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Dargel S, Westphal J, Kloos C, Schleußner E, Weschenfelder F, Groten T. Stillbirth in women with Type 1 Diabetes mellitus-still a current topic. Arch Gynecol Obstet 2024; 310:2015-2021. [PMID: 38958733 PMCID: PMC11392961 DOI: 10.1007/s00404-024-07609-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 06/19/2024] [Indexed: 07/04/2024]
Abstract
PURPOSE Compared to the general stillbirth rate in Germany for term deliveries of 0.12% the risk in type 1 diabetes mellitus is reported to be up to ten times higher. The reasons for this excess risk of intrauterine demise are still not fully elucidated. Risk factors named in the literature include poor glycemic control before and during pregnancy and the occurrence of ketoacidosis. Additionally there might be a diabetes related type of placental dysfunction leading to organ failure in late pregnancy. Understanding the underlying causes is mandatory to develop strategies to reduce the incidences. The Purpose of this publication is to point out the difficulties in prediction of intrauterine death in pregnant type 1 diabetes patients and thus emphasizing the necessity of constant awareness to all caregivers. METHODS We present a case series of four cases of stillbirth that occurred in patients with type 1 diabetes mellitus at our tertiary care obstetric unit during a five-year period. RESULTS In all four presented cases the underlying cause of intrauterine demise was different and we could not find a common mechanism or risk profile. Furthermore, established monitoring tools did not become peculiar to raise awareness. We compared our cases to published data. Underlying causes of intrauterine death in type 1 diabetes are discussed in the light of the current literature. CONCLUSIONS The main risk factors of stillbirth in diabetic pregnancies are high maternal blood glucose levels including pre-conceptional HbA1c and diabetic ketoacidosis. Late acute placental insufficiency are associated with intrauterine death in type 1 diabetes. Despite the elevated risk of near term intrauterine demise there are currently no guidelines on how to monitor pregnancies in type 1 diabetes for fetal distress during the third trimester. Established thresholds for fetal Doppler data indicating fetal distress in normal and growth restricted fetuses may not be applicable for overgrown fetuses. Future research on how to monitor the diabetic fetus needs to be initiated.
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Affiliation(s)
- Susanne Dargel
- Department of Obstetrics, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - Jana Westphal
- Department of Obstetrics, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - Christof Kloos
- Department for Internal Medicine III, Jena University Hospital, Jena, Germany
| | - Ekkehard Schleußner
- Department of Obstetrics, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | | | - Tanja Groten
- Department of Obstetrics, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany.
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2
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Walz M, Hamill N. Maternal and fetal outcomes in a retrospective cohort of obstetrical patients that used an insulin pump paired with a continuous glucose monitor. J Matern Fetal Neonatal Med 2023; 36:2238237. [PMID: 37469103 DOI: 10.1080/14767058.2023.2238237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 06/05/2023] [Accepted: 07/14/2023] [Indexed: 07/21/2023]
Abstract
OBJECTIVE To assess maternal and neonatal outcomes in pregnant pregestational diabetic patients using a continuous subcutaneous insulin infusion (CSII) pump paired with a continuous glucose monitor (CGM). METHODS This retrospective cohort study included 55 patients who delivered within one healthcare system from October 2019 to October 2022 with pregestational diabetes managed using CSII pumps paired with CGM. Maternal blood glucose (BG) data were analyzed for the two-week period preceding delivery. The percentage of time spent at a BG level of less than 140 mg/dL was recorded and compared between patients with and without obstetric and neonatal morbidities. RESULTS Patients who delivered with severe preeclampsia (S. PreE) had a significantly lower mean percentage of time spent at BG < 140 mg/dL than those who did not (S. PreE 15/55, 63.1% ± 19.0 vs. 40/55, 73.6% ± 13.8; p = 0.03). Mothers who had a preterm birth (PTB) had a significantly lower mean percentage of time spent at BG < 140 mg/dL than those who delivered at term (PTB 35/55, 66.4% ± 16.4 vs 20/55, 78.3% ± 11.9; p = 0.006). The mean percentage of time spent at a BG < 140 mg/dL among mothers of neonates with respiratory distress syndrome (RDS) was significantly lower than those without RDS (RDS present 13/55, 59.7% ± 20.4 vs 42/55, 74.1% ± 12.7; p = 0.003). There was a significant correlation between a greater neonatal birth weight percentile and worse time spent at BG < 140 mg/dL (r = - 0.31; p = 0.02). No other significant differences were observed between the groups. CONCLUSION Improved blood glucose levels in pregestational diabetic patients using a CSII pump and CGM is associated with reduced maternal and neonatal morbidity as well as lower birth weight percentile neonates. Future studies are needed to clarify how much time each day a patient needs to spend below a given blood sugar, how long this blood glucose should be maintained, and what specific blood glucose target should be selected.
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Affiliation(s)
- Macy Walz
- Perinatal Center, Nebraska Methodist Health System Women's Hospital, Omaha, NE, USA
- Department of Obstetrics and Gynecology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Neil Hamill
- Perinatal Center, Nebraska Methodist Health System Women's Hospital, Omaha, NE, USA
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3
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Fazekas-Pongor V, Svébis MM, Major D, Pártos K, Dósa N, Mészáros Á, Horváth VJ, Domján BA, Zsirai L, Tabák AG. Trend of pregnancy outcomes in type 1 diabetes compared to control women: a register-based analysis in 1996-2018. Front Endocrinol (Lausanne) 2023; 14:1232618. [PMID: 37501784 PMCID: PMC10369353 DOI: 10.3389/fendo.2023.1232618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 06/19/2023] [Indexed: 07/29/2023] Open
Abstract
Introduction In 1989, the St Vincent declaration aimed to approximate pregnancy outcomes of diabetes to that of healthy pregnancies. We aimed to compare frequency and trends of outcomes of pregnancies affected by type 1 diabetes and controls in 1996-2018. Methods We used anonymized records of a mandatory nation-wide registry of all deliveries between gestational weeks 24 and 42 in Hungary. We included all singleton births (4,091 type 1 diabetes, 1,879,183 controls) between 1996 and 2018. We compared frequency and trends of pregnancy outcomes between type 1 diabetes and control pregnancies using hierarchical Poisson regression. Results The frequency of stillbirth, perinatal mortality, large for gestational age, caesarean section, admission to neonatal intensive care unit (NICU), and low Appearance, Pulse, Grimace, Activity, and Respiration (APGAR) score was 2-4 times higher in type 1 diabetes compared to controls, while the risk of congenital malformations was increased by 51% and SGA was decreased by 42% (all p<0.05). These observations remained significant after adjustment for confounders except for low APGAR scores. We found decreasing rate ratios comparing cases and controls over time for caesarean sections, low APGAR scores (p<0.05), and for NICU admissions (p=0.052) in adjusted models. The difference between cases and controls became non-significant after 2009. No linear trends were observed for the other outcomes. Conclusions Although we found that the rates of SGA, NICU care, and low APGAR score improved in pregnancies complicated by type 1 diabetes, the target of the St Vincent Declaration was only achieved for the occurrence of low APGAR scores.
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Affiliation(s)
- Vince Fazekas-Pongor
- Department of Public Health, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Mark M. Svébis
- Department of Internal Medicine and Oncology, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - David Major
- Department of Public Health, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Katalin Pártos
- Department of Public Health, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Norbert Dósa
- Department of Public Health, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Ágota Mészáros
- Department of Public Health, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Viktor J. Horváth
- Department of Internal Medicine and Oncology, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Beatrix A. Domján
- Department of Internal Medicine and Oncology, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - László Zsirai
- Department of Gynecology and Family Planning, Istenhegyi Gene Diagnostic Center, Budapest, Hungary
| | - Adam G. Tabák
- Department of Public Health, Faculty of Medicine, Semmelweis University, Budapest, Hungary
- Department of Internal Medicine and Oncology, Faculty of Medicine, Semmelweis University, Budapest, Hungary
- University College London (UCL) Brain Sciences, University College London, London, United Kingdom
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4
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Wang Z, Chen J, Long T, Liang L, Zhong C, Li Y. Clinical analysis of diabetes in pregnancy with stillbirth. Medicine (Baltimore) 2023; 102:e33898. [PMID: 37233404 PMCID: PMC10219722 DOI: 10.1097/md.0000000000033898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 05/10/2023] [Indexed: 05/27/2023] Open
Abstract
We analyzed the clinical characteristics of patients with diabetes in pregnancy (DIP) associated with stillbirth and explored strategies to reduce its incidence. We retrospectively analyzed 71 stillbirths associated with DIP (group A) and 150 normal pregnancies (group B) during 2009 to 2018. The incidence of the following was higher in group A (P < .05): hypertensive disorders (38.03% vs 6.00%), placenta previa (14.08% vs 2.67%), placental abruption (5.63% vs 0.67%), fetal malformation (8.45% vs 0.67%), fasting plasma glucose (FPG) ≥ 7.0 mmol/L (46.48% vs 0.67%), 2-h postprandial plasma glucose ≥ 11.1 mmol/L (57.75% vs 6.00%), HbA1c ≥ 6.5% (63.38% vs 6.00%), and polyhydramnios (11.27% vs 4.67). The incidence of oligohydramnios (4.23% vs 6.67%) was lower in group A than in group B (P < .05). According to the gestational age at the time of stillbirth, Group-A cases were subgrouped into miscarriages (20-27+6 weeks), premature deliveries (28-36+6 weeks), and full-term deliveries (≥37 weeks). Age, parity, and DIP type did not differ among the subgroups (P > .05). Among patients with DIP, antenatal FPG, 2-h postprandial plasma glucose, and HbA1c were significantly associated with stillbirth (P < .05). Stillbirth was first detected at 22 weeks and typically occurred at 28-36+6 weeks. DIP was associated with a higher incidence of stillbirth, and FPG, 2-h postprandial plasma glucose, and HbA1c were potential indicators of stillbirth in DIP. Age (odds ratio [OR]: 2.21, 95% confidence interval [CI]: 1.67-2.74), gestational hypertension (OR: 3.44, 95% CI: 2.21-4.67), body mass index (OR: 2.86, 95% CI: 1.95-3.76), preeclampsia (OR: 2.29, 95% CI: 1.45-3.12), and diabetic ketoacidosis (OR: 3.99, 95% CI: 1.22-6.76) were positively correlated with the occurrence of stillbirth in DIP. Controlling perinatal plasma glucose, accurately detecting and managing comorbidities/complications, and timely termination of pregnancy can reduce the incidence of stillbirths associated with DIP.
