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Grasch JL, Venkatesh KK, Grobman WA, Silver RM, Saade GR, Mercer B, Yee LM, Scifres C, Parry S, Simhan HN, Reddy UM, Frey HA. Association of maternal body mass index with success and outcomes of attempted operative vaginal delivery. Am J Obstet Gynecol MFM 2023; 5:101081. [PMID: 37422004 DOI: 10.1016/j.ajogmf.2023.101081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/28/2023] [Accepted: 07/01/2023] [Indexed: 07/10/2023]
Abstract
BACKGROUND Increasing maternal body mass index is associated with increased morbidity at cesarean delivery in a dose-dependent manner. In some clinical scenarios, operative vaginal delivery is a strategy to prevent the morbidity associated with second-stage cesarean delivery, but the relationship between maternal body mass index and outcomes of attempted operative vaginal delivery is not well characterized. OBJECTIVE This study aimed to assess whether the success of and adverse outcomes after attempted operative vaginal delivery are associated with maternal body mass index at delivery among nulliparous individuals. STUDY DESIGN This was a secondary analysis from the prospective cohort Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-To-Be study. This analysis included cephalic live-born nonanomalous singleton pregnancies ≥34 weeks at delivery with an attempted operative vaginal delivery (either forceps or vacuum). The primary exposure was maternal body mass index at delivery (≥30 vs <30 kg/m2 [referent]). The primary outcome was an unsuccessful operative vaginal delivery attempt, defined as a cesarean delivery after an attempted operative vaginal delivery. The secondary outcomes included maternal and neonatal adverse outcomes. Multivariable logistic regression was used, and statistical interaction between operative instrument type (vacuum vs forceps) and body mass index was assessed. RESULTS Of 10,038 assessed individuals, 791 (7.9%) had an attempted operative vaginal delivery and were included in this analysis. Of note, 325 individuals (41%) had a body mass index ≥30 kg/m2 at delivery. Overall, 42 of 791 participants (5%) experienced an unsuccessful operative vaginal delivery. Individuals with a body mass index ≥30 kg/m2 at delivery were more than twice as likely to have an unsuccessful operative vaginal delivery than those with a body mass index <30 kg/m2 (8.0% vs 3.4%; adjusted odds ratio, 2.23; 95% confidence interval, 1.16-4.28; P=.005). Composite maternal morbidity and composite neonatal morbidity did not vary by body mass index group. There was no evidence of interaction or effect modification by operative instrument type for the rate of unsuccessful operative vaginal delivery attempt, composite maternal morbidity, or composite neonatal morbidity. CONCLUSION Among nulliparous individuals who underwent an attempted operative vaginal delivery, those with a body mass index ≥30 kg/m2 at delivery were more likely to have an unsuccessful operative vaginal delivery attempt than those with a body mass index <30 kg/m2. There was no difference in composite maternal or neonatal morbidity after attempted operative vaginal delivery by body mass index category.
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Affiliation(s)
- Jennifer L Grasch
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University Wexner Medical Center, Columbus, OH (Drs Grasch, Venkatesh, Grobman, and Frey).
| | - Kartik K Venkatesh
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University Wexner Medical Center, Columbus, OH (Drs Grasch, Venkatesh, Grobman, and Frey)
| | - William A Grobman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University Wexner Medical Center, Columbus, OH (Drs Grasch, Venkatesh, Grobman, and Frey)
| | - Robert M Silver
- Department of Obstetrics and Gynecology, School of Medicine, University of Utah, Salt Lake City, UT (Dr Silver)
| | - George R Saade
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, TX (Dr Saade)
| | - Brian Mercer
- Department of Obstetrics and Gynecology, Case Western Reserve University, Cleveland, OH (Dr Mercer)
| | - Lynn M Yee
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL (Dr Yee)
| | - Christina Scifres
- Department of Obstetrics and Gynecology, School of Medicine, Indiana University School of Medicine, Indianapolis, IN (Dr Scifres)
| | - Samuel Parry
- Department of Maternal-Fetal Medicine, School of Medicine, University of Pennsylvania, Philadelphia, PA (Dr Parry)
| | - Hyagriv N Simhan
- Department of Obstetrics, Gynecology, and Reproductive Science, School of Medicine, University of Pittsburgh, Pittsburgh, PA (Dr Simhan)
| | - Uma M Reddy
- Department of Obstetrics and Gynecology, Columbia University, New York City, NY (Dr Reddy)
| | - Heather A Frey
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University Wexner Medical Center, Columbus, OH (Drs Grasch, Venkatesh, Grobman, and Frey)
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Metcalfe A, Hutcheon JA, Sabr Y, Lyons J, Burrows J, Donovan LE, Joseph KS. Timing of delivery in women with diabetes: A population-based study. Acta Obstet Gynecol Scand 2019; 99:341-349. [PMID: 31654401 PMCID: PMC7065101 DOI: 10.1111/aogs.13761] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 10/21/2019] [Accepted: 10/22/2019] [Indexed: 12/14/2022]
Abstract
