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Iqbal M, Zubair M, Saeed Awan A, Khan Y, Yasmin H, Rahim R, Srichand P, Pal SA, Mazhar SB, Sohail R, Zaman F, Ali S, Ali T. Consensus Statements for Assessment and Management of Threatened Miscarriage in the First Trimester in Pakistan: A Three-Step Modified Delphi Approach. Cureus 2024; 16:e65079. [PMID: 39171060 PMCID: PMC11337146 DOI: 10.7759/cureus.65079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2024] [Indexed: 08/23/2024] Open
Abstract
BACKGROUND AND OBJECTIVE It aimed to develop an expert consensus regarding the risk assessment, diagnosis, and threatened miscarriage management during the first trimester in Pakistan. METHODS A three-step modified Delphi method was applied to develop the consensus. Eleven specialized obstetricians and gynecologists participated in its development. If 75% or higher agreement level was attained on each assertion, it was declared as a consensus. RESULTS Age of 35 or above, previous history of two or more previous miscarriages, and direct strong trauma were considered to be threatened miscarriage risk factors. Infection was discussed and specified to include specific infectious diseases, like malaria, and COVID-19 as a risk factor. The experts agreed from the first time on considering endocrinological disorders, thrombophilia, and lifestyle variables as threatened miscarriage risk factors. They proposed adding a statement concerning acquired thrombophilia which was accepted unanimously. Finally, experts agreed on the importance of educating pregnant women about factors whose risk can be modified by modifying their behavior. As for diagnosis statements, it was agreed to be trifold: physical examination, imaging, and laboratory testing. Physical examination included abdominal and pelvic exams but focused more on vaginal examination with speculum to identify bleeding severity and etiology. The statements regarding the imaging approaches to diagnose threatened miscarriage in the first trimester achieved a consensus in most statements. TVS was recommended to check on uterine structural abnormalities, fetus viability focusing on heartbeat and crown-to-rump length, gestation sac size and emptiness, subchorionic hematoma, and ectopic pregnancy. Each was defined on how to identify and diagnose in separate statements. Statements about laboratory tests indicated the need for human chorionic gonadotropin hormone assessment whether serial or once is dependent on the ultrasound. Recommended hematologic investigations include complete blood count for anemia, Rh factor for potential bleeding risk and in special cases, thrombophilia assessment is undertaken. The first and foremost management aspect was follow-up while most management statements were controversial, and some were altogether removed with only some reaching agreement after discussion. CONCLUSION These consensus statements aggregated the best available evidence and experts' opinion-supported statements to improve patient education, risk assessment, diagnosis, and evaluation as well as management of threatened miscarriage during the first trimester in Pakistan.
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Affiliation(s)
- Maryam Iqbal
- Obstetrics and Gynecology, Integrated Medical Care Hospital, Lahore, PAK
| | - Maryam Zubair
- Obstetrics and Gynecology, Azad Jammu Kashmir Medical College, Muzaffarabad, PAK
| | - Azra Saeed Awan
- Obstetrics and Gynecology, Fauji Foundation Hospital, Rawalpindi, PAK
| | - Yousaf Khan
- Obstetrics and Gynecology, Hameed Latif Hospital, Lahore, PAK
| | - Haleema Yasmin
- Obstetrics and Gynecology, Jinnah Postgraduate Medical Center (JPMC), Karachi, PAK
| | - Rehana Rahim
- Obstetrics and Gynecology, Lady Ready Hospital, Peshawar, PAK
| | - Pushpa Srichand
- Obstetrics and Gynecology, Isra University Hospital, Hyderabad, PAK
| | - Sadiah A Pal
- Epidemiology, Concept Fertility Center, Karachi, PAK
| | - Syeda Batool Mazhar
- Obstetrics and Gynecology, Pakistan Institute of Medical Sciences, Islamabad, PAK
| | - Rubina Sohail
- Epidemiology and Public Health, Hameed Latif Hospital, Lahore, PAK
| | - Farrukh Zaman
- Obstetrics and Gynecology, Hameed Latif Hospital, Lahore, PAK
| | - Sobia Ali
- Medical Affairs, Established Pharmaceutical Division, Abbott Laboratories (Pakistan) Limited, Karachi, PAK
| | - Tabrez Ali
- Medical Affairs, Established Pharmaceutical Division, Abbott Laboratories (Pakistan) Limited, Karachi, PAK
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2
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Lee LMY, Leung YC, Shum ASW. Hyperglycemia alters retinoic acid catabolism in embryos exposed to a maternal diabetic milieu. PLoS One 2023; 18:e0287253. [PMID: 37616226 PMCID: PMC10449132 DOI: 10.1371/journal.pone.0287253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 06/01/2023] [Indexed: 08/26/2023] Open
Abstract
Pregestational diabetes is highly associated with increased risk of birth defects. We previously reported that the expression of Cyp26a1, the major catabolizing enzyme for controlling retinoic acid (RA) homeostasis, is significantly down-regulated in embryos of diabetic mice, thereby increasing the embryo's susceptibility to malformations caused by RA dysregulation. However, the underlying mechanism for the down-regulation of Cyp26a1 remains unclear. This study aimed to investigate whether elevated maternal blood glucose in the diabetic milieu is a critical factor for the altered Cyp26a1 expression. Streptozotozin-induced diabetic pregnant mice were treated with phlorizin (PHZ) to reduce blood glucose concentrations via induction of renal glucosuria. Embryonic Cyp26a1 expression level, RA catabolic activity and susceptibility to various RA-induced abnormalities were examined. To test the dose-dependent effect of glucose on Cyp26a1 level, early head-fold stage rat embryos of normal pregnancy were cultured in vitro with varying concentrations of D-glucose, followed by quantification of Cyp26a1 transcripts. We found that Cyp26a1 expression, which was down-regulated in diabetic pregnancy, could be normalized under reduced maternal blood glucose level, concomitant with an increase in RA catabolic activity in embryonic tissues. Such normalization could successfully reduce the susceptibility to different RA-induced malformations including caudal regression, cleft palate and renal malformations. The expression level of Cyp26a1 in the embryo was inversely correlated with D-glucose concentrations. Diabetic patients suffer from retinopathy, dermopathy, male infertility and increased cancer risk. Coincidentally, RA dysregulation is also associated with these health problems. Our results provided evidence that elevated glucose can down-regulate Cyp26a1 expression level and disturb RA homeostasis, shedding light on the possibility of affecting the health of diabetic patients via a similar mechanism.
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Affiliation(s)
- Leo Man Yuen Lee
- Department of Applied Biology and Chemical Technology, Lo Ka Chung Research Centre for Natural Anti-Cancer Drug Development and State Key Laboratory of Chemical Biology and Drug Discovery, The Hong Kong Polytechnic University, Hong Kong, Hong Kong
- School of Biomedical Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Yun-chung Leung
- Department of Applied Biology and Chemical Technology, Lo Ka Chung Research Centre for Natural Anti-Cancer Drug Development and State Key Laboratory of Chemical Biology and Drug Discovery, The Hong Kong Polytechnic University, Hong Kong, Hong Kong
| | - Alisa Sau Wun Shum
- School of Biomedical Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong
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Jain R, Magaret A, Vu PT, VanDalfsen JM, Keller A, Wilson A, Putman MS, Mayer-Hamblett N, Esther CR, Taylor-Cousar JL. Prospectively evaluating maternal and fetal outcomes in the era of CFTR modulators: the MAYFLOWERS observational clinical trial study design. BMJ Open Respir Res 2022; 9:9/1/e001289. [PMID: 35710144 PMCID: PMC9204448 DOI: 10.1136/bmjresp-2022-001289] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 06/06/2022] [Indexed: 11/12/2022] Open
Abstract
Introduction Therapeutic advances have markedly increased life expectancy for those with cystic fibrosis (CF), resulting in a median predicted survival over 50 years. Consequently, people with CF (pwCF) are living through their reproductive years and the rate of pregnancy is rapidly rising. Despite the increased relevance of this topic, multicentre studies investigating the association between maternal health and choices made during pregnancy on maternal and fetal outcomes do not exist. Furthermore, there are very limited data on the outcomes following CF transmembrane conductance regulator (CFTR) modulator use during pregnancy and lactation. Methods and analysis Maternal and Fetal Outcomes in the Era of Modulators (MAYFLOWERS) is a prospective, multicentre observational clinical trial which will enrol approximately 285 pregnant pwCF including those who are modulator ineligible and those who choose to continue or discontinue CFTR modulator therapy during pregnancy and lactation. The primary aim of this 35-month study is to assess whether lung function changes during pregnancy differ based on the continued use of modulators or other factors such as pre-existing comorbid conditions. Secondary objectives include evaluation of pregnancy related and obstetrical complications and changes in mental health. Ethics and dissemination The design of this study required special consideration of study burden on pregnant and lactating people with chronic illness in the setting of a substantial number of unanswered questions under these conditions. MAYFLOWERS is the first prospective clinical trial examining pregnancy in CF; the outcomes will guide providers on pregnancy management in pwCF and others with chronic respiratory disease.
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Affiliation(s)
- Raksha Jain
- Department of Medicine, University of Texas Southwestern, Dallas, Texas, USA
| | - Amalia Magaret
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Hospital, Seattle, Washington, USA.,Department of Biostatistics, University of Washington, Seattle, Texas, USA
| | - Phuong T Vu
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Hospital, Seattle, Washington, USA
| | - Jill M VanDalfsen
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Hospital, Seattle, Washington, USA
| | - Ashley Keller
- Department of Medicine, University of Texas Southwestern, Dallas, Texas, USA
| | - Alexandra Wilson
- Clinical Research Services, National Jewish Health, Denver, Colorado, USA
| | - Melissa S Putman
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Division of Endocrinology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nicole Mayer-Hamblett
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Hospital, Seattle, Washington, USA.,Department of Biostatistics, University of Washington, Seattle, Texas, USA.,Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Charles R Esther
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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4
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Nakanishi K, Kanagawa T, Fujikawa K, Ishii K, Waguri M. Congenital malformation and hemoglobin A1c in the first trimester among Japanese women with pregestational diabetes. J Obstet Gynaecol Res 2021; 47:4164-4170. [PMID: 34488239 DOI: 10.1111/jog.15015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 08/01/2021] [Accepted: 08/28/2021] [Indexed: 01/12/2023]
Abstract
AIM To investigate the incidence of major congenital malformations in Japanese women with pregestational diabetes, and to determine the cutoff value of hemoglobin A1c (HbA1c) in the first trimester associated with congenital malformations. METHODS This retrospective cohort study included singleton pregnancies in Japanese women with pregestational diabetes, including type 1 and type 2 diabetes, and specific types of diabetes due to other causes. The primary outcome was the incidence of major congenital malformations. The secondary outcome was the incidence of all congenital malformations. The cutoff value of HbA1c for congenital malformations was calculated using receiver operating characteristic curve analysis. The adjusted odds ratios (aOR) of major congenital malformations were calculated using multiple logistic regression analyses. RESULTS This study enrolled 292 patients, including 132 (45.2%) with type 1 diabetes, 156 (53.4%) with type 2 diabetes, and 4 (1.4%) with other specific types. The incidence rates of major congenital malformations and all congenital malformations were 7.2% (21/292) and 12.7% (37/292), respectively. The cutoff value of HbA1c in the first trimester for major malformations and for all congenital malformations was 6.5%. HbA1c ≥ 6.5% was significantly associated with major malformations (aOR 3.5; 95% confidence interval: 1.2-12.6; p = 0.018). CONCLUSION The incidence of major congenital malformations significantly increased in pregnant Japanese women with HbA1c values of 6.5% or higher. The recommended HbA1c value during the first trimester used in other countries can be applied to pregnant Japanese women.