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Affiliation(s)
- Zhenyu Wang
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Guangdong Provincial Key Laboratory of Major Obstetric Diseases, Guangzhou, China
- Department of Obstetrics and Gynecology, Sun Yat-Sen Memorial Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jia Chen
- Department of Obstetrics, Foshan Women and Children Hospital, Foshan, China
| | - Tuhong Long
- Department of Medical Affairs Section, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Lixuan Liang
- Department of Obstetrics, Dongguan Songshan Lake Central Hospital, Dongguan, China
| | - Caijuan Zhong
- Department of Obstetrics, Maternal and Child Health Hospital of Guangdong, Guangzhou, China
| | - Yingtao Li
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Guangdong Provincial Key Laboratory of Major Obstetric Diseases, Guangzhou, China
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Thorius IH, Husemoen LLN, Nordsborg RB, Alibegovic AC, Gall MA, Petersen J, Mathiesen ER. Congenital malformations among offspring of women with type 1 diabetes who use insulin pumps: a prospective cohort study. Diabetologia 2023; 66:826-836. [PMID: 36640191 DOI: 10.1007/s00125-022-05864-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 11/23/2022] [Indexed: 01/15/2023]
Abstract
AIMS/HYPOTHESIS Continuous subcutaneous insulin infusion by insulin pump is often superior in improving glycaemic control compared with conventional multiple daily insulin injection (MDI). However, whether pump treatment leads to improved pregnancy outcomes in terms of congenital malformations and perinatal death remains unknown. The present aim was to evaluate the risk of malformations and perinatal and neonatal death in pregnant women with type 1 diabetes treated with pump or MDI. METHODS We performed a secondary analysis of a prospective multinational cohort of 2088 pregnant women with type 1 diabetes in a real-world setting who were treated by pump (n=750) or MDI (n=1338). ORs for offspring with congenital malformations or perinatal or neonatal death were calculated using crude data and by logistic regression on propensity score-matched data. RESULTS At enrolment (gestational week 8; 95% CI 4, 14), pump users had a higher educational level (university degree: 37.3% vs 25.1%; p<0.001) and better glycaemic control (mean HbA1c: 51±10 mmol/mol [6.8±0.9%] vs 54±14 mmol/mol [7.1±1.3%], p<0.001) compared with MDI users. Moreover, a greater proportion of pump users had an HbA1c level below 75 mmol/mol (9%) (97.6% vs 91.9%, p<0.001), and more often reported taking folic acid supplementation (86.3% vs 74.8%; p<0.001) compared with MDI users. All clinically important potential confounders were balanced after propensity score matching, and HbA1c remained lower in pump users. The proportion of fetuses with at least one malformation was 13.5% in pump users vs 11.2% in MDI users (crude OR 1.23; 95% CI 0.94, 1.61; p=0.13; propensity score-matched (adjusted) OR 1.11; 95% CI 0.81, 1.52; p=0.52). The proportion of fetuses with at least one major malformation was 2.8% in pump users vs 3.1% in MDI users (crude OR 0.89; 95% CI 0.52, 1.51; p=0.66; adjusted OR 0.78; 95% CI 0.42, 1.45; p=0.43), and the proportions of fetuses carrying one or more minor malformations (but no major malformations) were 10.7% vs 8.1% (crude OR 1.36; 95% CI 1.00, 1.84; p=0.05; adjusted OR 1.23; 95% CI 0.87, 1.75; p=0.25). The proportions of perinatal and neonatal death were 1.6% vs 1.3% (crude OR 1.23; 95% CI 0.57, 2.67; p=0.59; adjusted OR 2.02; 95% CI 0.69, 5.93; p=0.20) and 0.3% vs 0.3% (n=2 vs n=4, p=not applicable), respectively. CONCLUSIONS/INTERPRETATIONS Insulin pump treatment was not associated with a lower risk of congenital malformations, despite better glycaemic control in early pregnancy compared with MDI. Further studies exploring the efficacy and safety of pump treatment during pregnancy are needed.
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Affiliation(s)
- Ida H Thorius
- Center for Pregnant Women with Diabetes, Department of Endocrinology, Rigshospitalet, and Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
- Novo Nordisk A/S, Søborg, Denmark.
- Copenhagen Phase IV Unit, Department of Clinical Pharmacology and Center for Clinical Research and Prevention, Copenhagen University Hospital, Frederiksberg, Denmark.
| | | | | | | | | | - Janne Petersen
- Copenhagen Phase IV Unit, Department of Clinical Pharmacology and Center for Clinical Research and Prevention, Copenhagen University Hospital, Frederiksberg, Denmark
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Elisabeth R Mathiesen
- Center for Pregnant Women with Diabetes, Department of Endocrinology, Rigshospitalet, and Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Maduro C, Castro LFD, Moleiro ML, Guedes-Martins L. Pregestational Diabetes and Congenital Heart Defects. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRICIA : REVISTA DA FEDERACAO BRASILEIRA DAS SOCIEDADES DE GINECOLOGIA E OBSTETRICIA 2022; 44:953-961. [PMID: 36446562 PMCID: PMC9708403 DOI: 10.1055/s-0042-1755458] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Studies have consistently shown a significant increase in the risk of congenital heart defects in the offspring of diabetic mothers compared with those of nondiabetic pregnancies. Evidence points that all types of pregestational diabetes have the capacity of generating cardiac malformations in a more accentuated manner than in gestational diabetes, and there seems to be an increased risk for all congenital heart defects phenotypes in the presence of maternal diabetes. Currently, the application of some therapies is under study in an attempt to reduce the risks inherent to diabetic pregnancies; however, it has not yet been possible to fully prove their effectiveness. The present review aims to better understand the mechanisms that govern the association between pregestational diabetes and congenital heart defects and how maternal diabetes interferes with fetal cardiac development, as there is still a long way to go in the investigation of this complex process.
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Affiliation(s)
- Catarina Maduro
- Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal,Address for correspondence Catarina Maduro, MSc Rua Jorge de Viterbo Ferreira 228, 4050-313, PortoPortugal
| | - Luís Ferreira de Castro
- Departamento da Mulher e da Medicina Reprodutiva, Centro Hospitalar do Porto EPE, Centro Materno Infantil do Norte, Largo Prof. Abel Salazar, Porto, Portugal
| | - Maria Lúcia Moleiro
- Departamento da Mulher e da Medicina Reprodutiva, Centro Hospitalar do Porto EPE, Centro Materno Infantil do Norte, Largo Prof. Abel Salazar, Porto, Portugal
| | - Luís Guedes-Martins
- Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal,Departamento da Mulher e da Medicina Reprodutiva, Centro Hospitalar do Porto EPE, Centro Materno Infantil do Norte, Largo Prof. Abel Salazar, Porto, Portugal,Unidade de Investigação e Formação, Centro Materno Infantil do Norte, Porto, Portugal,Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
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7
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Guo ZH, Tian HL, Zhang XQ, Zhang DH, Wang ZM, Wang K, Su WW, Chen F. Effect of anemia and erythrocyte indices on hemoglobin A1c levels among pregnant women. Clin Chim Acta 2022; 534:1-5. [PMID: 35803335 DOI: 10.1016/j.cca.2022.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 06/27/2022] [Accepted: 07/04/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Anemia is a common disorder among pregnant women; however, the effect of anemia on hemoglobin A1c (HbA1c) levels has not been adequately explored. We aim to examine the influence of anemia on the HbA1c concentration and investigate the relationship between erythrocyte indices and HbA1c levels during pregnancy. METHODS We performed a retrospective analysis of 1369 pregnant Chinese women. The clinical and analytical data were collected. Independent t-test and Analysis of Variance were used for comparative studies, and multiple linear regression analysis was used to identify the association between erythrocyte indices and HbA1c. RESULTS The differences in HbA1c between non-anemia and mild anemia were negligible, and the differences in HbA1c between non-anemia and moderate anemia were well within the allowable variability for clinical practice (≥0.5% absolute changes). Mean corpuscular hemoglobin (MCH) correlated with HbA1c significantly, independent of pregnancy, trimester, and anemia. The distinction of HbA1c levels between grades of Hb became no significant (P = 0.955), while differences between trimesters persisted after adjusting for MCH. CONCLUSION Mild and moderate anemia should not be the primary concern when using HbA1c to monitor blood glucose in pregnancy. MCH showed negative correlations with HbA1c independently, suggesting a previously unknown mechanism affecting HbA1c levels.
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Affiliation(s)
- Zong-Hui Guo
- Department of Medical Laboratory, PKU Care Luzhong Hospital, Zibo, People's Republic of China.
| | - Huai-Liang Tian
- Department of Medical Laboratory, PKU Care Luzhong Hospital, Zibo, People's Republic of China
| | - Xiao-Qian Zhang
- Department of Medical Laboratory, PKU Care Luzhong Hospital, Zibo, People's Republic of China
| | - Deng-Han Zhang
- Department of Medical Laboratory, PKU Care Luzhong Hospital, Zibo, People's Republic of China
| | - Zhi-Min Wang
- Department of Medical Laboratory, PKU Care Luzhong Hospital, Zibo, People's Republic of China
| | - Kun Wang
- Department of Medical Laboratory, PKU Care Luzhong Hospital, Zibo, People's Republic of China
| | - Wen-Wen Su
- Department of Medical Laboratory, PKU Care Luzhong Hospital, Zibo, People's Republic of China
| | - Fei Chen
- Department of Medical Laboratory, PKU Care Luzhong Hospital, Zibo, People's Republic of China
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8
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Morales-Suárez-Varela M, Peraita-Costa I, Perales-Marín A, Llopis-Morales A, Llopis-González A. Risk of Gestational Diabetes Due to Maternal and Partner Smoking. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19020925. [PMID: 35055745 PMCID: PMC8775944 DOI: 10.3390/ijerph19020925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 01/10/2022] [Accepted: 01/11/2022] [Indexed: 11/27/2022]
Abstract
Pregnant women are among the most vulnerable to environmental exposure to tobacco smoke (EET); which has been linked to problems in the mothers’ health; one of the most frequent is gestational diabetes (GD). For this reason, there are specific interventions and prevention strategies designed to reduce this exposure risk. However, currently, they are mostly aimed only at aiding the pregnant women with smoking cessation during pregnancy and do not assess or address the risk from passive exposure due to partner smoking. The aim of this work is to study the exposure to EET of pregnant women considering active and passive smoking and to evaluate its effect on the development of GD. This is an observational case-control study within a retrospective cohort of pregnant women. Information on smoking habits was obtained from both personal interviews and recorded medical history. In total, 16.2% of mothers and 28.3% of partners declared having been active smokers during pregnancy; 36.5% of the women presented EET during pregnancy when both active and passive smoking were considered. After adjustments, the association with the EET and GD of the mother was (aOR 1.10 95% CI: 0.64–1.92); for the EET of the partner, it was (aOR 1.66 95% CI: 1.01–2.77); for both partners, it was (aOR 1.82 95% CI: 1.15–2.89), adjusted by the mother’s age and body mass index. There is a lack of education regarding the effects of passive exposure to tobacco smoke. It is essential that pregnant women and their partners are educated on the risks of active and passive smoking; this could improve the effectiveness of other GD prevention strategies.
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Affiliation(s)
- María Morales-Suárez-Varela
- Unit of Public Health and Environmental Care, Department of Preventive Medicine, University of Valencia, 46100 Burjassot, Spain; (I.P.-C.); (A.L.-M.); (A.L.-G.)
- CIBER Epidemiology and Public Health (CIBERESP), 28029 Madrid, Spain
- Correspondence: ; Tel.: +34-96-3544951
| | - Isabel Peraita-Costa
- Unit of Public Health and Environmental Care, Department of Preventive Medicine, University of Valencia, 46100 Burjassot, Spain; (I.P.-C.); (A.L.-M.); (A.L.-G.)
- CIBER Epidemiology and Public Health (CIBERESP), 28029 Madrid, Spain
| | - Alfredo Perales-Marín
- Department of Obstetrics, La Fe University Polytechnic Hospital, 46026 Valencia, Spain;
- Department of Pediatrics, Obstetrics and Gynecology, University of Valencia, 46010 Valencia, Spain
| | - Agustín Llopis-Morales
- Unit of Public Health and Environmental Care, Department of Preventive Medicine, University of Valencia, 46100 Burjassot, Spain; (I.P.-C.); (A.L.-M.); (A.L.-G.)
| | - Agustín Llopis-González
- Unit of Public Health and Environmental Care, Department of Preventive Medicine, University of Valencia, 46100 Burjassot, Spain; (I.P.-C.); (A.L.-M.); (A.L.-G.)