Introduction Women with diabetes, and their infants, have an increased risk of adverse events due to excess fetal growth. Earlier delivery, when fetuses are smaller, may reduce these risks. This study aimed to evaluate the week‐specific risks of maternal and neonatal morbidity/mortality to assist with obstetrical decision making. Material and methods In this population‐based cohort study, women with type 1 diabetes (n = 5889), type 2 diabetes (n = 9422) and gestational diabetes (n = 138 917) and a comparison group without diabetes (n = 2 553 243) who delivered a singleton infant at ≥36 completed weeks of gestation between 2004 and 2014 were identified from the Canadian Institute of Health Information Discharge Abstract Database. Multivariate logistic regression was used to determine the week‐specific rates of severe maternal and neonatal morbidity/mortality among women delivered iatrogenically vs those undergoing expectant management. Results For all women, the absolute risk of severe maternal morbidity/mortality was low, typically impacting less than 1% of women, and there was no significant difference in gestational age‐specific severe maternal morbidity/mortality between iatrogenic delivery and expectant management among women with any form of diabetes. Among women with gestational diabetes, iatrogenic delivery was associated with an increased risk of neonatal morbidity/mortality compared with expectant management at 36 and 37 weeks’ gestation (76.7 and 27.8 excess cases per 1000 deliveries, respectively) and a lower risk of neonatal morbidity/mortality at 38, 39 and 40 weeks’ gestation (7.9, 27.3 and 15.9 fewer cases per 1000 deliveries, respectively). Increased risks of severe neonatal morbidity following iatrogenic delivery compared with expectant management were also observed for women with type 1 diabetes at 36 (98.3 excess cases per 1000 deliveries) and 37 weeks’ gestation (44.5 excess cases per 1000 deliveries) and for women with type 2 diabetes at 36 weeks’ gestation (77.9 excess cases per 1000 deliveries) weeks. Conclusions The clinical decision regarding timing of delivery is complex and contingent on maternal‐fetal wellbeing, including adequate glycemic control. This study suggests that delivery at 38, 39 or 40 weeks’ gestation may optimize neonatal outcomes among women with diabetes.
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Affiliation(s)
- Amy Metcalfe
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, Alberta, Canada.,Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Jennifer A Hutcheon
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, British Columbia, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Yasser Sabr
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, British Columbia, Canada.,Department of Obstetrics and Gynecology, King Saud University, Riyadh, Saudi Arabia
| | - Janet Lyons
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jason Burrows
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lois E Donovan
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, Alberta, Canada.,Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - K S Joseph
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, British Columbia, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
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Zhang X, Liao Q, Wang F, Li D. Association of gestational diabetes mellitus and abnormal vaginal flora with adverse pregnancy outcomes. Medicine (Baltimore) 2018; 97:e11891. [PMID: 30142788 PMCID: PMC6112872 DOI: 10.1097/md.0000000000011891] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 07/07/2018] [Indexed: 12/26/2022] Open
Abstract
Gestational diabetes mellitus (GDM) is associated with adverse perinatal outcomes. This study aimed to examine the association between GDM and abnormal vaginal flora, and the association between abnormal vaginal flora and adverse pregnancy outcomes.This was a prospective study of pregnant women who visited Xuanwu Hospital of the Capital Medical University (Beijing, China) between February and October 2015. All women were screened for GDM according to the International Association of the Diabetes and Pregnancy Study Groups (IADPSG) recommendations. Vaginal secretions were sampled at 28 to 30 and 37 to 40 weeks. Microorganisms were examined.The women were 28.3 ± 2.6 years and their body mass index was 22.8 ± 1.4 kg/m. GDM was associated with higher frequencies of vulvovaginal candidiasis (22.6% vs 9.7%, P < .001), premature rupture of membranes (PROM) (22.6% vs 11.5%, P = .004), premature delivery (16.1% vs 5.5%, P = .02), chorioamnionitis/puerperal infection (19.4% vs 4.5%, P < .001), macrosomia (9.7% vs 4.0%, P = .04), neonatal hypoglycemia (5.4% vs 1.0%, P = .02), and neonatal referral (15.1% vs 6.5%, P = .008). Among healthy women, abnormal flora was associated with PROM (19.4% vs 7.5%, P = .02) and chorioamnionitis/puerperal infection (11.9% vs 0.8%, P < .001). Among women with GDM, abnormal flora was associated with PROM (32.1% vs 10.0%, P < .001), premature delivery (17.7% vs 6.3%, P = .04), and chorioamnionitis/puerperal infection (32.8% vs 2.5%, P < .001).The vaginal infection rate was higher in patients with GDM compared with healthy pregnant women. GDM and abnormal vaginal flora were both associated with adverse pregnancy outcomes. The vaginal Lactobacillus species were different between the 2 groups, which could contribute to the adverse outcomes.
