1
|
Pomytkina NV, Sorokin EL. [Investigation of diabetic retinopathy progression in women with diabetes mellitus during pregnancy]. Vestn Oftalmol 2023; 139:30-40. [PMID: 37379107 DOI: 10.17116/oftalma202313903130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
PURPOSE The study evaluates the transient and stationary diabetic retinal changes in pregnant women with diabetes mellitus (DM) based on the analysis of individual clinical cases of diabetic retinopathy (DR) progression. MATERIAL AND METHODS The study examined 24 pregnant women with DM. The examination was carried out in each trimester of pregnancy and 6 months after delivery. In 10 pregnant women DR was not detected, and 14 (58%) were diagnosed with DR. RESULTS Progression of DR during pregnancy was observed in 9 patients with pre-proliferative and proliferative DR (PPDR and PDR) and uncompensated glycemia, 3 patients developed macular edema (ME) in both eyes. Panretinal laser coagulation (PRLC) was performed in patients with ongoing DR progression. In the postpartum period, the manifestations of DR did not regress. ME turned out to be transient in one patient with PPDR. Three clinical cases of DR manifesting in the first trimester of pregnancy are presented: PPDR with transient ME, PDR with ME, non-proliferative DR with a stable course. CONCLUSION 1. DR detected at the beginning of gestation in women with decompensated glycemic status progressed in 64% of cases. 2. Progression of DR during pregnancy was noted in patients with PPDR and PDR. 3. Progression of DR during pregnancy is more often true than transient. 4. Detection of PPDR and PDR during pregnancy is a direct indication for laser coagulation of the retina.
Collapse
Affiliation(s)
- N V Pomytkina
- Khabarovsk branch of S.N. Fedorov National Medical Research Center "MNTK "Eye Microsurgery", Khabarovsk, Russia
- Far-Eastern State Medical University, Khabarovsk, Russia
| | - E L Sorokin
- Khabarovsk branch of S.N. Fedorov National Medical Research Center "MNTK "Eye Microsurgery", Khabarovsk, Russia
- Far-Eastern State Medical University, Khabarovsk, Russia
| |
Collapse
|
2
|
Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
Collapse
|
3
|
Bowers K, Ehrlich S, Dolan LM, Gupta R, Altaye M, Ollberding NJ, Szczesniak R, Catalano P, Smith E, Khoury JC. Elevated Anthropometric and Metabolic Indicators among Young Adult Offspring of Mothers with Pregestational Diabetes: Early Results from the Transgenerational Effect on Adult Morbidity Study (the TEAM Study). J Diabetes Res 2021; 2021:6590431. [PMID: 34761006 PMCID: PMC8575612 DOI: 10.1155/2021/6590431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 09/30/2021] [Accepted: 10/15/2021] [Indexed: 12/03/2022] Open
Abstract
Exposure to maternal diabetes in utero increases the risk in the offspring for a range of metabolic disturbances. However, the timing and variability of in utero hyperglycemic exposure necessary to cause impairment have not been elucidated. The TEAM Study was initiated to evaluate young adult offspring of mothers with pregestational diabetes mellitus. This paper outlines the unique enrollment challenges of the TEAM Study and preliminary analysis of the association between exposure to diabetes in pregnancy and adverse metabolic outcomes. The TEAM Study enrolls offspring of women who participated in a Diabetes in Pregnancy (DiP) Program Project Grant between 1978 and 1995. The DiP Study collected medical and obstetric data across pregnancy. The first 96 eligible offspring of women with pregestational diabetes were age-, sex-, and race-matched to adults from the National Health and Nutrition Examination Survey (NHANES) 2015-2016 with an OGTT. Descriptive and regression analyses were employed to compare TEAM participants to NHANES participants. Among a subset of TEAM participants, we compared the metabolic outcomes across maternal glucose profiles using a longitudinal data clustering technique that characterizes level and variability, in maternal glucose across pregnancy. By comparing categories of BMI, TEAM Study participants had over 2.0 times the odds of being obese compared to matched NHANES participants (for class III obesity, OR = 2.81; 95% confidence interval (CI): 1.15, 6.87). Increasing levels of two-hour glucose were also associated with in utero exposure to pregestational diabetes in matched analyses. Exposure to pregestational diabetes in utero may be associated with an increased risk of metabolic impairment in the offspring with clinical implications.
Collapse
Affiliation(s)
- Katherine Bowers
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- University of Cincinnati College of Medicine, Department of Pediatrics, Cincinnati, Ohio, USA
| | - Shelley Ehrlich
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- University of Cincinnati College of Medicine, Department of Pediatrics, Cincinnati, Ohio, USA
| | - Lawrence M. Dolan
- University of Cincinnati College of Medicine, Department of Pediatrics, Cincinnati, Ohio, USA
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Resmi Gupta
- Biostatistics and Epidemiology/Research Design Component, Division of Clinical and Translational Sciences, Department of Internal Medicine, University of Texas McGovern Medical School, Houston, Texas, USA
| | - Mekibib Altaye
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- University of Cincinnati College of Medicine, Department of Pediatrics, Cincinnati, Ohio, USA
| | - Nicholas J. Ollberding
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- University of Cincinnati College of Medicine, Department of Pediatrics, Cincinnati, Ohio, USA
| | - Rhonda Szczesniak
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- University of Cincinnati College of Medicine, Department of Pediatrics, Cincinnati, Ohio, USA
| | - Patrick Catalano
- Tufts University School of Medicine, Friedman School of Nutrition, Science and Policy, Boston, Massachusetts, USA
| | - Emily Smith
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jane C. Khoury
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- University of Cincinnati College of Medicine, Department of Pediatrics, Cincinnati, Ohio, USA
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| |
Collapse
|
4
|
Abstract
Continuous glucose monitoring (CGM) is being used with increasing frequency as an adjunct to self-monitoring of blood glucose in pregnancy, and novel targets based on CGM data are becoming standardized. This adoption of CGM is the result of its improving accuracy, patient preference, and evolving data demonstrating associations of novel targets such as time in range (TIR) with pregnancy and neonatal outcomes. A greater understanding of the relationship of various CGM metrics to outcomes in pregnancy complicated by diabetes is needed. It is clear that TIR parameters need to be uniquely lower for pregnant women than for nonpregnant individuals. CGM technology is also an integral part of hybrid closed-loop insulin delivery systems. These insulin delivery systems will be a significant advance in the management of diabetes during pregnancy if they can achieve the pre- and postprandial targets required for pregnancy and optimize TIR.
Collapse
|
5
|
Gupta R, Khoury JC, Altaye M, Jandarov R, Szczesniak RD. Flexible multivariate joint model of longitudinal intensity and binary process for medical monitoring of frequently collected data. Stat Med 2021; 40:1845-1858. [PMID: 33426642 DOI: 10.1002/sim.8875] [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: 06/02/2020] [Revised: 12/22/2020] [Accepted: 12/23/2020] [Indexed: 11/08/2022]
Abstract
A frequent problem in longitudinal studies is that data may be assessed at subject-selected, irregularly spaced time-points, resulting in highly unbalanced outcome data, inducing bias, especially if availability of data is directly related to outcome. Our aim was to develop a multivariate joint model in a mixed outcomes framework to minimize irregular sampling bias. We demonstrate using blood glucose monitoring throughout pregnancy and risk of preterm birth among women with type 1 diabetes mellitus. Blood glucose measurements were unequally spaced and intensity of sampling varied between and within individuals over time. Multivariate linear mixed effects submodel for the longitudinal outcome (blood glucose), Poisson model for the intensity of glucose sampling, and logistic regression model for binary process (preterm birth) were specified. Association between models is captured through shared random effects. Markov chain Monte Carlo methods were used to fit the model. The multivariate joint model provided better prediction, compared with a joint model with a multivariate linear mixed effects submodel (ignoring intensity of glucose sampling) and a two-stage model. Most association parameters were significant in the preterm birth outcome model, signifying improvement of predictive ability of the binary endpoint by sharing random effects between glucose monitoring and preterm birth. A simulation study is presented to illustrate the effectiveness of the multivariate joint modeling approach.
Collapse
Affiliation(s)
- Resmi Gupta
- Biostatistics and Epidemiology/Research Design Component, Division of Clinical and Translational Sciences, Department of Internal Medicine, University of Texas McGovern Medical School, Houston, Texas, USA
| | - Jane C Khoury
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Mekibib Altaye
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Roman Jandarov
- Department of Biostatistics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Rhonda D Szczesniak
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| |
Collapse
|
6
|
Ali DS, Davern R, Rutter E, Coveney C, Devine H, Walsh JM, Higgins M, Hatunic M. Pre-Gestational Diabetes and Pregnancy Outcomes. Diabetes Ther 2020; 11:2873-2885. [PMID: 33010001 PMCID: PMC7644712 DOI: 10.1007/s13300-020-00932-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 09/15/2020] [Indexed: 10/25/2022] Open
Abstract
INTRODUCTION Pre-gestational, type 1 and type 2 diabetes are associated with adverse neonatal outcomes and increased rates of emergency caesarean sections. METHODS We studied pregnancy outcomes associated with pre-gestational diabetes in 174 women who attended the National Maternity Hospital in Dublin, Ireland, between 2015 and 2017. RESULTS Fifty women (28.6%) had type 2 diabetes mellitus, and 124 women (71.4%) had type 1 diabetes mellitus. Women with type 2 diabetes mellitus were older (36 vs. 34 years, p 0.02) and had a higher BMI (32.6 vs. 26.2 kg/m2, p 0.00). Duration of diabetes mellitus in type 1 and type 2 was 15.7 and 5.7 years, respectively, and mean HbA1c in type 2 diabetes mellitus at booking was 44.5 mmol/mol (6.2%) and in type 1 diabetes mellitus was 56.3 mmol/mol (7.3%). Forty women (32%) with type 1 diabetes mellitus used continuous subcutaneous insulin infusion. In our cohort, 45.4% had a caesarean delivery. Offspring of patients with multiple dose injections were lighter (3.58 kg) than infants of continuous subcutaneous insulin infusion-treated patients (3.75 kg). More emergency caesarean sections were observed in the continuous subcutaneous insulin infusion group than in the group treated with multiple dose injections (37.5% vs. 28.5%), while the elective caesarean section rate was higher in the multiple dose injection group (17.8% vs. 12.5%). Women treated with continuous subcutaneous insulin infusion had a higher rate of miscarriage (25% vs. 19%) with more congenital malformations (10% vs. 2.3%). CONCLUSIONS Women in our study with pre-gestational diabetes were overweight, were older and had long-standing diabetes mellitus. Our patients with type 2 diabetes had a higher BMI, were older, had a shorter duration of diabetes mellitus and had better diabetes control compared to women with type 1 diabetes. Women treated with continuous subcutaneous insulin infusion had a higher rate of miscarriage with more congenital malformations. The initial inadequate diabetes control was significantly improved during pregnancy.