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Affiliation(s)
- Kentaro Nakanishi
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Takeshi Kanagawa
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Kei Fujikawa
- Department of Obstetric Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Keisuke Ishii
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Masako Waguri
- Department of Obstetric Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
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Rudland VL, Price SAL, Hughes R, Barrett HL, Lagstrom J, Porter C, Britten FL, Glastras S, Fulcher I, Wein P, Simmons D, McIntyre HD, Callaway L. ADIPS 2020 guideline for pre-existing diabetes and pregnancy. Aust N Z J Obstet Gynaecol 2020; 60:E18-E52. [PMID: 33200400 DOI: 10.1111/ajo.13265] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 09/14/2020] [Indexed: 02/07/2023]
Abstract
This is the full version of the Australasian Diabetes in Pregnancy Society (ADIPS) 2020 guideline for pre-existing diabetes and pregnancy. The guideline encompasses the management of women with pre-existing type 1 diabetes and type 2 diabetes in relation to pregnancy, including preconception, antepartum, intrapartum and postpartum care. The management of women with monogenic diabetes or cystic fibrosis-related diabetes in relation to pregnancy is also discussed.
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Affiliation(s)
- Victoria L Rudland
- Department of Diabetes and Endocrinology, Westmead Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Sarah A L Price
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Diabetes, Royal Women's Hospital, Melbourne, Victoria, Australia.,Mercy Hospital for Women, Melbourne, Victoria, Australia.,Faculty of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Ruth Hughes
- Department of Obstetrics and Gynaecology, University of Otago, Christchurch, New Zealand
| | - Helen L Barrett
- Department of Endocrinology, Mater Health, Brisbane, Queensland, Australia.,Mater Research, The University of Queensland, Brisbane, Queensland, Australia
| | - Janet Lagstrom
- Green St Specialists Wangaratta, Wangaratta, Victoria, Australia.,Denis Medical Yarrawonga, Yarrawonga, Victoria, Australia.,Corowa Medical Clinic, Corowa, New South Wales, Australia.,NCN Health, Numurkah, Victoria, Australia
| | - Cynthia Porter
- Geraldton Diabetes Clinic, Geraldton, Western Australia, Australia
| | - Fiona L Britten
- Department of Obstetric Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Mater Private Hospital and Mater Mother's Private Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Sarah Glastras
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Department of Diabetes, Endocrinology and Metabolism, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Ian Fulcher
- Liverpool Hospital, Sydney, New South Wales, Australia
| | - Peter Wein
- Mercy Hospital for Women, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
| | - David Simmons
- Western Sydney University, Sydney, New South Wales, Australia.,Campbelltown Hospital, Sydney, New South Wales, Australia
| | - H David McIntyre
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Mater Health, Brisbane, Queensland, Australia
| | - Leonie Callaway
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Women's and Children's Services, Metro North Hospital and Health Service District, Brisbane, Queensland, Australia.,Women's and Newborn Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
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6
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Wahabi HA, Fayed A, Esmaeil S, Elmorshedy H, Titi MA, Amer YS, Alzeidan RA, Alodhayani AA, Saeed E, Bahkali KH, Kahili-Heede MK, Jamal A, Sabr Y. Systematic review and meta-analysis of the effectiveness of pre-pregnancy care for women with diabetes for improving maternal and perinatal outcomes. PLoS One 2020; 15:e0237571. [PMID: 32810195 PMCID: PMC7433888 DOI: 10.1371/journal.pone.0237571] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 07/30/2020] [Indexed: 12/17/2022] Open
Abstract
Background Pre-gestational diabetes mellitus is associated with increased risk of maternal and perinatal adverse outcomes. This systematic review was conducted to evaluate the effectiveness and safety of pre-conception care (PCC) in improving maternal and perinatal outcomes. Methods Databases from MEDLINE, EMBASE, WEB OF SCIENCE, and Cochrane Library were searched, including the CENTRAL register of controlled trials, and CINHAL up until March 2019, without any language restrictions, for any pre-pregnancy care aiming at health promotion, glycemic control, and screening and treatment of diabetes complications in women with type I or type II pre-gestational diabetes. Trials and observational studies were included in the review. Newcastle-Ottawa scale and the Cochrane collaboration methodology for data synthesis and analysis were used, along with the GRADE tool to evaluate the body of evidence. Results The search identified 8500 potentially relevant citations of which 40 reports of 36 studies were included. The meta-analysis results show that PCC reduced congenital malformations risk by 71%, (Risk ratio (RR) 0.29; 95% CI: 0.21–0.40, 25 studies; 5903 women; high-certainty evidence). The results also show that PCC may lower HbA1c in the first trimester of pregnancy by an average of 1.27% (Mean difference (MD) 1.27; 95% CI: 1.33–1.22; 4927 women; 24 studies, moderate-certainty evidence). Furthermore, the results suggest that PCC may lead to a slight reduction in the risk of preterm delivery of 15%, (RR 0.85; 95% CI: 0.73–0.99; nine studies, 2414 women; moderate-certainty evidence). Moreover, PCC may result in risk reduction of perinatal mortality by 54%, (RR 0.46; 95% CI: 0.30–0.73; ten studies; 3071 women; moderate-certainty evidence). There is uncertainty about the effects of PCC on the early booking for antenatal care (MD 1.31; 95% CI: 1.40–1.23; five studies, 1081 women; very low-certainty evidence) and maternal hypoglycemia in the first trimester, (RR 1.38; 95% CI: 1.07–1.79; three studies; 686 women; very low- certainty evidence). In addition, results of the meta-analysis indicate that PCC may lead to 48% reduction in the risk of small for gestational age (SGA) (RR 0.52; 95% CI: 0.37–0.75; six studies, 2261 women; moderate-certainty evidence). PCC may reduce the risk of neonatal admission to intensive care unit (NICU) by 25% (RR 0.75; 95% CI: 0.67–0.84; four studies; 1322 women; moderate-certainty evidence). However, PCC may have little or no effect in reducing the cesarean section rate (RR 1.02; 95% CI: 0.96–1.07; 14 studies; 3641 women; low-certainty evidence); miscarriage rate (RR 0.86; 95% CI: 0.70–1.06; 11 studies; 2698 women; low-certainty evidence); macrosomia rate (RR 1.06; 95% CI: 0.97–1.15; nine studies; 2787 women, low-certainty evidence); neonatal hypoglycemia (RR 0.93; 95% CI: 0.74–1.18; five studies; 880 women; low-certainty evidence); respiratory distress syndrome (RR 0.78; 95% CI: 0.47–1.29; four studies; 466 women; very low-certainty evidence); or shoulder dystocia (RR 0.28; 95% CI: 0.07–1.12; 2 studies; 530 women; very low-certainty evidence). Conclusion PCC for women with pre-gestational type 1 or type 2 diabetes mellitus is effective in improving rates of congenital malformations. In addition, it may improve the risk of preterm delivery and admission to NICU. PCC probably reduces maternal HbA1C in the first trimester of pregnancy, perinatal mortality and SGA. There is uncertainty regarding the effects of PCC on early booking for antenatal care or maternal hypoglycemia during the first trimester of pregnancy. PCC has little or no effect on other maternal and perinatal outcomes.
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Affiliation(s)
- Hayfaa A. Wahabi
- Research Chair for Evidence-Based Healthcare and Knowledge Translation, King Saud University, Riyadh, Saudi Arabia
- Department of Family and Community Medicine, King Saud University Medical City and College of Medicine, Riyadh, Saudi Arabia
| | - Amel Fayed
- College of Medicine, Clinical Department, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
- High Institute of Public Health, Alexandria University, Alexandria, Egypt
- * E-mail:
| | - Samia Esmaeil
- Research Chair for Evidence-Based Healthcare and Knowledge Translation, King Saud University, Riyadh, Saudi Arabia
| | - Hala Elmorshedy
- College of Medicine, Clinical Department, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
- High Institute of Public Health, Alexandria University, Alexandria, Egypt
| | - Maher A. Titi
- Research Chair for Evidence-Based Healthcare and Knowledge Translation, King Saud University, Riyadh, Saudi Arabia
- Patient Safety Unit, Quality Management Department, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Yasser S. Amer
- Research Chair for Evidence-Based Healthcare and Knowledge Translation, King Saud University, Riyadh, Saudi Arabia
- Clinical Practice Guidelines Unit, Quality Management Department, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Rasmieh A. Alzeidan
- Cardiac Science Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Abdulaziz A. Alodhayani
- Department of Family and Community Medicine, King Saud University Medical City and College of Medicine, Riyadh, Saudi Arabia
| | - Elshazaly Saeed
- Prince Abdulla bin Khaled Coeliac Disease Research Chair, King Saud University, Riyadh, Saudi Arabia
| | | | - Melissa K. Kahili-Heede
- John A. Burns School of Medicine, Health Sciences Library, University of Hawaii at Manoa, Honolulu, HI, United States of America
| | - Amr Jamal
- Research Chair for Evidence-Based Healthcare and Knowledge Translation, King Saud University, Riyadh, Saudi Arabia
- Department of Family and Community Medicine, King Saud University Medical City and College of Medicine, Riyadh, Saudi Arabia
| | - Yasser Sabr
- Department of Obstetrics and Gynecology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Patti AM, Giglio RV, Pafili K, Rizzo M, Papanas N. Advances in pharmacological treatment of type 1 diabetes during pregnancy. Expert Opin Pharmacother 2019; 20:983-989. [PMID: 30924387 DOI: 10.1080/14656566.2019.1593372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION In women with type 1 diabetes mellitus (T1DM), pregnancy is associated with a potential risk of maternal, foetal and neonatal outcomes. Stringent metabolic control is required to improve these outcomes. AREAS COVERED In this review, the authors summarise the current evidence from studies on the pharmacological therapy and on monitoring of T1DM during pregnancy. The authors also discuss the use of new technologies to improve therapeutic management and patient compliance. EXPERT OPINION Pre-conception counselling is essential in T1DM to minimise pregnancy risks. Pregnancy in T1DM is always considered a high-risk pregnancy. During pregnancy, the target haemoglobin A1C (HbA1c) is near-normal at <6%, without excessive hypoglycaemia. Strict control of pre- and post-prandial glucose is also required. Human soluble insulin, neutral protamine Hagedorn and the quick-acting insulin analogues aspart and lispro are widely used. Insulin is administered either as a basal-bolus regimen or by continuous subcutaneous insulin infusion. Careful and strict glucose monitoring is also needed during labour and delivery, including caesarean section. Moreover, the control of retinopathy, hypertension, nephropathy, hyper- and hypothyroidism is required. Post-partum, insulin requirements decrease, and less stringent glycaemic control is pursued, to avoid hypoglycaemias. Finally, breastfeeding is recommended and should be encouraged.