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Affiliation(s)
- Xinhong Zhang
- Department of Obstetrics and Gynecology, Xuanwu Hospital, Capital Medical University
| | - Qinping Liao
- Department of Obstetrics and Gynecology, Xuanwu Hospital, Capital Medical University
- Department of Obstetrics and Gynecology, Beijing Tsinghua Changgung Hospital, Beijing 102218, China
| | - Fengying Wang
- Department of Obstetrics and Gynecology, Xuanwu Hospital, Capital Medical University
| | - Dan Li
- Department of Obstetrics and Gynecology, Xuanwu Hospital, Capital Medical University
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Forster DA, Moorhead AM, Jacobs SE, Davis PG, Walker SP, McEgan KM, Opie GF, Donath SM, Gold L, McNamara C, Aylward A, East C, Ford R, Amir LH. Advising women with diabetes in pregnancy to express breastmilk in late pregnancy (Diabetes and Antenatal Milk Expressing [DAME]): a multicentre, unblinded, randomised controlled trial. Lancet 2017; 389:2204-2213. [PMID: 28589894 DOI: 10.1016/s0140-6736(17)31373-9] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 04/09/2017] [Accepted: 04/13/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND Infants of women with diabetes in pregnancy are at increased risk of hypoglycaemia, admission to a neonatal intensive care unit (NICU), and not being exclusively breastfed. Many clinicians encourage women with diabetes in pregnancy to express and store breastmilk in late pregnancy, yet no evidence exists for this practice. We aimed to determine the safety and efficacy of antenatal expressing in women with diabetes in pregnancy. METHODS We did a multicentre, two-group, unblinded, randomised controlled trial in six hospitals in Victoria, Australia. We recruited women with pre-existing or gestational diabetes in a singleton pregnancy from 34 to 37 weeks' gestation and randomly assigned them (1:1) to either expressing breastmilk twice per day from 36 weeks' gestation (antenatal expressing) or standard care (usual midwifery and obstetric care, supplemented by support from a diabetes educator). Randomisation was done with a computerised random number generator in blocks of size two and four, and was stratified by site, parity, and diabetes type. Investigators were masked to block size but masking of caregivers was not possible. The primary outcome was the proportion of infants admitted to the NICU. We did the analyses by intention to treat; the data were obtained and analysed masked to group allocation. This trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12611000217909. FINDINGS Between June 6, 2011, and Oct 29, 2015, we recruited and randomly assigned 635 women: 319 to antenatal expressing and 316 to standard care. Three were not included in the primary analysis (one withdrawal from the standard care group, and one post-randomisation exclusion and one withdrawal from the antenatal expressing group). The proportion of infants admitted to the NICU did not differ between groups (46 [15%] of 317 assigned to antenatal expressing vs 44 [14%] of 315 assigned to standard care; adjusted relative risk 1·06, 95% CI 0·66 to 1·46). In the antenatal expressing group, the most common serious adverse event for infants was admission to the NICU for respiratory support (for three [<1%] of 317. In the standard care group, the most common serious adverse event for infants was moderate to severe encephalopathy with or without seizures (for three [<1%] of 315). INTERPRETATION There is no harm in advising women with diabetes in pregnancy at low risk of complications to express breastmilk from 36 weeks' gestation. FUNDING Australian National Health and Medical Research Council.
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Affiliation(s)
- Della A Forster
- Judith Lumley Centre, School of Nursing and Midwifery, La Trobe University, Melbourne, VIC, Australia; Royal Women's Hospital, Parkville, VIC, Australia.