Collapse
Affiliation(s)
- Dalal S Ali
- Endocrinology Department, Mater Misericordiae University Hospital, Dublin, Ireland
- The National Maternity Hospital, Holles Street, Dublin, Ireland
| | - Recie Davern
- Endocrinology Department, Mater Misericordiae University Hospital, Dublin, Ireland
- The National Maternity Hospital, Holles Street, Dublin, Ireland
- University College Dublin, Dublin, Ireland
| | - Eimear Rutter
- The National Maternity Hospital, Holles Street, Dublin, Ireland
| | - Ciara Coveney
- The National Maternity Hospital, Holles Street, Dublin, Ireland
| | - Hilary Devine
- Endocrinology Department, Mater Misericordiae University Hospital, Dublin, Ireland
- The National Maternity Hospital, Holles Street, Dublin, Ireland
- University College Dublin, Dublin, Ireland
| | - Jennifer M Walsh
- The National Maternity Hospital, Holles Street, Dublin, Ireland
- University College Dublin, Dublin, Ireland
| | - Mary Higgins
- The National Maternity Hospital, Holles Street, Dublin, Ireland
- University College Dublin, Dublin, Ireland
| | - Mensud Hatunic
- Endocrinology Department, Mater Misericordiae University Hospital, Dublin, Ireland.
- The National Maternity Hospital, Holles Street, Dublin, Ireland.
- University College Dublin, Dublin, Ireland.
| |
Collapse
|
7
|
Dedov II, Shestakova MV, Mayorov AY, Shamkhalova MS, Nikonova TV, Sukhareva OY, Pekareva EV, Ibragimova LI, Mikhina MS, Galstyan GR, Tokmakova AY, Surkova EV, Laptev DN, Kononenko IV, Egorova DN, Klefortova II, Sklyanik IA, Yarek-Martynova IY, Severina AS, Martynov SA, Vikulova OK, Kalashnikov VY, Gomova IS, Lipatov DV, Starostina EG, Ametov AS, Antsiferov MB, Bardymova TP, Bondar IA, Valeeva FV, Demidova TY, Klimontov VV, Mkrtumyan AM, Petunina NA, Suplotova LA, Ushakova OV, Khalimov YS, Ruyatkina LA. Diabetes mellitus type 1 in adults. DIABETES MELLITUS 2020. [DOI: 10.14341/dm12505] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Tatiana P. Bardymova
- Irkutsk State Medical Academy of Postgraduate Education – Branch Campus of the Russian Medical Academy of Continuing Professional Education
| | | | | | | | - Vadim V. Klimontov
- Research Institute of Clinical and Experimental Lymphology – Branch of the Institute of Cytology and Genetics, Siberian Branch of Russian Academy of Sciences
| | - Ashot M. Mkrtumyan
- Moscow State University of Medicine and Dentistry named after A.I. Evdokimov
| | - Nina A. Petunina
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | | | | | | | | |
Collapse
|
8
|
Stone RG, Scully P, Troy E, Moloney Y, Quinn A, Noctor E, Neylon O, Slevin J, Murphy A, O'Gorman C. Pregnancy outcomes in women with onset of type 1 diabetes mellitus less than 18 years of age. BMJ Open Diabetes Res Care 2020; 8:8/1/e001080. [PMID: 32349996 PMCID: PMC7213751 DOI: 10.1136/bmjdrc-2019-001080] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 02/13/2020] [Accepted: 03/09/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Pregnancy in women with type 1 diabetes mellitus (T1DM) is associated with an increased risk of congenital malformations, obstetric complications and neonatal morbidity. This study aims to investigate maternal, perinatal and neonatal outcomes of pregnancies in women with onset of T1DM less than 18 years of age. METHODS This retrospective cohort study extracted data regarding prenatal, intrapartum and postnatal outcomes of pregnancies in women with onset of T1DM<18 years identified from the diabetes in pregnancy register at University Maternity Hospital Limerick, treated from July 1, 2007 to July 1, 2017. RESULTS Seventeen women with onset of T1DM <18 years gave birth to 23 live infants during the period studied. 73.9% of pregnancies were unplanned. Only 21.7% of pregnancies took preconceptual folic acid. 60.9% of infants required treatment for hypoglycemia. CONCLUSION The high prevalence of unplanned pregnancy and poor uptake of prepregnancy care must be improved on in order to improve outcomes for this high-risk group.
Collapse
Affiliation(s)
- Roy Gavin Stone
- Department of Paediatrics, University Hospital Limerick, Dooradoyle, Limerick, Ireland
| | - Paul Scully
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Emma Troy
- Department of General Medicine, University Hospital Limerick, Dooradoyle, Limerick, Ireland
| | - Yvonne Moloney
- Department of Obstetrics, University Maternity Hospital Limerick, Limerick, Ireland
| | - Anne Quinn
- Department of Paediatrics, University Hospital Limerick, Dooradoyle, Limerick, Ireland
| | - Eoin Noctor
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
- Department of General Medicine, University Hospital Limerick, Dooradoyle, Limerick, Ireland
| | - Orla Neylon
- Department of Paediatrics, University Hospital Limerick, Dooradoyle, Limerick, Ireland
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - John Slevin
- Department of Obstetrics, University Maternity Hospital Limerick, Limerick, Ireland
| | - Annemarie Murphy
- Department of Paediatrics, University Hospital Limerick, Dooradoyle, Limerick, Ireland
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Clodagh O'Gorman
- Department of Paediatrics, University Hospital Limerick, Dooradoyle, Limerick, Ireland
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| |
Collapse
|
9
|
Gupta R, Khoury JC, Altaye M, Jandarov R, Szczesniak RD. Assessing the Relationship between Gestational Glycemic Control and Risk of Preterm Birth in Women with Type 1 Diabetes: A Joint Modeling Approach. J Diabetes Res 2020; 2020:3074532. [PMID: 32685553 PMCID: PMC7333058 DOI: 10.1155/2020/3074532] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 05/19/2020] [Accepted: 06/10/2020] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Characterizing maternal glucose sampling over the course of the entire pregnancy is an important step toward improvement in prediction of adverse birth outcome, such as preterm birth, for women with type 1 diabetes mellitus (T1DM). OBJECTIVES To characterize the relationship between the gestational glycemic profile and risk of preterm birth using a joint modeling approach. METHODS A joint model was developed to simultaneously characterize the relationship between a longitudinal outcome (daily blood glucose sampling) and an event process (preterm birth). A linear mixed effects model using natural cubic splines was fitted to predict the longitudinal submodel. Covariates included mother's age at last menstrual period, age at diabetes onset, body mass index, hypertension, retinopathy, and nephropathy. Various association structures (value, value plus slope, and area under the curve) were examined before selecting the final joint model. We compared the joint modeling approach to the time-dependent Cox model (TDCM). RESULTS A total of 16,480 glucose readings over gestation (range: 50-260 days) with 32 women (28%) having preterm birth was included in the study. Mother's age at last menstrual period and age at diabetes onset were statistically significant (beta = 1.29, 95% CI 1.10, 1.72; beta = 0.84, 95% CI 0.62, 0.98) for the longitudinal submodel, reflecting that older women tended to have higher mean blood glucose and those with later diabetes onset tended to have a lower mean blood glucose level. The presence of nephropathy was statistically significant in the event submodel (beta = 2.29, 95% CI 1.05, 4.48). Cumulative association parameterization provided the best joint model fit. The joint model provided better fit compared to the time-dependent Cox model (DIC (JM) = 19,895; DIC (TDCM) = 19,932). CONCLUSION The joint model approach was able to simultaneously characterize the glycemic profile and assess the risk of preterm birth and provided additional insights and a better model fit compared to the time-dependent Cox model.
Collapse
Affiliation(s)
- Resmi Gupta
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Jane C. Khoury
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Mekibib Altaye
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Roman Jandarov
- Department of Biostatistics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Rhonda D. Szczesniak
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| |
Collapse
|
10
|
Dyer E, Bell R, Graham R, Rankin J. Pregnancy decisions after fetal or perinatal death: systematic review of qualitative research. BMJ Open 2019; 9:e029930. [PMID: 31874867 PMCID: PMC7008435 DOI: 10.1136/bmjopen-2019-029930] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 10/24/2019] [Accepted: 11/22/2019] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To synthesise the findings of qualitative research exploring parents' experiences, views and decisions about becoming pregnant following a perinatal death or fetal loss. DESIGN Systematic review and meta-synthesis of qualitative research. DATA SOURCES Medline, Web of Science, CINAHL, PsycINFO, ASSIA, Embase, PUBMED, Scopus and Google Scholar. ELIGIBILITY CRITERIA Nine electronic databases were searched using predefined search terms. Articles published in English, in peer-reviewed journals, using qualitative methods to explore the experiences and attitudes of bereaved parents following perinatal or fetal loss, were included. DATA EXTRACTION AND SYNTHESIS Qualitative data relating to first-order and second-order constructs were extracted and synthesised across studies using a thematic analysis. RESULTS 15 studies were included. Four descriptive themes and 10 subthemes were identified. The descriptive themes were: deciding about subsequent pregnancy, diversity of reactions to the event, social network influences, and planning or timing of subsequent pregnancy. The decision to become pregnant after death is complex and varies between individuals and sometimes within couples. Decisions are often made quickly, in the immediate aftermath of a pregnancy loss, but may evolve over time. Bereaved parents may feel isolated from social networks. CONCLUSIONS There is an opportunity to support parents to prepare for a pregnancy after a fetal or perinatal loss, and conversations may be welcomed at an early stage. Health professionals may play an important role providing support lacking from usual social networks. PROSPERO REGISTRATION NUMBER CRD42018112839.
