery for infant birthweight ≥5.0 kg

AIM

Infant birthweight ≥5.0 kg represents a significant risk factor for mother and neonate. The objective of this study was to examine the obstetric and neonatal outcome measures in a large cohort of such deliveries.

METHODS

The data used for this study were prospectively entered into an obstetric computerized database during the period 1989-2013. All pregnancies where the delivery resulted in an infant weighing ≥5.0 kg were identified. The results were retrospectively analyzed separately for parity, and a separate analysis was performed comparing the outcome measures observed in the earlier years of the study with those of the later years.

RESULTS

There were 73,796 deliveries in the time period of which there were n = 201 (0.3%) infants with birth weight ≥5.0 kg. The mean maternal body mass index (BMI) was in the obese category range (30.9 kg/m²) and the median gestation at delivery was 40.8 weeks. The cesarean delivery rate for nulliparous women was 56.3% and for parous women 30.8%. The overall rate of third degree perineal tears was 3.8%, the rate of shoulder dystocia was 4.6% and the rate of Erb's Palsy was 1.5%. There was a significant increase in cesarean delivery in the latter of the study (26.7% versus 43.0%, p = 0.02), due to an increase in the planned pre-labor cesarean deliveries (30.0 versus 12.9%, p = 0.005). There was no difference in adverse outcomes in both groups.

CONCLUSION

These findings describe the features of pregnancy associated with infant birthweight ≥5.0 kg, and outline reliable maternal and neonatal morbidity data for these pregnancies. In this cohort, there was no apparent benefit from increased planned pre-labor cesarean delivery rates.

Recurrent Shoulder Dystocia: Risk Factors and Counseling

A prior history of delivery complicated by shoulder dystocia confers a 6-fold to nearly 30-fold increased risk of shoulder dystocia recurrence in a subsequent vaginal delivery, with most reported rates between 12% and 17%. Whereas prevention of shoulder dystocia in the general population is neither feasible nor cost-effective, directing intervention efforts at the particular subgroup of women with a prior history of shoulder dystocia has merit. Potentially modifiable risk factors and individualized management strategies that may reduce shoulder dystocia recurrence and its associated significant morbidities are reviewed.

Children born to diabetic mothers may be more likely to have intellectual disability

Intellectual disability (ID) is a major public health condition that usually develops in utero and causes lifelong disability. Despite improvements in pregnancy and delivery care that have resulted in dramatic decreases in infant mortality rates, the incidence of ID has remained constant over the past 20 years. There may still be uncharacterized preventable causes of ID such as Diabetes Mellitus (DM). We used statewide individual level de-identified data for maternal and child pairs obtained by linking Medicaid claims, Department of Education, and Department of Disabilities and Special Needs data from 2000 to 2007 for all mother-child pairs with a minimum follow-up of 3-years post birth or until a diagnosis of ID. To ascertain the adjusted relationship between DM and ID, we fit a logistic regression model taking into account individual level clustering on mothers for multiple pregnancies using the population-averaged Generalized Estimating Equations method. Of the 162,611 eligible maternal and child pairs, 5,667 (3.49 %) of the children were diagnosed with ID between birth and 3-years of age. After adjustment for covariates the independent relationship between DM and ID was significant with odds ratio of 1.10 (1.01-1.12). On sub-analysis, patients with pre-pregnancy DM had the highest effect measure with an estimated odds ratio of 1.32 (0.84, 2.09), although this was not statistically significant. In this large cohort of mothers and children in South Carolina, we found a small but statistically significant increased risk for ID among children born to mothers with DM. Additional information about the association between maternal DM and risk of ID in children may lead to the development of effective preventive interventions on the individual and public health levels.

Gestational diabetes mellitus

Gestational diabetes mellitus (GDM) represents a heterogeneous group of metabolic disorders, which result in varying degrees of maternal hyperglycemia and pregnancy-associated risk. The frequency of GDM is rising globally and may also increase further as less-stringent criteria for the diagnosis are potentially adopted. The additional burden placed on the health care system by increasing cases of GDM requires consideration of diagnostic approaches and currently used treatment strategies. Debate continues to surround both the diagnosis and treatment of GDM despite several recent large-scale studies addressing these controversial issues. As many now have come to reassess their approach to the management of GDM, we provide information in this review to help guide this process. The goal for each health care practitioner should continue to be to provide optimum care for women discovered to have carbohydrate intolerance during pregnancy.