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Affiliation(s)
- Angelo Maria Patti
- a Department of Internal Medicine and Medical Specialties , University of Palermo , Palermo , Italy
| | - Rosaria Vincenza Giglio
- a Department of Internal Medicine and Medical Specialties , University of Palermo , Palermo , Italy
| | - Kalliopi Pafili
- b Diabetes Centre, Second Department of Internal Medicine , Democritus University of Thrace, University Hospital of Alexandroupolis , Alexandroupolis , Greece
| | - Manfredi Rizzo
- a Department of Internal Medicine and Medical Specialties , University of Palermo , Palermo , Italy
| | - Nikolaos Papanas
- b Diabetes Centre, Second Department of Internal Medicine , Democritus University of Thrace, University Hospital of Alexandroupolis , Alexandroupolis , Greece
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8
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Xie GH, Zheng Z, Liu TC, Qing LL, Hong XQ, Zha WT, Lv Y. Health care and risk of adverse pregnancy outcomes among diabetic women: an updated meta-analysis. Arch Gynecol Obstet 2019; 299:891-899. [PMID: 30656442 DOI: 10.1007/s00404-019-05042-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 01/05/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE Diabetic women appear to have adverse pregnancy outcomes. Although there were two meta-analyzes that examined the association between health care and adverse pregnancy outcomes, their results were limited because they only included congenital anomaly and perinatal mortality, and they did not clarify the detailed situations of diabetes and health care. This meta-analysis aims to completely evaluate the effects of health care in improving adverse pregnancy outcomes among diabetic mothers. METHODS CNKI, EMBASE, Web of Science, and PubMed databases were searched for eligible studies up to December 2017, without any restrictions. Relevant cohort studies characterizing the relationship between health care and adverse pregnancy outcomes were selected for inclusion in the meta-analysis. We also screened the reference list of relevant studies. The fixed-effect models or random-effect models were used to calculate the risk estimates. The potential sources of heterogeneity were explored by stratified and sensitivity analyzes. RESULTS Twenty-one studies with 6685 cases were included in our analysis. Health care was associated with significantly decreased risk of congenital anomaly (RR 0.237; 95% CI 0.166-0.338), perinatal death (RR 0.457; 95% CI 0.294-0.712), large for gestational age (LGA) (RR 0.794; 95% CI 0.640-0.986), and neonatal hypoglycemia (RR 0.672; 95% CI 0.486-0.929). Publication bias was not found in most results, with the exception of congenital anomaly and small for gestational age (SGA). CONCLUSION Health care is associated with decreased risk of congenital anomaly, perinatal death, LGA, neonatal hypoglycemia.
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Affiliation(s)
- Guo-Hong Xie
- Department of Epidemiology and Health Statistics, Key Laboratory of Molecular Epidemiology of Hunan Province, Medical College of Hunan Normal University, No. 371, Tongzipo Road, Yuelu District, Changsha, 410000, Hunan, People's Republic of China
| | - Zan Zheng
- Department of Epidemiology and Health Statistics, XiangYa School of Public Health, Changsha, 410000, Hunan, People's Republic of China
| | - Tao-Cheng Liu
- Department of Epidemiology and Health Statistics, Key Laboratory of Molecular Epidemiology of Hunan Province, Medical College of Hunan Normal University, No. 371, Tongzipo Road, Yuelu District, Changsha, 410000, Hunan, People's Republic of China
| | - Lu-Lu Qing
- Department of Epidemiology and Health Statistics, Key Laboratory of Molecular Epidemiology of Hunan Province, Medical College of Hunan Normal University, No. 371, Tongzipo Road, Yuelu District, Changsha, 410000, Hunan, People's Republic of China
| | - Xiu-Qin Hong
- Department of Epidemiology and Health Statistics, Key Laboratory of Molecular Epidemiology of Hunan Province, Medical College of Hunan Normal University, No. 371, Tongzipo Road, Yuelu District, Changsha, 410000, Hunan, People's Republic of China
| | - Wen-Ting Zha
- Department of Epidemiology and Health Statistics, Key Laboratory of Molecular Epidemiology of Hunan Province, Medical College of Hunan Normal University, No. 371, Tongzipo Road, Yuelu District, Changsha, 410000, Hunan, People's Republic of China.
| | - Yuan Lv
- Department of Epidemiology and Health Statistics, Key Laboratory of Molecular Epidemiology of Hunan Province, Medical College of Hunan Normal University, No. 371, Tongzipo Road, Yuelu District, Changsha, 410000, Hunan, People's Republic of China.
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9
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McCarthy EA, Williamson R, Shub A. Pregnancy outcomes for women with pre‐pregnancy diabetes mellitus in Australian populations, rural and metropolitan: A review. Aust N Z J Obstet Gynaecol 2018; 59:183-194. [DOI: 10.1111/ajo.12913] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Accepted: 09/22/2018] [Indexed: 12/19/2022]
Affiliation(s)
- Elizabeth A. McCarthy
- Department of Obstetrics and GynaecologyUniversity of Melbourne Melbourne Victoria Australia
- Department of Perinatal MedicineMercy Hospital for Women Melbourne Victoria Australia
| | - Rebecca Williamson
- Department of Obstetrics and GynaecologyUniversity of Melbourne Melbourne Victoria Australia
| | - Alexis Shub
- Department of Obstetrics and GynaecologyUniversity of Melbourne Melbourne Victoria Australia
- Mercy Hospital for Women Melbourne Victoria Australia
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Abstract
BACKGROUND Miscarriage is a common complication encountered during pregnancy. It is defined as spontaneous pregnancy loss before 20 weeks' gestation. Progesterone's physiological role is to prepare the uterus for the implantation of the embryo, enhance uterine quiescence and suppress uterine contractions, hence, it may play a role in preventing rejection of the embryo. Inadequate secretion of progesterone in early pregnancy has been linked to the aetiology of miscarriage and progesterone supplementation has been used as a treatment for threatened miscarriage to prevent spontaneous pregnancy loss. This update of the Cochrane Review first published in 2007, and previously updated in 2011, investigates the evidence base for this practice. OBJECTIVES To determine the efficacy and the safety of progestogens in the treatment of threatened miscarriage. SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (8 August 2017) and reference lists of retrieved trials. SELECTION CRITERIA Randomised, quasi-randomised or cluster-randomised controlled trials, that compared progestogen with placebo, no treatment or any other treatment for the treatment of threatened miscarriage in women carrying singleton pregnancy. DATA COLLECTION AND ANALYSIS At least two review authors assessed the trials for inclusion in the review, assessed trial quality and extracted the data and graded the body of evidence. MAIN RESULTS We included seven trials (involving 696 participants) in this update of the review. The included trials were conducted in different countries, covering the full spectrum of the World Bank's economic classification, which enhances the applicability of evidence drawn from this review. Two trials were conducted in Germany and Italy which are high-income countries, while four trials were conducted in upper-middle income countries; two in Iran, one in Malaysia and the fourth in Turkey, and the seventh trial was conducted in Jordan, which is a lower-middle income country. In six trials all the participants met the inclusion criteria and in the seventh study, we included in the meta-analysis only the subgroup of participants who met the inclusion criteria. We assessed the body of evidence for the main outcomes using the GRADE tool and the quality of the evidence ranged from very low to moderate. Downgrading of evidence was based on the high risk of bias in six of the seven included trials and a small number of events and wide confidence intervals for some outcomes.Treatment of miscarriage with progestogens compared to placebo or no treatment probably reduces the risk of miscarriage; (risk ratio (RR) 0.64, 95% confidence interval (CI) 0.47 to 0.87; 7 trials; 696 women; moderate-quality evidence). Treatment with oral progestogen compared to no treatment also probably reduces the miscarriage rate (RR 0.57, 95% CI 0.38 to 0.85; 3 trials; 408 women; moderate-quality evidence). However treatment with vaginal progesterone compared to placebo, probably has little or no effect in reducing the miscarriage rate (RR 0.75, 95% CI 0.47 to 1.21; 4 trials; 288 women; moderate-quality evidence). The subgroup interaction test indicated no difference according to route of administration between the oral and vaginal subgroups of progesterone.Treatment of preterm birth with the use of progestogens compared to placebo or no treatment may have little or no effect in reducing the rate of preterm birth (RR 0.86, 95% CI 0.52 to 1.44; 5 trials; 588 women; low-quality evidence).We are uncertain if treatment of threatened miscarriage with progestogens compared to placebo or no treatment has any effect on the rate of congenital abnormalities because the quality of the evidence is very low (RR 0.70, 95% CI 0.10 to 4.82; 2 trials; 337 infants; very-low quality evidence). AUTHORS' CONCLUSIONS The results of this Cochrane Review suggest that progestogens are probably effective in the treatment of threatened miscarriage but may have little or no effect in the rate of preterm birth. The evidence on congenital abnormalities is uncertain, because the quality of the evidence for this outcome was based on only two small trials with very few events and was found to be of very low quality.