- CIBER Epidemiology and Public Health (CIBERESP), 28029 Madrid, Spain
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9
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Arslan E, Allshouse AA, Page JM, Varner MW, Thorsten V, Parker C, Dudley DJ, Saade GR, Goldenberg RL, Stoll BJ, Hogue CJ, Bukowski R, Conway D, Pinar H, Reddy UM, Silver RM. Maternal serum fructosamine levels and stillbirth: a case-control study of the Stillbirth Collaborative Research Network. BJOG 2021; 129:619-626. [PMID: 34529344 DOI: 10.1111/1471-0528.16922] [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: 05/17/2021] [Accepted: 09/12/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate the association between maternal fructosamine levels at the time of delivery and stillbirth. DESIGN Secondary analysis of a case-control study. SETTING Multicentre study of five geographic catchment areas in the USA. POPULATION All singleton stillbirths with known diabetes status and fructosamine measurement, and representative live birth controls. MAIN OUTCOME MEASURES Fructosamine levels in stillbirths and live births among groups were adjusted for potential confounding factors, including diabetes. Optimal thresholds of fructosamine to discriminate stillbirth and live birth. RESULTS A total of 529 women with a stillbirth and 1499 women with a live birth were included in the analysis. Mean fructosamine levels were significantly higher in women with a stillbirth than in women with a live birth after adjustment (177 ± 3.05 versus 165 ± 2.89 μmol/L, P < 0.001). The difference in fructosamine levels between stillbirths and live births was greater among women with diabetes (194 ± 8.54 versus 162 ± 3.21 μmol/L), compared with women without diabetes (171 ± 2.50 versus 162 ± 2.56 μmol/L). The area under the curve (AUC) for fructosamine level and stillbirth was 0.634 (0.605-0.663) overall, 0.713 (0.624-0.802) with diabetes and 0.625 (0.595-0.656) with no diabetes. CONCLUSIONS Maternal fructosamine levels at the time of delivery were higher in women with stillbirth compared with women with live birth. Differences were substantial in women with diabetes, suggesting a potential benefit of glycaemic control in women with diabetes during pregnancy. The small differences noted in women without diabetes are not likely to justify routine screening in all cases of stillbirth. TWEETABLE ABSTRACT Maternal serum fructosamine levels are higher in women with stillbirth than in women with live birth, especially in women with diabetes.
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Affiliation(s)
- E Arslan
- Department of Obstetrics and Gynecology, University of Utah Health Sciences, Salt Lake City, Utah, USA
| | - A A Allshouse
- Department of Obstetrics and Gynecology, University of Utah Health Sciences, Salt Lake City, Utah, USA
| | - J M Page
- Department of Obstetrics and Gynecology, University of Utah Health Sciences, Salt Lake City, Utah, USA.,Department of Obstetrics and Gynecology, Intermountain Health Care, Murray, Utah, USA
| | - M W Varner
- Department of Obstetrics and Gynecology, University of Utah Health Sciences, Salt Lake City, Utah, USA
| | - V Thorsten
- RTI International, Research Triangle Park, North Carolina, USA
| | - C Parker
- RTI International, Research Triangle Park, North Carolina, USA
| | - D J Dudley
- Department of Obstetrics and Gynecology, University of Virginia, Charlottesville, Virginia, USA
| | - G R Saade
- Department of Obstetrics and Gynecology, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - R L Goldenberg
- Department of Obstetrics and Gynecology, Columbia University, New York, New York, USA
| | - B J Stoll
- Department of Pediatrics, McGovern Medical School at University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - C J Hogue
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - R Bukowski
- Department of Women's Health, University of Texas Health Science Center at Austin, Austin, Texas, USA
| | - D Conway
- Department of Obstetrics and Gynecology, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - H Pinar
- Division of Perinatal Pathology, Brown University School of Medicine, Providence, Rhode Island, USA
| | - U M Reddy
- Department of Obstetrics and Gynecology, Yale School of Medicine, New Haven, Connecticut, USA
| | - R M Silver
- Department of Obstetrics and Gynecology, University of Utah Health Sciences, Salt Lake City, Utah, USA
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Nelson KM, Irvin-Choy N, Hoffman MK, Gleghorn JP, Day ES. Diseases and conditions that impact maternal and fetal health and the potential for nanomedicine therapies. Adv Drug Deliv Rev 2021; 170:425-438. [PMID: 33002575 DOI: 10.1016/j.addr.2020.09.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 09/22/2020] [Accepted: 09/25/2020] [Indexed: 12/14/2022]
Abstract
Maternal mortality rates in the United States have steadily increased since 1987 to the current rate of over 16 deaths per 100,000 live births. Whereas most of these deaths are related to an underlying condition, such as cardiovascular disease, many pregnant women die from diseases that emerge as a consequence of pregnancy. Both pre-existing and emergent diseases and conditions are difficult to treat in pregnant women because of the potential harmful effects of the treatment on the developing fetus. Often the health of the woman and the health of the baby are at odds and must be weighed against each other when medical treatment is needed, frequently leading to iatrogenic preterm birth. However, the use of engineered nanomedicines has the potential to fill the treatment gap for pregnant women. This review describes several conditions that may afflict pregnant women and fetuses and introduces how engineered nanomedicines may be used to treat these illnesses. Although the field of maternal-fetal nanomedicine is in its infancy, with additional research and development, engineered nanotherapeutics may greatly improve outcomes for pregnant women and their offspring in the future.
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Abstract
OBJECTIVE To characterize stillbirths associated with pregestational diabetes and gestational diabetes mellitus (GDM) in a large, prospective, U.S. case-control study. METHODS A secondary analysis of stillbirths among patients enrolled in a prospective; multisite; geographically, racially, and ethnically diverse case-control study in the United States was performed. Singleton gestations with complete information regarding diabetes status and with a complete postmortem evaluation were included. A standard evaluation protocol for stillbirth cases included postmortem evaluation, placental pathology, clinical testing as performed at the discretion of the health care professional, and a recommended panel of tests. A potential cause of death was assigned to stillbirth cases using a standardized classification tool. Demographic and delivery characteristics among women with pregestational diabetes and GDM were compared with characteristics of women with no diabetes in pairwise comparisons using χ or two-sample t tests as appropriate. Sensitivity analysis was performed excluding pregnancies with genetic conditions or major fetal malformations. RESULTS Of 455 stillbirth cases included in the primary analysis, women with stillbirth and diabetes were more likely to be older than 35 years and have a higher body mass index. They were also more likely to have a gestational hypertensive disorder than women without diabetes (28% vs 9.1%; P<.001). Women with pregestational diabetes had more large-for-gestational-age (LGA) neonates (26% vs 3.4%; P<.001). Stillbirths occurred more often at term in women with pregestational diabetes (36%) and those with GDM (52%). Maternal medical complications, including pregestational diabetes and others, were more often identified as a probable or possible cause of death among stillbirths with maternal diabetes (43% vs 4%, P<.001) as compared with stillbirths without diabetes. CONCLUSION Compared with stillbirths in women with no diabetes, stillbirths among women with pregestational diabetes and GDM occur later in pregnancy and are associated with hypertensive disorders of pregnancy, maternal medical complications, and LGA.
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12
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Klemetti MM, Teramo K, Kautiainen H, Wasenius N, Eriksson JG, Laine MK. Late-Pregnancy Fetal Hypoxia Is Associated With Altered Glucose Metabolism and Adiposity in Young Adult Offspring of Women With Type 1 Diabetes. Front Endocrinol (Lausanne) 2021; 12:738570. [PMID: 34777246 PMCID: PMC8578885 DOI: 10.3389/fendo.2021.738570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 10/11/2021] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To investigate associations between exposure to fetal hypoxia and indicators of metabolic health in young adult offspring of women with type 1 diabetes (OT1D). METHODS 156 OT1D born between 7/1995 and 12/2000 at Helsinki University Hospital, Finland, were invited for follow-up between 3/2019 and 11/2019. A control group of 442 adults born from non-diabetic pregnancies, matched for date and place of birth, was obtained from the Finnish Medical Birth Register. In total, 58 OT1D and 86 controls agreed to participate. All OT1D had amniotic fluid (AF) sampled for erythropoietin (EPO) measurement within two days before delivery in order to diagnose fetal hypoxia. In total, 29 OTID had an AF EPO concentration <14.0 mU/l, defined as normal, and were categorized into the low EPO (L-EPO) group. The remaining 29 OT1D had AF EPO ≥14.0 mU/ml, defined as fetal hypoxia, and were categorized into the high EPO (H-EPO) group. At the age of 18-23 years, participants underwent a 2-h 75g oral glucose tolerance test (OGTT) in addition to height, weight, waist circumference, body composition, blood pressure, HbA1c, cholesterol, triglyceride, high-sensitivity CRP and leisure-time physical activity measurements. RESULTS Two OT1D were diagnosed with diabetes and excluded from further analyses. At young adult age, OT1D in the H-EPO group had a higher BMI than those in the L-EPO group. In addition, among female participants, waist circumference and body fat percentage were highest in the H-EPO group. In the OGTTs, the mean (SD) 2-h post-load plasma glucose (mmol/L) was higher in the H-EPO [6.50 (2.11)] than in the L-EPO [5.21 (1.10)] or control [5.67 (1.48)] offspring (p=0.009). AF EPO concentrations correlated positively with 2-h post-load plasma glucose [r=0.35 (95% CI: 0.07 to 0.62)] and serum insulin [r=0.44 (95% CI: 0.14 to 0.69)] concentrations, even after adjusting for maternal BMI, birth weight z-score, gestational age at birth and adult BMI. Control, L-EPO and H-EPO groups did not differ with regards to other assessed parameters. CONCLUSIONS High AF EPO concentrations in late pregnancy, indicating fetal hypoxia, are associated with increased adiposity and elevated post-load glucose and insulin concentrations in young adult OT1D.
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Affiliation(s)
- Miira M. Klemetti
- Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada
- Department of Medical Genetics, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Obstetrics and Gynecology, South Karelia Central Hospital, Lappeenranta, Finland
- *Correspondence: Miira M. Klemetti,
| | - Kari Teramo
- Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Hannu Kautiainen
- Folkhälsan Research Center, Helsinki, Finland
- Primary Health Care Unit, Kuopio University Hospital, Kuopio, Finland
| | | | - Johan G. Eriksson
- Folkhälsan Research Center, Helsinki, Finland
- National University of Singapore, Yong Loo Lin School of Medicine, Department of Obstetrics and Gynaecology and Human Potential Translational Research Programme, Singapore, Singapore
- Singapore Institute for Clinical Sciences (SICS), Agency for Science, Technology and Research (A*STAR), Singapore, Singapore
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Sørensen A, Sinding M. Placental Magnetic Resonance Imaging: A Method to Evaluate Placental Function In Vivo. Obstet Gynecol Clin North Am 2020; 47:197-213. [PMID: 32008669 DOI: 10.1016/j.ogc.2019.10.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
This article describes the use of placental magnetic resonance imaging (MRI) relaxation times in the in vivo assessment of placental function. It focuses on T2*-weighted placental MRI, the main area of the authors' research over the past decade. The rationale behind T2*-weighted placental MRI, the main findings reported in the literature, and directions for future research and clinical applications of this method are discussed. The article concludes that placental T2* relaxation time is an easily obtained and robust measurement, which can discriminate between normal and dysfunctional placenta. Placenta T2* is a promising tool for in vivo assessment of placental function.