Intrapartum cardiotocography (CTG) and ST-analysis of labor in diabetic patients

AIM

To determine the prevalence and types of intrapartum cardiotocography (CTG) patterns and investigate their relationship to moderate acidemia in term fetuses of diabetic mothers. Also, to assess if the combination of fetal electrocardiogram (FECG) and those CTG patterns strengthens the association with moderate acidemia.

MATERIAL AND METHODS

The material for this study is obtained from the Swedish randomized control trial and the European Union ST-analysis trial. We developed an analytical model for CTG patterns based on the progress in CTG changes, in a longitudinal periodic manner. The model was then combined with information regarding changes in ST interval that indicate threatening asphyxia, and the findings were analyzed to determine correlation with the presence of moderate acidemia at birth.

RESULTS

This study involved data of 413 diabetic mothers. A preterminal CTG was more common in the diabetes mellitus (DM) group (6/70, 8.6%) than in the gestational diabetes (GD) group (3/307, 1.0%; P=0.003). For diabetic mothers (i.e., DM+GD) with a normal CTG at the start of monitoring, the presence of FECG data indicating asphyxia significantly increased the likelihood of an umbilical artery pH<7.15 at birth [odds ratio (OR)=3.65, 95% confidence interval (CI)=1.33-10.05]. Among labors where the CTG was non-reassuring at the start of monitoring, no significant association was found between pH<7.15 and indication to intervene according to FECG information (OR=1.51, 95% CI=0.33-7.0).

CONCLUSIONS

A preterminal CTG is more common in the fetuses of DM than GD mothers during labor. When CTG was normal at the start of recording, the addition of FECG information gave a significant add on information to predict moderate acidemia.

Fetal macrosomia and pregnancy outcomes

BACKGROUND

Pregnancies with a macrosomic fetus comprise a subgroup of high-risk pregnancies. There is uncertainty in the clinical management and outcomes of such pregnancies.

AIM

We sought to examine clinical management and maternal and fetal outcomes in pregnancies with macrosomic infants at Royal Brisbane and Women's Hospital (RBWH).

METHODS

Data from 276 macrosomic births (weighing > or = 4500 g) and 294 controls (weighing 3250-3750 g) delivered during 2002-2004 at RBWH were collected from the hospital database. Univariate and logistic regression analyses were performed for maternal risk factors and maternal and neonatal outcomes that were associated with fetal macrosomia.

RESULTS

Macrosomia was more than two times likely in women with body mass index (BMI) of > 30 kg/m(2) (odds ratio (OR) 2.41, 95% confidence interval (CI) 1.26-4.61) and in male infant sex (OR 2.05, 95% CI 1.35-3.12), and four times more likely in gestation of > 40 weeks (OR 3.93, 95% CI 1.99-7.74). Maternal smoking reduced the risk of fetal macrosomia (OR 0.27, 95% CI 0.14-0.51). Macrosomia was associated with nearly two times higher risk of emergency caesarean section (OR 1.75, 95% CI 1.02-2.97) and maternal hospital stay of > 3 days (OR 1.66, 95% CI 1.11-2.50), and four times higher risk of shoulder dystocia (OR 4.08, 95% CI 1.62-10.29). Macrosomic infants were twice as likely to have resuscitation (OR 2.21, 95% CI 1.46-3.34) and intensive care nursery admission (OR 1.89, 95% CI 1.03-3.46).

CONCLUSION

Macrosomia was associated with an increased risk of adverse maternal and neonatal health outcomes. Optimal management strategies of macrosomic pregnancies need evaluation.

TYPE 1 DIABETES IN PREGNANCY; INFLUENCES ON MOTHER AND FETUS

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

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.

Optimizing shoulder dystocia management to prevent birth injury

A practical clinical review of those aspects of shoulder dystocia management that are directly relevant to birth injury is presented. In contrast to more popular viewpoints, the tenets of this paper are that, with few exceptions, clinically relevant, permanent brachial plexus injury is nearly universally associated with shoulder dystocia, injury is causally related to mechanical stresses induced during shoulder dystocia delivery, and management algorithms can be optimized to reduce the incidence of mechanical birth injury from shoulder dystocia. Advantages of direct rotational manipulation of the fetus within the birth canal are emphasized, supported by critical analysis of maneuver-related outcomes research. The competing issue of potential asphyxial insult with prolonged shoulder dystocia is addressed in light of evidence for differential time-dependency between central and peripheral nerve injury as head-to-body interval increases. The importance of proper execution of shoulder dystocia maneuvers for maximizing favorable outcome of shoulder dystocia is iterated, as is coordination of teamed response by multiple healthcare providers. To avoid permanent neurologic sequelae from shoulder dystocia, clinicians are encouraged to be ever mindful of traction applied to the fetal head and neck, to become adept at performance of alternative maneuvers that instead concentrate on finesse rather than force, and to be more favorably disposed to the use of such maneuvers early and often in shoulder dystocia management algorithms.