Collapse
Affiliation(s)
- Eleanor Dyer
- Population Health Sciences Institute, Newcastle University, Newcastle, UK
| | - Ruth Bell
- Population Health Sciences Institute, Newcastle University, Newcastle, UK
| | - Ruth Graham
- School of Geography, Sociology and Politics, Newcastle University, Newcastle, UK
| | - Judith Rankin
- Population Health Sciences Institute, Newcastle University, Newcastle, UK
| |
Collapse
|
11
|
Singh H, Ingersoll K, Gonder-Frederick L, Ritterband L. "Diabetes Just Tends to Take Over Everything": Experiences of Support and Barriers to Diabetes Management for Pregnancy in Women With Type 1 Diabetes. Diabetes Spectr 2019; 32:118-124. [PMID: 31168282 PMCID: PMC6528394 DOI: 10.2337/ds18-0035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
To optimize clinical outcomes, women with type 1 diabetes are advised to consistently achieve blood glucose levels in their target range before becoming pregnant. However, following this recommendation can be clinically and psychologically challenging for patients. We explored women's experiences of pregnancy-related diabetes management and any barriers and support systems affecting their self-management. Fifteen semi-structured telephone interviews were conducted with a nationwide sample. Interviews focused on women's perceptions of barriers hindering pregnancy-related diabetes management and support systems facilitating their self-management. Audio recordings were analyzed using inductive thematic analysis. Results indicated significant impairment of psychological health and overall quality of life in women with type 1 diabetes who were pregnant or planning pregnancy. Most participants reported a lack of support and empathetic engagement from their health care team, which affected their clinical management. Guilt and concerns about high blood glucose levels, constant pressure to meet glucose targets, and difficult interactions with health care professionals were a few of the primary themes with regard to barriers to optimal management. Patient-centered programs that provide effective clinical and psychosocial support for women who are preparing for pregnancy with preexisting diabetes are urgently needed so that these women feel adequately supported and empowered to undertake pregnancy.
Collapse
Affiliation(s)
- Harsimran Singh
- Mary & Dick Allen Diabetes Center, Hoag Memorial Hospital Presbyterian, Newport Beach, CA
| | - Karen Ingersoll
- Center for Behavioral Health and Technology, Department of Psychiatry and Neurobehavioral Sciences, University of Virginia, Charlottesville, VA
| | - Linda Gonder-Frederick
- Center for Behavioral Health and Technology, Department of Psychiatry and Neurobehavioral Sciences, University of Virginia, Charlottesville, VA
| | - Lee Ritterband
- Center for Behavioral Health and Technology, Department of Psychiatry and Neurobehavioral Sciences, University of Virginia, Charlottesville, VA
| |
Collapse
|
12
|
Wilson RD. Woman's Pre-Conception Evaluation: Genetic and Fetal Risk Considerations for Counselling and Informed Choice. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 40:935-949. [DOI: 10.1016/j.jogc.2017.07.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 07/26/2017] [Accepted: 07/26/2017] [Indexed: 12/30/2022]
|
13
|
Clement M, Filteau P, Harvey B, Jin S, Laubscher T, Mukerji G, Sherifali D. Organization of Diabetes Care. Can J Diabetes 2018; 42 Suppl 1:S27-S35. [DOI: 10.1016/j.jcjd.2017.10.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Indexed: 02/06/2023]
|
14
|
Lin SF, Kuo CF, Chiou MJ, Chang SH. Maternal and fetal outcomes of pregnant women with type 1 diabetes, a national population study. Oncotarget 2017; 8:80679-80687. [PMID: 29113335 PMCID: PMC5655230 DOI: 10.18632/oncotarget.20952] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Accepted: 08/26/2017] [Indexed: 01/30/2023] Open
Abstract
Pregnancy in women with type 1 diabetes is associated with poor maternal and neonatal outcomes. However, the risk of these outcomes has never been evaluated in an Asian national population. In this work, we report the maternal and fetal outcomes of pregnant women with type 1 diabetes in Taiwan. A total of 2,350,339 pregnancy records created between 2001 and 2012 were obtained from the National Health Insurance database and analyzed. Here, 630 pregnancy records were identified in women having type 1 diabetes. Compared with pregnant women without type 1 diabetes, pregnant women with the disease showed increased risk of multiple adverse outcomes, including preeclampsia, eclampsia, cesarean delivery, adult respiratory distress syndrome, pulmonary edema, sepsis, chorioamnionitis, pregnancy-related hypertension, puerperal cerebrovascular disorders, acute renal failure, and shock. Fetuses of type 1 diabetic mothers were at increased risk of stillbirth, premature birth, large for gestational age, low birth weight, and low Apgar score. Of the studied endpoints, only preeclampsia showed an improvement in the late period (2011–2012) when compared with the early period (2001–2010). These findings reveal that pregnant women with type 1 diabetes are at significantly increased risk of developing many adverse maternal and fetal outcomes. Therefore, pregnancy outcomes in women with type 1 diabetes should be improved.
Collapse
Affiliation(s)
- Shu-Fu Lin
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan.,Chang Gung University, Taoyuan, Taiwan
| | - Chang-Fu Kuo
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Chang Gung University, Taoyuan, Taiwan
| | - Meng-Jiun Chiou
- Office for Big Data Research, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Shang-Hung Chang
- Office for Big Data Research, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Chang Gung University, Taoyuan, Taiwan
| |
Collapse
|
15
|
Egan AM, Galjaard S, Maresh MJA, Loeken MR, Napoli A, Anastasiou E, Noctor E, de Valk HW, van Poppel M, Todd M, Smith V, Devane D, Dunne FP. A core outcome set for studies evaluating the effectiveness of prepregnancy care for women with pregestational diabetes. Diabetologia 2017; 60:1190-1196. [PMID: 28409213 PMCID: PMC5487596 DOI: 10.1007/s00125-017-4277-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 03/13/2017] [Indexed: 12/30/2022]
Abstract
AIMS/HYPOTHESIS The aim of this study was to develop a core outcome set (COS) for trials and other studies evaluating the effectiveness of prepregnancy care for women with pregestational (pre-existing) diabetes mellitus. METHODS A systematic literature review was completed to identify all outcomes reported in prior studies in this area. Key stakeholders then prioritised these outcomes using a Delphi study. The list of outcomes included in the final COS were finalised at a face-to-face consensus meeting. RESULTS In total, 17 outcomes were selected and agreed on for inclusion in the final COS. These outcomes were grouped under three domains: measures of pregnancy preparation (n = 9), neonatal outcomes (n = 6) and maternal outcomes (n = 2). CONCLUSIONS/INTERPRETATION This study identified a COS essential for studies evaluating prepregnancy care for women with pregestational diabetes. It is advocated that all trials and other non-randomised studies and audits in this area use this COS with the aim of improving transparency and the ability to compare and combine future studies with greater ease.
Collapse
Affiliation(s)
- Aoife M Egan
- Galway Diabetes Research Centre, Department of Medicine, National University of Ireland Galway, Galway, Ireland.
| | - Sander Galjaard
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Prenatal Medicine, Erasmus MC, University Medical Centre Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, the Netherlands.
| | - Michael J A Maresh
- Department of Obstetrics, St Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Mary R Loeken
- Section of Islet Cell and Regenerative Biology, Joslin Diabetes Center, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Angela Napoli
- Department of Clinical and Molecular Medicine, S. Andrea University Hospital, Sapienza, University of Rome, Rome, Italy
| | - Eleni Anastasiou
- Department of Endocrinology & Diabetes Center Alexandra Hospital, Athens, Greece
| | - Eoin Noctor
- Department of Endocrinology, University Hospital Limerick, Limerick, Ireland
| | - Harold W de Valk
- Department of Internal Medicine, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Mireille van Poppel
- Institute of Sport Science, University of Graz, Graz, Austria
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, VU University Medical Centre, Amsterdam, the Netherlands
| | - Marie Todd
- Department of Medicine, Mayo University Hospital, Castlebar, Ireland
| | - Valerie Smith
- School of Nursing & Midwifery, Trinity College Dublin, Dublin, Ireland
- School of Nursing & Midwifery, National University of Ireland Galway, Galway, Ireland
| | - Declan Devane
- School of Nursing & Midwifery, National University of Ireland Galway, Galway, Ireland
- Health Research Board - Trials Methodology Research Network (HRB-TMRN), Galway, Ireland
| | - Fidelma P Dunne
- Galway Diabetes Research Centre, Department of Medicine, National University of Ireland Galway, Galway, Ireland
| |
Collapse
|
16
|
Gupta R, Khoury J, Altaye M, Dolan L, Szczesniak RD. Glycemic Excursions in Type 1 Diabetes in Pregnancy: A Semiparametric Statistical Approach to Identify Sensitive Time Points during Gestation. J Diabetes Res 2017; 2017:2852913. [PMID: 28280744 PMCID: PMC5320381 DOI: 10.1155/2017/2852913] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 12/15/2016] [Accepted: 01/09/2017] [Indexed: 02/03/2023] Open
Abstract
Aim. To examine the gestational glycemic profile and identify specific times during pregnancy that variability in glucose levels, measured by change in velocity and acceleration/deceleration of blood glucose fluctuations, is associated with delivery of a large-for-gestational-age (LGA) baby, in women with type 1 diabetes. Methods. Retrospective analysis of capillary blood glucose levels measured multiple times daily throughout gestation in women with type 1 diabetes was performed using semiparametric mixed models. Results. Velocity and acceleration/deceleration in glucose levels varied across gestation regardless of delivery outcome. Compared to women delivering LGA babies, those delivering babies appropriate for gestational age exhibited significantly smaller rates of change and less variation in glucose levels between 180 days of gestation and birth. Conclusions. Use of innovative statistical methods enabled detection of gestational intervals in which blood glucose fluctuation parameters might influence the likelihood of delivering LGA baby in mothers with type 1 diabetes. Understanding dynamics and being able to visualize gestational changes in blood glucose are a potentially useful tool to assist care providers in determining the optimal timing to initiate continuous glucose monitoring.
Collapse
Affiliation(s)
- Resmi Gupta
- Division of Biostatistics & Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jane Khoury
- Division of Biostatistics & Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | - Mekibib Altaye
- Division of Biostatistics & Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | - Lawrence Dolan
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | - Rhonda D. Szczesniak
- Division of Biostatistics & Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
- *Rhonda D. Szczesniak:
| |
Collapse
|
17
|
Forde R, Patelarou EE, Forbes A. The experiences of prepregnancy care for women with type 2 diabetes mellitus: a meta-synthesis. Int J Womens Health 2016; 8:691-703. [PMID: 27994487 PMCID: PMC5153267 DOI: 10.2147/ijwh.s115955] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Diabetes is one of the most common medical conditions affecting pregnancy and is associated with a number of adverse fetal, infant, and maternal outcomes. These adverse outcomes can be avoided or minimized with appropriate prepregnancy care (PPC). However, the uptake of PPC is limited in women with type 2 diabetes mellitus (T2DM). The reasons for poor uptake are multifactorial, reflecting both women's understanding of pregnancy risks, and limitations in care delivery. METHODS A systematic literature review with meta-synthesis was undertaken to identify qualitative studies exploring experiences of PPC for women with T2DM incorporating the views of women with T2DM and health care professionals (HCPs). Identified studies included were synthesized in a meta-ethnography to develop an understanding of the elements contributing to the uptake of PPC among women with T2DM. RESULTS The systematic review identified seven studies yielding data from 28 women with T2DM and 83 HCPs. The following six third-order constructs were identified from the synthesis: understanding PPC, emotive catalysts, beliefs about reproduction among women with T2DM, relationships and social factors, HCP behaviors and perspectives, and health care system factors. These constructs were used to develop a multifactorial model expressing the interactive issues that shape the reproductive health-seeking behaviors of women with T2DM to identify potential areas for intervention. CONCLUSION The uptake of PPC among women with T2DM seems to be informed by their personal orientation to their reproductive needs, their interactions with HCPs, and system-level influences. Future interventions to enhance PPC uptake need to address these underlying issues.