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Affiliation(s)
- Hayfaa A Wahabi
- King Saud UniversityChair of Evidence‐Based Healthcare and Knowledge TranslationRiyadhSaudi Arabia11451
| | - Amel A Fayed
- Princess Nourah Bint Abdulrahman UniversityCollege of Medicine, Clinical DepartmentKhurais RoadKing Abdulaziz Medical CityRiyadhSaudi Arabia22490
| | - Samia A Esmaeil
- King Saud UniversityDepartment of Family and Community MedicineRiyadhSaudi Arabia
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11
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Diabetes and pregnancy in Wistar rats: renal effects for mothers in the postpartum period. J Dev Orig Health Dis 2017; 9:77-86. [PMID: 28805180 DOI: 10.1017/s2040174417000605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
In this study, diabetes mellitus (DM) was induced in Wistar rats during pregnancy and maintained in the postpartum period (PP) and we evaluated systolic blood pressure (SBP), glomerular filtration rate (GFR) and renal immunohistochemical and morphometric studies from different groups: G1 (non-pregnant control rats), G2 (non-pregnant diabetic rats), G3 (control mothers) and G4 (diabetic mothers). We found that there were no differences in relation to SBP, but there was a tendency for reduction in GFR from G4 compared with the other groups (G). There was increased total kidney weight/body weight ratio of G4 compared with other G. There were increase in glomerular tuft area in G3 and G4 compared with G1 and G2. G2 and G4 showed even higher percentage of cortical collagen. G3 showed increased glomerular proliferating cells compared with G1 and G2, while in G4 this number was smaller than G3. Cell proliferation was higher in the tubulointerstitial (TBI) compartment from G4. Glomerular and TBI α-smooth muscle actin expression was increased in G4 compared with other G. The glomerular p-p38 expression showed a pattern similar to proliferation cell nuclear antigen, with a reduction of p-p38 in G4 relative to other G. The immunoreactivity of p-JNK was higher in both the glomeruli and TBI compartment in G4 compared with G1, G2 and G3. The DM induced during pregnancy and maintained in the PP resulted in renal structural and functional changes to mothers. In addition, altered mitogen-activated protein kinase expression in association with these changes may play an important role in renal damage observed in the present investigation.
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12
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Egan AM, Galjaard S, Maresh MJA, Loeken MR, Napoli A, Anastasiou E, Noctor E, de Valk HW, van Poppel M, Todd M, Smith V, Devane D, Dunne FP. A core outcome set for studies evaluating the effectiveness of prepregnancy care for women with pregestational diabetes. Diabetologia 2017; 60:1190-1196. [PMID: 28409213 PMCID: PMC5487596 DOI: 10.1007/s00125-017-4277-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 03/13/2017] [Indexed: 12/30/2022]
Abstract
AIMS/HYPOTHESIS The aim of this study was to develop a core outcome set (COS) for trials and other studies evaluating the effectiveness of prepregnancy care for women with pregestational (pre-existing) diabetes mellitus. METHODS A systematic literature review was completed to identify all outcomes reported in prior studies in this area. Key stakeholders then prioritised these outcomes using a Delphi study. The list of outcomes included in the final COS were finalised at a face-to-face consensus meeting. RESULTS In total, 17 outcomes were selected and agreed on for inclusion in the final COS. These outcomes were grouped under three domains: measures of pregnancy preparation (n = 9), neonatal outcomes (n = 6) and maternal outcomes (n = 2). CONCLUSIONS/INTERPRETATION This study identified a COS essential for studies evaluating prepregnancy care for women with pregestational diabetes. It is advocated that all trials and other non-randomised studies and audits in this area use this COS with the aim of improving transparency and the ability to compare and combine future studies with greater ease.
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Affiliation(s)
- Aoife M Egan
- Galway Diabetes Research Centre, Department of Medicine, National University of Ireland Galway, Galway, Ireland.
| | - Sander Galjaard
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Prenatal Medicine, Erasmus MC, University Medical Centre Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, the Netherlands.
| | - Michael J A Maresh
- Department of Obstetrics, St Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Mary R Loeken
- Section of Islet Cell and Regenerative Biology, Joslin Diabetes Center, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Angela Napoli
- Department of Clinical and Molecular Medicine, S. Andrea University Hospital, Sapienza, University of Rome, Rome, Italy
| | - Eleni Anastasiou
- Department of Endocrinology & Diabetes Center Alexandra Hospital, Athens, Greece
| | - Eoin Noctor
- Department of Endocrinology, University Hospital Limerick, Limerick, Ireland
| | - Harold W de Valk
- Department of Internal Medicine, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Mireille van Poppel
- Institute of Sport Science, University of Graz, Graz, Austria
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, VU University Medical Centre, Amsterdam, the Netherlands
| | - Marie Todd
- Department of Medicine, Mayo University Hospital, Castlebar, Ireland
| | - Valerie Smith
- School of Nursing & Midwifery, Trinity College Dublin, Dublin, Ireland
- School of Nursing & Midwifery, National University of Ireland Galway, Galway, Ireland
| | - Declan Devane
- School of Nursing & Midwifery, National University of Ireland Galway, Galway, Ireland
- Health Research Board - Trials Methodology Research Network (HRB-TMRN), Galway, Ireland
| | - Fidelma P Dunne
- Galway Diabetes Research Centre, Department of Medicine, National University of Ireland Galway, Galway, Ireland
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13
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Nwolise CH, Carey N, Shawe J. Preconception Care Education for Women With Diabetes: A Systematic Review of Conventional and Digital Health Interventions. J Med Internet Res 2016; 18:e291. [PMID: 27826131 PMCID: PMC5120238 DOI: 10.2196/jmir.5615] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Revised: 06/26/2016] [Accepted: 09/21/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Worldwide, 199.5 million women have diabetes mellitus (DM). Preconception care (PCC) education starting from adolescence has been recommended as an effective strategy for safeguarding maternal and child health. However, traditional preconception care advice provided by health care professionals (HCPs) within clinic settings is hindered by inadequate resources, suboptimal coverage, and busy clinics. Electronic health (eHealth), which is instrumental in solving problems around scarce health resources, could be of value in overcoming these limitations and be used to improve preconception care and pregnancy outcomes for women with DM. OBJECTIVE The objectives were to: (1) identify, summarize, and critically appraise the current methods of providing PCC education; (2) examine the relationship between PCC educational interventions (including use of technology as an intervention medium) on patient and behavioral outcomes; and (3) highlight limitations of current interventions and make recommendations for development of eHealth in this field. METHODS Electronic databases were searched using predefined search terms for PCC education in women with type 1 or 2 DM for quantitative studies from 2003 until June 2016. Of the 1969 titles identified, 20 full papers were retrieved and 12 papers were included in this review. RESULTS The reviewed studies consistently reported that women receiving educational interventions via health care professionals and eHealth had significantly improved levels of glycosylated hemoglobin (P<.001) with fewer preterm deliveries (P=.02) and adverse fetal outcomes (P=.03). Significant improvements in knowledge (P<.001) and attitudes toward seeking PCC (P=.003) were reported along with reduced barriers (P<.001). CONCLUSIONS PCC has a positive effect on pregnancy outcomes for women with DM. However, uptake of PCC is low and the use of eHealth applications for PCC of women with DM is still in its infancy. Initial results are promising; however, future research incorporating mobile phones and apps is needed. Clearly, there is much to be done if the full potential of eHealth PCC to improve obstetric outcomes for women with DM is to be realized.
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Affiliation(s)
- Chidiebere Hope Nwolise
- School of Health Sciences, Faculty of Health & Medical Sciences, University of Surrey, Guildford, United Kingdom
| | - Nicola Carey
- School of Health Sciences, Faculty of Health & Medical Sciences, University of Surrey, Guildford, United Kingdom
| | - Jill Shawe
- School of Health Sciences, Faculty of Health & Medical Sciences, University of Surrey, Guildford, United Kingdom
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14
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Wong VW, Chong S, Mediratta S, Jalaludin B. Measuring glycated haemoglobin in women with gestational diabetes mellitus: How useful is it? Aust N Z J Obstet Gynaecol 2016; 57:260-265. [PMID: 27501522 DOI: 10.1111/ajo.12511] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Accepted: 07/02/2016] [Indexed: 01/15/2023]
Abstract
BACKGROUND Glycated haemoglobin (HbA1c) is an important tool for assessing glycaemic status in patients with diabetes, but its usefulness in gestational diabetes mellitus (GDM), is unclear. AIMS The aim of this study is to evaluate whether HbA1c in women with GDM is valuable in predicting adverse pregnancy outcomes. MATERIALS AND METHODS A retrospective review of women with GDM who had HbA1c measured at diagnosis of GDM (GHb-diag) and at 36 weeks gestation (GHb-36 weeks) was conducted. The association between HbA1c and various pregnancy outcomes was assessed RESULTS: Among 1244 women with GDM in our cohort, both GHb-diag and GHb-36 weeks were independent predictors for large-for-gestation (LGA) babies (OR 1.06, P = 0.005 and OR 1.06, P = 0.002, respectively) and neonatal hypoglycaemia (OR 1.10, P < 0.001 and OR 1.09, P < 0.001, respectively). Women with HbA1c ≥ 5.4% (35 mmol/mol) at diagnosis had significantly greater risk for LGA (15.3% vs 8.2%, P < 0.001) and neonatal hypoglycaemia (42.2% vs 23.6%, P < 0.001) than those below this cut-off. The difference between GHb-diag and GHb-36 weeks was small and improvement in HbA1c by 36 weeks was not associated with better pregnancy outcomes. CONCLUSION We showed that measurement of HbA1c, either at the time of diagnosis of GDM or toward the end of pregnancy, were both associated with adverse pregnancy outcomes. Women with elevated HbA1c (>5.4% or 35 mmol/mol) at diagnosis of GDM should be monitored closely during pregnancy. However, there is not enough evidence to suggest that repeating HbA1c toward the end of pregnancy will provide additional information in predicting adverse pregnancy outcomes.
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Affiliation(s)
- Vincent W Wong
- Liverpool Diabetes Collaborative Research Unit, Ingham Institute of Applied Science, Liverpool, New South Wales, Australia.,South Western Sydney Clinical School, University of New South Wales, Liverpool, New South Wales, Australia
| | - Shanley Chong
- South Western Sydney Clinical School, University of New South Wales, Liverpool, New South Wales, Australia.,Epidemiology Group, Healthy People and Places Unit, South Western Sydney Local Health District, Liverpool, New South Wales, Australia
| | - Sahil Mediratta
- South Western Sydney Clinical School, University of New South Wales, Liverpool, New South Wales, Australia
| | - Bin Jalaludin
- Epidemiology Group, Healthy People and Places Unit, South Western Sydney Local Health District, Liverpool, New South Wales, Australia.,Ingham Institute, University of New South Wales, Liverpool, New South Wales, Australia
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15
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Abstract
Women with type 1 diabetes (T1DM) have unique needs during the preconception, pregnancy, and postpartum periods. Preconception counseling is essential for women with T1DM to minimize pregnancy risks. The goals of preconception care should be tight glycemic control with a hemoglobin A1c (A1C) < 7 % and as close to 6 % as possible, without significant hypoglycemia. This will lower risks of congenital malformations, preeclampsia, and perinatal mortality. The safety of medications should be assessed prior to conception. Optimal control of retinopathy, hypertension, and nephropathy should be achieved. During pregnancy, the goal A1C is near-normal at <6 %, without excessive hypoglycemia. There is no clear evidence that continuous subcutaneous insulin infusion (CSII) versus multiple daily injections (MDI) is superior in achieving the desired tight glycemic control of T1DM during pregnancy. Data regarding continuous glucose monitoring (CGM) in pregnant women with T1DM is conflicting regarding improved glycemic control. However, a recent CGM study does provide some distinct patterns of glucose levels associated with large for gestational age infants. Frequent eye exams during pregnancy are essential due to risk of progression of retinopathy during pregnancy. Chronic hypertension treatment goals are systolic blood pressure 110-129 mmHg and diastolic blood pressure 65-79 mmHg. Labor and delivery target plasma glucose levels are 80-110 mg/dl, and an insulin drip is recommended to achieve these targets during active labor. Postpartum, insulin doses must be reduced and glucoses closely monitored in women with T1DM because of the enhanced insulin sensitivity after delivery. Breastfeeding is recommended and should be highly encouraged due to maternal benefits including increased insulin sensitivity and weight loss and infant and childhood benefits including reduced prevalence of overweight. In this article, we discuss the care of pregnant patients with T1DM.