Ultrasound Prediction of Fetal Macrosomia in Diabetic Women and its Effect on the Route of Delivery and the Outcome of Pregnancy

Objective: The purpose of this study is to review the maternal and neonatal outcome in pregnant diabetic women given a trial of labor and delivered macrosomic infants (>4000 grams) and to assess the accuracy of birth weight prediction by ultrasound examination at term.

Methods: One hundred and twenty-nine charts of pregnant diabetic women were reviewed, sixty eight women were given a trial of labor and delivered macrosomic fetuses (>4000 grams), fifty of them had vaginal delivery and the other eighteen had caesarean delivery. In the other group, 61 patients delivered by elective caesarean section, for 41 of them the indication was fetal macrosomia (>4000 grams) as estimated by ultrasound examination and in the other 20, it was due to clinical estimation of big baby. Maternal and neonatal complications were reviewed in each group. Maternal complications included lacerations, hemorrhage and infection and the neonatal complications evaluated were shoulder dystocia and associated birth trauma, asphyxia, and mortality. The accuracy of ultrasound in estimating fetal weight was also evaluated.

Results: Sixty eight (52.7%) women attempted a trial of labor; 73.5% delivered vaginally and 26.5% had a caesarean delivery. All, except two, had macrosomic fetuses (>4000 grams). Only one woman, of those who delivered vaginally, had postpartum hemorrhage due to atonic uterus. The incidence of shoulder dystocia for infants weighing 4000-4499 grams was 6.3% and those infants had the same incidence (6.3%) of brachial plexus injury. There was no perinatal asphyxia or perinatal mortality among those infants who were delivered vaginally. There were no maternal complications for women who had caesarean delivery after labor (18 patients) but there was perinatal asphyxia in two infants who were treated properly without any neurological sequele. Elective caesarean delivery was performed in 47.3% of the study population. There were no neonatal complications or perinatal mortality in this group of patients and only one woman had wound infection. The sonographic prediction of fetal weight was accurate in 52.4% of the cases. The over estimation was in 50.8% of the estimated fetal weights and 49.2% of them were underestimated when compared to actual birth weights.

Conclusions: Caution should be taken in the use of sonographic estimations of fetal weight to guide obstetric decisions concerning labor and delivery. Special consideration should be given to diabetic patients having fetuses with estimatedfetal weights between 4000 and 4500 grams. Flexibility in the management of these patients is best, taking in consideration their previous obstetric performance and if the estimated fetal weight is closer to 4500grams than to 4000 grams, it is perhaps, better to proceed to a primary caesarean delivery.

After shoulder dystocia: managing the subsequent pregnancy and delivery

Among risk factors for shoulder dystocia, a prior history of delivery complicated by shoulder dystocia is the single greatest risk factor for shoulder dystocia occurrence, with odds ratios 7 to 10 times that of the general population. Recurrence rates have been reported to be as high as 16%. Whereas prevention of shoulder dystocia in the general population is neither feasible nor cost-effective, intervention efforts directed at the particular subgroup of women with a prior history of shoulder dystocia can concentrate on potentially modifiable risk factors and individualized management strategies that can minimize recurrence and the associated significant morbidities and mortality.

Active management of risk in pregnancy at term in an urban population: an association between a higher induction of labor rate and a lower cesarean delivery rate

OBJECTIVE

The purpose of this study was to determine whether exposure to an alternative method of care, called the active management of risk in pregnancy at term, was associated with a lower group cesarean delivery rate.

STUDY DESIGN

Active management of risk in pregnancy at term used risk factors for cesarean delivery to guide an increased use of labor induction. A retrospective cohort design was used to compare clinical outcomes of 100 pregnant women who were exposed to active management of risk in pregnancy at term to 300 randomly selected subjects who received standard management.

RESULTS

The 2 groups had comparable levels of prenatal risk. The group exposed to the active management of risk in pregnancy at term exposure group encountered a higher induction rate (63% vs 25.7%; P < .001) and a lower cesarean delivery rate (4% vs 16.7%; P = .01). Findings were similar for both nulliparous and multiparous subgroups. Active management of risk in pregnancy at term exposure was not associated with higher rates of other major birth outcomes.

CONCLUSION

Exposure to the active management of risk in pregnancy at term exposure was associated with a significantly lower group cesarean delivery rate. A prospective randomized trial that involved active management of risk in pregnancy at term exposure is needed to further explore this association.