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Affiliation(s)
- Anne Sørensen
- Department of Obstetrics and Gynecology, Aalborg University Hospital, Reberbansgade 15, Aalborg 9000, Denmark; Department of Clinical Medicine, Aalborg University, Sdr. Skovvej 15, Aalborg 9000, Denmark.
| | - Marianne Sinding
- Department of Obstetrics and Gynecology, Aalborg University Hospital, Reberbansgade 15, Aalborg 9000, Denmark; Department of Clinical Medicine, Aalborg University, Sdr. Skovvej 15, Aalborg 9000, Denmark
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Jørgensen IL, Vestgaard M, Ásbjörnsdóttir B, Mathiesen ER, Damm P. Routine use of antenatal nonstress tests in pregnant women with diabetes-What is the practice? Eur J Obstet Gynecol Reprod Biol 2020; 248:89-94. [PMID: 32199298 DOI: 10.1016/j.ejogrb.2020.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 03/01/2020] [Accepted: 03/05/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Pregnancies complicated by maternal preexisting diabetes have a 4-5-fold increased risk of stillbirth, and consequently routine antenatal nonstress testing (NST) was implemented into clinical practice decades ago. Though, international guidelines lack consensus and recommend anything from twice weekly testing from 32 weeks to once weekly testing from 38 weeks. The objective of this study was to examine how routine antenatal NST was used in centers with specific interest and dedication in the care of pregnant women with preexisting diabetes. STUDY DESIGN An electronic survey concerning the routine use of antenatal NST was sent to members of the European Diabetic Pregnancy Study Group (DPSG) between October 2016 and January 2017, representing in total 55 centers in 26 countries taking care of pregnant women with diabetes. RESULTS Answers from 38 centers (69.1 % (38/55)) in 22 countries were received. Based on real world information from these primarily European centers, anything from avoiding routine antenatal NST to testing twice weekly from early in third trimester in women with preexisting diabetes was reported. NST was commonly used (71.1 % of centers) if insulin treatment was needed. NST was also used among diet treated women with type 2 diabetes in several places. The use varied markedly within and between countries. The most common practice was routine NST once weekly from 32 weeks. CONCLUSION Among pregnant women with preexisting diabetes, routine antenatal testing practice with NST differs considerably both within and between countries. Studies examining the cost benefit of routine antenatal NST in pregnancies in women with the different types of diabetes are needed.
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Affiliation(s)
- Isabella L Jørgensen
- Center for Pregnant Women with Diabetes, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen O, Denmark; Department of Obstetrics, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen O, Denmark; Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen N, Denmark.
| | - Marianne Vestgaard
- Center for Pregnant Women with Diabetes, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen O, Denmark; Department of Endocrinology, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen O, Denmark; Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen N, Denmark.
| | - Björg Ásbjörnsdóttir
- Center for Pregnant Women with Diabetes, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen O, Denmark; Department of Endocrinology, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen O, Denmark; Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen N, Denmark.
| | - Elisabeth R Mathiesen
- Center for Pregnant Women with Diabetes, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen O, Denmark; Department of Endocrinology, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen O, Denmark; Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen N, Denmark.
| | - Peter Damm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen O, Denmark; Department of Obstetrics, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen O, Denmark; Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen N, Denmark.
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Mackin ST, Nelson SM, Wild SH, Colhoun HM, Wood R, Lindsay RS. Factors associated with stillbirth in women with diabetes. Diabetologia 2019; 62:1938-1947. [PMID: 31353418 PMCID: PMC6731193 DOI: 10.1007/s00125-019-4943-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 05/20/2019] [Indexed: 11/26/2022]
Abstract
AIMS/HYPOTHESIS Stillbirth risk is increased in pregnancy complicated by diabetes. Fear of stillbirth has major influence on obstetric management, particularly timing of delivery. We analysed population-level data from Scotland to describe timing of stillbirths in women with diabetes and associated risk factors. METHODS A retrospective cohort of singleton deliveries to mothers with type 1 (n = 3778) and type 2 diabetes (n = 1614) from 1 April 1998 to 30 June 2016 was analysed using linked routine care datasets. Maternal and fetal characteristics, HbA1c data and delivery timing were compared between stillborn and liveborn groups. RESULTS Stillbirth rates were 16.1 (95% CI 12.4, 20.8) and 22.9 (95% CI 16.4, 31.8) per 1000 births in women with type 1 (n = 61) and type 2 diabetes (n = 37), respectively. In women with type 1 diabetes, higher HbA1c before pregnancy (OR 1.03 [95% CI 1.01, 1.04]; p = 0.0003) and in later pregnancy (OR 1.06 [95% CI 1.04, 1.08]; p < 0.0001) were associated with stillbirth, while in women with type 2 diabetes, higher maternal BMI (OR 1.07 [95% CI 1.01, 1.14]; p = 0.02) and pre-pregnancy HbA1c (OR 1.02 [95% CI 1.00, 1.04]; p = 0.016) were associated with stillbirth. Risk was highest in infants with birthweights <10th centile (sixfold higher born to women with type 1 diabetes [n = 5 stillbirths, 67 livebirths]; threefold higher for women with type 2 diabetes [n = 4 stillbirths, 78 livebirths]) compared with those in the 10th-90th centile (n = 20 stillbirths, 1685 livebirths). Risk was twofold higher in infants with birthweights >95th centile born to women with type 2 diabetes (n = 15 stillbirths, 402 livebirths). A high proportion of stillborn infants were male among mothers with type 2 diabetes (81.1% vs 50.5% livebirths, p = 0.0002). A third of stillbirths occurred at term, with highest rates in the 38th week (7.0 [95% CI 3.7, 12.9] per 1000 ongoing pregnancies) among mothers with type 1 diabetes and in the 39th week (9.3 [95% CI 2.4, 29.2]) for type 2 diabetes. CONCLUSIONS/INTERPRETATION Maternal blood glucose levels and BMI are important modifiable risk factors for stillbirth in diabetes. Babies at extremes of weight centiles are at most risk. Many stillbirths occur at term and could potentially be prevented by change in routine care and delivery policies.
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Affiliation(s)
- Sharon T Mackin
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK
| | | | - Sarah H Wild
- Usher Institute of Population Health Science and Informatics, University of Edinburgh, Edinburgh, UK
| | - Helen M Colhoun
- Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | | | - Robert S Lindsay
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK.
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Kansu-Celik H, Ozgu-Erdinc AS, Kisa B, Eldem S, Hancerliogullari N, Engin-Ustun Y. Maternal serum glycosylated hemoglobin and fasting plasma glucose predicts gestational diabetes at the first trimester in Turkish women with a low-risk pregnancy and its relationship with fetal birth weight; a retrospective cohort study. J Matern Fetal Neonatal Med 2019; 34:1970-1977. [PMID: 31370710 DOI: 10.1080/14767058.2019.1651837] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To examine the accuracy of maternal serum glycosylated hemoglobin (HbA1c) and fasting plasma glucose (FPG) levels in predicting gestational diabetes at the first trimester in Turkish women with a low-risk pregnancy and its relationship with fetal birth weight. METHODS This cohort study was conducted retrospectively in a tertiary referral hospital from January 2010 to January 2017. HbA1c and FPG serum concentrations were measured in 670 pregnant women at the first-trimester screening. HbA1c and FPG concentrations of women who subsequently developed gestational diabetes mellitus (GDM) were compared to those who did not, and its relationship with fetal weight was investigated. RESULTS First-trimester screening was performed on 608 pregnant women, of whom 69 (11.3%) women had developed GDM. Median HbA1c and FPG concentrations were significantly higher in women developing GDM (n = 69) in comparison to those with uncomplicated pregnancies (n = 539) (5.31 ± 0.58% versus 5.01 ± 0.45%, p < .001 and 89.74 ± 8.71% versus 84.09 ± 9.16%, p < .001, respectively). The cut-off value calculated with the highest Youden index was HbA1c levels above 5.6% with a sensitivity of 34.78%, specificity of 89.8%, with a diagnostic accuracy of 83.55%, and FPG levels above 86.85 mg/dl with a sensitivity of 69.57%, specificity of 61.78%, with a diagnostic accuracy of 62.66%. The calculated odds ratio (OR) for HbA1c > 5.6% and FPG > 86 mg/dl were 4.69 (95% CI: 2.66-8.29), and 3.7 (95% CI: 2.15-6.35), respectively. HbA1c and FPG combined had improved the predictive capability for GDM (OR: 7.26, 95% CI: 3.71-14.19). According to correlation analyses, a noteworthy positive correlation was found between HbA1c and, FPG, 50 g GCT, age, BMI, parity, and birth weight. However, there was no correlation between FPG and birth weight. CONCLUSION Diagnostic accuracy of HbA1c for GDM prediction in Turkish women with a low-risk pregnancy is 83.55% with a very good negative predictive value of 91.49%. HbA1c and FPG combined enhanced the predictive capability for GDM. In addition, there is a positive relationship between HbA1c and 50 g GCT, and birth weight. However, to suggest HbA1c as a potential screening test for gestational diabetes mellitus, further research is warranted.
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Affiliation(s)
- Hatice Kansu-Celik
- Dr. Zekai Tahir Burak Women's Health Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - A Seval Ozgu-Erdinc
- Dr. Zekai Tahir Burak Women's Health Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Burcu Kisa
- Dr. Zekai Tahir Burak Women's Health Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Sinem Eldem
- Dr. Zekai Tahir Burak Women's Health Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Necati Hancerliogullari
- Dr. Zekai Tahir Burak Women's Health Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Yaprak Engin-Ustun
- Dr. Zekai Tahir Burak Women's Health Training and Research Hospital, University of Health Sciences, Ankara, Turkey
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Jørgensen IL, Vestgaard M, Àsbjörnsdóttir B, Mathiesen ER, Damm P. An audit on a routine antenatal nonstress testing program in pregnant women with preexisting diabetes. Acta Obstet Gynecol Scand 2019; 98:1148-1156. [PMID: 30825321 DOI: 10.1111/aogs.13602] [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: 05/14/2018] [Accepted: 02/26/2019] [Indexed: 01/19/2023]
Abstract
INTRODUCTION The objective was to evaluate the effectiveness of routine (planned) antenatal nonstress tests (NSTs) in pregnant women with preexisting diabetes. MATERIAL AND METHODS A retrospective single-center study of 642 consecutive pregnancies in women with preexisting diabetes who gave birth to a singleton ≥22 weeks. Weekly planned NSTs were commenced at 33-35 weeks. In pregnancies with maternal-fetal complications, the initiation and frequency of the planned NST were individualized. Daily maternal assessment of fetal activity was recommended from 28 weeks, and decreased fetal activity indicated an unplanned NST. Data were collected from medical records, and local and regional databases. RESULTS In total, 3016 planned NSTs were performed, with a median of five (range 0-12) tests per pregnancy. Ninety-five planned NSTs (3.1%) were abnormal, a finding confirmed by retesting the same day in eight cases (8.4%), thus leading to delivery. Complications were present in seven of these eight pregnancies, whereas no fetal movements for the last 3 days were reported when the planned NST was performed in the eighth pregnancy. When specifically asked, five of the eight women stated that they had observed decreased fetal activity preceding the planned NST. In 86 pregnancies (13.4%), maternal perception of decreased fetal activity indicated in total 127 unplanned NSTs. The combination of decreased fetal activity and further obstetrical assessment led to delivery in 10 of these pregnancies (11.6%). One stillbirth occurred at 37 weeks in a pregnancy complicated by fetal achondroplasia and polyhydramnios, where the weekly planned NSTs had been normal. The overall stillbirth rate was thus 1.6/1000. CONCLUSIONS Routine use of planned antenatal NSTs does not appear to be indicated in pregnancies in women with preexisting diabetes in the absence of maternal-fetal complications.