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Affiliation(s)
- Anna Z Feldman
- Joslin Diabetes Center, 1 Joslin Place, Boston, MA, 02115, USA
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16
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Yang P, Reece EA, Wang F, Gabbay-Benziv R. Decoding the oxidative stress hypothesis in diabetic embryopathy through proapoptotic kinase signaling. Am J Obstet Gynecol 2015; 212:569-79. [PMID: 25434839 PMCID: PMC4417047 DOI: 10.1016/j.ajog.2014.11.036] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Revised: 11/14/2014] [Accepted: 11/24/2014] [Indexed: 12/25/2022]
Abstract
Maternal diabetes-induced birth defects occur in 6-10% of babies born to mothers with pregestational diabetes, representing a significant maternal-fetal health problem. Currently, these congenital malformations represent a significant maternal-fetal medicine issue, but are likely to create an even greater public health threat as 3 million women of reproductive age (19-44 years) have diabetes in the United States alone, and this number is expected to double by 2030. Neural tube defects (NTDs) and congenital heart defects are the most common types of birth defects associated with maternal diabetes. Animal studies have revealed that embryos under hyperglycemic conditions exhibit high levels of oxidative stress resulting from enhanced production of reactive oxygen species and impaired antioxidant capability. Oxidative stress activates a set of proapoptotic kinase signaling intermediates leading to abnormal cell death in the embryonic neural tube, which causes NTD formation. Work in animal models also has revealed that maternal diabetes triggers a series of signaling intermediates: protein kinase C (PKC) isoforms, PKCα, βII and δ; apoptosis signal-regulating kinase 1; c-Jun-N-terminal kinase (JNK)1/2; caspase; and apoptosis. Specifically, maternal diabetes in rodent models activates the proapoptotic unfolded protein response and endoplasmic reticulum (ER) stress. A reciprocal causation between JNK1/2 activation and ER stress exists in diabetic embryopathy. Molecular studies further demonstrate that deletion of the genes for Prkc, Ask1, Jnk1, or Jnk2 abolishes maternal diabetes-induced neural progenitor apoptosis and ameliorates NTD formation. Similar preventive effects are also observed when apoptosis signal-regulating kinase 1, JNK1/2, or ER stress is inhibited. Cell membrane stabilizers and antioxidant supplements are also effective in prevention of diabetes-induced birth defects. Mechanistic studies have revealed important insights into our understanding the cause of diabetic embryopathy and have provided a basis for future interventions against birth defects or other pregnancy complications associated with maternal diabetes. The knowledge of a molecular pathway map identified in animal studies has created unique opportunities to identify molecular targets for therapeutic intervention.
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Affiliation(s)
- Peixin Yang
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD; Department of Biochemistry and Molecular Biology, University of Maryland School of Medicine, Baltimore, MD.
| | - E Albert Reece
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD; Department of Biochemistry and Molecular Biology, University of Maryland School of Medicine, Baltimore, MD
| | - Fang Wang
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD
| | - Rinat Gabbay-Benziv
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD
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Allnutt KJ, Allan CA, Brown J. Early pregnancy screening for identification of undiagnosed pre-existing diabetes to improve maternal and infant health. Hippokratia 2015. [DOI: 10.1002/14651858.cd011601] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Katherine J Allnutt
- Monash University; Department of Obstetrics and Gynaecology; 246 Clayton Road Clayton Victoria Australia 3168
| | - Carolyn A Allan
- Monash University; Department of Obstetrics and Gynaecology; 246 Clayton Road Clayton Victoria Australia 3168
| | - Julie Brown
- The University of Auckland; Liggins Institute; Park Rd Grafton Auckland New Zealand 1142
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18
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Gabbay-Benziv R, Reece EA, Wang F, Yang P. Birth defects in pregestational diabetes: Defect range, glycemic threshold and pathogenesis. World J Diabetes 2015; 6:481-488. [PMID: 25897357 PMCID: PMC4398903 DOI: 10.4239/wjd.v6.i3.481] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Revised: 12/09/2014] [Accepted: 01/12/2015] [Indexed: 02/05/2023] Open
Abstract
Currently, 60 million women of reproductive age (18-44 years old) worldwide, and approximately 3 million American women have diabetes mellitus, and it has been estimated that this number will double by 2030. Pregestational diabetes mellitus (PGD) is a significant public health problem that increases the risk for structural birth defects affecting both maternal and neonatal pregnancy outcome. The most common types of human structural birth defects associated with PGD are congenital heart defects and central nervous system defects. However, diabetes can induce birth defects in any other fetal organ. In general, the rate of birth defects increases linearly with the degree of maternal hyperglycemia, which is the major factor that mediates teratogenicity of PGD. Stringent prenatal care and glycemic control are effective means to reduce birth defects in PGD pregnancies, but cannot reduce the incidence of birth defects to the rate of that is seen in the nondiabetic population. Studies in animal models have revealed that PGD induces oxidative stress, which activates cellular stress signalling leading to dysregulation of gene expression and excess apoptosis in the target organs, including the neural tube and embryonic heart. Activation of the apoptosis signal-regulating kinase 1 (ASK1)-forkhead transcription factor 3a (FoxO3a)-caspase 8 pathway causes apoptosis in the developing neural tube leading to neural tube defects (NTDs). ASK1 activates the c-Jun-N-Terminal kinase 1/2 (JNK1/2), which leads to activation of the unfolded protein response and endoplasmic reticulum (ER) stress. Deletion of the ASK1 gene, the JNK1 gene, or the JNK2 gene, or inhibition of ER stress by 4-Phenylbutyric acid abrogates diabetes-induced apoptosis and reduces the formation of NTDs. Antioxidants, such as thioredoxin, which inhibits the ASK1-FoxO3a-caspase 8 pathway or ER stress inhibitors, may prevent PGD-induced birth defects.
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Postpartum metabolic control in a cohort of women with type 1 diabetes. ACTA ACUST UNITED AC 2014; 62:125-9. [PMID: 25544593 DOI: 10.1016/j.endonu.2014.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Revised: 10/29/2014] [Accepted: 11/05/2014] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVE Pregnancy in women with type 1 diabetes (T1D) involves greater risks as compared to non-diabetic women, but less information is available about blood glucose and weight control after delivery. Our aim was to evaluate the postpartum metabolic profile (blood glucose and weight control) of women with T1D and the factors related to those metabolic outcomes. METHODS A retrospective, observational study of 36 women with T1D during pregnancy and for up to one year after delivery. RESULTS Fifty percent of patients attended a preconceptional planning program (PPP), and 44.4% of women were treated with continuous subcutaneous insulin infusion. Mean preconceptional HbA1c and body mass index (BMI) were 7.2±1.2% and 23.8±5.0 respectively. In the total cohort, blood glucose control significantly worsened one year after delivery (HbA1c: 7.2±1.2 vs 7.6±1.2%, P<0.001). Lower preconceptional HbA1c values were found in patients who attended PPP (6.6±0.5 vs. 7.8±1.4%; P=0.02), and were maintained for one year after delivery. No differences were found in body mass index (BMI) from the pregestational period to one year after delivery in any of two groups (No PPP 22.5±4.6 vs 23.2±4.8, P=0.078; PPP 25.4±3.4 vs 25.5±3.4 kg/m(2), P=0.947). Preconceptional HbA1c was shown to be the most important determinant of metabolic control (β=0.962, p<0.001) and weight one year after delivery (β=0.524, p=0.025) and weight gain during pregnancy (β=0.633, p=0.004). CONCLUSIONS Pregnant women with T1D return to prepregnancy body weight one year after delivery, especially those with lower HbA1c levels and BMI before pregnancy. However, blood glucose control deteriorates after delivery, suggesting the need for changes in clinical practice after delivery.
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Lassi ZS, Imam AM, Dean SV, Bhutta ZA. Preconception care: screening and management of chronic disease and promoting psychological health. Reprod Health 2014; 11 Suppl 3:S5. [PMID: 25415675 PMCID: PMC4196564 DOI: 10.1186/1742-4755-11-s3-s5] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION A large proportion of women around the world suffer from chronic diseases including mental health diseases. In the United States alone, over 12% of women of reproductive age suffer from a chronic medical condition, especially diabetes and hypertension. Chronic diseases significantly increase the odds for poor maternal and newborn outcomes in pregnant women. METHODS A systematic review and meta-analysis of the evidence was conducted to ascertain the possible impact of preconception care for preventing and managing chronic diseases and promoting psychological health on maternal, newborn and child health outcomes. A comprehensive strategy was used to search electronic reference libraries, and both observational and clinical controlled trials were included. Cross-referencing and a separate search strategy for each preconception risk and intervention ensured wider study capture. RESULTS Maternal prepregnancy diabetic care is a significant intervention that reduces the occurrence of congenital malformations by 70% (95% Confidence Interval (CI): 59-78%) and perinatal mortality by 69% (95% CI: 47-81%). Furthermore, preconception management of epilepsy and phenylketonuria are essential and can optimize maternal, fetal and neonatal outcomes if given before conception. Ideally changes in antiepileptic drug therapy should be made at least 6 months before planned conception. Interventions specifically targeting women of reproductive age suffering from a psychiatric condition show that group-counseling and interventions leading to empowerment of women have reported non-significant reduction in depression (economic skill building: Mean Difference (MD) -7.53; 95% CI: -17.24, 2.18; counseling: MD-2.92; 95% CI: -13.17, 7.33). CONCLUSION While prevention and management of the chronic diseases like diabetes and hypertension, through counseling, and other dietary and pharmacological intervention, is important, delivering solutions to prevent and respond to women's psychological health problems are urgently needed to combat this leading cause of morbidity.