| | - Anita M Moorhead
- Judith Lumley Centre, School of Nursing and Midwifery, La Trobe University, Melbourne, VIC, Australia; Royal Women's Hospital, Parkville, VIC, Australia
| | - Susan E Jacobs
- Royal Women's Hospital, Parkville, VIC, Australia; Department of Obstetrics and Gynaecology, University of Melbourne, VIC, Australia; Clinical Sciences, Murdoch Childrens Research Institute, Parkville, VIC, Australia
| | - Peter G Davis
- Royal Women's Hospital, Parkville, VIC, Australia; Department of Obstetrics and Gynaecology, University of Melbourne, VIC, Australia
| | - Susan P Walker
- Department of Obstetrics and Gynaecology, University of Melbourne, VIC, Australia; Mercy Hospital for Women, Heidelberg, VIC, Australia
| | | | - Gillian F Opie
- Department of Obstetrics and Gynaecology, University of Melbourne, VIC, Australia; Mercy Hospital for Women, Heidelberg, VIC, Australia
| | - Susan M Donath
- Clinical Epidemiology and Biostatistics Unit, Murdoch Childrens Research Institute, Parkville, VIC, Australia
| | - Lisa Gold
- School of Health and Social Development, Deakin University, Geelong, VIC, Australia
| | | | | | - Christine East
- School of Nursing and Midwifery, Monash University and Monash Health, Clayton, VIC, Australia
| | - Rachael Ford
- Royal Women's Hospital, Parkville, VIC, Australia
| | - Lisa H Amir
- Judith Lumley Centre, School of Nursing and Midwifery, La Trobe University, Melbourne, VIC, Australia; Royal Women's Hospital, Parkville, VIC, Australia
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Forster DA, Jacobs S, Amir LH, Davis P, Walker SP, McEgan K, Opie G, Donath SM, Moorhead AM, Ford R, McNamara C, Aylward A, Gold L. Safety and efficacy of antenatal milk expressing for women with diabetes in pregnancy: protocol for a randomised controlled trial. BMJ Open 2014; 4:e006571. [PMID: 25358679 PMCID: PMC4216858 DOI: 10.1136/bmjopen-2014-006571] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Revised: 10/02/2014] [Accepted: 10/06/2014] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Many maternity providers recommend that women with diabetes in pregnancy express and store breast milk in late pregnancy so breast milk is available after birth, given (1) infants of these women are at increased risk of hypoglycaemia in the first 24 h of life; and (2) the delay in lactogenesis II compared with women without diabetes that increases their infant's risk of receiving infant formula. The Diabetes and Antenatal Milk Expressing (DAME) trial will establish whether advising women with diabetes in pregnancy (pre-existing or gestational) to express breast milk from 36 weeks gestation increases the proportion of infants who require admission to special or neonatal intensive care units (SCN/NICU) compared with infants of women receiving standard care. Secondary outcomes include birth gestation, breastfeeding outcomes and economic impact. METHODS AND ANALYSIS Women will be recruited from 34 weeks gestation to a multicentre, two arm, unblinded randomised controlled trial. The intervention starts at 36 weeks. Randomisation will be stratified by site, parity and diabetes type. Women allocated to the intervention will be taught expressing and encouraged to hand express twice daily for 10 min and keep an expressing diary. The sample size of 658 (329 per group) will detect a 10% difference in proportion of babies admitted to SCN/NICU (85% power, α 0.05). Data are collected at recruitment (structured questionnaire), after birth (abstracted from medical record blinded to group), and 2 and 12 weeks postpartum (telephone interview). DATA ANALYSIS the intervention group will be compared with the standard care group by intention to treat analysis, and the primary outcome compared using χ(2) and ORs. ETHICS AND DISSEMINATION Research ethics approval will be obtained from participating sites. Results will be published in peer-reviewed journals and presented to clinicians, policymakers and study participants. TRIAL REGISTRATION NUMBER Australian Controlled Trials Register ACTRN12611000217909.
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Affiliation(s)
- Della A Forster
- Judith Lumley Centre (formerly Mother & Child Health Research), La Trobe University, Melbourne, Victoria, Australia
- Royal Women's Hospital, Parkville, Victoria, Australia
| | - Susan Jacobs
- Royal Women's Hospital, Parkville, Victoria, Australia
- Clinical Sciences, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Carlton, Victoria, Australia
| | - Lisa H Amir
- Judith Lumley Centre (formerly Mother & Child Health Research), La Trobe University, Melbourne, Victoria, Australia
| | - Peter Davis
- Royal Women's Hospital, Parkville, Victoria, Australia
| | - Susan P Walker
- Department of Obstetrics and Gynaecology, University of Melbourne, Carlton, Victoria, Australia
- Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - Kerri McEgan
- Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - Gillian Opie
- Department of Obstetrics and Gynaecology, University of Melbourne, Carlton, Victoria, Australia
- Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - Susan M Donath
- Clinical Epidemiology and Biostatistics Unit, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | - Anita M Moorhead
- Judith Lumley Centre (formerly Mother & Child Health Research), La Trobe University, Melbourne, Victoria, Australia
- Royal Women's Hospital, Parkville, Victoria, Australia
| | - Rachael Ford
- Judith Lumley Centre (formerly Mother & Child Health Research), La Trobe University, Melbourne, Victoria, Australia
- Royal Women's Hospital, Parkville, Victoria, Australia
| | | | | | - Lisa Gold
- Deakin Health Economics, Deakin University, Burwood, Victoria, Australia
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Flores Le-Roux JA, Benaiges Boix D, Pedro-Botet J. [Gestational diabetes mellitus: importance of blood glucose monitoring]. CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE ARTERIOSCLEROSIS 2013; 25:175-181. [PMID: 24183482 DOI: 10.1016/j.arteri.2012.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Accepted: 10/31/2012] [Indexed: 06/02/2023]
Abstract
Gestational diabetes mellitus (GDM) is common during pregnancy, and is frequently associated with maternal and perinatal complications. Intensive treatment of hyperglycaemia during pregnancy has been shown to reduce perinatal morbidity. In women with pregestational type 1 or 2 diabetes, hyperglycaemia during labour and delivery is an important factor in the development of neonatal hypoglycaemia. There are no generally accepted recommendations for women with GDM. Recent studies evaluating patients with GDM show that peripartum glucose control can be achieved in these women without the need for insulin use in the majority of cases. Hyperglycaemia during labour is not related with treatment established during pregnancy but rather with non-compliance of endocrinological follow-up. Factors such as ethnic origin, neonatal hypoxaemia, and large for gestational age seem to play an important role in the development of neonatal hypoglycaemia.