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Affiliation(s)
- Isabella L Jørgensen
- Center for Pregnant Women with Diabetes, Rigshospitalet University Hospital, Copenhagen, Denmark.,Department of Obstetrics, Rigshospitalet University Hospital, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Marianne Vestgaard
- Center for Pregnant Women with Diabetes, Rigshospitalet University Hospital, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Endocrinology, Rigshospitalet University Hospital, Copenhagen, Denmark
| | - Björg Àsbjörnsdóttir
- Center for Pregnant Women with Diabetes, Rigshospitalet University Hospital, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Endocrinology, Rigshospitalet University Hospital, Copenhagen, Denmark
| | - Elisabeth R Mathiesen
- Center for Pregnant Women with Diabetes, Rigshospitalet University Hospital, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Endocrinology, Rigshospitalet University Hospital, Copenhagen, Denmark
| | - Peter Damm
- Center for Pregnant Women with Diabetes, Rigshospitalet University Hospital, Copenhagen, Denmark.,Department of Obstetrics, Rigshospitalet University Hospital, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Abstract
Diabetes is a common chronic condition in women of reproductive age. Preconception care is crucial to reducing the risk of adverse maternal and fetal outcomes, such as hypertensive disorders, abnormal fetal growth, traumatic delivery and stillbirth, associated with poor glycemic control. Insulin is the preferred medication to optimize glucose control in women with pregestational diabetes. Frequent dose adjustments are needed during pregnancy to achieve glycemic goals, and team-based multidisciplinary care may help. Postpartum care should include lactation support, counseling on contraceptive options, and transition to primary care.
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Affiliation(s)
- Ronan Sugrue
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Chloe Zera
- Division of Maternal Fetal Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
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Emeruwa UN, Zera C. Optimal Obstetric Management for Women with Diabetes: the Benefits and Costs of Fetal Surveillance. Curr Diab Rep 2018; 18:96. [PMID: 30194499 DOI: 10.1007/s11892-018-1058-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW To elaborate on the risks and benefits associated with antenatal fetal surveillance for stillbirth prevention in women with diabetes. RECENT FINDINGS Women with pregestational diabetes have a 3- to 5-fold increased odds of stillbirth compared to women without diabetes. The stillbirth risk in women with gestational diabetes (GDM) is more controversial; while recent data suggest the odds for stillbirth are approximately 50% higher in women with GDM at term (37 weeks and beyond) than in those without GDM, it is unclear if this risk is seen in women with optimal glycemic control. Current professional society guidelines are broad with respect to fetal testing strategies and delivery timing in women with diabetes. The data supporting strategies to reduce the risk of stillbirth in women with diabetes are limited. Antepartum fetal surveillance should be performed to reduce stillbirth rates; however, the optimal test, frequency of testing, and delivery timing are not yet clear. Future studies of obstetric management for women with diabetes should consider not just individual but also system level costs and benefits associated with antenatal surveillance.
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Affiliation(s)
- Ukachi N Emeruwa
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, 75 Francis Street, ASB 1-3, Boston, MA, 02115, USA.
| | - Chloe Zera
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA
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20
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Abstract
There is growing evidence from randomized trials that induction of labor at or near term does not increase cesarean delivery; observational data show that the optimal gestation for spontaneous delivery for the baby is 39 weeks. Elective cesarean at these gestations is also sometimes considered, but evaluating the associated risks is complex. For the baby, although cesarean obviates the risks of labor, it carries a risk of respiratory problems, which may be severe. For the mother, cesarean is more dangerous than vaginal and emergency cesarean is more dangerous than elective. The authors consider the evidence base for near-term induction of labor and cesarean for a range of scenarios.
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Lepercq J, Le Ray C, Godefroy C, Pelage L, Dubois-Laforgue D, Timsit J. Determinants of a good perinatal outcome in 588 pregnancies in women with type 1 diabetes. DIABETES & METABOLISM 2018; 45:191-196. [PMID: 29776801 DOI: 10.1016/j.diabet.2018.04.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 04/13/2018] [Accepted: 04/18/2018] [Indexed: 11/28/2022]
Abstract
AIM This study assessed pregnancy outcomes in women with type 1 diabetes (T1D) over the last 15 years and identified modifiable factors associated with good perinatal outcomes. METHODS Pregnancy outcomes were prospectively assessed in this cohort study of 588 singleton pregnancies (441 women) managed by standardized care from 2000 to 2014. A good perinatal outcome was defined as the uncomplicated delivery of a normally formed, non-macrosomic, full-term infant with no neonatal morbidity. Factors associated with good perinatal outcomes were identified by logistic regression. RESULTS The rate of severe congenital malformations was 1.5%, and 0.7% for perinatal mortality. The most frequent perinatal complications were macrosomia (41%), preterm delivery (16%) and neonatal hypoglycaemia (11%). Shoulder dystocia occurred in 2.6% of cases, but without sequelae. Perinatal outcomes were good in 254 (44%) pregnancies, and were associated with lower maternal HbA1c values at delivery [adjusted odds ratio (aOR): 2.78, 95% CI: 2.04-3.70, for each 1% (11mmol/mol) absolute decrease], lower gestational weight gains (aOR: 1.06, 95% CI: 1.02-1.10) and absence of preeclampsia (aOR: 2.63, 95% CI: 1.09-6.25). The relationship between HbA1c at delivery and a good perinatal outcome was continuous, with no discrimination threshold. CONCLUSION In our study, rates of severe congenital malformations and perinatal mortality were similar to those of the general population. Less severe complications, mainly macrosomia and late preterm delivery, persisted. Also, our study identified modifiable risk factors that could be targeted to further improve the prognosis of pregnancy in T1D.
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Affiliation(s)
- J Lepercq
- Port-Royal maternity unit, DHU risks in pregnancy, Paris Descartes university, Cochin hospital, Assistance publique-Hôpitaux de Paris, 75014 Paris, France.
| | - C Le Ray
- Port-Royal maternity unit, DHU risks in pregnancy, Paris Descartes university, Cochin hospital, Assistance publique-Hôpitaux de Paris, 75014 Paris, France; Inserm UMR 1153, obstetrical, perinatal and pediatric epidemiology research team (EPOPe), centre for epidemiology and statistics Sorbonne Paris Cité (CRESS), 75014 Paris, France
| | - C Godefroy
- Port-Royal maternity unit, DHU risks in pregnancy, Paris Descartes university, Cochin hospital, Assistance publique-Hôpitaux de Paris, 75014 Paris, France
| | - L Pelage
- Port-Royal maternity unit, DHU risks in pregnancy, Paris Descartes university, Cochin hospital, Assistance publique-Hôpitaux de Paris, 75014 Paris, France
| | - D Dubois-Laforgue
- Department of diabetology, DHU AUTHORS, Paris Descartes university, Cochin hospital, Assistance publique-Hôpitaux de Paris, 75014 Paris, France; Inserm U1016, Cochin hospital, 75014 Paris, France
| | - J Timsit
- Department of diabetology, DHU AUTHORS, Paris Descartes university, Cochin hospital, Assistance publique-Hôpitaux de Paris, 75014 Paris, France
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Mendes N, Tavares Ribeiro R, Serrano F. Beyond self-monitored plasma glucose and HbA1c: the role of non-traditional glycaemic markers in gestational diabetes mellitus. J OBSTET GYNAECOL 2018; 38:762-769. [PMID: 29620435 DOI: 10.1080/01443615.2017.1412409] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Strict glycaemic management is the cornerstone of metabolic control in gestational diabetes mellitus (GDM). Current monitoring standards involve self-monitoring plasma glucose (SMBG) and haemoglobin A1c (HbA1c). However, both have important limitations. SMBG only reflects instantaneous blood glucose and the inconvenience of self-collecting blood frequently results in poor compliance. HbA1c provides information on blood glucose levels from the previous 2 to 3 months and it is influenced by iron-deficient states, common during pregnancy. There is an urgent need for new shorter-term glycaemic markers, as glycated albumin, fructosamine or 1,5-anhydroglucitol. Glycated albumin seems especially interesting as it provides information on blood glucose levels over the foregoing 2-3 weeks and it is not influenced by iron deficiency or the dilutional anaemia of pregnancy. Fructosamine has a precise and inexpensive measurement and it is not affected by haemoglobin characteristics. This review further discusses the potential value of these non-traditional indicators of glycaemic control in patients with GDM, outlining their possible future applications.
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Affiliation(s)
- Neuza Mendes
- a Department of Maternal-Fetal Medicine , Maternidade Dr. Alfredo da Costa, Central Lisbon Hospital Center , Lisbon , Portugal.,b NOVA Medical School , Universidade NOVA de Lisboa , Lisbon , Portugal
| | - Rogério Tavares Ribeiro
- c Education and Research Center (APDP-ERC) , Portuguese Diabetes Association , Lisboa , Portugal.,d CEDOC Chronic Diseases , NOVA Medical School , Lisbon , Portugal
| | - Fátima Serrano
- a Department of Maternal-Fetal Medicine , Maternidade Dr. Alfredo da Costa, Central Lisbon Hospital Center , Lisbon , Portugal.,b NOVA Medical School , Universidade NOVA de Lisboa , Lisbon , Portugal
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Feig DS, Berger H, Donovan L, Godbout A, Kader T, Keely E, Sanghera R. Diabetes and Pregnancy. Can J Diabetes 2018; 42 Suppl 1:S255-S282. [DOI: 10.1016/j.jcjd.2017.10.038] [Citation(s) in RCA: 108] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Quantitative assessment of the effect of pre-gestational diabetes and risk of adverse maternal, perinatal and neonatal outcomes. Oncotarget 2017; 8:61048-61056. [PMID: 28977845 PMCID: PMC5617405 DOI: 10.18632/oncotarget.17824] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 04/05/2017] [Indexed: 01/11/2023] Open
Abstract
Pregnancies complicated by pre-gestational diabetes (PGD) are associated with a higher rate of adverse outcomes, including an increased rage of preterm delivery, pregnancy-induced hypertension, pre-eclampsia, caesarean section, perinatal mortality, stillbirth, shoulder dystocia, macrosomia, small for gestational age, large for gestational age, low birth weight, neonatal hypoglycemia, neonatal death, low Apgar score, NICU admission, jaundice and respiratory distress. In the past two decades, numerous reports have been published regarding associations between PGD and risk of adverse outcomes. However, study results are inconsistent. To provide a synopsis of the current understanding of PGD for risk of adverse pregnancy outcomes, a random-effects meta-analysis over 40 million subjects from 100 studies was performed to calculate the pooled ORs. Potential sources of heterogeneity were systematically explored by multiple strata analyses and meta-regression. Overall, PGD were significantly associated with increased risk of preterm delivery (OR=3.48), LGA (OR=3.90), perinatal mortality (OR=3.39), stillbirth (OR=3.52), pre-eclampsia (OR=3.48), caesarean section (OR=3.52), NICU admission (OR=3.92), and neonatal hypoglycemia (OR=26.62). Significant results were also observed for 7 adverse outcomes with OR range from 1.54 to 2.82, while no association was found for SGA and respiratory distress after Bonferroni correction. We found that women with T1DM had higher risks for most of adverse pregnancy outcomes compared with women with T2DM. When stratified by study design, sample size, type of diabetes, geographic region, and study quality, significant associations remains. Our findings demonstrated that PGD is a strong risk-conferring factor for adverse maternal, perinatal and neonatal outcomes.
