Does pregnancy increase the risk for development and progression of diabetic nephropathy?

Chronic kidney disease and adverse pregnancy outcomes: a systematic review and meta-analysis

OBJECTIVE

Limited evidence exists on the role that the cause of chronic kidney disease plays in determining pregnancy outcomes. The aim of this systematic review and meta-analysis was to examine the association between chronic kidney disease and adverse pregnancy outcomes by the cause and severity of chronic kidney disease where reported. The protocol was registered under the International Prospective Register of Systematic Reviews (CRD42020211925).

DATA SOURCES

PubMed, Embase, and Web of Science were searched until May 24, 2021, supplemented with reference list checking.

STUDY ELIGIBILITY CRITERIA

Studies that compared the pregnancy outcomes in women with or without chronic kidney disease were included. Two reviewers independently screened titles, abstracts, and full-text articles according to a priori defined inclusion criteria.

METHODS

Data extraction and quality appraisal were performed independently by 3 reviewers. The grading of recommendations, assessment, development, and evaluation approach was used to assess the overall certainty of the evidence. Random-effects meta-analyses were used to calculate the pooled estimates using the generic inverse variance method. The primary outcomes included preeclampsia, cesarean delivery, preterm birth (<37 weeks' gestation), and small for gestational age babies.

RESULTS

Of 4076 citations, 31 studies were included. Prepregnancy chronic kidney disease was significantly associated with a higher odds of preeclampsia (pooled crude odds ratio, 8.13; [95% confidence interval, 4.41-15], and adjusted odds ratio, 2.58; [1.33-5.01]), cesarean delivery (adjusted odds ratio, 1.65; [1.21-2.25]), preterm birth (adjusted odds ratio, 1.73; [1.31-2.27]), and small for gestational age babies (adjusted odds ratio, 1.93; [1.06-3.52]). The association with stillbirth was not statistically significant (adjusted odds ratio, 1.67; [0.96-2.92]). Subgroup analyses indicated that different causes of chronic kidney disease might confer different risks and that the severity of chronic kidney disease is associated with a risk of adverse pregnancy outcomes, as pregnancies with later stages of chronic kidney disease had higher odds of preeclampsia, preterm birth, and small for gestational age babies than those at earlier stages. The grading of recommendations, assessment, development, and evaluation certainty of the evidence overall was "very low".

CONCLUSION

This meta-analysis quantified the associations between prepregnancy chronic kidney disease and adverse pregnancy outcomes, both overall and according to the cause and severity of the disease. These findings might support the clinicians aiming to counsel women having chronic kidney disease by allowing them to tailor their advice according to cause and severity of the chronic kidney disease. We identified the gaps in the literature, and further studies examining the effect of specific kidney diseases and other clinical characteristics (eg, proteinuria, hypertension) on adverse pregnancy outcomes are warranted.

Adverse pregnancy outcomes in women with diabetes-related microvascular disease and risks of disease progression in pregnancy: A systematic review and meta-analysis

BACKGROUND

The rise in the global prevalence of diabetes, particularly among younger people, has led to an increase in the number of pregnant women with preexisting diabetes, many of whom have diabetes-related microvascular complications. We aimed to estimate the magnitude of the risks of adverse pregnancy outcomes or disease progression in this population.