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Affiliation(s)
- Juana A Flores Le-Roux
- Servicio de Endocrinología y Nutrición, Hospital del Mar, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, España
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Harizopoulou VC, Tsiartas P, Goulis DG, Vavilis D, Grimbizis G, Theodoridis TD, Tarlatzis BC. Intrapartum application of the continuous glucose monitoring system in pregnancies complicated with diabetes: A review and feasibility study. World J Obstet Gynecol 2013; 2:42-46. [DOI: 10.5317/wjog.v2.i3.42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2012] [Revised: 04/01/2013] [Accepted: 05/19/2013] [Indexed: 02/05/2023] Open
Abstract
Intrapartum maternal normoglycemia seems to play an important role in the prevention of adverse perinatal, maternal and neonatal outcomes. Several glucose monitoring protocols have been developed, aiming to achieve a tight glucose monitoring and control. Depending on the type of diabetes and the optimal or suboptimal glycemic control, the treatment options include fasting status of the parturient, frequent monitoring of capillary blood glucose, intravenous dextrose infusion and subcutaneous or intravenous use of insulin. Continuous glucose monitoring system (CGMS) is a relatively new technology that measures interstitial glucose at very short time intervals over a specific period of time. The resulting profile provides a more comprehensive measure of glycemic excursions than intermittent home blood glucose monitoring. Results of studies applying the CGMS technology in patients with or without diabetes mellitus (DM) have revealed new insights in glucose metabolism. Moreover, CGMS have a potential role in the improvement of glycemic control during pregnancy and labor, which may lead to a decrease in perinatal morbidity and mortality. In conclusion, the use of CGMS, with its important technical advantages compared to the conventional way of monitoring, may lead into a more etiological intrapartum management of both the mother and her fetus/infant in pregnancies complicated with DM.
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Reif P, Panzitt T, Moser F, Resch B, Haas J, Lang U. Short-term neonatal outcome in diabetic versus non-diabetic pregnancies complicated by non-reassuring foetal heart rate tracings. J Matern Fetal Neonatal Med 2013; 26:1500-5. [DOI: 10.3109/14767058.2013.789845] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Appleton K, Barnard J, Jantz AK, Pooh R, Comas-Gabriel C. The Role of Ultrasound in the Diagnosis of Complications Associated with Maternal Diabetes. ACTA ACUST UNITED AC 2013. [DOI: 10.5005/jp-journals-10009-1325] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
ABSTRACT
Gestational diabetes mellitus (GDM) is defined as glucose intolerance that begins or is first recognized during pregnancy. Numerous clinical factors are associated with an increased likelihood of GDM, such as increasing age, obesity, ethnicity, family history of diabetes and past obstetric history. There is a well-documented relationship between maternal hyperglycemia and increased rate of macrosomia, cesarean section, stillbirth, fetal congenital malformations, shoulder dystocia, hypoglycemia, hyperbilirubinemia, pre-eclampsia, preterm delivery, childhood obesity, and increased risk of maternal development of type 2 DM later on in her life. This case-based review is designed to provide health care workers a framework on using various ultrasound imaging modalities in early detection of the effects of gestational diabetes, and the specific conditions and/or anomalies seen in diabetic pregnancies.
How to cite this article
Appleton K, Barnard J, Jantz AK, Pooh R, Comas-Gabriel C, Kupesic-Plavsic S. The Role of Ultrasound in the Diagnosis of Complications Associated with Maternal Diabetes. Donald School J Ultrasound Obstet Gynecol 2013;7(4):506-515.