Collapse
Affiliation(s)
- Rita Forde
- Department of Adult Nursing, Florence Nightingale Faculty of Nursing and Midwifery, King's College London, London, UK
| | - Evridiki E Patelarou
- Department of Adult Nursing, Florence Nightingale Faculty of Nursing and Midwifery, King's College London, London, UK
| | - Angus Forbes
- Department of Adult Nursing, Florence Nightingale Faculty of Nursing and Midwifery, King's College London, London, UK
| |
Collapse
|
18
|
Szczesniak RD, Li D, Duan LL, Altaye M, Miodovnik M, Khoury JC. Longitudinal Patterns of Glycemic Control and Blood Pressure in Pregnant Women with Type 1 Diabetes Mellitus: Phenotypes from Functional Data Analysis. Am J Perinatol 2016; 33:1282-1290. [PMID: 27490775 PMCID: PMC5294951 DOI: 10.1055/s-0036-1586507] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Objective To identify phenotypes of type 1 diabetes control and associations with maternal/neonatal characteristics based on blood pressure (BP), glucose, and insulin curves during gestation, using a novel functional data analysis approach that accounts for sparse longitudinal patterns of medical monitoring during pregnancy. Methods We performed a retrospective longitudinal cohort study of women with type 1 diabetes whose BP, glucose, and insulin requirements were monitored throughout gestation as part of a program-project grant. Scores from sparse functional principal component analysis (fPCA) were used to classify gestational profiles according to the degree of control for each monitored measure. Phenotypes created using fPCA were compared with respect to maternal and neonatal characteristics and outcome. Results Most of the gestational profile variation in the monitored measures was explained by the first principal component (82-94%). Profiles clustered into three subgroups of high, moderate, or low heterogeneity, relative to the overall mean response. Phenotypes were associated with baseline characteristics, longitudinal changes in glycohemoglobin A1 and weight, and to pregnancy-related outcomes. Conclusion Three distinct longitudinal patterns of glucose, insulin, and BP control were found. By identifying these phenotypes, interventions can be targeted for subgroups at highest risk for compromised outcome, to optimize diabetes management during pregnancy.
Collapse
Affiliation(s)
- Rhonda D. Szczesniak
- Division of Biostatistics & Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH,Division of Pulmonary Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH,Address for correspondence: Rhonda Szczesniak, PhD, Division of Biostatistics & Epidemiology (MLC 5041), Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; Phone: (513) 803-0563; Fax: (513) 636-7509;
| | - Dan Li
- Department of Mathematical Sciences, University of Cincinnati, Cincinnati, OH
| | - Leo L. Duan
- Department of Mathematical Sciences, University of Cincinnati, Cincinnati, OH
| | - Mekibib Altaye
- Division of Biostatistics & Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Menachem Miodovnik
- Pregnancy and Perinatology Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
| | - Jane C Khoury
- Division of Biostatistics & Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH,Division of Endocrinology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| |
Collapse
|
19
|
Toledano Y, Hadar E, Hod M. Safety of insulin analogues as compared with human insulin in pregnancy. Expert Opin Drug Saf 2016; 15:963-73. [DOI: 10.1080/14740338.2016.1182153] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
|
20
|
Nelson AL, Shabaik S, Xandre P, Awaida JY. Reproductive Life Planning and Preconception Care 2015: Attitudes of English-Speaking Family Planning Patients. J Womens Health (Larchmt) 2016; 25:832-9. [PMID: 26974353 DOI: 10.1089/jwh.2015.5323] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Reproductive life planning has become an essential element in programs designed to promote preconceptional care and increase utilization of effective contraceptive methods. This study sought to determine if women have reproductive life plans and what they think women should do to prepare for pregnancy. MATERIALS AND METHODS Indigent English-speaking women in a family planning clinic were asked individually about their reproductive life plans, preparations needed for pregnancy, and the relative health risks of pregnancy compared to oral contraceptives. RESULTS Of the 250 women interviewed, only 53% were confident how many pregnancies they wanted in their lifetime; 46.3% were confident about when they desired their next pregnancy. Although virtually all agreed that women should plan and prepare for pregnancy, only 25.8% of women mentioned that any medical preparations were necessary before pregnancy. Women's choice of contraception did not match their pregnancy intentions. Over 60% of women thought that the pill was at least as hazardous to a woman's health as pregnancy. CONCLUSIONS In this study, many English-speaking women had no distinct reproductive life plans. Most did not think that medical preparations are needed before pregnancy. New approaches may be useful to more productively identify women who need individualized counseling, preconception care, and/or more effective contraceptive methods.
Collapse
Affiliation(s)
- Anita L Nelson
- 1 Department of Obstetrics and Gynecology, Los Angeles BioMedical Research Institute at Harbor-UCLA Medical Center , David Geffen School of Medicine at UCLA, Manhattan Beach, California
| | - Salma Shabaik
- 2 Department of Family Medicine, Harbor-UCLA Medical Center , Harbor City, California
| | - Pamela Xandre
- 3 Los Angeles BioMedical Research Institute at Harbor-UCLA Medical Center, School of Nursing at California State University , Long Beach, California
| | | |
Collapse
|
21
|
Koren R, Toledano Y, Hod M. The use of insulin detemir during pregnancy: a safety evaluation. Expert Opin Drug Saf 2015; 14:593-9. [DOI: 10.1517/14740338.2015.1013533] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
|
22
|
Kachoria R, Oza-Frank R. Receipt of preconception care among women with prepregnancy and gestational diabetes. Diabet Med 2014; 31:1690-5. [PMID: 24984802 DOI: 10.1111/dme.12546] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Revised: 05/07/2014] [Accepted: 06/27/2014] [Indexed: 11/27/2022]
Abstract
AIMS To determine the extent of provision of preconception care among women with prepregnancy diabetes or women who develop gestational diabetes compared with women without diabetes and to examine the association between preconception care receipt and diabetes status, adjusting for maternal characteristics. METHODS Data were collected from women who completed the Pregnancy Risk Assessment Monitoring System questionnaire in 10 U.S. states (Hawaii, Maryland, Maine, Michigan, Minnesota, New Jersey, Ohio, Tennessee, Utah and West Virginia) in the period 2009 to 2010. Weighted, self-reported receipt of preconception care by diabetes status was examined. Multivariate logistic regression was used to identify the association between preconception care receipt and diabetes status. RESULTS Overall, 31% of women reported receiving preconception care. Women with prepregnancy diabetes (53%) reported the highest prevalence of preconception care, while women with gestational diabetes and women without diabetes reported a lower prevalence (32 and 31%, respectively). In the adjusted model, there was no difference in reported preconception care receipt between women with gestational diabetes and women without diabetes (odds ratio 1.1, 95% CI 0.9, 1.3), while women with prepregnancy diabetes were significantly more likely to report receipt of preconception care (odds ratio 2.2, 95% CI 1.5, 3.3) than women without diabetes. CONCLUSIONS Although all women of reproductive age should receive preconception care, it is vital that women with known risk factors, such as those with prepregnancy diabetes and with risk factors for gestational diabetes, are counselled before pregnancy to optimize maternal and infant health outcomes. It is encouraging that women with prepregnancy diabetes report receiving preconception care more often than women on average, but preconception care is still not reaching all women at high risk.
Collapse
Affiliation(s)
- R Kachoria
- The Research Institute at Nationwide Children's Hospital
| | | |
Collapse
|
23
|
Lassi ZS, Imam AM, Dean SV, Bhutta ZA. Preconception care: screening and management of chronic disease and promoting psychological health. Reprod Health 2014; 11 Suppl 3:S5. [PMID: 25415675 PMCID: PMC4196564 DOI: 10.1186/1742-4755-11-s3-s5] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION A large proportion of women around the world suffer from chronic diseases including mental health diseases. In the United States alone, over 12% of women of reproductive age suffer from a chronic medical condition, especially diabetes and hypertension. Chronic diseases significantly increase the odds for poor maternal and newborn outcomes in pregnant women. METHODS A systematic review and meta-analysis of the evidence was conducted to ascertain the possible impact of preconception care for preventing and managing chronic diseases and promoting psychological health on maternal, newborn and child health outcomes. A comprehensive strategy was used to search electronic reference libraries, and both observational and clinical controlled trials were included. Cross-referencing and a separate search strategy for each preconception risk and intervention ensured wider study capture. RESULTS Maternal prepregnancy diabetic care is a significant intervention that reduces the occurrence of congenital malformations by 70% (95% Confidence Interval (CI): 59-78%) and perinatal mortality by 69% (95% CI: 47-81%). Furthermore, preconception management of epilepsy and phenylketonuria are essential and can optimize maternal, fetal and neonatal outcomes if given before conception. Ideally changes in antiepileptic drug therapy should be made at least 6 months before planned conception. Interventions specifically targeting women of reproductive age suffering from a psychiatric condition show that group-counseling and interventions leading to empowerment of women have reported non-significant reduction in depression (economic skill building: Mean Difference (MD) -7.53; 95% CI: -17.24, 2.18; counseling: MD-2.92; 95% CI: -13.17, 7.33). CONCLUSION While prevention and management of the chronic diseases like diabetes and hypertension, through counseling, and other dietary and pharmacological intervention, is important, delivering solutions to prevent and respond to women's psychological health problems are urgently needed to combat this leading cause of morbidity.