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Affiliation(s)
- Zohra S Lassi
- Division of Women and Child Health, Aga Khan University Karachi, Pakistan
| | - Ayesha M Imam
- Division of Women and Child Health, Aga Khan University Karachi, Pakistan
| | - Sohni V Dean
- Division of Women and Child Health, Aga Khan University Karachi, Pakistan
| | - Zulfiqar A Bhutta
- Division of Women and Child Health, Aga Khan University Karachi, Pakistan
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Abstract
The notion of preconception care aims to target the existing risks before pregnancy, whereby resources may be used to improve reproductive health and optimize knowledge before conceiving. The preconception period provides an opportunity to intervene earlier to optimize the health of potential mothers (and fathers) and to prevent harmful exposures from affecting the developing fetus. These interventions include birth spacing and preventing teenage pregnancy, promotion of contraceptive use, optimization of weight and micronutrient status, prevention and management of infectious diseases, and screening for and managing chronic conditions. Given existing interventions and the need to organize services to optimize delivery of care in a logical and effective manner, interventions are frequently co-packaged or bundled together. This paper highlights packages of preconception interventions that can be combined and co-delivered to women through various delivery channels and provides a logical framework for development of such packages in varying contexts.
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Affiliation(s)
- Zohra S Lassi
- Division of Women and Child Health, Aga Khan University Karachi, Pakistan
| | - Sohni V Dean
- Division of Women and Child Health, Aga Khan University Karachi, Pakistan
| | - Dania Mallick
- Division of Women and Child Health, Aga Khan University Karachi, Pakistan
| | - Zulfiqar A Bhutta
- Division of Women and Child Health, Aga Khan University Karachi, Pakistan
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22
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Baack ML, Wang C, Hu S, Segar JL, Norris AW. Hyperglycemia induces embryopathy, even in the absence of systemic maternal diabetes: an in vivo test of the fuel mediated teratogenesis hypothesis. Reprod Toxicol 2014; 46:129-36. [PMID: 24721120 DOI: 10.1016/j.reprotox.2014.03.013] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Revised: 03/31/2014] [Accepted: 03/31/2014] [Indexed: 12/29/2022]
Abstract
Embryonic exposure to excess circulating fuels is proposed to underlie diabetic embryopathy. To isolate the effects of hyperglycemia from the many systemic anomalies of diabetes, we infused 4 mg/min glucose into the left uterine artery of non-diabetic pregnant rats on gestation days (GD) 7-9. Right-sided embryos and dams exhibited no glucose elevation. Embryos were assessed on GD13, comparing the left versus right uterine horns. Hyperglycemic exposure increased rates of embryopathy, resorptions, and worsened embryopathy severity. By contrast, saline infusion did not affect any of these parameters. To assess for possible embryopathy susceptibility bias between uterine horns, separate dams were given retinoic acid (25mg/kg, a mildly embryopathic dose) systemically on GD7.5. The resultant embryopathy rates were equivalent between uterine horns. We conclude that hyperglycemia, even in the absence of systemic maternal diabetes, is sufficient to produce in vivo embryopathy during organogenesis.
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Affiliation(s)
- Michelle L Baack
- University of Iowa Children's Hospital, Department of Pediatrics, Iowa City, IA, USA
| | - Chunlin Wang
- University of Iowa Children's Hospital, Department of Pediatrics, Iowa City, IA, USA
| | - Shanming Hu
- University of Iowa Children's Hospital, Department of Pediatrics, Iowa City, IA, USA
| | - Jeffrey L Segar
- University of Iowa Children's Hospital, Department of Pediatrics, Iowa City, IA, USA
| | - Andrew W Norris
- University of Iowa Children's Hospital, Department of Pediatrics, Iowa City, IA, USA.
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James-Todd T, Janevic T, Brown FM, Savitz DA. Race/ethnicity, educational attainment, and pregnancy complications in New York City women with pre-existing diabetes. Paediatr Perinat Epidemiol 2014; 28:157-65. [PMID: 24354778 PMCID: PMC4282790 DOI: 10.1111/ppe.12100] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND More women are entering pregnancy with pre-existing diabetes. Disease severity, glycaemic control, and predictors of pregnancy complications may differ by race/ethnicity or educational attainment, leading to differences in adverse pregnancy outcomes. METHODS We used linked New York City hospital record and birth certificate data for 6291 singleton births among women with pre-existing diabetes between 1995 and 2003. We defined maternal race/ethnicity as non-Hispanic white, non-Hispanic black, Hispanic, South Asian, and East Asian, and education level as <12, 12, and >12 years. Our outcomes were pre-eclampsia, preterm birth (PTB) (<37 weeks gestation and categorised as spontaneous or medically indicated), as well as small-for-gestational age (SGA) and large-for-gestational age (LGA). Using multivariable binomial regression, we estimated the risk ratios for pre-eclampsia, SGA, and LGA. We used multivariable multinomial regression to estimate odds ratios (OR) for PTB. RESULTS Compared with non-Hispanic white women with pre-existing diabetes, non-Hispanic black and Hispanic women with pre-existing diabetes had a 1.50-fold increased risk of pre-eclampsia compared with non-Hispanic whites with pre-existing diabetes, after full adjustment. Non-Hispanic black and Hispanic women with pre-existing diabetes had adjusted ORs of 1.72 [adj. 95% confidence interval (CI) 1.38, 2.15] and 1.65 [adj.95% CI 1.32, 2.05], respectively, for medically indicated PTB. South Asian women with pre-existing diabetes had the highest risk for having an SGA infant [adj. OR: 2.29; adj. 95% CI 1.73, 3.03]. East Asian ethnicity was not associated with these pregnancy complications. CONCLUSIONS Non-Hispanic black, Hispanic, and South Asian women with pre-existing diabetes may benefit from targeted interventions to improve pregnancy outcomes.
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Affiliation(s)
- Tamarra James-Todd
- Connors Center for Women's Health and Gender Biology, Brigham and Women's Hospital and Harvard Medical SchoolBoston, MA
| | - Teresa Janevic
- Department of Epidemiology, Rutgers School of Public HealthPiscataway, NJ
| | | | - David A Savitz
- Departments of Epidemiology and Obstetrics and Gynecology, Brown UniversityProvidence, RI
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Lassi ZS, Bhutta ZA. Risk factors and interventions related to maternal and pre-pregnancy obesity, pre-diabetes and diabetes for maternal, fetal and neonatal outcomes: a systematic review. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/17474108.2013.841453] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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An update on diabetic women obstetrical outcomes linked to preconception and pregnancy glycemic profile: a systematic literature review. ScientificWorldJournal 2013; 2013:254901. [PMID: 24319351 PMCID: PMC3836410 DOI: 10.1155/2013/254901] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Accepted: 09/24/2013] [Indexed: 12/25/2022] Open
Abstract
Women with type 2 diabetes were less likely to have diabetes related complications than women with type 1. Women with type 1 diabetes had a high prepregnancy care and showed a worse glycemic control than women with type 2 both in the preconception period and during pregnancy. Obstetrical outcomes showed that preeclampsia and stillbirth rate is almost doubled in type 1 patients while perinatal deaths and SGA importantly increased in type 2 diabetes. In modern obstetrical care it is mandatory to maintain glucose levels as close to normal as possible particularly in diabetic population. HbA1C no higher than 6% before pregnancy and during the first trimester seems to decrease the risk of adverse obstetrical outcomes. Both the preconceptional counseling and glycemic profile optimization represent a fundamental step to improve pregnancy outcomes in women with preexisting diabetes. A systematic approach to family planning and the availability of preconception care for all diabetic women who desire pregnancy could be an essential step for diabetic management program.
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26
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Komiti A, Jackson HJ, Nankervis A, Conn J, Allan C, Judd F. An investigation of psycho-social factors associated with the uptake of pre-pregnancy care in Australian women with type 1 and type 2 diabetes. J Psychosom Obstet Gynaecol 2013; 34:75-81. [PMID: 23701456 DOI: 10.3109/0167482x.2013.793664] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Pre-pregnancy care (PPC) reduces adverse pregnancy outcomes for women with pre-existing diabetes. Yet, despite the compelling case for PPC, participation rates remain poor. The reasons for poor participation are as yet unclear. The aim of this study was to further our understanding of the factors-associated PPC uptake, particularly attitudes and beliefs towards PPC using models of health behaviour: The Health Belief Model, Social Cognitive Theory, and Theory of Reasoned Action. Participants comprised 123 women with type 1 and 2 diabetes attending outpatient clinics for diabetes and pregnancy, who completed questionnaires. Logistic regression analysis indicated that after adjusting for socio-demographic factors, exposure to a greater number of cues was a significant predictor of PPC participation (odds ratio [OR]: 1.93; 95% confidence interval [95% CI]: 1.13-3.28). Other significant predictors of PPC uptake were older age (OR: 1.13; 95% CI: 1.01-1.26) and not having children (OR: 3.93; 95% CI: 1.28-12.06). The findings from this study support initiatives to provide cues to PPC for women with diabetes to enhance PPC uptake. Further, some groups such as younger women as well as women with children may possibly be considered for the focus of more vigorous intervention efforts.
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Affiliation(s)
- A Komiti
- Department of Psychiatry, The University of Melbourne, Parkville, Victoria, Australia.
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Passarella G, Trifirò G, Gasparetto M, Moreolo GS, Milanesi O. Disorders in glucidic metabolism and congenital heart diseases: detection and prevention. Pediatr Cardiol 2013; 34:931-7. [PMID: 23229289 DOI: 10.1007/s00246-012-0577-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2012] [Accepted: 10/12/2012] [Indexed: 11/24/2022]
Abstract
The identification of gestational diabetes (GDM) through appropriate screening and its subsequent treatment have not been demonstrated to limit neonatal malformations to date. This study aimed to detect congenital heart diseases in newborns of mothers with GDM by evaluating the existence of a correlation with maternal glycemic control. This observational prospective study investigated newborns of mothers with GDM enrolled during a period of 9 months. Four subgroups were considered according to the type of maternal glucidic alteration during pregnancy and the home treatment: impaired glucose tolerance, insulin-dependent gestational diabetes mellitus (IDDM), non-insulin-dependent gestational diabetes mellitus (NIDDM), and gestational diabetes not controlled (NC: untreated diabetes). Student's t test was used to compare the subgroups. The study enrolled 65 newborns (30 boys) born to 82 of mothers with impaired glucidic metabolism. Patent ductus arteriosus was observed in 11 patients (16.9 %), pulmonary stenosis of mild grade in 4 patients ( 6.2 %), and hypertrophy of the ventricular septum in 22 patients (33.8 %). A total of 14 patients had increased thickness in the left ventricle posterior wall, and 17 patients had an abnormal electrocardiogram. Hyperglycemia can influence the development of the fetal heart, affecting both its structure and its function. A treatment with insulin for women with GDM is supported by the study data.
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Affiliation(s)
- G Passarella
- Struttura Operativa Complessa di Pediatria, Ospedale Santa Maria della Misericordia, Viale Tre Martiri n° 140, CAP 45100, Rovigo, Italy.