METHODS AND FINDINGS

We undertook a systematic review and meta-analysis on maternal and perinatal complications in women with type 1 or 2 diabetic microvascular disease and the risk factors for worsening of microvascular disease in pregnancy using a prospective protocol (PROSPERO CRD42017076647). We searched major databases (January 1990 to July 2021) for relevant cohort studies. Study quality was assessed using the Newcastle-Ottawa Scale. We summarized the findings as odds ratios (ORs) with 95% confidence intervals (CIs) using random effects meta-analysis. We included 56 cohort studies involving 12,819 pregnant women with diabetes; including 40 from Europe and 9 from North America. Pregnant women with diabetic nephropathy were at greater risk of preeclampsia (OR 10.76, CI 6.43 to 17.99, p < 0.001), early (<34 weeks) (OR 6.90, 95% CI 3.38 to 14.06, p < 0.001) and any preterm birth (OR 4.48, CI 3.40 to 5.92, p < 0.001), and cesarean section (OR 3.04, CI 1.24 to 7.47, p = 0.015); their babies were at higher risk of perinatal death (OR 2.26, CI 1.07 to 4.75, p = 0.032), congenital abnormality (OR 2.71, CI 1.58 to 4.66, p < 0.001), small for gestational age (OR 16.89, CI 7.07 to 40.37, p < 0.001), and admission to neonatal unit (OR 2.59, CI 1.72 to 3.90, p < 0.001) compared to those without nephropathy. Diabetic retinopathy was associated with any preterm birth (OR 1.67, CI 1.27 to 2.20, p < 0.001) and preeclampsia (OR 2.20, CI 1.57 to 3.10, p < 0.001) but not other complications. The risks of onset or worsening of retinopathy were increased in women who were nulliparous (OR 1.75, 95% CI 1.28 to 2.40, p < 0.001), smokers (OR 2.31, 95% CI 1.25 to 4.27, p = 0.008), with existing proliferative disease (OR 2.12, 95% CI 1.11 to 4.04, p = 0.022), and longer duration of diabetes (weighted mean difference: 4.51 years, 95% CI 2.26 to 6.76, p < 0.001) compared to those without the risk factors. The main limitations of this analysis are the heterogeneity of definition of retinopathy and nephropathy and the inclusion of women both with type 1 and type 2 diabetes.

CONCLUSIONS

In pregnant women with diabetes, presence of nephropathy and/or retinopathy appear to further increase the risks of maternal complications.

Diabetic nephropathy in pregnancy: Report of two cases progressing to end-stage renal disease within one year postpartum

Background

Diabetes mellitus is a leading cause of nephropathy and end-stage renal disease. However, diabetic nephropathy during pregnancy in patients with normal glomerular filtration rate and subsequent progression to end-stage renal disease has not been well studied.

Cases

This report presents two patients with poorly controlled type 1 diabetes mellitus who had diabetic nephropathy with preserved estimated glomerular filtration rate (Case 1: 117 mL/min/1.73m²; Case 2: 79 mL/min/1.73m²) and shared a similar clinical course, with glomerular filtration rates decreasing by approximately one-half during pregnancy and progression to end-stage renal disease within the first year postpartum. Both women had a long history of type 1 diabetes: 18 years and 24 years for case 1 and case 2 respectively. The first patient's course of pregnancy was complicated by difficult-to-control blood glucose and hypertension with subsequent preeclampsia. The second patient's course of pregnancy was complicated by difficult-to-control blood sugars and preterm labor resulting in classical cesarean delivery at 24 weeks. Both patients had renal biopsies shortly after delivery as their renal function continued to worsen postpartum. Both kidney biopsies demonstrated advanced diabetic nephropathy changes and ultimately required chronic renal replacement therapy within 7–9 months postpartum.

Conclusion

Comprehensive family planning discussions with women who have diabetic nephropathy should include the risks of renal disease progression, even in those patients with preserved renal function at the time of conception.

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Diabetic nephropathy carries a high risk for renal disease progression.

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Diabetics with nephropathy need counseling on risk of kidney disease progression.

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Diabetic women should be started on kidney-protective medications postpartum.

Pregnancy Outcomes in Women with Long-Duration Type 1 Diabetes-25 Years of Experience

AIMS

Our study aimed to examine the pregnancy outcomes (maternal and fetal) concerning different models of antenatal care across a period of over 25 years (1993-2018) in 459 women with type 1 diabetes. Data from patients with a history of the condition lasting at least 15 years were considered eligible for analysis.

METHODS

The study group was divided into three cohorts based on the different models of treatment used in Poznan University Hospital, Poland: 1993-2000 (cohort I, n = 91), 2001-2005 (cohort II, n = 83), 2006-2018 (cohort III, n = 284). To identify predictors for the selected dichotomous outcomes, we calculated the risks for fetal or maternal complications as dependent variables for cohorts II and III against cohort I, using multivariate logistic regression analysis.