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Ibiebele I, Coory M, Smith GCS, Boyle FM, Vlack S, Middleton P, Roe Y, Flenady V. Gestational age specific stillbirth risk among Indigenous and non-Indigenous women in Queensland, Australia: a population based study. BMC Pregnancy Childbirth 2016; 16:159. [PMID: 27417076 PMCID: PMC4946098 DOI: 10.1186/s12884-016-0943-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 06/08/2016] [Indexed: 11/25/2022] Open
Abstract
Background In Australia, significant disparity persists in stillbirth rates between Aboriginal and Torres Strait Islander (Indigenous Australian) and non-Indigenous women. Diabetes, hypertension, antepartum haemorrhage and small-for-gestational age (SGA) have been identified as important contributors to higher rates among Indigenous women. The objective of this study was to examine gestational age specific risk of stillbirth associated with these conditions among Indigenous and non-Indigenous women. Methods Retrospective population-based study of all singleton births of at least 20 weeks gestation or at least 400 grams birthweight in Queensland between July 2005 and December 2011 using data from the Queensland Perinatal Data Collection, which is a routinely-maintained database that collects data on all births in Queensland. Multivariate logistic regression was used to calculate adjusted odds ratios (aOR) and 95 % confidence intervals, adjusting for maternal demographic and pregnancy factors. Results Of 360987 births analysed, 20273 (5.6 %) were to Indigenous women and 340714 (94.4 %) were to non-Indigenous women. Stillbirth rates were 7.9 (95 % CI 6.8–9.2) and 4.1 (95 % CI 3.9–4.3) per 1000 births, respectively. For both Indigenous and non-Indigenous women across most gestational age groups, antepartum haemorrhage, SGA, pre-existing diabetes and pre-existing hypertension were associated with increased risk of stillbirth. There were mixed results for pre-eclampsia and eclampsia and a consistently raised risk of stillbirth was not seen for gestational diabetes. Conclusion This study highlights gestational age specific stillbirth risk for Indigenous and non-Indigenous women; and disparity in risk at term gestations. Improving access to and utilisation of appropriate and responsive healthcare may help to address disparities in stillbirth risk for Indigenous women. Electronic supplementary material The online version of this article (doi:10.1186/s12884-016-0943-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ibinabo Ibiebele
- Mater Research Institute-University of Queensland (MRI-UQ), Level 2 Aubigny Place, Raymond Terrace, South Brisbane, Queensland, 4101, Australia. .,School of Public Health, University of Queensland, Brisbane, Australia.
| | - Michael Coory
- Murdoch Childrens Research Institute, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Gordon C S Smith
- Department of Obstetrics and Gynaecology, University of Cambridge, NIHR Biomedical Research Centre, Cambridge, UK
| | - Frances M Boyle
- Mater Research Institute-University of Queensland (MRI-UQ), Level 2 Aubigny Place, Raymond Terrace, South Brisbane, Queensland, 4101, Australia.,School of Public Health, University of Queensland, Brisbane, Australia
| | - Susan Vlack
- School of Public Health, University of Queensland, Brisbane, Australia.,Queensland Health Metro North Brisbane Public Health Unit, Brisbane, Australia
| | - Philippa Middleton
- South Australian Health and Medical Institute & Robinson Research Institute, The University of Adelaide, Adelaide, Australia
| | - Yvette Roe
- Institute for Urban Indigenous Health, Brisbane, Australia
| | - Vicki Flenady
- Mater Research Institute-University of Queensland (MRI-UQ), Level 2 Aubigny Place, Raymond Terrace, South Brisbane, Queensland, 4101, Australia.,School of Public Health, University of Queensland, Brisbane, Australia
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Hladunewich MA, Melamed N, Bramham K. Pregnancy across the spectrum of chronic kidney disease. Kidney Int 2016; 89:995-1007. [PMID: 27083278 DOI: 10.1016/j.kint.2015.12.050] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Revised: 12/06/2015] [Accepted: 12/18/2015] [Indexed: 01/14/2023]
Abstract
Management of the pregnant woman with chronic kidney disease is difficult for both nephrologists and obstetricians. Prepregnancy counselling with respect to risk stratification, optimization of maternal health prior to pregnancy, as well as management of the many potential pregnancy-associated complications in this complex patient population remains challenging due to the paucity of large, well-designed clinical studies. Furthermore, the heterogeneity of disease and the relative infrequency of pregnancy, particularly in more advanced stages of chronic kidney disease, leaves many clinicians feeling ill prepared to manage these pregnancies. As such, counselling is imprecise and management varies substantially across centers. All pregnancies in women with chronic kidney disease can benefit from a collaborative multidisciplinary approach with a team that consists of nephrologists experienced in the management of kidney disease in pregnancy, maternal-fetal medicine specialists, high-risk pregnancy nursing staff, dieticians, and pharmacists. Further access to skilled neonatologists and neonatal intensive care unit support is essential given the risks for preterm delivery in this patient population. The goal of this paper is to highlight some of the data that currently exist in the literature, provide management strategies for the practicing nephrologist at all stages of chronic kidney disease, and explore some of the knowledge gaps where future multinational collaborative research efforts should concentrate to improve pregnancy outcomes in women with kidney disease across the globe.
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Affiliation(s)
- Michelle A Hladunewich
- Division of Nephrology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
| | - Nir Melamed
- Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Kate Bramham
- Division of Transplantation, Immunology and Mucosal Biology, Department of Renal Medicine, King's College, London, UK
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Cappelletti M, Ethun K, Meeker T, Von Scherr G, Wallen K. Early adolescent Depo-Provera exposure increases stillbirths in adult sooty mangabeys. Reproduction 2015; 150:497-505. [DOI: 10.1530/rep-15-0314] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 09/30/2015] [Indexed: 11/08/2022]
Abstract
The 3-month injectable contraceptive medroxyprogesterone acetate (MPA; Depo-Provera) is a synthetic progestin that protects against pregnancy by suppressing ovulation. Studies have focused on the resumption of ovulation after MPA-treatment cessation but neglected potential long-term effects of MPA exposure on future successful reproduction. MPA is frequently administered to adolescent girls; however, long-term fertility effects of adolescent MPA exposure have not been explored. We investigated fertility after extended MPA exposure in a species of old world primate, the sooty mangabey (Cercocebus atys). Female sooty mangabeys (n=31) received chronic MPA-treatment for 4–8 years. At MPA-treatment onset, subjects were either parous adults (n=14) or nulliparous adolescents (n=17), with adolescent-treated subjects being further divided into those who had reached first ovulation (n=10) and those who had not (n=7). After MPA-treatment cessation, adolescent-treated females had a significantly higher incidence of stillbirth than did age-matched and parity-matched controls, whereas adult-treated females did not differ from their matched controls. Females placed on MPA-treatment prior to first ovulation had a significantly higher incidence of stillbirth post-treatment than did females placed on MPA-treatment after first ovulation. Diabetic females had an increased incidence of stillbirth as compared to nondiabetic females; however, when controlling for diabetes, MPA exposure prior to first ovulation was still a significant positive predictor of stillbirth. These findings suggest that the post-treatment fertility effects of chronic MPA exposure vary with the developmental timing of treatment onset and raise concern about the use of MPA as a contraceptive for adolescent girls.
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Hashimoto K, Koga M. Indicators of glycemic control in patients with gestational diabetes mellitus and pregnant women with diabetes mellitus. World J Diabetes 2015; 6:1045-1056. [PMID: 26240701 PMCID: PMC4515444 DOI: 10.4239/wjd.v6.i8.1045] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Revised: 02/20/2015] [Accepted: 05/06/2015] [Indexed: 02/05/2023] Open
Abstract
Recently, it has become clear that mild abnormal glucose tolerance increases the incidence of perinatal maternal-infant complications, and so the definition and diagnostic criteria of gestational diabetes mellitus (GDM) have been changed. Therefore, in patients with GDM and pregnant women with diabetes mellitus, even stricter glycemic control than before is required to reduce the incidence of perinatal maternal-infant complications. Strict glycemic control cannot be attained without an indicator of glycemic control; this review proposes a reliable indicator. The gold standard indicator of glycemic control in patients with diabetes mellitus is hemoglobin A1c (HbA1c); however, we have demonstrated that HbA1c does not reflect glycemic control accurately during pregnancy because of iron deficiency. It has also become clear that glycated albumin, another indicator of glycemic control, is not influenced by iron deficiency and therefore might be a better indicator of glycemic control in patients with GDM and pregnant women with diabetes mellitus. However, large-population epidemiological studies are necessary in order to confirm our proposal. Here, we outline the most recent findings about the indicators of glycemic control during pregnancy including fructosamine and 1,5-anhydroglucitol.
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Abstract
Pregestational diabetes currently complicates 4% of pregnancies, while gestational diabetes complicates approximately 8% of pregnancies. Increased risk of stillbirth in diabetic pregnancies has been a well-known and recognized complication for decades. While stillbirth rates for diabetic pregnancies have decreased due to screening, treatment, and antenatal surveillance of these patients, about 4% of all stillbirths remain attributable to diabetes, and diabetic pregnancies continue to be at increased risk for perinatal mortality. The purpose of this article is to review the literature on the epidemiology, pathophysiology, and prevention, as well as future research, of diabetes-associated perinatal mortality.
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Affiliation(s)
- Roman Starikov
- , 106 Irving Street Suite 108, Washington, DC, 20010, USA,
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31
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Abstract
The main purpose of treating diabetes is to prevent the onset and the progression of diabetic chronic complications. Since the mechanism of onset of chronic complications is still not well understood, the main strategy to achieve this purpose is to bring the plasma glucose level in diabetic patients as close as possible to that in healthy subjects and try to maintain good glycemic control over the long term. Glycated hemoglobin (HbA1c), glycated albumin (GA), fructosamine, and 1,5-anhydroglucitol (1,5 AG) are used for evaluating glycemic control. At present, HbA1c is widely used as a gold standard index for glycemic control in clinical practice. While HbA1c reflects the long-term glycemic control state (for the past 1-2 months), it does not accurately reflect glycemic control in the clinical state in which glycemic control improves or deteriorates in the short-term. It is also known that HbA1c in patients with hematological disorders such as anemia and variant hemoglobin shows an abnormal value. In addition, HbA1c mainly reflects the mean plasma glucose but does not reflect the postprandial plasma glucose. On the other hand, GA and 1,5-AG reflect intermediate- or short-term glycemic control and are not influenced by hemoglobin metabolism. While 1,5-AG is known to reflect the postprandial plasma glucose, it was shown recently that GA also reflects the postprandial plasma glucose. This chapter summarizes the measurement methods, usage methods, evidence, and problems concerning such indices for glycemic control.
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Abstract
Diabetes in pregnancy represents a risk condition for adverse maternal and feto-neonatal outcomes and many of these complications might occur during labor and delivery. In this context, the obstetrician managing women with pre-existing and gestational diabetes should consider (1) how these conditions might affect labor and delivery outcomes; (2) what are the current recommendations on management; and (3) which other factors should be considered to decide about the timing and mode of delivery. The analysis of the studies considered in this review leads to the conclusion that the decision to deliver should be primarily intended to reduce the risk of stillbirth, macrosomia, and shoulder dystocia. In this context, this review provides useful information for managing specific subgroups of diabetic women that may present overlapping risk factors, such as women with insulin-requiring diabetes and/or obesity and/or prenatal suspicion of macrosomic fetus. To date, the lack of definitive evidences and the complexity of the problem suggest that the "appropriate" clinical management should be customized according with the clinical condition, the type and mode of intervention, its consequences on outcomes, and considering the woman's consent and informed decisions.