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Abstract
Diabetic men have benefited in the last 30 years from a significant improvement in total and cardiovascular mortality, whereas diabetic women have had no improvement at all. Moreover, recent research focused on the role of sex hormones in glucose homeostasis, and might account for different pathophysiologic mechanisms in the development of diabetes-related complications. Thus, care of diabetic women is a challenge that requires particular attention. The available data regarding gender-specific care of diabetes mellitus are uneven, rich in some domains but very poor in others. The large prospective trials performed in the last 20 years have assumed that the natural history of diabetes mellitus in men and women, as well as the efficiency of glucose-lowering therapies and management of hyperglycemic-related complications, could be attributable without distinction to men and women. We propose in this paper to analyze the published medical literature according to the specific management of diabetes mellitus in women, and to try to distinguish some particular features. We found important distinctions between diabetic men and women regarding the patterns of abnormalities of glucose regulation, epidemiology, development of diabetes-related complications, ischemic heart disease, morbidity and mortality, impact of cardiovascular risk factors, development of the metabolic syndrome, depression and osteoporosis, as well as the impact of lifestyle modifications or primary and secondary preventions on cardiovascular risk factors, and finally medical therapeutics. Moreover, special considerations were given to some particular aspects of the medical life in diabetic women, such as the features of gestational diabetes mellitus and the management of pregnancy in pregestational diabetic women, use of contraception, hormone-replacement therapy and polycystic ovary syndrome.
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Affiliation(s)
- Auryan Szalat
- Hadassah Hebrew University Hospital, Internal Medicine, Endocrinology and Metabolism, Jerusalem, Israel.
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Glycemic control during labor and delivery: a survey of academic centers in the United States. Arch Gynecol Obstet 2011; 285:305-10. [DOI: 10.1007/s00404-011-1972-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2011] [Accepted: 06/23/2011] [Indexed: 11/30/2022]
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Monari F, Facchinetti F. Management of subsequent pregnancy after antepartum stillbirth. A review. J Matern Fetal Neonatal Med 2011; 23:1073-84. [PMID: 20504070 DOI: 10.3109/14767051003678036] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
In literature, there is a paucity of information about the management of the subsequent pregnancy after stillbirth (SB). we undertook a systematic review of the literature focusing on the evidence for antenatal interventions with the potential to prevent SB and we try to summarise the management of the pregnancy subsequent to a SB. The diverse interventions and their efficacy will be reported according to the possible causes and/or conditions associated to the previous SB. Few of the studies reported SB as an outcome and the evidence was frequently conflicting. Several interventions showed clear evidence of impact on SB, including the scrupulous control of blood sugar by using multiple doses of insulin, frequent antenatal foetal monitoring and timing of delivery in diabetic women; the prophylaxis with low dose of aspirin in high-risk women; or serial sonograms for foetal growth, Doppler studies and antepartum foetal testing in women with previous growth restricted foetus. Other interventions instead reduced know risk factors for SB but failed to show statistically significant impact on SB rate. Overall, early access to care, at least three ultrasounds examinations, screening for the main pregnancy-related disorders and timely delivery are the milestone of appropriate antenatal care in women with previous SB.
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Affiliation(s)
- Francesca Monari
- Department of Mother-Infant, University of Modena and Reggio Emilia, and Unit of Obstetrics, Azienda Ospedaliero Universitaria, Modena Italy
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Accouchement (terme, voie, équilibre glycémique perpartum) adapté au diabète gestationnel. ACTA ACUST UNITED AC 2010; 39:S274-80. [DOI: 10.1016/s0368-2315(10)70053-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Garabedian C, Deruelle P. Delivery (timing, route, peripartum glycemic control) in women with gestational diabetes mellitus. DIABETES & METABOLISM 2010; 36:515-21. [DOI: 10.1016/j.diabet.2010.11.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Chaves EGS, Franciscon PDM, Nascentes GAN, Paschoini MC, Silva APD, Borges MDF. Estudo retrospectivo das implicações maternas, fetais e perinatais em mulheres portadoras de diabetes, em 20 anos de acompanhamento no Hospital Escola da Universidade Federal do Triângulo Mineiro. ACTA ACUST UNITED AC 2010; 54:620-9. [DOI: 10.1590/s0004-27302010000700006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Accepted: 09/14/2010] [Indexed: 11/22/2022]
Abstract
OBJETIVOS: Avaliar implicações do diabetes melito (DM) na morbimortalidade materno-fetal, segundo experiência da Universidade Federal do Triângulo Mineiro. MATERIAIS E METODOS: Procedeu-se à análise retrospectiva dos prontuários de gestantes diabéticas assistidas entre 1990 e 2009 focando dados e complicações maternas e neonatais. RESULTADOS: A última gestação de 93 diabéticas foi avaliada, sendo 34 com DM tipo 1, em que se observou maior ocorrência de tocotrauma (p = 0,023) e retinopatia (p = 0,023). Vinte e uma pacientes tinham DM tipo 2; suas necessidades de insulina aumentaram progressivamente (p < 0,01) e observou-se maior prevalência de tabagismo (p = 0,004). Trinta e oito tiveram diabetes gestacional e iniciaram acompanhamento do diabetes em idade gestacional mais tardia (p < 0,001), tiveram mais antecedentes de macrossomia fetal (p = 0,028) e maior prevalência de fatores de risco cardiovascular. CONCLUSÕES: Não obstante melhora do controle glicêmico durante a gestação, nenhum dos grupos atingiu alvos glicêmicos ideais. Ainda assim, a maioria das gestações em diabéticas, conduzidas em nosso meio, evoluiu favoravelmente.
