Short-term neonatal outcome in diabetic versus non-diabetic pregnancies complicated by non-reassuring foetal heart rate tracings

Effect of later cord clamping on umbilical cord blood gas in term neonates of diabetic mothers: a randomized clinical trial

Objective

To evaluate the effect of later cord clamping (LCC) on umbilical arterial blood gas in neonates of diabetic mothers.

Methods

This prospective study included a group of 160 diabetic mothers (DM) whose neonates were randomized to immediate cord clamping (ICC) (≤ 15 s after birth) or LCC (≥ 30 s after birth), and a group of 208 non-diabetic mothers (NDM) whose neonates were randomized to ICC or LCC as a reference. Cord arterial pH, base excess (BE), bicarbonate (HCO₃⁻), partial pressure of carbon dioxide (pCO₂), partial pressure of oxygen (pO₂), lactate, hemoglobin, hematocrit and glucose were compared among groups.

Results

In neonates of DM, there was no significant difference in cord arterial pH between the ICC and LCC group. LCC of ≥ 30 s decreased umbilical arterial HCO₃⁻ and BE and increased lactate (ICC versus LCC, HCO₃⁻: 24.3 (22.7, 25.8) versus 23.7 (22.3, 24.7) mmol/L, P = 0.01; BE: -2.70 (-4.80, -1.50) versus − 3.72 (-5.66, -2.36) mmol/L, P = 0.006; lactate: 2.1 (1.6, 3.7) versus 2.7 (2.1, 4.3) mmol/L, P = 0.005), without the alterations of pCO₂, pO₂, hemoglobin, hematocrit and glucose. Similar results were found in neonates of NDM (ICC versus LCC, HCO₃⁻: 24.3 (23.1, 25.7) versus 23.5 (22.3, 24.8) mmol/L, P = 0.01; BE: -2.39 (-3.73, -1.51) versus − 3.40 (-4.73, -1.91) mmol/L, P = 0.001; lactate: 2.2 (1.9, 3.3) versus 2.5 (2.0, 4.3) mmol/L, P = 0.01), except for the higher level of hemoglobin in the LCC group. The majority of diabetic mothers (ICC: 92.0%; LCC: 91.8%) had good blood glucose control. No differences were observed in acid-base status and glucose between neonates of DM and neonates of NDM in both ICC and LCC, but hemoglobin and hematocrit were elevated after ICC in neonates of DM compared to neonates of NDM.

Conclusions

Later cord clamping of ≥ 30 s resulted in a tendency towards metabolic acidosis of umbilical arterial blood in neonates of DM and NDM. Umbilical arterial blood gas parameters at birth were similar in neonates of DM and NDM.

Trial registration

ClinicalTrials.gov: NCT04369313; date of registration: 30/04/2020 (retrospectively registered).

Risk of complications in the late versus early days of the 42nd week of pregnancy: A nationwide cohort study

INTRODUCTION

Uncertainty remains about the most appropriate timing of induction of labor in late-term pregnancies. To address this issue, this study aimed to compare the risk of neonatal morbidity and pregnancy- and birth-related complications between gestational age (GA) 41⁺⁴ -42⁺⁰ and GA 41⁺⁰ -41⁺³  weeks.

MATERIAL AND METHODS

This nationwide registry-based cohort study included singleton births without major congenital malformations, with registered GA, and with intended vaginal delivery at GA 41⁺⁰ - 42⁺⁰  weeks between 2009 and 2018 in Denmark. Logistic regression models were used to estimate the crude risk ratio and adjusted risk ratio (RR_A ) of neonatal and obstetric adverse outcomes in births at GA 41⁺⁴ - 42⁺⁰  weeks compared with GA 41⁺⁰ - 41⁺³  weeks. The results were adjusted for relevant confounders, including induction of labor.

RESULTS

A higher incidence of neonatal morbidity and birth complications was observed in births at GA 41⁺⁴ -42⁺⁰  weeks than in births at GA 41⁺⁰ -41⁺³  weeks. Neonatal morbidities included an increased risk of low Apgar score (Apgar 0-6 after 5 min; RR_A 1.17, 95% confidence interval [CI] 1.01-1.34), meconium aspiration (RR_A 1.25, 95% CI 1.06-1.48), need for respiratory support (continuous positive airway pressure; RR_A 1.09, 95% CI 1.03-1.15), and a composite outcome of need for comprehensive treatment at a neonatal department or neonatal death (RR_A 1.65, 95% CI 1.29-2.11). Birth complications included emergency cesarean section (RR_A 1.17, 95% CI 1.14-1.21), severe lacerations (RR_A 1.11, 95% Cl 1.04-1.17), and increased blood loss after birth (RR_A 1.13, 95% CI 1.06-1.21).