RESULTS

The mean gestational age was 36.8 ± 2.4 weeks in the total cohort. The percentages of deliveries before the 33rd and the 37th weeks was high. We observed a decreasing percentage during the following periods, from 41.5% in the first period to 30.4% in the third group. There was a tendency for newborn weight to show a gradual increase across three time periods (2850, 3189, 3321 g, p < 0.0001). In the last period, we noticed significantly more newborns delivered after 36 weeks with a weight above 4000 g and below 2500 g. Caesarean section was performed in 88% of patients from the whole group, but in the subsequent periods this number visibly decreased (from 97.6%, 86.7%, to 71%, p = 0.001). The number of emergency caesarean sections was lowest in the third period (27.5%, 16.7%, 11.2%, p = 0.006). We observed a decreasing number of "small for gestational age" newborns (SGA) in consecutive periods of treatment (from 24.4% to 8.7%, p = 0.002), but also a higher percentage of "large for gestational age" (LGA) newborns (from 6.1% to 21.6%, p = 0.001). Modification of treatment might be associated with the gradual reduction of SGA rates (cohort I 3.6%, cohort III 2.3% p < 0,0005).

CONCLUSIONS

Strict glycemic and blood pressure control from the very beginning of pregnancy, as well as modern fetal surveillance techniques, may contribute to the improvement of perinatal outcomes in women with long-duration type 1 diabetes.

The Impact of Pregnancy and Parity on Type 1 Diabetes Complications

BACKGROUND

The potential influence of pregnancy and parity on the risk of chronic diabetic complications is a matter of great concern and constant discussion. This aspect seems relevant and should be the subject of thorough discussion with the woman planning childbirth.

INTRODUCTION

Current data concerning the impact of pregnancy and parity covers primarily retinopathy and nephropathy, while the aspects of neuropathy and macrovascular complications are unsatisfactorily documented. Majority of studies focus on single complication only, while the number of papers assessing this problem in a complex setting is limited. The available body of evidence concerns mainly the short-term impact of pregnancy on diabetic chronic complications while the data concerning the longer perspective are scarce. Moreover, the results found in the available literature are conflicting. The aim of the study was to summarize all available data concerning the longer impact of parity on the chronic complications in the women with type 1 diabetes.

METHODS

PubMed database has been searched between October 2013 and September 2018 and all relevant papers were selected. This review summarizes data on the impact of pregnancy and parity on chronic complications in type 1 diabetic women.

RESULTS

Current data assessing this matter in a complex way are limited, and the available results are controversial. It seems however that pregnancy itself may rather influence pre-existing diabetic complication than affect risk of its development. Additionally, evidence suggests that any deleterious changes appearing during pregnancy are transient and tend to remit after delivery.

CONCLUSION

It seems that neither pregnancy nor parity affects the risk of diabetic chronic complications in the longer perspective.

Pregnancy in women with diabetic nephropathy

The number of pregnancies in women with pregestational diabetes has been steadily increasing worldwide. These pregnancies are associated with an increased risk of a variety of complications, including miscarriages, congenital malformations, macrosomia, fetal growth restriction, preeclampsia, preterm delivery and stillbirth. In pregnant women with diabetic nephropathy it is important to evaluate both the effect of pregnancy on kidney function and the effect of kidney disease on pregnancy outcomes. Pregnant women with normal renal function and microalbuminuria have a low risk of loss of kidney function during pregnancy, while women with GFR < 60 ml/min and/or proteinuria ≥ 3 g/24 h at the beginning of pregnancy are at risk of permanent kidney damage. The risk of fetal and maternal complications is associated with the severity of chronic kidney disease and glycemic control. Advances in prenatal care have improved fetal and maternal outcomes and preconception counseling has become key for a successful pregnancy in all women with diabetes and especially in those with diabetes and chronic kidney disease.

Diabetic Nephropathy and Pregnancy

Women with diabetic nephropathy have challenging pregnancies, with pregnancy outcomes far worse than expected for the stage of chronic kidney disease. The underlying mechanisms that cause the adverse events remain poorly understood, but it is a widely held belief that substantial endothelial injury in these women likely contributes. Maternal hypertension, preeclampsia, and cesarean section rates are high, and offspring are often preterm and of low birth weight, with additional neonatal complications associated with glycemic control. This review will present the current evidence for maternal and fetal outcomes of women with diabetic nephropathy and describe prepregnancy, antenatal, and peripartum optimization strategies.