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Flores-Le Roux JA, Chillaron JJ, Goday A, Puig De Dou J, Paya A, Lopez-Vilchez MA, Cano JF. Peripartum metabolic control in gestational diabetes. Am J Obstet Gynecol 2010; 202:568.e1-6. [PMID: 20231009 DOI: 10.1016/j.ajog.2010.01.064] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2009] [Revised: 10/25/2009] [Accepted: 01/20/2010] [Indexed: 11/17/2022]
Abstract
OBJECTIVE We sought to evaluate intrapartum metabolic control in gestational diabetes mellitus (GDM) patients and maternal factors influencing intrapartum glycemic control and neonatal hypoglycemia risk. STUDY DESIGN A prospective observational study included 129 women with GDM admitted for delivery. Data collected included maternal intrapartum capillary blood glucose (CBG) and ketonemia, use of insulin, and neonatal hypoglycemia. RESULTS In all, 86% of maternal intrapartum CBG values fell within target range (3.3-7.2 mmol/L) without need for insulin use. There were no cases of maternal hypoglycemia or severe ketosis. Intrapartum CBG >7.2 mmol/L was associated with third-trimester glycated hemoglobin (P = .02) and lack of endocrinologic follow-up (P = .04). Risk of neonatal hypoglycemia was related with pregnancy insulin use compared with dietary control (60.5% vs 29.5%; P = .02). CONCLUSION Peripartum metabolic control in GDM patients was achieved without insulin in most cases. Intrapartum glycemic control was related with third-trimester glycated hemoglobin and with no endocrinologic follow-up. Neonatal hypoglycemia was associated with insulin use during pregnancy.
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Affiliation(s)
- Juana A Flores-Le Roux
- Department of Endocrinology, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain.
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Abstract
Self-monitoring of blood glucose in women with mild gestational diabetes has recently been proven to be useful in reducing the rates of fetal overgrowth and gestational weight gain. However, uncertainty remains with respect to the optimal frequency and timing of self-monitoring. A continuous glucose monitoring system may have utility in pregnant women with insulin-treated diabetes, especially for those women with blood sugars that are difficult to control or who experience nocturnal hypoglycemia; however, continuous glucose monitoring systems need additional study as part of larger, randomized trials.
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Affiliation(s)
- J Seth Hawkins
- Department of Obstetrics & Gynecology, University of California, Irvine, Building 56, Suite 800, Orange, CA 92868, USA.
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Abstract
BACKGROUND Pregnancies with a macrosomic fetus comprise a subgroup of high-risk pregnancies. There is uncertainty in the clinical management and outcomes of such pregnancies. AIM We sought to examine clinical management and maternal and fetal outcomes in pregnancies with macrosomic infants at Royal Brisbane and Women's Hospital (RBWH). METHODS Data from 276 macrosomic births (weighing > or = 4500 g) and 294 controls (weighing 3250-3750 g) delivered during 2002-2004 at RBWH were collected from the hospital database. Univariate and logistic regression analyses were performed for maternal risk factors and maternal and neonatal outcomes that were associated with fetal macrosomia. RESULTS Macrosomia was more than two times likely in women with body mass index (BMI) of > 30 kg/m(2) (odds ratio (OR) 2.41, 95% confidence interval (CI) 1.26-4.61) and in male infant sex (OR 2.05, 95% CI 1.35-3.12), and four times more likely in gestation of > 40 weeks (OR 3.93, 95% CI 1.99-7.74). Maternal smoking reduced the risk of fetal macrosomia (OR 0.27, 95% CI 0.14-0.51). Macrosomia was associated with nearly two times higher risk of emergency caesarean section (OR 1.75, 95% CI 1.02-2.97) and maternal hospital stay of > 3 days (OR 1.66, 95% CI 1.11-2.50), and four times higher risk of shoulder dystocia (OR 4.08, 95% CI 1.62-10.29). Macrosomic infants were twice as likely to have resuscitation (OR 2.21, 95% CI 1.46-3.34) and intensive care nursery admission (OR 1.89, 95% CI 1.03-3.46). CONCLUSION Macrosomia was associated with an increased risk of adverse maternal and neonatal health outcomes. Optimal management strategies of macrosomic pregnancies need evaluation.