Collapse
Affiliation(s)
- Zohra S Lassi
- Division of Women and Child Health, Aga Khan University Karachi, Pakistan
| | - Ayesha M Imam
- Division of Women and Child Health, Aga Khan University Karachi, Pakistan
| | - Sohni V Dean
- Division of Women and Child Health, Aga Khan University Karachi, Pakistan
| | - Zulfiqar A Bhutta
- Division of Women and Child Health, Aga Khan University Karachi, Pakistan
| |
Collapse
|
24
|
Abstract
The notion of preconception care aims to target the existing risks before pregnancy, whereby resources may be used to improve reproductive health and optimize knowledge before conceiving. The preconception period provides an opportunity to intervene earlier to optimize the health of potential mothers (and fathers) and to prevent harmful exposures from affecting the developing fetus. These interventions include birth spacing and preventing teenage pregnancy, promotion of contraceptive use, optimization of weight and micronutrient status, prevention and management of infectious diseases, and screening for and managing chronic conditions. Given existing interventions and the need to organize services to optimize delivery of care in a logical and effective manner, interventions are frequently co-packaged or bundled together. This paper highlights packages of preconception interventions that can be combined and co-delivered to women through various delivery channels and provides a logical framework for development of such packages in varying contexts.
Collapse
Affiliation(s)
- Zohra S Lassi
- Division of Women and Child Health, Aga Khan University Karachi, Pakistan
| | - Sohni V Dean
- Division of Women and Child Health, Aga Khan University Karachi, Pakistan
| | - Dania Mallick
- Division of Women and Child Health, Aga Khan University Karachi, Pakistan
| | - Zulfiqar A Bhutta
- Division of Women and Child Health, Aga Khan University Karachi, Pakistan
| |
Collapse
|
25
|
Chiang JL, Kirkman MS, Laffel LMB, Peters AL. Type 1 diabetes through the life span: a position statement of the American Diabetes Association. Diabetes Care 2014; 37:2034-54. [PMID: 24935775 PMCID: PMC5865481 DOI: 10.2337/dc14-1140] [Citation(s) in RCA: 577] [Impact Index Per Article: 57.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
| | - M Sue Kirkman
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Lori M B Laffel
- Pediatric, Adolescent and Young Adult Section, Joslin Diabetes Center; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Anne L Peters
- Division of Endocrinology, Keck School of Medicine of the University of Southern California, Los Angeles, CA
| |
Collapse
|
26
|
DeNoble AE, Hall KS, Xu X, Zochowski MK, Piehl K, Dalton VK. Receipt of prescription contraception by commercially insured women with chronic medical conditions. Obstet Gynecol 2014; 123:1213-1220. [PMID: 24807345 PMCID: PMC4169713 DOI: 10.1097/aog.0000000000000279] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess differences in receipt of prescription contraception among women with and without chronic medical conditions. METHODS This observational study used 3 years of administrative claims records for insured women aged 21-45 years who were enrolled in a commercial insurance company in Michigan between 2004 and 2009. Women were considered to have a chronic medical condition if they had at least two claims for one of the following conditions, in order of prevalence in our study population: hypertension, asthma, hypothyroidism, diabetes, obesity, rheumatoid arthritis, inflammatory bowel disease, or systemic lupus erythematosus. Our primary outcome was receipt of prescription contraception, defined by a pharmacy claim or diagnostic or procedural code. We used multivariable logistic regression to estimate the association of chronic condition status with the odds of receiving prescription contraception within 3 years adjusting for age, community-level socioeconomic status, total outpatient visits, and cervical cancer screening. RESULTS Of 11,649 women studied, 16.0% (n=1,862) had at least one of the chronic conditions we considered. Of those with a chronic condition, 33.5% (n=623) received prescription contraception during the 3-year study period compared with 41.1% (n=4,018) of those without a chronic condition (P<.001). After adjusting for covariates, women with a chronic condition remained less likely than women without a chronic condition to have received prescription contraception (adjusted odds ratio 0.85, 95% confidence interval 0.76-0.96, P=.010). CONCLUSION Despite a greater risk for adverse outcomes with an unplanned pregnancy, women with these chronic conditions were less likely to receive prescription contraception. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
- Anna E DeNoble
- Program on Women's Healthcare Effectiveness Research, Department of Obstetrics and Gynecology, the University of Michigan Medical School, Ann Arbor, Michigan; and the Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut
| | | | | | | | | | | |
Collapse
|
27
|
Vinceti M, Malagoli C, Rothman KJ, Rodolfi R, Astolfi G, Calzolari E, Puccini A, Bertolotti M, Lunt M, Paterlini L, Martini M, Nicolini F. Risk of birth defects associated with maternal pregestational diabetes. Eur J Epidemiol 2014; 29:411-8. [PMID: 24861339 DOI: 10.1007/s10654-014-9913-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Accepted: 05/13/2014] [Indexed: 01/01/2023]
Abstract
Maternal diabetes preceding pregnancy may increase the risk of birth defects in the offspring, but not all studies confirm this association, which has shown considerable variation over time, and the effect of having type 1 versus type 2 diabetes is unclear. We conducted a population-based cohort study in the Northern Italy Emilia-Romagna region linking administrative databases with a Birth Defects Registry. From hospital discharge records we identified all diabetic pregnancies during 1997-2010, and a population of non-diabetic parturients matched for age, residence, year and delivery hospital. We collected available information on education, smoking and drug prescriptions, from which we inferred the type of diabetes. We found 62 malformed infants out of 2,269 births among diabetic women, and 162 out of 10,648 births among non-diabetic women. The age-standardized prevalence ratio (PR) of malformation associated with maternal pregestational diabetes was 1.79 (95 % confidence interval 1.34-2.39), a value that varied little by age. Type of diabetes strongly influenced the PR, with higher values related to type 2 diabetic women. Most major subgroups of anomalies had PRs above 1, including cardiovascular, genitourinary, musculoskeletal, and chromosomal abnormalities. There was an unusually high PR for the rare defect 'extra-ribs', but it was based on only two cases. This study indicates that maternal pregestational type 2 diabetes is associated with a higher prevalence of specific birth defects in offspring, whereas for type 1 diabetic mothers, particularly in recent years, the association was unremarkable.
Collapse
Affiliation(s)
- Marco Vinceti
- CREAGEN - Environmental, Genetic and Nutritional Epidemiology Research Center, University of Modena and Reggio Emilia, Reggio Emilia, Italy,
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
28
|
Tennant PWG, Glinianaia SV, Bilous RW, Rankin J, Bell R. Pre-existing diabetes, maternal glycated haemoglobin, and the risks of fetal and infant death: a population-based study. Diabetologia 2014; 57:285-94. [PMID: 24292565 DOI: 10.1007/s00125-013-3108-5] [Citation(s) in RCA: 120] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Accepted: 10/28/2013] [Indexed: 10/26/2022]
Abstract
AIMS/HYPOTHESIS Pre-existing diabetes is associated with an increased risk of stillbirth, but few studies have excluded the effect of congenital anomalies. This study used data from a long-standing population-based survey of women with pre-existing diabetes to investigate the risks of fetal and infant death and quantify the contribution of glycaemic control. METHODS All normally formed singleton offspring of women with pre-existing diabetes (1,206 with type 1 diabetes and 342 with type 2 diabetes) in the North of England during 1996-2008 were identified from the Northern Diabetes in Pregnancy Survey. RRs of fetal death (≥20 weeks of gestation) and infant death were estimated by comparison with population data from the Northern Perinatal Morbidity and Mortality Survey. Predictors of fetal and infant death in women with pre-existing diabetes were examined by logistic regression. RESULTS The prevalence of fetal death in women with diabetes was over four times greater than in those without (RR 4.56 [95% CI 3.42, 6.07], p < 0.0001), and for infant death it was nearly doubled (RR 1.86 [95% CI 1.00, 3.46], p = 0.046). There was no difference in the prevalence of fetal death (p = 0.51) or infant death (p = 0.70) between women with type 1 diabetes and women with type 2 diabetes. There was no evidence that the RR of fetal and infant death had changed over time (p = 0.95). Increasing periconception HbA1c concentration above 49 mmol/mol (6.6%) (adjusted odds ratio [aOR] 1.02 [95% CI 1.00, 1.04], p = 0.01), prepregnancy retinopathy (aOR 2.05 [95% CI 1.04, 4.05], p = 0.04) and lack of prepregnancy folic acid consumption (aOR 2.52 [95% CI 1.12, 5.65], p = 0.03) were all independently associated with increased odds of fetal and infant death. CONCLUSIONS/INTERPRETATION Pre-existing diabetes is associated with a substantially increased risk of fetal and infant death in normally formed offspring, the effect of which is largely moderated by glycaemic control.
Collapse
Affiliation(s)
- Peter W G Tennant
- Institute of Health & Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK,
| | | | | | | | | |
Collapse
|
29
|
Piccoli GB, Clari R, Ghiotto S, Castelluccia N, Colombi N, Mauro G, Tavassoli E, Melluzza C, Cabiddu G, Gernone G, Mongilardi E, Ferraresi M, Rolfo A, Todros T. Type 1 diabetes, diabetic nephropathy, and pregnancy: a systematic review and meta-study. Rev Diabet Stud 2013; 10:6-26. [PMID: 24172695 DOI: 10.1900/rds.2013.10.6] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND In the last decade, significant improvements have been achieved in maternal-fetal and diabetic care which make pregnancy possible in an increasing number of type 1 diabetic women with end-organ damage. Optimal counseling is important to make the advancements available to the relevant patients and to ensure the safety of mother and child. A systematic review will help to provide a survey of the available methods and to promote optimal counseling. OBJECTIVES To review the literature on diabetic nephropathy and pregnancy in type 1 diabetes. METHODS Medline, Embase, and the Cochrane Library were scanned in November 2012 (MESH, Emtree, and free terms on pregnancy and diabetic nephropathy). Studies were selected that report on pregnancy outcomes in type 1 diabetic patients with diabetic nephropathy in 1980-2012 (i.e. since the detection of microalbuminuria). Case reports with less than 5 cases and reports on kidney grafts were excluded. Paper selection and data extraction were performed in duplicate and matched for consistency. As the relevant reports were highly heterogeneous, we decided to perform a narrative review, with discussions oriented towards the period of publication. RESULTS Of the 1058 references considered, 34 fulfilled the selection criteria, and one was added from reference lists. The number of cases considered in the reports, which generally involved single-center studies, ranged from 5 to 311. The following issues were significant: (i) the evidence is scattered over many reports of differing format and involving small series (only 2 included over 100 patients), (ii) definitions are non-homogeneous, (iii) risks for pregnancy-related adverse events are increased (preterm delivery, caesarean section, perinatal death, and stillbirth) and do not substantially change over time, except for stillbirth (from over 10% to about 5%), (iv) the increase in risks with nephropathy progression needs confirmation in large homogeneous series, (v) the newly reported increase in malformations in diabetic nephropathy underlines the need for further studies. CONCLUSIONS The heterogeneous evidence from studies on diabetic nephropathy in pregnancy emphasizes the need for further perspective studies on this issue.