Prenatal, Obstetric and Perinatal Aspects in Pregnancy Associated with Pregestational Diabetes

ABSTRACT: We report the case of a 37-year old primigesta, primipara (IGIP) patient with a singleton, naturally obtained pregnancy, diagnosed with type I diabetes mellitus from the age of three, carrier of an insulin pump for 11 years. The patient was diagnosed in adolescence with with a tumor of the ischio-rectal fossa with multiple attempts of excision which failed due to the particular situation of the tumor. Ultrasound examination diagnosed in the first trimester of pregnancy a voluminous right ovarian cystic tumor. The patient presented pregnancy-induced hypertension starting with 28 gestational weeks. Maternal-fetal and obstetric management assumed sequential ultrasound examination, ovarian tumor and maternal blood pressure drug control, and also the surgical management of the ischio-rectal tumor. Cesarean section was performed at 38 gestational weeks, outcoming with a live fetus, normal weight, good neonatal progression and favorable postoperative progression of the mother. In this case report, we emphasize the fact that in pregestational diabetes mellitus and pregnancy-induced hypertension, constant glycemic control, performed by the insulin pump, prior and during gestation, and the maternal blood pressure control are essential for maternal-fetal outcome.

Diabetes and pregnancy in Wistar rats: renal effects for mothers in the postpartum period

In this study, diabetes mellitus (DM) was induced in Wistar rats during pregnancy and maintained in the postpartum period (PP) and we evaluated systolic blood pressure (SBP), glomerular filtration rate (GFR) and renal immunohistochemical and morphometric studies from different groups: G1 (non-pregnant control rats), G2 (non-pregnant diabetic rats), G3 (control mothers) and G4 (diabetic mothers). We found that there were no differences in relation to SBP, but there was a tendency for reduction in GFR from G4 compared with the other groups (G). There was increased total kidney weight/body weight ratio of G4 compared with other G. There were increase in glomerular tuft area in G3 and G4 compared with G1 and G2. G2 and G4 showed even higher percentage of cortical collagen. G3 showed increased glomerular proliferating cells compared with G1 and G2, while in G4 this number was smaller than G3. Cell proliferation was higher in the tubulointerstitial (TBI) compartment from G4. Glomerular and TBI α-smooth muscle actin expression was increased in G4 compared with other G. The glomerular p-p38 expression showed a pattern similar to proliferation cell nuclear antigen, with a reduction of p-p38 in G4 relative to other G. The immunoreactivity of p-JNK was higher in both the glomeruli and TBI compartment in G4 compared with G1, G2 and G3. The DM induced during pregnancy and maintained in the PP resulted in renal structural and functional changes to mothers. In addition, altered mitogen-activated protein kinase expression in association with these changes may play an important role in renal damage observed in the present investigation.

Does parity worsen diabetes-related chronic complications in women with type 1 diabetes?

AIM: To determine the relationship between parity, glycemic control, cardiovascular risk factors and diabetes-related chronic complications in women with type 1 diabetes.

METHODS: This was a multicenter cross-sectional study conducted between December 2008 and December 2010 in 28 public clinics in 20 cities from the 4 Brazilian geographic regions. Data were obtained from 1532 female patients, 59.2% Caucasians, and aged 25.2 ± 10.6 years. Diabetes duration was of 11.5 ± 8.2 years. Patient’s information was obtained through a questionnaire and a chart review. Parity was stratified in five groups: Group 0 (nulliparous), group 1 (1 pregnancy), group 2 (2 pregnancies), group 3 (3 pregnancies), group 4 (≥ 4 pregnancies). Test for trend and multivariate random intercept logistic and linear regression models were used to evaluate the effect of parity upon glycemic control, cardiovascular risk factors and diabetes-related complications.

RESULTS: Parity was not related with glycemic control and nephropathy. Moreover, the effect of parity upon hypertension, retinopathy and macrovascular disease did not persist after adjustments for demographic and clinical variables in multivariate analysis. For retinopathy, the duration of diabetes and hypertension were the most important independent variables and for macrovascular disease, these variables were age and hypertension. Overweight or obesity was noted in a total of 538 patients (35.1%). A linear association was found between the frequency of overweight or obesity and parity (P = 0.004). Using a random intercept multivariate linear regression model with body mass index (BMI) as dependent variable a borderline effect for parity (P = 0.06) was noted after adjustment for clinical and demographic data. The observed variability of BMI was not attributable to differences between centers.

CONCLUSION: Our results suggest that parity has a borderline effect on body mass index but does not have an important effect upon hypertension and micro or macrovascular chronic complications. Future prospective evaluations must be conducted to clarify the relationship between parity, appearance or worsening of diabetes-related chronic complications.