CONCLUSIONS

Births at GA 41⁺⁴ -42⁺⁰  weeks were associated with an increased risk of neonatal morbidity and birth complications compared with births at GA 41⁺⁰ -41⁺³  weeks. The results of this study may aid clinicians in deciding when to recommend induction of labor in late-term pregnancies.

Peripartum fetal distress in diabetic women: a retrospective case-cohort study

Background

Major concerns of pregnancies complicated by diabetes mellitus are an increased risk of adverse perinatal outcome. The objective of this study was to analyse the rate of fetal distress during labor in women with type 1, type 2 and gestational diabetes compared to control women.

Methods

A retrospective case-cohort study was conducted at the VU University Medical Center, Amsterdam; a tertiary care hospital. 117 women with type 1 diabetes, 59 women with type 2 diabetes, 303 women with gestational diabetes and 15,260 control women were included, who delivered between March 2004 and February 2014. Linear and logistic regression analyses were used to compare maternal and pregnancy characteristics. Risk of fetal distress and perinatal asphyxia was assessed by multiple regression analyses, adjusted for confounding factors as age, smoking, parity, previous cesarean section, hypertensive disorder, pre-eclampsia, prematurity, induction of labor and macrosomia. Main outcome measure was fetal distress, defined either as clinical indication for instrumental or cesarean delivery; or low umbilical artery pH (UA pH), or admission to neonatal unit (NU).

Results

The indication for instrumental or cesarean delivery in women with type 1 and type 2 diabetes mellitus was more frequently based on fetal distress as compared to controls (adjusted OR 2.76 CI 1.74–4.40 and adjusted OR 2.31 CI 1.19–4.51, respectively). In comparison with the control group, infants of women with type 1 diabetes had an increased risk of UA pH < 7.20 (adjusted OR 1.88 CI 1.23–2.87) or UA pH < 7.10 (adjusted OR 3.35 CI 1.79–6.27). Also, infants of women with type 1 diabetes were at increased risk for admission to NU as compared to infants of control women (OR 8.07 CI 4.75–13.70).

Conclusions

Women with type 1 and type 2 diabetes are at increased risk of fetal distress during labor as compared to controls.

Risk factors for advanced resuscitation in term and near-term infants: a case-control study

OBJECTIVE

(1) To determine which antepartum and/or intrapartum factors are associated with the need for advanced neonatal resuscitation (ANR) at birth in infants with gestational age (GA) ≥34 weeks. (2) To develop a risk score for the need for ANR in neonates with GA ≥34 weeks.

DESIGN

Prospective multicentre, case-control study. In total, 16 centres participated in this study: 10 in Argentina, 1 in Chile, 3 in Brazil and 2 in the USA.

RESULTS

A case-control study conducted from December 2011 to April 2013. Of a total of 61 593 births, 58 429 were reported as an GA ≥34 weeks, and of these, only 219 (0.37%) received ANR. After excluding 23 cases, 196 cases and 784 consecutive birth controls were included in the analysis. The final model was generated with three antepartum and seven intrapartum factors, which correctly classified 88.9% of the observations. The area under the receiver operating characteristic (AROC) performed to evaluate discrimination was 0.88, 95% CI 0.62 to 0.91. The AROC performed for external validity testing of the model in the validation sample was 0.87 with 95% CI 0.58 to 0.92.

CONCLUSIONS

We identified 10 risk factors significantly associated with the need for ANR in newborns ≥34 weeks. We developed a validated risk score that allows the identification of newborns at higher risk of need for ANR. Using this tool, the presence of specialised personnel in the delivery room may be designated more appropriately.

Impact of gestational hyperglycemia on maternal and child health

PURPOSE OF REVIEW

To address the recent evidence regarding the association between hyperglycemia during pregnancy and adverse short-term and long-term outcome for both mothers and offspring.

RECENT FINDINGS

Recent data suggest a relationship between hyperglycemia during pregnancy and adverse short-term fetal outcomes, mainly those associated with excessive fetal growth. The degree of hyperglycemia plays an important role in risk stratification. Moreover, the long-term effect of hyperglycemia during pregnancy is expressed mainly as cardiometabolic morbidity and increased risk for the development of metabolic syndrome both maternal and in early adolescence. Alternation in DNA methylation and gene expression of metabolic pathways were found in association with hyperglycemia in utero, supporting the 'developmental origins of disease' hypothesis.

SUMMARY

The effect of hyperglycemia on the early life metabolic environment may contribute to the subsequent risk of cardiovascular or metabolic morbidity later in life. It is also a sign of future maternal metabolic alternation. Several future randomized trials, hopefully will help to determine if early intervention could decrease the risk for gestational diabetes and whether long term adverse outcome are preventable and importantly the association with degree of maternal hyperglycemia in pregnancy and future morbidity.