Collapse
|
30
|
Cyganek K, Hebda-Szydlo A, Skupien J, Janas I, Walczyk J, Lipowska A, Borys S, Malecki MT. Postpregnancy glycemic control and weight changes in type 1 diabetic women. Diabetes Care 2013; 36:1083-7. [PMID: 23250804 PMCID: PMC3631857 DOI: 10.2337/dc12-1340] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Pregnancy in type 1 diabetes requires excellent glycemic control. Most pregnant type 1 diabetic women achieve normoglycemia; however, there is scarce data on their postdelivery characteristics. We aimed to examine postpregnancy glycemic control and weight changes in type 1 diabetes. RESEARCH DESIGN AND METHODS We identified and followed (median 20 months) 254 women with singleton pregnancies receiving postdelivery medical care at a single institution. RESULTS Study subjects were 28.3 ± 4.7 years of age (mean ± SD), with a diabetes duration of 12.0 ± 7.7 years. Mean A1C before conception was 6.9 ± 1.4%, and preconception weight and BMI were 64.4 ± 10.0 kg and 23.9 ± 3.3 kg/m(2), respectively. Mean A1C decreased during pregnancy, reaching 5.7 ± 0.8% in the third trimester. We observed a mean weight gain of 14.4 ± 6.5 kg during pregnancy. Within 6 months after delivery, A1C increased by 0.8% (P < 0.0001) compared with the last trimester, and body weight and BMI were 4.4 kg and 2.5 kg/m(2) higher (P < 0.0001) compared with the preconception baseline. A1C further deteriorated by 0.8% until the end of follow-up. For women in the "pregnancy planning" program (n = 117), A1C >12 months after delivery was worse compared with before conception (7.1 vs. 6.5%, P = 0.0018), whereas in women with unplanned pregnancies, it was similar to the pregestational levels (7.3 vs.7.4%, P = 0.59). Weight and BMI in the entire study group did not return to prepregnancy levels and were 2.5 kg (P = 0.0079) and 0.9 kg/m(2) higher (P = 0.0058). CONCLUSIONS In this clinical observation, type 1 diabetic women showed postpregnancy deterioration in glycemic control and were unable to return to prepregnancy weight. Type 1 diabetic women seem to require special attention after delivery to meet therapeutic targets.
Collapse
|
31
|
Abstract
Current knowledge and advances in insulin formulations, insulin pump technology, and blood glucose monitoring techniques have improved practitioners' ability to achieve diabetic people's blood glucose targets. Practitioners and pregnant women should bear in mind that important differences exist in glucose metabolism during pregnancy and require a different approach from non-pregnant people to avoid pregnant women's experience being adversely affected. Insulin pump therapy, if used skillfully by practitioners and their pregnant patients, can be especially beneficial for some diabetic women during their pregnancies. Women's healthcare practitioners should endeavor to be familiar with this therapy, even if they are not experts in its full complexity.
Collapse
Affiliation(s)
- James Bernasko
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Beth Israel Medical Center, NY 10030, USA.
| |
Collapse
|
32
|
Khoury JC, Dolan LM, Vandyke R, Rosenn B, Feghali M, Miodovnik M. Fetal development in women with diabetes: imprinting for a life-time? J Matern Fetal Neonatal Med 2011; 25:11-4. [PMID: 21955035 DOI: 10.3109/14767058.2012.626921] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To test the hypothesis that fetal exposure to a hyperglycemic intrauterine environment in women with type 1 diabetes is associated with asymmetrically distributed excessive fetal growth and imprinting consistent with adverse health issues later in life. METHODS We report findings from a feasibility study on 19 young adults, born to mothers with type 1 diabetes. Long-term follow-up of the offspring in young adulthood included: oral glucose tolerance test, body mass index (BMI), dual X-ray absorptiometry, and blood pressure (BP). We report z-BMI and z-BP to account for varying gender and age. RESULTS The young adults born to women with diabetes averaged 19.9 years at follow-up; 37% were female, and 21% African American. Maternal glycohemoglobin A(1) concentration in the 2nd trimester was 9.2% for offspring born with asymmetric LGA and 7.5% for those born with symmetric LGA or AGA. There was significant correlation between maternal glucose control during pregnancy and fasting glucose, z-BMI and z-systolic BP in the young adults. CONCLUSION The hyperglycemic intrauterine environment is associated with short-term morbidity, manifested as asymmetric LGA (the "fat" baby). In addition, increasing level of maternal hyperglycemia during pregnancy is associated with increased adiposity and elevated fasting glucose in the young adult offspring.
Collapse
Affiliation(s)
- Jane C Khoury
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center and University of Cincinnati School of Medicine, Cincinnati, OH 45208, USA.
| | | | | | | | | | | |
Collapse
|
33
|
Syed M, Javed H, Yakoob MY, Bhutta ZA. Effect of screening and management of diabetes during pregnancy on stillbirths. BMC Public Health 2011; 11 Suppl 3:S2. [PMID: 21501437 PMCID: PMC3231893 DOI: 10.1186/1471-2458-11-s3-s2] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Diabetes during pregnancy is associated with significant risk of complications to the mother, fetus and newborn. We reviewed the potential impact of early detection and control of diabetes mellitus during pregnancy on stillbirths for possible inclusion in the Lives Saved Tool (LiST). METHODS A systematic literature search up to July 2010 was done to identify all published randomized controlled trials and observational studies. A standardized data abstraction sheet was employed and data were abstracted by two independent authors. Meta-analyses were performed with different sub-group analyses. The analyses were graded according to the CHERG rules using the adapted GRADE criteria and recommendations made after assessing the overall quality of the studies included in the meta-analyses. RESULTS A total of 70 studies were selected for data extraction including fourteen intervention studies and fifty six observational studies. No randomized controlled trials were identified evaluating early detection of diabetes mellitus in pregnancy versus standard screening (glucose challenge test between 24th to 28th week of gestation) in pregnancy. Intensive management of gestational diabetes (including specialized dietary advice, increased monitoring and tailored dietary therapy) during pregnancy (3 studies: 3791 participants) versus conventional management (dietary advice and insulin as required) was associated with a non-significant reduction in the risk of stillbirths (RR 0.20; 95% CI: 0.03-1.10) ('moderate' quality evidence). Optimal control of serum blood glucose versus sub-optimal control was associated with a significant reduction in the risk of perinatal mortality (2 studies, 5286 participants: RR = 0.40, 95% CI 0.25- 0.63), but not stillbirths (3 studies, 2469 participants: RR = 0.51, 95% CI 0.14-1.88). Preconception care of diabetes (information about need for optimization of glycemic control before pregnancy, assessment of diabetes complications, review of dietary habits, intensification of capillary blood glucose self-monitoring and optimization of insulin therapy) versus none (3 studies: 910 participants) was associated with a reduction in perinatal mortality (RR = 0.29, 95% CI 0.14 -0.60). Using the Delphi process for estimating effect size of optimal diabetes recognition and management yielded a median effect size of 10% reduction in stillbirths. CONCLUSIONS Diabetes, especially pre-gestational diabetes with its attendant vascular complications, is a significant risk factor for stillbirth and perinatal death. Our review highlights the fact that very few studies of adequate quality are available that can provide estimates of the effect of screening for aid management of diabetes in pregnancy on stillbirth risk. Using the Delphi process we recommend a conservative 10% reduction in the risk of stillbirths, as a point estimate for inclusion in the LiST.
Collapse
Affiliation(s)
- Madiha Syed
- Division of Women & Child Health, The Aga Khan University, Stadium Road, P.O. Box 3500, Karachi, Pakistan
| | - Hasan Javed
- Division of Women & Child Health, The Aga Khan University, Stadium Road, P.O. Box 3500, Karachi, Pakistan
| | - Mohammad Yawar Yakoob
- Division of Women & Child Health, The Aga Khan University, Stadium Road, P.O. Box 3500, Karachi, Pakistan
| | - Zulfiqar A Bhutta
- Division of Women & Child Health, The Aga Khan University, Stadium Road, P.O. Box 3500, Karachi, Pakistan
| |
Collapse
|
34
|
Affiliation(s)
- Sara J. Meltzer
- From the Department of Medicine and Obstetrics and Gynecology, McGill University, Montreal, Quebec, Canada
| |
Collapse
|
35
|
Ouzounian JG, Rosenheck R, Lee RH, Yedigarova L, Walden CL, Korst LM. One-hour post-glucola results and pre-pregnancy body mass index are associated with the need for insulin therapy in women with gestational diabetes. J Matern Fetal Neonatal Med 2010; 24:718-22. [PMID: 20937005 DOI: 10.3109/14767058.2010.521869] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The purpose of this study was to analyze the relationship of 1-h post-glucola (PG) screening results and the need for insulin therapy in women with gestational diabetes (GDM). METHODS The study group was comprised of women with GDM treated at a single institution during calendar years 2000-2004. Women with singleton, term (≥ 37 weeks gestation), liveborn fetuses were included. The association of 1-h PG results and other perinatal risk factors to the need for subsequent insulin therapy was analyzed using multivariable logistic regression models. RESULTS Of the 1451 women were included in the analysis, 18.1% required insulin treatment. The mean 1-h PG result was 170.0 ± 26.1 mg/dl (range 140-414 mg/dl). We determined that a 1-h PG ≥ 190 mg/dl (p < 0.0001), an obese body mass index (BMI) (p < 0.0001), an overweight BMI (p = 0.0019), prior GDM (p = 0.0019), and prior macrosomia (p = 0.0210) were each highly associated with the need for subsequent insulin therapy during the pregnancy. CONCLUSIONS A 1-h PG ≥ 190 mg/dl was strongly associated with the need for insulin therapy in women with GDM. These data may be helpful in counseling and managing women with GDM.