A Systematic Review and Meta-Analysis of Outcomes of Pregnancy in CKD and CKD Outcomes in Pregnancy

BACKGROUND AND OBJECTIVES

We undertook a systematic review and meta-analysis of published cohort studies and case-control studies to estimate (1) the risk of pregnancy complications among patients with CKD versus those without CKD and (2) the risk of CKD progression among pregnant patients versus nonpregnant controls with CKD.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We searched electronic databases for studies published between 1946 and 2014, and we reviewed articles using validity criteria. Random-effects analytical methods were used.

RESULTS

Twenty-three studies (14 with data for adverse pregnancy outcomes and 9 for renal outcomes) with 506,340 pregnancies were included. Pregnancy with CKD had greater odds of preeclampsia (odds ratio [OR], 10.36; 95% confidence interval [95% CI], 6.28 to 17.09), premature delivery (OR, 5.72; 95% CI, 3.26 to 10.03), small for gestational age/low birth weight (OR, 4.85; 95% CI, 3.03 to 7.76), cesarean section (OR, 2.67; 95% CI, 2.01 to 3.54), and failure of pregnancy (OR, 1.80; 95% CI, 1.03 to 3.13). Subgroup analysis showed that odds of preeclampsia (P<0.01) and premature delivery (P<0.01) were higher in women with nondiabetic nephropathy compared with diabetic nephropathy, and the odds of preeclampsia (P=0.01) and premature delivery (P<0.01) were higher in women with macroproteinuria compared with microproteinuria. The median for follow-up time for renal events was 5 years (interquartile range, 5-14.7 years). There were no significant differences in the occurrence of renal events between CKD pregnant women and those without pregnancy (OR, 0.96; 95% CI, 0.69 to 1.35). Subgroup analysis showed that publication year, sample size, follow-up years, type of primary disease, CKD classification, level of serum creatinine at baseline, proteinuria, and level of systolic BP did not modify the renal outcomes.

CONCLUSIONS

The risks of adverse maternal and fetal outcomes in pregnancy are higher for women with CKD versus pregnant women without CKD. However, pregnancy was not a risk factor for progression of renal disease in women with CKD before pregnancy.

Vascular complications in the diabetic pregnancy

Long-standing hyperglycemia frequently leads to vasculopathy. Microvascular disease is characterized by retinopathy and nephropathy, while macrovascular involvement can affect coronary arteries. Diabetic autonomic neuropathy, when present, is generally associated with retinal and/or renal involvement. Early identification of these diabetic complications allows appropriate counseling and early treatment. Among women with diabetic vasculopathy, nephropathy, chronic hypertension, preeclampsia, preterm delivery, and fetal growth restriction are frequently observed. Furthermore, women with impaired renal function in early pregnancy have increased risk of long-term deterioration of glomerular filtration rate. Proliferative retinopathy can progress during pregnancy and 1 year after delivery, but long-term effects are not likely to occur. When coronary artery disease or gastroparesis diabeticorum are present, excessive maternal and fetal morbidity is observed. When modern management is synchronized with early medical care, favorable maternal and perinatal outcomes can be expected.

Obstetric and perinatal outcome in type 1 diabetes patients with diabetic nephropathy during 1988-2011

AIMS/HYPOTHESIS

Our aim was to analyse possible changes in the glycaemic control, BP, markers of renal function, and obstetric and perinatal outcomes of parturients with diabetic nephropathy during 1988-2011.

METHODS

The most recent childbirth of 108 consecutive type 1 diabetes patients with diabetic nephropathy and a singleton pregnancy were studied. Two periods, 1988-1999 and 2000-2011, were compared.

RESULTS

The prepregnancy and the first trimester median HbA1c values persisted at high levels (8.2% [66 mmol/mol] vs 8.5% [69 mmol/mol], p = 0.16 and 8.3% [67 mmol/mol] vs 8.4% [68 mmol/mol], p = 0.67, respectively), but decreased by mid-pregnancy (6.7% [50 mmol/mol] vs 6.9% [52 mmol/mol], p = 0.11). Antihypertensive medication usage increased before pregnancy (34% vs 65%, p = 0.002) and in the second and third trimesters of pregnancy (25% vs 47%, p = 0.02, and 36% vs 60%, p = 0.01, respectively). BP exceeded 130/80 mmHg in 62% and 61% (p = 0.87) of patients in the first trimester, and in 95% and 93% (p = 0.69) in the third trimester, respectively. No changes were observed in the markers of renal function. Pre-eclampsia (52% vs 42%, p = 0.29) and preterm birth rates before 32 and 37 gestational weeks (14% vs 21%, p = 0.33, and 71% vs 77%, p = 0.49, respectively) remained high. The elective and emergency Caesarean section rates were 71% and 45% (p = 0.01) and 29% and 48% (p = 0.05), respectively. Neonatal intensive care unit admissions increased from 26% to 49% (p = 0.02).