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Wong VW, Suwandarathne H, Russell H. Women with pre-existing diabetes under the care of diabetes specialist prior to pregnancy: are their outcomes better? Aust N Z J Obstet Gynaecol 2013; 53:207-10. [PMID: 23452190 DOI: 10.1111/ajo.12044] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Accepted: 11/23/2012] [Indexed: 11/30/2022]
Abstract
In this retrospective study, pregnant women with type 1 diabetes under the care of diabetes specialists pre-conception were found to have better glycaemic control and pregnancy outcomes than those not under specialist care prior to pregnancy. These differences were not seen in women with type 2 diabetes. The study showed that tight glycaemic control in women with pre-existing diabetes was associated with better pregnancy outcomes, and we believe women with type 1 diabetes should be managed by a diabetes specialist before pregnancy.
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Affiliation(s)
- Vincent W Wong
- Diabetes and Endocrine Service, Liverpool Hospital, Liverpool BC, New South Wales, Australia.
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29
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Wahabi HA, Alzeidan RA, Esmaeil SA. Pre-pregnancy care for women with pre-gestational diabetes mellitus: a systematic review and meta-analysis. BMC Public Health 2012; 12:792. [PMID: 22978747 PMCID: PMC3575330 DOI: 10.1186/1471-2458-12-792] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Accepted: 09/14/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pre-gestational diabetes mellitus is associated with increased risk for maternal and fetal adverse outcomes. This systematic review was carried out to evaluate the effectiveness and safety of pre-pregnancy care in improving the rate of congenital malformations and perinatal mortality for women with pre-gestational diabetes mellitus. METHODS We searched the following databases, MEDLINE, EMBASE, WEB OF SCIENCE, Cochrane Library, including the CENTRAL register of controlled trials and CINHAL up to December 2011, without language restriction, for any pre-pregnancy care aiming at health promotion, glycemic control and screening and treatment of diabetes complications in women with type I or type II diabetes mellitus. Study design were trials (randomized and non-randomized), cohort and case-control studies. RESULTS Of the 2452 title scanned 54 full papers were retrieved of those 21 studies were included in this review. Twelve cohort studies at low and medium risk of bias, with 3088 women, were included in the meta-analysis. Meta-analysis suggested that pre-pregnancy care is effective in reducing congenital malformation, Risk Ratio (RR) 0.25 (95% CI 0.16-0.37), number needed to treat (NNT) 19 (95% CI 14-24), and perinatal mortality RR 0.34 (95% CI 0.15-0.75), NNT = 46 (95% CI 28-115). Pre-pregnancy care lowers glycosylated hemoglobin A1c (HbA1c) in the first trimester of pregnancy by an average of 1.92% (95% CI -2.05 to -1.79). However women who received pre-pregnancy care were at increased risk of hypoglycemia during the first trimester of pregnancy RR 1.51 (95% CI 1.15-1.99). CONCLUSION Pre-pregnancy care for women with pre-gestational type 1 or type 2 diabetes mellitus is effective in improving rates of congenital malformations, perinatal mortality and in reducing maternal HbA1C in the first trimester of pregnancy. Pre-pregnancy care might cause maternal hypoglycemia in the first trimester of pregnancy.
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Affiliation(s)
- Hayfaa A Wahabi
- Sheikh Bahmdan Chair of Evidence-based Healthcare and Knowledge Translation, College of Medicine, King Saud University, Riyadh, Saudi Arabia.
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Biomarkers of maternal diabetes and its complication in pregnancy. Reprod Toxicol 2012; 34:174-9. [PMID: 22659274 DOI: 10.1016/j.reprotox.2012.05.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Revised: 05/08/2012] [Accepted: 05/10/2012] [Indexed: 01/05/2023]
Abstract
There are specific biomarkers - indicators of normal and abnormal processes - in diabetic pregnancies that predict the degree of diabetic control as well as embryonic and fetal growth and development. They can be detected in maternal blood, amniotic fluid or in the cord plasma of the newborn infant. While the cord plasma levels are of little clinical relevance because they do not allow us to interfere with the outcome of pregnancy, biomarkers in maternal blood or amniotic fluid may help us to better control the outcome of diabetic pregnancies. Important biomarkers in maternal blood are fasting glucose, HbA1c and IGFs. Relevant biomarkers in amniotic fluid are insulin, erythropoietin and markers of bone formation and resorption. Cord plasma biomarkers include IGFs, leptin, adiponectin, resistin, markers of oxidative stress and of hypoxia. Whether these biomarkers can be predictors of long term outcome in infants of diabetic mothers is yet to be determined.
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31
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Denny CH, Floyd RL, Green PP, Hayes DK. Racial and ethnic disparities in preconception risk factors and preconception care. J Womens Health (Larchmt) 2012; 21:720-9. [PMID: 22559934 DOI: 10.1089/jwh.2011.3259] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE At-risk drinking, cigarette smoking, obesity, diabetes, and frequent mental distress, as well as their co-occurrence in childbearing aged women, are risk factors for adverse pregnancy outcomes. This study estimated the prevalence of these five risk factors individually and in combination among nonpregnant women aged 18-44 years by demographic and psychosocial characteristics, with a focus on racial and ethnic disparities. METHODS Data from the 2008 Behavioral Risk Factor Surveillance System (BRFSS) on nonpregnant women aged 18-44 years (n=54,612) were used to estimate the prevalences of five risk factors, pairs of co-occurring risk factors, and multiple risk factors for poor pregnancy outcomes. RESULTS The majority of women had at least one risk factor, and 18.7% had two or more risk factors. Having two or more risk factors was highest among women who were American Indian and Alaska Native (34.4%), had less than a high school education (28.7%), were unable to work (50.1%), were unmarried (23.3%), and reported sometimes, rarely, or never receiving sufficient social and emotional support (32.8%). The most prevalent pair of co-occurring risk factors was at-risk drinking and smoking (5.7%). CONCLUSIONS The high proportion of women of childbearing age with preconception risk factors highlights the need for preconception care. The common occurrence of multiple risk factors suggests the importance of developing screening tools and interventions that address risk factors that can lead to poor pregnancy outcomes. Increased attention should be given to high-risk subgroups.
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Affiliation(s)
- Clark H Denny
- Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA.
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Cyganek K, Hebda-Szydlo A, Skupien J, Katra B, Janas I, Borodako A, Kaim I, Klupa T, Reron A, Malecki MT. Glycemic control and pregnancy outcomes in women with type 2 diabetes from Poland. The impact of pregnancy planning and a comparison with type 1 diabetes subjects. Endocrine 2011; 40:243-9. [PMID: 21528433 DOI: 10.1007/s12020-011-9475-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2011] [Accepted: 04/06/2011] [Indexed: 12/22/2022]
Abstract
The number of pregnancies complicated by type 2 diabetes mellitus (T2DM) is growing; however, their clinical characteristics remain incomplete. We aimed to assess clinical characteristics, glycemic control, and selected pregnancy outcomes in pregestational T2DM from Poland and to compare them with those of T1DM. We analyzed 415 consecutive singleton pregnancies; among them, there were 70 women with T2DM and 345 with T1DM. As compared to T1DM patients, women with T2DM were older (mean age 33.1 years vs. 27.8, respectively), heavier before pregnancy (mean BMI 30.8 kg/m² vs. 23.9), and had a shorter duration of diabetes (mean 3.3 years vs. 11.4); ( P<0.0001 for all comparisons). The gestational age at the first visit was higher in T2DM (mean 11.4 weeks vs. 8.6; P=0.0004). Nevertheless, they had better glycemic control in the first trimester (mean HbA1c 6.2% vs. 7.0; P=0.003); in subsequent months, the differences in HbA1c were no longer significant. T2DM women gained less weight during pregnancy (mean 9.9 kgs vs. 14.1; P<0.0001). The proportion of miscarriages (10.0 vs. 7.3%; P=0.32), preterm deliveries (12.7 vs. 17.8%; P=0.32), combined infant deaths, and congenital malformations were similar in both groups (9.5 vs. 8.8%; P=0.4) as was the frequency of caesarean sections (58.7 vs. 64.1%; P=0.30). Macrosomic babies were more than twice less frequent in T2DM and the difference reached borderline significance (7.9 vs. 17.5%, P=0.07). Pregnancy planning in T2DM had a significant impact on HbA1c in the first trimester (5.7 vs. 6.4% in the planning vs. the not planning group, P=0.02); the difference was not significant in the second and third trimester. T2DM women had better glycemic control in the first trimester than T1DM subjects and gained less weight during pregnancy. This could have been the reason for the slightly lower number of macrosomic babies but did not affect other outcomes. In T2DM, pregnancy planning had a beneficial glycemic effect in the first trimester.
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Affiliation(s)
- Katarzyna Cyganek
- Department of Metabolic Diseases, Jagiellonian University, Medical College, 15 Kopernika Street, 31-511, Krakow, Poland
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Yehuda I, Nagtalon‐Ramos J, Trout K. Fetal Growth Scans and Amniotic Fluid Assessments in Pregestational and Gestational Diabetes. J Obstet Gynecol Neonatal Nurs 2011; 40:603-14; quiz 614-6. [DOI: 10.1111/j.1552-6909.2011.01283.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Nolan JA, McCrone S, Chertok IRA. The maternal experience of having diabetes in pregnancy. ACTA ACUST UNITED AC 2011; 23:611-8. [DOI: 10.1111/j.1745-7599.2011.00646.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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35
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Segev Y, Riskin-Mashiah S, Lavie O, Auslender R. Assisted reproductive technologies: medical safety issues in the older woman. J Womens Health (Larchmt) 2011; 20:853-61. [PMID: 21510806 DOI: 10.1089/jwh.2010.2603] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Abstract Previous study has shown that in the United States, most maternal deaths and severe obstetric complications due to chronic disease are potentially preventable through improved medical care before conception. Many women who need assisted reproductive technology (ART) because of infertility are older than the average pregnant woman. Risks for such chronic diseases as obesity, diabetes mellitus, chronic hypertension, cardiovascular disease (CVD), and malignancy greatly increase with maternal age. Chronic illness increases the risk of the in vitro fertilization (IVF) procedure and is also associated with increased obstetric risk and even death. The objective of this review is to outline the potential risks for older women who undergo ART procedures and pregnancy and to characterize guidelines for evaluation before enrollment in ART programs. A PubMed search revealed that very few studies have related to pre-ART medical evaluation. Therefore, we suggest a pre-ART medical assessment, comparable to the recommendations of the American Heart Association before noncompetitive physical activity and the American Society of Anesthesiologists before elective surgery. This assessment should include a thorough medical questionnaire and medical examination. Further evaluation and treatment should follow to ensure the safety of ART procedures and of ensuing pregnancies.
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Affiliation(s)
- Yakir Segev
- Department of Obstetrics and Gynecology, The Lady Davis Carmel Medical Center, Rappaport Faculty of Medicine, Technion, 7 Michal Street, Haifa, Israel .