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Affiliation(s)
- Hong Ju
- Adelaide Health Technology Assessment, Discipline of Public Health, The University of Adelaide, Adelaide, South Australia 5005, Australia.
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Mastrogiannis DS, Spiliopoulos M, Mulla W, Homko CJ. Insulin resistance: the possible link between gestational diabetes mellitus and hypertensive disorders of pregnancy. Curr Diab Rep 2009; 9:296-302. [PMID: 19640343 DOI: 10.1007/s11892-009-0046-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Gestational hypertension, preeclampsia, and diabetes are all associated with increased risks of poor maternal and perinatal outcomes. Pregnant women with gestational diabetes have been shown in population studies to have increased risk of pregnancy-associated hypertension compared with nondiabetic women. Moreover, pregnant patients with hypertension are at increased risk for developing gestational diabetes mellitus. It has been hypothesized that this association could be due, at least in part, to insulin resistance. Although insulin resistance is a physiologic phenomenon in normal pregnancy, in predisposed individuals this could lead to hyperinsulinemia with the development of gestational hypertension, gestational diabetes mellitus, or both.
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Affiliation(s)
- Dimitrios S Mastrogiannis
- Obstetrics, Gynecology, and Reproductive Sciences, Temple University Medical School, Philadelphia, PA 19140, USA.
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Forster DA, McEgan K, Ford R, Moorhead A, Opie G, Walker S, McNamara C. Diabetes and antenatal milk expressing: a pilot project to inform the development of a randomised controlled trial. Midwifery 2009; 27:209-14. [PMID: 19615797 DOI: 10.1016/j.midw.2009.05.009] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2008] [Revised: 04/30/2009] [Accepted: 05/20/2009] [Indexed: 12/17/2022]
Abstract
OBJECTIVE infants of women with diabetes in pregnancy are at increased risk of hypoglycaemia. If the infant's blood glucose is low and the mother is unable to breast feed/provide sufficient expressed breast milk, infants are often given formula. Some hospitals encourage women with diabetes to express breast milk before birth. However, there is limited evidence for this practice, including its impact on labour and birth, e.g. causing premature birth may be a concern. A pilot study was undertaken to establish the feasibility of conducting an adequately powered randomised controlled trial to evaluate this practice. DESIGN consecutive eligible women with pre-existing or gestational diabetes (requiring insulin), planning to breast feed and attending the study hospital were offered participation. INCLUSION CRITERIA 34-36 weeks of gestation; singleton pregnancy; cephalic presentation; and able to speak, read and write in English. EXCLUSION CRITERIA history of spontaneous preterm birth, antepartum haemorrhage, placenta praevia and suspected fetal compromise. Women were encouraged to express colostrum twice a day from 36 weeks of gestation, and advised how to store the colostrum, which was frozen for their infant's use after birth. They were asked to keep a diary documenting their expressing. DATA demographic questionnaire, telephone interview at six and 12 weeks postpartum and medical record data. SETTING a public, tertiary, women's hospital in Melbourne, Australia. PARTICIPANTS 43 women with diabetes in pregnancy (requiring insulin). FINDINGS cardiotocographs were undertaken after the first expressing episode and none of the infants showed any sign of fetal compromise. Forty per cent of infants received formula in the 24 hours postpartum. The proportion of infants receiving any breast milk at six weeks was 90%, and this decreased to 75% at 12 weeks. No women showed evidence of hypoglycaemia post expressing. The intervention was positively received by most women; 95% said that they would express antenatally again if the practice proved to be beneficial. The amount of colostrum varied according to the number of expressions, the length of time in the study and the time spent expressing, with a median of 14 days expressing and 39.6 ml of colostrum obtained. KEY CONCLUSIONS the small number of women in this pilot was not an adequate number to examine safety or efficacy, but this study does provide evidence that it would be feasible and desirable to conduct a randomised controlled trial of antenatal milk expressing for women with diabetes requiring insulin in pregnancy. IMPLICATIONS FOR PRACTICE it is important that this widespread practice undergoes rigorous evaluation to assess both efficacy and safety. Until such evidence is available, the authors suggest that the routine encouragement of antenatal milk expressing in women with diabetes in pregnancy should cease.
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Affiliation(s)
- Della A Forster
- Mother and Child Health Research, La Trobe University, 324–328 Little Lonsdale Street, Melbourne, Australia.
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