Collapse
Affiliation(s)
- Joseph G Ouzounian
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| | | | | | | | | | | |
Collapse
|
36
|
Kitzmiller JL, Wallerstein R, Correa A, Kwan S. Preconception care for women with diabetes and prevention of major congenital malformations. ACTA ACUST UNITED AC 2010; 88:791-803. [DOI: 10.1002/bdra.20734] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
|
37
|
Heller S, Damm P, Mersebach H, Skjøth TV, Kaaja R, Hod M, Durán-García S, McCance D, Mathiesen ER. Hypoglycemia in type 1 diabetic pregnancy: role of preconception insulin aspart treatment in a randomized study. Diabetes Care 2010; 33:473-7. [PMID: 20007944 PMCID: PMC2827491 DOI: 10.2337/dc09-1605] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE A recent randomized trial compared prandial insulin aspart (IAsp) with human insulin in type 1 diabetic pregnancy. The aim of this exploratory analysis was to investigate the incidence of severe hypoglycemia during pregnancy and compare women enrolled preconception with women enrolled during early pregnancy. RESEARCH DESIGN AND METHODS IAsp administered immediately before each meal was compared with human insulin administered 30 min before each meal in 99 subjects (44 to IAsp and 55 to human insulin) randomly assigned preconception and in 223 subjects (113 for IAsp and 110 for human insulin) randomly assigned in early pregnancy (<10 weeks). NPH insulin was the basal insulin. Severe hypoglycemia (requiring third-party assistance) was recorded prospectively preconception (where possible), during pregnancy, and postpartum. Relative risk (RR) of severe hypoglycemia was evaluated with a gamma frailty model. RESULTS Of the patients, 23% experienced severe hypoglycemia during pregnancy with the peak incidence in early pregnancy. In the first half of pregnancy, the RR of severe hypoglycemia in women randomly assigned in early pregnancy/preconception was 1.70 (95% CI 0.91-3.18, P = 0.097); the RR in the second half of pregnancy was 1.35 (0.38-4.77, P = 0.640). In women randomly assigned preconception, severe hypoglycemia rates occurring before and during the first and second halves of pregnancy and postpartum for IAsp versus human insulin were 0.9 versus 2.4, 0.9 versus 2.4, 0.3 versus 1.2, and 0.2 versus 2.2 episodes per patient per year, respectively (NS). CONCLUSIONS These data suggest that initiation of insulin analog treatment preconception rather than during early pregnancy may result in a lower risk of severe hypoglycemia in women with type 1 diabetes.
Collapse
|
38
|
Haws RA, Yakoob MY, Soomro T, Menezes EV, Darmstadt GL, Bhutta ZA. Reducing stillbirths: screening and monitoring during pregnancy and labour. BMC Pregnancy Childbirth 2009; 9 Suppl 1:S5. [PMID: 19426468 PMCID: PMC2679411 DOI: 10.1186/1471-2393-9-s1-s5] [Citation(s) in RCA: 107] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Screening and monitoring in pregnancy are strategies used by healthcare providers to identify high-risk pregnancies so that they can provide more targeted and appropriate treatment and follow-up care, and to monitor fetal well-being in both low- and high-risk pregnancies. The use of many of these techniques is controversial and their ability to detect fetal compromise often unknown. Theoretically, appropriate management of maternal and fetal risk factors and complications that are detected in pregnancy and labour could prevent a large proportion of the world's 3.2 million estimated annual stillbirths, as well as minimise maternal and neonatal morbidity and mortality. METHODS The fourth in a series of papers assessing the evidence base for prevention of stillbirths, this paper reviews available published evidence for the impact of 14 screening and monitoring interventions in pregnancy on stillbirth, including identification and management of high-risk pregnancies, advanced monitoring techniques, and monitoring of labour. Using broad and specific strategies to search PubMed and the Cochrane Library, we identified 221 relevant reviews and studies testing screening and monitoring interventions during the antenatal and intrapartum periods and reporting stillbirth or perinatal mortality as an outcome. RESULTS We found a dearth of rigorous evidence of direct impact of any of these screening procedures and interventions on stillbirth incidence. Observational studies testing some interventions, including fetal movement monitoring and Doppler monitoring, showed some evidence of impact on stillbirths in selected high-risk populations, but require larger rigourous trials to confirm impact. Other interventions, such as amniotic fluid assessment for oligohydramnios, appear predictive of stillbirth risk, but studies are lacking which assess the impact on perinatal mortality of subsequent intervention based on test findings. Few rigorous studies of cardiotocography have reported stillbirth outcomes, but steep declines in stillbirth rates have been observed in high-income settings such as the U.S., where cardiotocography is used in conjunction with Caesarean section for fetal distress. CONCLUSION There are numerous research gaps and large, adequately controlled trials are still needed for most of the interventions we considered. The impact of monitoring interventions on stillbirth relies on use of effective and timely intervention should problems be detected. Numerous studies indicated that positive tests were associated with increased perinatal mortality, but while some tests had good sensitivity in detecting distress, false-positive rates were high for most tests, and questions remain about optimal timing, frequency, and implications of testing. Few studies included assessments of impact of subsequent intervention needed before recommending particular monitoring strategies as a means to decrease stillbirth incidence. In high-income countries such as the US, observational evidence suggests that widespread use of cardiotocography with Caesarean section for fetal distress has led to significant declines in stillbirth rates. Efforts to increase availability of Caesarean section in low-/middle-income countries should be coupled with intrapartum monitoring technologies where resources and provider skills permit.
Collapse
Affiliation(s)
- Rachel A Haws
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Tanya Soomro
- Division of Maternal and Child Health, the Aga Khan University, Karachi, Pakistan
| | - Esme V Menezes
- Division of Maternal and Child Health, the Aga Khan University, Karachi, Pakistan
| | - Gary L Darmstadt
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Zulfiqar A Bhutta
- Division of Maternal and Child Health, the Aga Khan University, Karachi, Pakistan
| |
Collapse
|
39
|
Cundy T. Pregnancy loss and neonatal death in women with type 1 or type 2 diabetes mellitus. ACTA ACUST UNITED AC 2008. [DOI: 10.1016/s1557-0843(08)80036-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
40
|
Franz MB, Lack N, Schiessl B, Mylonas I, Friese K, Kainer F. Stillbirth following previous cesarean section in Bavaria/Germany 1987-2005. Arch Gynecol Obstet 2008; 279:29-36. [PMID: 18470524 DOI: 10.1007/s00404-008-0664-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2008] [Accepted: 04/15/2008] [Indexed: 11/27/2022]
Abstract
BACKGROUND An elevated risk for unexplained stillbirth in subsequent pregnancies after cesarean section was reported in 2003. This finding would imply renewed discussions about stronger indications for cesarean sections. OBJECTIVE To find out whether there is an elevated risk for stillbirth in subsequent pregnancies after cesarean section in our cohort in Bavaria. METHODS As data linkage of records is not possible in Germany, we devised a suitable adjustment for bias correction. Second pregnancies in Bavaria/Germany after previous vaginal birth and previous cesarean section from 1987 to 2005 were analyzed. Risk of unexplained stillbirth was estimated by time-to-event analysis. RESULTS In our cohort of 629,815 second pregnancies, no elevated stillbirth risk in pregnancies after previous cesarean section compared to previous vaginal birth was noted (crude risk 0.22% in both groups; hazard ratio (HR) 1.00; P = 1.0). A slightly decreased risk for stillbirth after previous cesarean section for the period of 1994-2005 (HR 0.674; P = 0.04) could be shown. CONCLUSION We found no elevated stillbirth risk in pregnancies after previous cesarean section. The significantly lower risk for stillbirths after previous cesarean section in the period 1994-2005 is interpreted as consequence of improved obstetric surveillance. With our adjustment for bias correction, we hope to have found a way to make our data largely comparable with other sources reported in the literature. However, because of the strict German data protection act, the Bavarian birth register is only of limited use for the presented study.
Collapse
Affiliation(s)
- Maximilian B Franz
- Department of Obstetrics and Gynaecology, Ludwig-Maximilians-University Munich, Maistrasse 11, 80337, Munich, Germany
| | | | | | | | | | | |
Collapse
|
41
|
Lapolla A, Dalfrà MG, Di Cianni G, Bonomo M, Parretti E, Mello G. A multicenter Italian study on pregnancy outcome in women with diabetes. Nutr Metab Cardiovasc Dis 2008; 18:291-297. [PMID: 17433638 DOI: 10.1016/j.numecd.2006.12.001] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2006] [Revised: 10/02/2006] [Accepted: 12/04/2006] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIM To determine pregnancy outcome in women with type 1 and type 2 diabetes. METHODS AND RESULTS A prospective study was conducted in 33 centers in Italy between 1999 and 2003, mainly recording preterm delivery, stillbirths, neonatal mortality, congenital malformations and birthweight. Of the 668 women examined, 504 had type 1 diabetes and 164 had type 2. Pre-pregnancy counseling had been provided to 43.9% of the women who had type 1 diabetes and 29.1% of the women who had type 2 diabetes and correlated with a better HbA1c value throughout pregnancy. The preterm delivery rate was significantly higher in type 1 and 2 diabetics than in normal pregnant women and was related to HbA1c values higher than 8%, gestational hypertension, pre-eclampsia and the presence of retinopathy before pregnancy. The stillbirth and neonatal mortality rates were also higher in diabetic pregnant women (1.26% and 0.63%, respectively) than in Italian pregnancies in general (0.30% and 0.32%), and the same was true for major congenital malformations (4.9% for diabetic pregnancies, 0.86% for normal Italian pregnancies). CONCLUSIONS In our population, pregnancy in diabetic women was still associated with a high rate of stillbirths, neonatal mortality and congenital malformations. Unplanned pregnancies and non-optimal glycemia control may help explain the high rates of maternal and neonatal complications.
Collapse
Affiliation(s)
- Annunziata Lapolla
- Department of Clinical and Surgical Sciences, Padova University, Via Giustiniani 2, 35100 Padova, Italy.
| | | | | | | | | | | |
Collapse
|
42
|
Allen VM, Armson BA, Wilson RD, Allen VM, Blight C, Gagnon A, Johnson JA, Langlois S, Summers A, Wyatt P, Farine D, Armson BA, Crane J, Delisle MF, Keenan-Lindsay L, Morin V, Schneider CE, Van Aerde J. Archivée: Tératogénicité associée aux diabètes gestationnel et préexistant. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2007. [DOI: 10.1016/s1701-2163(16)32652-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
|
43
|
Allen VM, Armson BA, Wilson RD, Allen VM, Blight C, Gagnon A, Johnson JA, Langlois S, Summers A, Wyatt P, Farine D, Armson BA, Crane J, Delisle MF, Keenan-Lindsay L, Morin V, Schneider CE, Van Aerde J. Teratogenicity Associated With Pre-Existing and Gestational Diabete. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2007; 29:927-934. [DOI: 10.1016/s1701-2163(16)32653-6] [Citation(s) in RCA: 97] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
|
44
|
Cundy T, Gamble G, Neale L, Elder R, McPherson P, Henley P, Rowan J. Differing causes of pregnancy loss in type 1 and type 2 diabetes. Diabetes Care 2007; 30:2603-7. [PMID: 17586739 DOI: 10.2337/dc07-0555] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Women with type 2 and type 1 diabetes have differing risk factors for pregnancy loss. We compared the rates and causes of pregnancy loss in women with type 1 and type 2 diabetes. RESEARCH DESIGN AND METHODS We utilized prospectively collected data on all pregnancies in a 20-year period (1986-2005) from a single center with a high prevalence of type 2 diabetes. Pregnancy losses included terminations for medical reasons and deaths up to 1 month postpartum but not spontaneous pregnancy losses <20 weeks' gestation. RESULTS There were 870 pregnancies in women with known diabetes (330 with type 1 and 540 with type 2 diabetes) and 325 in women with diabetes diagnosed in pregnancy but persisting postpartum (97% type 2 diabetes). The rate of pregnancy loss was similar in type 1 and type 2 diabetes (2.6 vs. 3.7%, P = 0.39), but the causes of pregnancy loss differed. In type 1 diabetes >75% were attributable to major congenital anomalies or prematurity; in type 2 diabetes >75% were attributable to stillbirth or chorioamnionitis (P = 0.017). Women with type 2 and type 1 diabetes had similar A1C at presentation and near term, but the former were older (P < 0.001) and more obese (P < 0.0001). CONCLUSIONS There are significant differences in the main causes of pregnancy loss in women with type 1 and type 2 diabetes. The higher rates of stillbirth in women with type 2 diabetes, suggest that other features, such as obesity, contribute significantly to pregnancy losses.