CONCLUSIONS/INTERPRETATION

Early pregnancy glycaemic control and hypertension management were suboptimal in both time periods. Pre-eclampsia and preterm delivery rates remained high in patients with diabetic nephropathy.

Type 1 diabetes, diabetic nephropathy, and pregnancy: a systematic review and meta-study

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.

Severe diabetic nephropathy in type 1 diabetes and pregnancy--a case series

BACKGROUND

Diabetes and nephropathy are important challenges during pregnancy, increasingly encountered because of the advances in maternal-fetal care.

AIM

To evaluate the maternal and fetal outcomes recorded in "severe" diabetic nephropathy in type 1 diabetic patients referred to nephrological healtcare.

METHODS

The study was performed in an outpatient unit dedicated to kidney diseases in pregnancy (with joint nephrological and obstetric follow-up and strict cooperation with the diabetes unit). 383 pregnancies were referred to the outpatient unit in 2000-2012, 14 of which were complicated by type 1 diabetes. The report includes 12 deliveries, including 2 pregnancies in 1 patient; one twin pregnancy; 2 spontaneous abortions were not included. All cases had long-standing type 1 diabetes (median of 21 (15-31) years), relatively high median age (35 (29-40) years) and end-organ damage (all patients presented laser-treated retinopathy and half of them clinical neuropathy). Median glomerular filtration rate (GFR) at referral was 67 ml/min (48-122.6), proteinuria was 1.6 g/day (0.1-6.3 g/day).

RESULTS

Proteinuria steeply increased in 11/12 patients, reaching the nephrotic range in nine (6 above 5 g/day). One patient increased by 2 chronic kidney disease (CKD) stages. Support therapy included blood pressure and diabetes control, bed rest, and moderate protein restriction. All children were preterm (7 early preterm); early spontaneous labor occurred in 4/12 patients. All singletons were appropriate for gestational age and developed normally after birth. The male twin child died 6 days after birth (after surgery for great vessel transposition).

CONCLUSIONS

Diabetic patients with severe diabetic nephropathy are still present a considerable challenge. Therefore, further investigations are required, particularly on proteinuria management and the occurrence of spontaneous labor.

Pregnancy in diabetes and kidney disease

With appropriate multi-disciplinary team care, most women with diabetic nephropathy will have successful pregnancy outcomes; however, pregnancy complications are increased compared to non-diabetic individuals, particularly in those with poor glycaemic control. Women with more severe renal impairment, especially those with hypertension and proteinuria at are highest risk of worse pregnancy outcomes and deterioration in pre-existing renal function. Pre-pregnancy counselling should be offered to all women with diabetes in order to optimise diabetic care, and inform women of potential complications. Pregnancy is an indicator of long-term health, and may indicate important issues for the future management of women with diabetic nephropathy.

Effects of pregnancy on the onset and progression of diabetic nephropathy and of diabetic nephropathy on pregnancy outcomes

Controversy exists regarding the effect of pregnancy on the development and course of diabetic nephropathy. This study followed 43 pregnant women with previous diabetes mellitus, 32 without nephropathy (Group I) and 11 with nephropathy (Group II). Urinary albumin excretion (UAE), serum creatinine (Cr) and creatinine clearance (CCr) in the pre-pregnancy (Pre-P), first trimester (1T), third trimester (3T) and 1 year postpartum (PP) were evaluated. In both groups there were an increase in 3T compared to Pre-P of CCr (137 vs. 98 ml/min and 110 vs. 81 ml/min, p=0.0001, respectively) and UAE (7.78 vs. 3.15 mg/24 h and 592 vs. 119 mg/24 h, p=0.0001, respectively). Increase of Cr in the PP compared to 1T in Group II (0.88 vs. 0.70 mg/dL, p=0.031) was observed. There were no difference in UAE, CCr and Cr in the PP when compared to pre-P as well variance over time between groups. Group II showed higher prevalence of chronic hypertension (72.7 vs. 21.9%, p=0.004), preeclampsia (63.6 vs. 6.3%, p=0.0003) and lower gestational age at birth (36 vs. 38 weeks, p=0.003). We conclude that pregnancy was not associated with development and progression of diabetic nephropathy in women with or without mild renal dysfunction. The presence of diabetic nephropathy was associated with increased risk of perinatal complications.