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Singh CK, Kumar A, Hitchcock DB, Fan D, Goodwin R, LaVoie HA, Nagarkatti P, DiPette DJ, Singh US. Resveratrol prevents embryonic oxidative stress and apoptosis associated with diabetic embryopathy and improves glucose and lipid profile of diabetic dam. Mol Nutr Food Res 2011; 55:1186-96. [PMID: 21254394 DOI: 10.1002/mnfr.201000457] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2010] [Revised: 11/26/2010] [Accepted: 11/30/2010] [Indexed: 01/12/2023]
Abstract
SCOPE Diabetic embryopathy, a consequence of diabetic pregnancy, is associated with increase in embryonic oxidative stress and apoptosis, which lead to severe embryonic damage at early stage of organogenesis. METHODS AND RESULTS This study investigated if resveratrol, found in red grapes and blue-berries, may prevent diabetes-induced oxidative stress and apoptosis in embryos and have beneficial effects in diabetic dams. A rodent model of diabetic embryopathy was used. Diabetes was associated with lowered reduced glutathione levels (26.98%), increased total thiol (100.47%) and lipid peroxidation (124.73%) in embryos, and increased blood sugar (384.03%), cholesterol (98.39%) and triglyceride (1025.35%) in diabetic dams. Increased apoptosis (272.20%) was also observed in the embryos of diabetic dams. Administration of resveratrol (100 mg/kg body weight (b.w.)) during pregnancy prevented both oxidative stress and apoptosis in embryos. Resveratrol reduced embryonic maldevelopment by improving embryo weight (41.23%), crown rump length (16.50%) and somite number (11.22%). It further improved the glucose (33.32%) and lipid (cholesterol 41.74%, triglyceride 60.64%) profile of the diabetic dams, which also represents the protective role of resveratrol in diabetes. CONCLUSION Resveratrol was found to prevent embryonic oxidative stress and apoptosis. It also improved glucose and lipid profile of diabetic dams, indicating the beneficial effects in diabetic pregnancy.
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Affiliation(s)
- Chandra K Singh
- Department of Pathology, Microbiology and Immunology, School of Medicine, University of South Carolina, Columbia, SC, USA
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37
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Pacaud D, Dewey D. Neurocognitive outcome of children exposed to severe hypoglycemiain utero. ACTA ACUST UNITED AC 2011. [DOI: 10.2217/dmt.10.10] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Preconception care for diabetic women for improving maternal and fetal outcomes: a systematic review and meta-analysis. BMC Pregnancy Childbirth 2010; 10:63. [PMID: 20946676 PMCID: PMC2972233 DOI: 10.1186/1471-2393-10-63] [Citation(s) in RCA: 133] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2010] [Accepted: 10/14/2010] [Indexed: 11/24/2022] Open
Abstract
Background Preexisting diabetes mellitus is associated with increased risk for maternal and fetal adverse outcomes. Despite improvement in the access and quality of antenatal care recent population based studies demonstrating increased congenital abnormalities and perinatal mortality in diabetic mothers as compared to the background population. This systematic review was carried out to evaluate the effectiveness and safety of preconception care in improving maternal and fetal outcomes for women with preexisting diabetes mellitus. Methods We searched the following databases, MEDLINE, EMBASE, WEB OF SCIENCE, Cochrane Library, including the CENTRAL register of controlled trials and CINHAL up to December 2009, without language restriction, for any preconception care aiming at health promotion, glycemic control and screening and treatment of diabetes complications in women of reproductive age group with type I or type II diabetes. Study design were trials (randomized and non-randomized), cohort and case-control studies. Of the 1612 title scanned 44 full papers were retrieved of those 24 were included in this review. Twelve cohort studies at low and medium risk of bias, with 2502 women, were included in the meta-analysis. Results Meta-analysis suggested that preconception care is effective in reducing congenital malformation, RR 0.25 (95% CI 0.15-0.42), NNT17 (95% CI 14-24), preterm delivery, RR 0.70 (95% CI 0.55-0.90), NNT = 8 (95% CI 5-23) and perinatal mortality RR 0.35 (95% CI 0.15-0.82), NNT = 32 (95% CI 19-109). Preconception care lowers HbA1c in the first trimester of pregnancy by an average of 2.43% (95% CI 2.27-2.58). Women who received preconception care booked earlier for antenatal care by an average of 1.32 weeks (95% CI 1.23-1.40). Conclusion Preconception care is effective in reducing diabetes related congenital malformations, preterm delivery and maternal hyperglycemia in the first trimester of pregnancy.
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Kitzmiller JL, Wallerstein R, Correa A, Kwan S. Preconception care for women with diabetes and prevention of major congenital malformations. ACTA ACUST UNITED AC 2010; 88:791-803. [DOI: 10.1002/bdra.20734] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Vitoratos N, Vrachnis N, Valsamakis G, Panoulis K, Creatsas G. Perinatal mortality in diabetic pregnancy. Ann N Y Acad Sci 2010; 1205:94-8. [PMID: 20840259 DOI: 10.1111/j.1749-6632.2010.05670.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Perinatal mortality rate (PMR) is one of the most important perinatal health indicators. PMR in diabetic pregnancies varies throughout the world and is higher than the background PMR. The prevalence of pregestational diabetes is increasing and is associated with an elevated risk of congenital malformations, macrosomia, preeclampsia, and preterm delivery. The incidence of PMR in preexisting diabetes mellitus ranges considerably, with congenital abnormalities and preterm labor the main factors contributing to the higher PMR. Women with gestational diabetes mellitus or impaired glucose tolerance are a mixed group that may have low to a high PMR, especially if they require insulin in their pregnancy. All the known diabetic women should plan their pregnancies and optimize glycemic control periconceptually and throughout pregnancy, as this reduces the frequency of congenital abnormalities, obstetric complications, and perinatal mortality.
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Affiliation(s)
- N Vitoratos
- Second Department of Obstetrics and Gynecology, Aretaieio Hospital, University of Athens Medical School, Athens, Greece.
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Cyganek K, Hebda-Szydlo A, Katra B, Skupien J, Klupa T, Janas I, Kaim I, Sieradzki J, Reron A, Malecki MT. Glycemic control and selected pregnancy outcomes in type 1 diabetes women on continuous subcutaneous insulin infusion and multiple daily injections: the significance of pregnancy planning. Diabetes Technol Ther 2010; 12:41-7. [PMID: 20082584 DOI: 10.1089/dia.2009.0081] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Two regimens are used to achieve excellent glycemic control during pregnancy in type 1 diabetes mellitus (T1DM): continuous subcutaneous insulin infusion (CSII) and multiple daily injections (MDI). We assessed their efficacy and safety and the effect of pregnancy planning. METHODS We examined 269 pregnant T1DM women: 157 treated with MDI (MDI group), 42 with CSII (CSII group), and 70 who switched from MDI to CSII in the first trimester (MDI/CSII group). There were 116 women who planned pregnancy: 58 in the MDI group, 38 in the CSII group, and 20 in the MDI/CSII group. The estimated differences in glycemic control and maternal and fetal outcomes were adjusted for baseline characteristics. RESULTS Mean glycated A1c (HbA1c) in the first trimester in the whole group was 6.9%, and the women differed depending on whether they planned pregnancy or not (P < 0.0001). A multiple regression model showed an average difference of about 0.9% in favor of pregnancy planning, with no interaction between the planning and treatments. In the second trimester, HbA1c decreased to a mean value of 5.8%, with improvement of HbA1c across all treatments: by 1.5% in not-planning and 0.9% in planning women. Despite greater improvement, not-planning women still had a higher HbA1c (by 0.3%, P = 0.05). In the third trimester, there was no further significant changes; nevertheless, women who planned pregnancy still had a lower HbA1c (by 0.5%, P = 0.02). There were 14 malformations, stillbirths, and perinatal infant deaths in the not-planning versus five in the planning group (P = 0.07). Patients in the CSII group had a 2 kg greater weight gain compared to the MDI group (15.0 kg vs. 13.0 kg; P = 0.005). CONCLUSIONS In pregnancy with T1DM, both MDI and CSII can provide excellent glycemic control. Pregnancy planning has a beneficial effect on glycemic control, independent from the therapy model. CSII seems to predispose to a larger weight gain in mothers.
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Affiliation(s)
- Katarzyna Cyganek
- Department of Metabolic Diseases, Jagiellonian University Medical College, 31-511 Krakow, Poland
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Peticca P, Keely EJ, Walker MC, Yang Q, Bottomley J. Pregnancy Outcomes in Diabetes Subtypes: How Do They Compare? A Province-based Study of Ontario, 2005–2006. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2009; 31:487-496. [DOI: 10.1016/s1701-2163(16)34210-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Effects of maternal glycemia on fetal heart rate in pregnancies complicated by pregestational diabetes mellitus. Eur J Obstet Gynecol Reprod Biol 2009; 143:14-7. [DOI: 10.1016/j.ejogrb.2008.10.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2008] [Revised: 08/21/2008] [Accepted: 10/22/2008] [Indexed: 11/21/2022]
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Abstract
According to the American Diabetes Association, unplanned pregnancies in women with diabetes could lead to abnormal metabolic control, which causes fetal and maternal complications. Preconception planning can decrease these risks. This article reports on the progress in preconception planning over the past 2 years.
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Affiliation(s)
- Denise Charron-Prochownik
- Health Promotion and Development, School of Nursing, University of Pittsburgh, 440 Victoria Building, Pittsburgh, PA 15261, USA.
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Jia DY, Liu HJ, Wang FW, Liu SM, Ling EA, Liu K, Hao AJ. Folic acid supplementation affects apoptosis and differentiation of embryonic neural stem cells exposed to high glucose. Neurosci Lett 2008; 440:27-31. [DOI: 10.1016/j.neulet.2008.05.053] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2008] [Revised: 05/03/2008] [Accepted: 05/13/2008] [Indexed: 11/27/2022]
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Abstract
Diabetes in pregnancy confers a number of risks for both the mother and her baby, and many of these risks are encountered in the labor and delivery unit. The obstetric provider caring for women with diabetes should be alert to the risk of hypertension and the potential for difficult delivery due to an overgrown fetus. Women with preexisting diabetes or poor glycemic control are at increased risk for poor obstetrical outcomes such as stillbirth or delivery of a malformed infant. Meticulous attention to avoiding maternal hyperglycemia during labor can prevent neonatal hypoglycemia.
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Affiliation(s)
- J Seth Hawkins
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, Texas 75390, USA
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Affiliation(s)
- Raul Artal
- Department of Obstetrics, Gynecology and Women's Health, Saint Louis University, School of Medicine, Saint Louis, MO 63117, USA.
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. JE, . SA, . NB. Microbial Population Dynamics as a Function of Sediment Salinity Gradients in the Qua Iboe Estuary Mangrove Swamp (Nigeria). ACTA ACUST UNITED AC 2006. [DOI: 10.3923/jm.2006.255.265] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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