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Affiliation(s)
- Gianpaolo Maso
- Department of Obstetrics and Gynecology, Institute for Maternal and Child Health - IRCCS Burlo Garofolo, Via dell'Istria 65/1, Trieste, 34137, Italy,
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Eidem I, Vangen S, Henriksen T, Vollset SE, Hanssen KF, Joner G, Stene LC. Discrepancy in term calculation from second trimester ultrasound scan versus last menstrual period in women with type 1 diabetes. Acta Obstet Gynecol Scand 2014; 93:809-16. [PMID: 24807126 DOI: 10.1111/aogs.12422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2013] [Accepted: 05/05/2014] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To study differences in ultrasound-based compared to menstrual-based term estimation in women with type 1 diabetes. DESIGN Nationwide register study. SETTING Norway. POPULATION Deliveries in Norway 1999-2004 by women registered in the Norwegian Childhood Diabetes Registry (n = 342) and the background population (n = 307 248), with data on both ultrasound-based and menstrual-based gestational age notified in the Birth Registry of Norway. Births with major malformations were excluded. METHODS Linkage of two nationwide registries, the Medical Birth Registry of Norway and the Norwegian Childhood Diabetes Registry. MAIN OUTCOME MEASURES Estimated gestational age at delivery based on routine second trimester ultrasound measurements and last menstrual period. RESULTS In women with type 1 diabetes, the distribution of gestational age at delivery was shifted considerably towards a lower gestational age when using second trimester ultrasound data for estimation, compared with last menstrual period data. The difference between the two estimation methods was larger among women with type 1 diabetes, although also evident in the general population. One in four women with diabetes and a certain last menstrual period date had their ultrasound-calculated term postponed 1 week or more, while one in 10 had it postponed 2 weeks or more. Corresponding numbers in the background population were one in five and one in 20. CONCLUSIONS We found a systematic postponement of ultrasound-based compared with menstrual-based term estimation in women with type 1 diabetes. Relying solely on routine ultrasound-based term calculation for delivery decision may imply a risk of going beyond an optimal pregnancy length.
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Affiliation(s)
- Ingvild Eidem
- Department of Pediatric Medicine, Oslo University Hospital, Oslo, Norway; Division of Epidemiology, Norwegian Institute of Public Health, Oslo, Norway
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Abstract
The incidence of both gestational and pre-gestational diabetes is increasing worldwide. The main cause of this increase is likely the concomitant increase in the incidence of global obesity, but in the case of gestational diabetes, changes in the diagnostic criteria are also a contributing factor. The adverse outcomes associated with pre-gestational diabetes are well known and have led clinicians to implement various strategies that include increased fetal surveillance and induction of labour at various gestational ages. In many cases these same strategies have been applied in clinical practice also to women with gestational diabetes despite there being differences in the type and magnitude of perinatal complications associated with this diagnosis. Despite the widespread application of these clinical practices, there is a paucity of quality data in the medical literature to guide the clinician in choosing a strategy for fetal surveillance and timing of delivery in both gestational diabetes and pre-gestational diabetes pregnancies. In the following review, we will discuss the rationale and consequences of planned delivery in gestational diabetes and pre-gestational diabetes, the evidence supporting different strategies for delivery and finally highlight future targets for research in this area.
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Affiliation(s)
- Howard Berger
- Maternal Fetal Medicine St Michael’s Hospital, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Nir Melamed
- Maternal Fetal Medicine St Michael’s Hospital, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
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35
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Fobker M. Stability of glucose in plasma with different anticoagulants. ACTA ACUST UNITED AC 2014; 52:1057-60. [DOI: 10.1515/cclm-2013-1049] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Accepted: 02/13/2014] [Indexed: 11/15/2022]
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Abstract
A major justification for the intentional delivery of a pregnancy before 39 weeks' gestation is a reduction in stillbirth. However, there is a considerable downside to late preterm or early term deliveries. Infants born before 39 weeks' gestation are at increased risk for numerous complications and even death. Thus, it is critical to identify which medical problems and circumstances place the fetus at high enough risk for stillbirth so as to justify late preterm or early term birth. This article highlights information pertinent to the pros and cons of iatrogenic preterm birth in pregnancies at risk for stillbirth.
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Affiliation(s)
- Sean F Edmunds
- Department of Obstetrics & Gynecology, University of Utah School of Medicine, 30 North 1900 East 2B200 SOM, Salt Lake City, UT 84132, USA
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Kodama Y, Sameshima H, Ohashi M, Ikenoue T. Impact of new gestational diabetes mellitus criteria on stillbirth: A regional population-based study in Japan. J Obstet Gynaecol Res 2013; 39:1242-5. [DOI: 10.1111/jog.12055] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2012] [Accepted: 12/12/2012] [Indexed: 11/28/2022]
Affiliation(s)
- Yuki Kodama
- Department of Obstetrics and Gynecology and Perinatal Center; Faculty of Medicine; University of Miyazaki; Miyazaki Japan
| | - Hiroshi Sameshima
- Department of Obstetrics and Gynecology and Perinatal Center; Faculty of Medicine; University of Miyazaki; Miyazaki Japan
| | - Masanao Ohashi
- Department of Obstetrics and Gynecology and Perinatal Center; Faculty of Medicine; University of Miyazaki; Miyazaki Japan
| | - Tsuyomu Ikenoue
- Department of Obstetrics and Gynecology and Perinatal Center; Faculty of Medicine; University of Miyazaki; Miyazaki Japan
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Castori M. Diabetic embryopathy: a developmental perspective from fertilization to adulthood. Mol Syndromol 2013; 4:74-86. [PMID: 23653578 DOI: 10.1159/000345205] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Maternal diabetes mellitus is one of the strongest human teratogens. Despite recent advances in the fields of clinical embryology, experimental teratology and preventive medicine, diabetes-related perturbations of the maternofetal unit maintain a considerable impact on the Healthcare System. Classic consequences of prenatal exposure to hyperglycemia encompass (early) spontaneous abortions, perinatal death and malformations. The spectrum of related malformations comprises some recurrent blastogenic monotopic patterns, i.e. holoprosencephaly, caudal dysgenesis and oculoauriculovertebral spectrum, as well as pleiotropic syndromes, i.e. femoral hypoplasia-unusual face syndrome. Despite this, most malformed fetuses display multiple blastogenic defects of the VACTERL type, whose (apparently) casual combination preclude recognizing recurrent patterns, but accurately testifies to their developmental stage at onset. With the application of developmental biology in modern medicine, the effects of diabetes on the unborn patient are expanded to include the predisposition to develop insulin resistance in adulthood. The mechanisms underlying the transgenerational correlation between maternal diabetes and proneness to adult disorders in the offspring remain unclear, and the epigenetic plasticity may represent the missing link. In this scenario, a development-driven summary of the multifaced consequences of maternal diabetes on fertility and child health may add a practical resource to the repertoire of available information on early stages of embryogenesis.
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Affiliation(s)
- M Castori
- Division of Medical Genetics, Department of Molecular Medicine, Sapienza University, San Camillo-Forlanini Hospital, Rome, Italy
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Factors Associated With Urgent Cesarean Delivery in Women With Type 1 Diabetes Mellitus. Obstet Gynecol 2013; 121:983-989. [DOI: 10.1097/aog.0b013e31828b6d97] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bismuth E, Bouche C, Caliman C, Lepercq J, Lubin V, Rouge D, Timsit J, Vambergue A. Management of pregnancy in women with type 1 diabetes mellitus: Guidelines of the French-Speaking Diabetes Society (Société francophone du diabète [SFD]). DIABETES & METABOLISM 2012; 38:205-16. [DOI: 10.1016/j.diabet.2012.02.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2012] [Accepted: 02/17/2012] [Indexed: 12/11/2022]
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Joubert M, Reznik Y. Personal continuous glucose monitoring (CGM) in diabetes management: review of the literature and implementation for practical use. Diabetes Res Clin Pract 2012; 96:294-305. [PMID: 22209014 DOI: 10.1016/j.diabres.2011.12.010] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2011] [Revised: 12/02/2011] [Accepted: 12/06/2011] [Indexed: 10/14/2022]
Abstract
AIM Despite recent advances in diabetes therapy including the new long- and rapid-insulin analogs, insulin intensification strategies such as basal/bolus or pump therapy and sophisticated methods for insulin titration derived from the principles of functional insulin therapy, many patients fail to reach or maintain target glycosylated hemoglobin (HbA1c) values, putting them at increased risk for vascular complications. Continuous glucose monitoring (CGM) systems represent an important advance in diabetes technology that can facilitate optimal glucose control in type 1 diabetes. METHOD This review focuses on the efficacy and safety of CGM systems in diabetes management. The different CGM devices available are also described, as the way to use them and the educational approach to the patient in a step-by-step progression toward optimal glycemic control. RESULTS In type 1 diabetes, CGM systems are associated with 0.5-1% reduction in HbA1c without increased risk of hypoglycemia. CGM efficacy correlates with compliance to sensor wear, whatever the patient's age range. CONCLUSION Efficacy of CGM systems is now proven but indications, terms of use and educational issues of this new technology still need to be specified.
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Affiliation(s)
- M Joubert
- Caen University Hospital, Department of Endocrinology, Caen F-14000, France
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42
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Ringholm L, Pedersen-Bjergaard U, Thorsteinsson B, Damm P, Mathiesen ER. Hypoglycaemia during pregnancy in women with Type 1 diabetes. Diabet Med 2012; 29:558-66. [PMID: 22313112 DOI: 10.1111/j.1464-5491.2012.03604.x] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
AIMS To explore incidence, risk factors, possible pathophysiological factors and clinical management of hypoglycaemia during pregnancy in women with Type 1 diabetes. METHODS Literature review. RESULTS In women with Type 1 diabetes, severe hypoglycaemia occurs three to five times more frequently in early pregnancy than in the period prior to pregnancy, whereas in the third trimester the incidence of severe hypoglycaemia is lower than in the year preceding pregnancy. The frequency distribution of severe hypoglycaemia is much skewed, as 10% of the pregnant women account for 60% of all recorded events. Risk factors for severe hypoglycaemia during pregnancy include a history with severe hypoglycaemia in the year preceding pregnancy, impaired hypoglycaemia awareness, long duration of diabetes, low HbA(1c) in early pregnancy, fluctuating plasma glucose values (≤ 3.9 mmol/l or ≥ 10.0 mmol/l) and excessive use of supplementary insulin injections between meals. Pregnancy-induced nausea and vomiting seem not to be contributing factors. CONCLUSIONS Striving for near-normoglycaemia with focus on reduction of plasma glucose fluctuations during pregnancy should have high priority among clinicians with the persistent aim of improving pregnancy outcome among women with Type 1 diabetes. Pre-conception counselling, carbohydrate counting, use of insulin analogues, continuous subcutaneous insulin infusion (insulin pump) therapy and real-time continuous glucose monitoring with alarms for low glucose values might be relevant tools to obtain near-normoglycaemia without episodes of severe hypoglycaemia.
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Affiliation(s)
- L Ringholm
- Center for Pregnant Women with Diabetes, Rigshospitalet, University of Copenhagen Department of Endocrinology, Rigshospitalet, Copenhagen, Denmark.
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43
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Abstract
During pregnancy, the glucose levels vary according to the hormonal changes and the metabolic needs necessary to maintain fetal nutrition but strict glycemic control is essential to minimize the maternal and fetal morbidity and mortality of pregnancies complicated by diabetes. Although considered the "gold standard" for diagnosis, measurement of glucose in the blood is subject to several limitations, many of which are not widely appreciated. Measurement of A1c for diagnosis is appealing as with one number, a total, integrated view of glycemia over time is derived though it has some inherent limitations. Thus, supplementation with HbA1c, as is common outside pregnancy, seems appropriate. Before pregnancy, the target for metabolic control in women with diabetes is HbA1c values near the normal range. However, the upper normal range of HbA1c during normal pregnancy is only sparsely investigated with different methods though recently a number of papers have been published regarding the determination of reference ranges for HbA1c in pregnancy. These changes may have clinical implications for the assessment and management of glycemic control in diabetic pregnancy and calls for establishment of separate reference limits of HbA1c levels in different trimesters as compared to general population.