Collapse
Affiliation(s)
- Tim Cundy
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland, New Zealand.
| | | | | | | | | | | | | |
Collapse
|
45
|
Leguizamón G, Igarzabal ML, Reece EA. Periconceptional care of women with diabetes mellitus. Obstet Gynecol Clin North Am 2007; 34:225-39, viii. [PMID: 17572269 DOI: 10.1016/j.ogc.2007.04.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Pregestational diabetes is a common complication of pregnancy that can be associated with severe maternal and fetal morbidity. In addition, some women could have progression of diabetic complications secondary to pregnancy. Preconception care can significantly reduce pregnancy complications with a dramatic impact on the diabetic mother and her infant. For those women whose condition could be hastened by conception education, better understanding and an improved decision should be available to them and their families. Because unplanned pregnancy is common among diabetic women, they should be counseled early for the importance of preconception care in the progression of this disease.
Collapse
Affiliation(s)
- Gustavo Leguizamón
- Department of Obstetrics and Gynecology, Center for Medical Education and Clinical Research (C.E.M.I.C.) University, Av. Galván 4102, Buenos Aires, Argentina
| | | | | |
Collapse
|
46
|
Kitzmiller JL, Dang-Kilduff L, Taslimi MM. Gestational diabetes after delivery. Short-term management and long-term risks. Diabetes Care 2007; 30 Suppl 2:S225-35. [PMID: 17596477 DOI: 10.2337/dc07-s221] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- John L Kitzmiller
- Division of Maternal-Fetal Medicine, Santa Clara County Health System, San Jose, California, USA.
| | | | | |
Collapse
|
47
|
Varughese GI, Chowdhury SR, Warner DP, Barton DM. Preconception care of women attending adult general diabetes clinics--are we doing enough? Diabetes Res Clin Pract 2007; 76:142-5. [PMID: 16950540 DOI: 10.1016/j.diabres.2006.07.025] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2006] [Accepted: 07/28/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND The presence of diabetes in pregnancy can result in substantial morbidity to both mother and baby if management is sub-optimal. AIMS To assess the process of standards of preconception care (against the National Service Framework standards) of women attending the adult general diabetes clinics in a district general hospital. METHODS Retrospective review of case notes of women aged 18-40 years attending the general diabetes clinics for annual review, over a period of 6 months. RESULTS Seventy sets of notes were reviewed. The mean age of the patients was 32 years. Fifty-six patients had type-1 diabetes and 14 patients had type-2 diabetes. Mean duration of diabetes was 13 years. Eighty-six percent of the patients had blood pressure recordings documented. Mean blood pressure was 124/74 mmHg. Mean HbA1c was 9.1%. Documented evidence of home blood glucose monitoring was seen in 66% of the patients. Preconception counselling/contraception were discussed in 17 patients (25%). Twenty-nine patients (41%) were on potentially teratogenic medications. Alcohol and smoking history was not documented in 91% and 61% of the patients, respectively. CONCLUSIONS This retrospective assessment highlights that reproductive issues in an at risk population of women with diabetes are not included in routine management of diabetes care in outpatient clinics.
Collapse
Affiliation(s)
- G I Varughese
- Department of Diabetes and Endocrinology, Princess Royal Hospital, Telford TF1 6TF, UK.
| | | | | | | |
Collapse
|
48
|
Mathiesen ER, Kinsley B, Amiel SA, Heller S, McCance D, Duran S, Bellaire S, Raben A. Maternal glycemic control and hypoglycemia in type 1 diabetic pregnancy: a randomized trial of insulin aspart versus human insulin in 322 pregnant women. Diabetes Care 2007; 30:771-6. [PMID: 17392539 DOI: 10.2337/dc06-1887] [Citation(s) in RCA: 158] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To assess the safety and efficacy of insulin aspart (IAsp) versus regular human insulin (HI) in basal-bolus therapy with NPH insulin in pregnant women with type 1 diabetes. RESEARCH DESIGN AND METHODS Subjects (n = 322) who were pregnant or planning pregnancy were randomized to IAsp or HI as meal-time insulin in an open-label, parallel-group, multicenter study. Subjects had A1C < or =8% at confirmation of pregnancy. Insulin doses were titrated toward predefined glucose targets and A1C <6.5%. Outcomes assessed included risk of major maternal hypoglycemia, A1C, plasma glucose profiles, and maternal safety outcomes. RESULTS Major hypoglycemia occurred at a rate of 1.4 vs. 2.1 episodes/year exposure with IAsp and HI, respectively (relative risk 0.720 [95% CI 0.36-1.46]). Risk of major/major nocturnal hypoglycemia was 52% (RR 0.48 [0.20-1.143]; P = NS) lower with IAsp compared with HI. A1C was comparable with human insulin in second (IAsp-HI -0.04 [-0.18 to 0.11]) and third (-0.08 [-0.23 to 0.06]) trimesters. A total of 80% of subjects achieved an A1C < or =6.5%. At the end of first and third trimesters, average postprandial plasma glucose increments were significantly lower with IAsp than HI (P = 0.003 and P = 0.044, respectively), as were mean plasma glucose levels 90 min after breakfast (P = 0.044 and P = 0.001, respectively). Maternal safety profiles and pregnancy outcomes were similar between treatments. CONCLUSIONS IAsp is at least as safe and effective as HI when used in basal-bolus therapy with NPH insulin in pregnant women with type 1 diabetes and may potentially offer some benefits in terms of postprandial glucose control and preventing severe hypoglycemia.
Collapse
|
49
|
Abstract
OBJECTIVE To estimate whether the incidences of adverse fetal and neonatal outcomes in infants of mothers with preexisting types 1 and 2 diabetes 1) differ from infants of nondiabetic mothers in Nova Scotia (NS); and 2) have changed between 1988 and 2002. METHODS Population-based cohort study using the NS Atlee Perinatal Database, a well-validated source of standardized clinical information. RESULTS A total of 516 infants of diabetic mothers and 150,589 infants of nondiabetic mothers from singleton pregnancies were studied. Infants of diabetic mothers had significantly higher rates of perinatal mortality (17.4/1,000 compared with 5.9/1,000, relative risk [RR] 3.01, 95% confidence interval [CI] 1.55-5.84), major congenital anomaly (9.1% compared with 3.1%, RR 2.97, 95% CI 2.25-3.90), and large for gestational age birth (LGA, more than 90th percentile weight for gestational age) (45.2% compared with 12.6%, RR 3.59, 95% CI 3.26-3.95) than infants of nondiabetic mothers. In infants of diabetic mothers, there was no improvement in perinatal mortality (23.4/1,000 in 1988-1995 compared with 11.5/1000 in 1996-2002, P = .340), incidence of LGA (48.0% in 1988-1995 compared with 42.3% in 1996-2002, P = .237), or rate of major congenital anomaly (8.2% in 1988-1995 compared with 10.0% in 1996-2002, P = .560). Diabetes remained an independent risk factor for LGA infants and major congenital anomaly after adjusting for possible confounders. CONCLUSION Rates of adverse neonatal outcomes are 3-9 times greater in infants of diabetic mothers compared with those of nondiabetic mothers. There were no significant improvements in rates of perinatal mortality, congenital anomaly, or LGA birth in infants of diabetic mothers in 1996-2002 compared with 1988-95.
Collapse
Affiliation(s)
- Joanne Yang
- Department of Pediatrics, Izaak Walton Killam Health Centre and Dalhousie University, Halifax, Nova Scotia, Canada
| | | | | | | |
Collapse
|
50
|
Abstract
OBJECTIVE To determine whether women with pregestational diabetes obtained long-term benefits from an intensive diabetes management program during pregnancy. RESEARCH DESIGN AND METHODS Women with pregestational diabetes who had attended an intensive diabetes management program in pregnancy between 1991 and 1999 were interviewed regarding diabetes self-management behaviors and current glycemic control. A retrospective chart review was done to obtain information on self-management behaviors at entry to the program and at delivery and compared with the present. RESULTS Comparing entry to the program to delivery, all diabetes self-management behaviors improved significantly, including frequency of self-monitoring of blood glucose, frequency of insulin injections, and frequency and complexity of insulin dose adjustment (IDA). HbA(1c) (A1C) also improved significantly from entry to delivery (mean 0.073-0.060) (P < 0.0001). Comparing entry to the present, frequency of insulin injections improved significantly (P = 0.0004), frequency of IDA improved significantly (P = 0.004), and complexity of IDA improved significantly (P = 0.0032). However, there was no significant change in frequency of self-monitoring of blood glucose (P = 0.766) from before pregnancy to the present, and A1C significantly worsened by 0.015 (P < 0.0001, 95% CI 0.009-0.021) from entry to the program to the present. CONCLUSIONS Women participating in an intensive diabetes management program during pregnancy improve significantly from entry to delivery in diabetes self-management behaviors and glycemic control and, in the long term, retain some of these behaviors and knowledge. However, this is not reflected in an improved A1C level. This may be explained by the loss of contact with the diabetes care team and/or the discontinuation of frequent self-monitoring of blood glucose-a critical behavior necessary for achieving optimal glycemic control.
Collapse
Affiliation(s)
- Denice S Feig
- Mount Sinai Hospital, 600 University Avenue, Lebovic Building, Suite 5027, Toronto, Ontario, Canada M5G 1X5.
| | | | | |
Collapse
|