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Affiliation(s)
- Dalia Rafat
- Department of Obstetrics and Gynecology, Faculty of Medicine, J.N. Medical College, Aligarh Muslim University, Aligarh 202002, India
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44
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Human serum albumin: from bench to bedside. Mol Aspects Med 2011; 33:209-90. [PMID: 22230555 DOI: 10.1016/j.mam.2011.12.002] [Citation(s) in RCA: 1195] [Impact Index Per Article: 91.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Accepted: 12/21/2011] [Indexed: 02/07/2023]
Abstract
Human serum albumin (HSA), the most abundant protein in plasma, is a monomeric multi-domain macromolecule, representing the main determinant of plasma oncotic pressure and the main modulator of fluid distribution between body compartments. HSA displays an extraordinary ligand binding capacity, providing a depot and carrier for many endogenous and exogenous compounds. Indeed, HSA represents the main carrier for fatty acids, affects pharmacokinetics of many drugs, provides the metabolic modification of some ligands, renders potential toxins harmless, accounts for most of the anti-oxidant capacity of human plasma, and displays (pseudo-)enzymatic properties. HSA is a valuable biomarker of many diseases, including cancer, rheumatoid arthritis, ischemia, post-menopausal obesity, severe acute graft-versus-host disease, and diseases that need monitoring of the glycemic control. Moreover, HSA is widely used clinically to treat several diseases, including hypovolemia, shock, burns, surgical blood loss, trauma, hemorrhage, cardiopulmonary bypass, acute respiratory distress syndrome, hemodialysis, acute liver failure, chronic liver disease, nutrition support, resuscitation, and hypoalbuminemia. Recently, biotechnological applications of HSA, including implantable biomaterials, surgical adhesives and sealants, biochromatography, ligand trapping, and fusion proteins, have been reported. Here, genetic, biochemical, biomedical, and biotechnological aspects of HSA are reviewed.
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Outcome of pregnancy in type 1 diabetes mellitus (T1DMP): results from combined diabetes–obstetrical clinics in Dublin in three university teaching hospitals (1995–2006). Ir J Med Sci 2011; 181:105-9. [DOI: 10.1007/s11845-011-0781-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2010] [Accepted: 10/22/2011] [Indexed: 11/26/2022]
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Eidem I, Vangen S, Hanssen KF, Vollset SE, Henriksen T, Joner G, Stene LC. Perinatal and infant mortality in term and preterm births among women with type 1 diabetes. Diabetologia 2011; 54:2771-8. [PMID: 21866407 DOI: 10.1007/s00125-011-2281-7] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2011] [Accepted: 07/01/2011] [Indexed: 12/14/2022]
Abstract
AIMS/HYPOTHESIS The aim of this study was to estimate the risks of adverse birth outcomes such as stillbirth, infant death, preterm birth and pre-eclampsia in women with type 1 diabetes, compared with the background population. We further aimed to explore the risks of adverse birth outcomes in preterm and term deliveries separately. METHODS By linkage of two nationwide registries, the Medical Birth Registry of Norway and the Norwegian Childhood Diabetes Registry, we identified 1,307 births among women with pregestational type 1 diabetes registered in the Diabetes Registry, and 1,161,092 births in the background population during the period 1985-2004. The ORs with 95% CIs for adverse outcome among women with type 1 diabetes vs the background population were estimated using logistic regression. RESULTS The OR for stillbirth (≥22 weeks of gestation) was 3.6 (95% CI 2.5, 5.3), and for perinatal death (stillbirth or death in the first week of life) it was 2.9 (95% CI 2.0, 4.1). The OR for infant death (first year of life) was 1.9 (95% CI 1.1, 3.2). For preterm birth (< 37 weeks of gestation) and pre-eclampsia the ORs were 4.9 (95% CI 4.3, 5.5) and 6.3 (95% CI 5.5, 7.2), respectively. When preterm and term deliveries were analysed separately, the excess risk of stillbirth and infant death in women with diabetes was confined to term deliveries. CONCLUSIONS/INTERPRETATION Pregestational type 1 diabetes was associated with a considerably higher risk of adverse pregnancy outcomes, including infant death, compared with the background population. A novel finding of the study was that the increased risk was confined to term births.
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Affiliation(s)
- I Eidem
- Department of Paediatrics, Oslo University Hospital Ullevål, Oslo, Norway.
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47
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Catalano PM, Sacks DA. Timing of indicated late preterm and early-term birth in chronic medical complications: diabetes. Semin Perinatol 2011; 35:297-301. [PMID: 21962630 PMCID: PMC3185292 DOI: 10.1053/j.semperi.2011.05.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The number of pregnant women who have type 2 diabetes and the number found to have gestational diabetes are progressively increasing. In the future, as many as 20% of pregnant women may be diagnosed with diabetes. Although there is consensus regarding many issues in the treatment of pregnant women with diabetes, there are few evidenced-based studies upon which to base the timing of delivery. There must be a balance between increased neonatal morbidity of late preterm and early-term delivery and fetal mortality. Potential adverse outcomes associated with late preterm and early-term delivery include respiratory problems as well as other metabolic dysfunctions characteristic of the preterm infant of a mother with diabetes. Delivery at term increases the risk of fetal demise, fetal overgrowth, and birth injury. Even among diabetic women who practice good glycemic control, the risk of intrauterine fetal demise in third trimester appears greater than that of neonatal death. Additional prospective data are urgently needed to better understand the short and long-term risks and benefits of the timing of delivery in this very common obstetrical dilemma.
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Affiliation(s)
- Patrick M Catalano
- Department of Reproductive Biology, Case Western Reserve University, MetroHealth Medical Center, Cleveland, OH 44109, USA.
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Flenady V, Middleton P, Smith GC, Duke W, Erwich JJ, Khong TY, Neilson J, Ezzati M, Koopmans L, Ellwood D, Fretts R, Frøen JF. Stillbirths: the way forward in high-income countries. Lancet 2011; 377:1703-17. [PMID: 21496907 DOI: 10.1016/s0140-6736(11)60064-0] [Citation(s) in RCA: 326] [Impact Index Per Article: 25.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Stillbirth rates in high-income countries declined dramatically from about 1940, but this decline has slowed or stalled over recent times. The present variation in stillbirth rates across and within high-income countries indicates that further reduction in stillbirth is possible. Large disparities (linked to disadvantage such as poverty) in stillbirth rates need to be addressed by providing more educational opportunities and improving living conditions for women. Placental pathologies and infection associated with preterm birth are linked to a substantial proportion of stillbirths. The proportion of unexplained stillbirths associated with under investigation continues to impede efforts in stillbirth prevention. Overweight, obesity, and smoking are important modifiable risk factors for stillbirth, and advanced maternal age is also an increasingly prevalent risk factor. Intensified efforts are needed to ameliorate the effects of these factors on stillbirth rates. Culturally appropriate preconception care and quality antenatal care that is accessible to all women has the potential to reduce stillbirth rates in high-income countries. Implementation of national perinatal mortality audit programmes aimed at improving the quality of care could substantially reduce stillbirths. Better data on numbers and causes of stillbirth are needed, and international consensus on definition and classification related to stillbirth is a priority. All parents should be offered a thorough investigation including a high-quality autopsy and placental histopathology. Parent organisations are powerful change agents and could have an important role in raising awareness to prevent stillbirth. Future research must focus on screening and interventions to reduce antepartum stillbirth as a result of placental dysfunction. Identification of ways to reduce maternal overweight and obesity is a high priority for high-income countries.
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Affiliation(s)
- Vicki Flenady
- Mater Medical Research Institute, South Brisbane, QLD, Australia.
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Mathiesen ER, Ringholm L, Damm P. Stillbirth in diabetic pregnancies. Best Pract Res Clin Obstet Gynaecol 2011; 25:105-11. [PMID: 21256813 DOI: 10.1016/j.bpobgyn.2010.11.001] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2010] [Accepted: 11/01/2010] [Indexed: 01/05/2023]
Abstract
Pregnancy in women with pregestational diabetes is associated with high perinatal morbidity and mortality. Stillbirth accounts for the majority of cases with perinatal death. Intrauterine growth restriction, pre-eclampsia, foetal hypoxia and congenital malformations may be contributing factors, but more than 50% of stillbirths are unexplained. Majority of stillbirths are characterised by suboptimal glycaemic control during pregnancy. Foetal hypoxia and cardiac dysfunction secondary to poor glycaemic control are probably the most important pathogenic factors in stillbirths among pregnant diabetic women. There is thus a need for new strategies for improving glycaemic control to near-normal levels throughout pregnancy and for preventing and treating hypertensive disorders in pregnancy. Antenatal surveillance tests including ultrasound examinations of the foetal growth rate, kick counting and non-stress testing of foetal cardiac function are widely used. However, future research should establish better antenatal surveillance tests to identify the infants susceptible to stillbirth before it happens.
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Affiliation(s)
- Elisabeth R Mathiesen
- Center for Pregnant Women with Diabetes, Rigshospitalet, Faculty of Health Science, University of Copenhagen, Denmark.
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50
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Verhaeghe J, van Bree R, Van Herck E. Oxidant balance markers at birth in relation to glycemic and acid-base parameters. Metabolism 2011; 60:71-7. [PMID: 20537667 DOI: 10.1016/j.metabol.2010.04.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2010] [Revised: 03/30/2010] [Accepted: 04/14/2010] [Indexed: 11/29/2022]
Abstract
In diabetic pregnancies, suboptimal glycemic control is a risk factor for fetal acidemia and stillbirth. We hypothesized that the diabetic intrauterine milieu (hyperglycemia, hyperinsulinemia, changes in acid-base status) might predispose to oxidative stress. We studied 70 newborns whose mothers had pregestational diabetes (58 with type 1 diabetes mellitus) and 71 control newborns from nondiabetic mothers. Protein carbonyls (PCs), malondialdehyde, and 8-hydroxy-2'deoxyguanosine were measured in umbilical vein plasma as a reflection of protein, lipid, and DNA oxidative damage, respectively; glutathione peroxidase-3 (GPx3), an important circulating antioxidant enzyme, was also assayed. Despite satisfactory glycemic control in the majority of diabetic mothers, their newborns showed higher birth weight and relative hyperglycemia, hyperinsulinemia, and respiratory acidemia. The oxidant balance marker concentrations were not different at the P < .05 level between the 2 groups, and there was no relationship to maternal hemoglobin A(₁C) levels in the diabetic group. However, in the entire sample, increasing glucose levels at birth were related to lower GPx3 and higher PC concentrations; and GPx3 and PC concentrations were inversely correlated. In addition, a depressed pH or larger base-deficit at birth was related to higher PC and 8-hydroxy-2'deoxyguanosine concentrations. In conclusion, oxidant balance markers at birth are not affected by maternal diabetes per se and its long-term glycemic control, yet some markers are acutely tuned to metabolic cues including glucose and the acid-base environment.
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Affiliation(s)
- Johan Verhaeghe
- Department of Obstetrics and Gynecology, Health Sciences Campus Gasthuisberg, Katholieke Universiteit Leuven, 3000 Leuven, Belgium.
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