Diabetes and the kidney in pregnancy

The prevalence of diabetes in pregnant women is increasing, with 4% of deliveries in the United States occurring in women with pregestational or gestational diabetes. The proteinuria of late pregnancy is exaggerated in women with diabetes. However, diabetic women with preserved renal function before pregnancy appear to have little risk of deterioration of kidney function during pregnancy. Women with impaired renal function before pregnancy may be at risk for permanent decline of renal function during pregnancy, although it is unclear whether this represents the effect of pregnancy or the natural history of their diabetic renal disease. Preeclampsia, which is more common in women with diabetes, may be difficult to diagnose in this group of women. From the currently available literature, there appears to be no negative effect of pregnancy on the long-term progression of diabetic renal disease if renal function is normal and marked proteinuria is absent, but in light of recent findings in which preeclampsia appears to be associated with an increased risk of end-stage renal disease, large cohort studies will be necessary before this question can be definitively answered.

Diabetes melito tipo 1 e gestação

As gestações em mulheres com diabetes têm apresentado resultados que melhoraram dramaticamente nas últimas décadas, em razão dos progressos com a monitorização das glicemias e administração de insulina. A gravidez nas mulheres com diabetes tipo 1 está associada a aumento de risco tanto para o feto quanto para a mãe. Antes da concepção, a prioridade é normalizar a glicemia para prevenir malformações congênitas e abortamentos espontâneos. Com o progresso da gestação, a mãe tem um risco aumentado de hipoglicemias e cetoacidose. Mais tarde existe risco de piora na retinopatia, hipertensão induzida pela gestação, pré-eclâmpsia-eclâmpsia, infecções de trato urinário e poliidrâmnios. No final da gestação, existe o risco de macrossomia e morte súbita intra-uterina do feto. Todas essas complicações podem ser prevenidas ou, pelo menos, minimizadas pelo planejamento da gestação e pelo controle intensivo das oscilações das glicemias, mantendo-as próximo ao normal.

Periconceptional care of women with diabetes mellitus

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.

Chronic kidney disease and pregnancy: maternal and fetal outcomes

Chronic kidney disease complicates an increasing number of pregnancies, and at least 4% of childbearing-aged women are afflicted by this condition. Although diabetic nephropathy is the most common type of chronic kidney disease found in pregnant women, a variety of other primary and systemic kidney diseases also commonly occur. In the setting of mild maternal primary chronic kidney disease (serum creatinine <1.3 mg/dL) without poorly controlled hypertension, most pregnancies result in live births and maternal kidney function is unaffected. In cases of more moderate and severe maternal primary chronic kidney disease, the incidence of fetal prematurity, low birth weight, and death increase substantially, and the risk of accelerated irreversible decline in maternal kidney function, proteinuria, and hypertensive complications rise dramatically. In addition to kidney function, maternal hypertension and proteinuria portend negative outcomes and are important factors to consider when risk stratifying for fetal and maternal complications. In the setting of diabetic nephropathy and lupus nephropathy, other systemic disease features such as disease activity, the presence of antiphospholipid antibodies, and glycemic control play important roles in determining pregnancy outcomes. Concomitant with advances in obstetrical management and kidney disease treatments, it appears that the historically dismal maternal and fetal outcomes have greatly improved.

Pre-eclampsia but not pregnancy-induced hypertension is a risk factor for diabetic nephropathy in type 1 diabetic women

AIMS/HYPOTHESIS

Our aim was to study whether pre-eclampsia and pregnancy-induced hypertension are predictors of diabetic nephropathy in type 1 diabetic women.

MATERIALS AND METHODS

A total of 203 type 1 diabetic women, who were pregnant between 1988 and 1996 and followed at the Department of Obstetrics and Gynaecology in Helsinki, were re-assessed after an average of 11 years within the nationwide, multi-centre Finnish Diabetic Nephropathy Study. Diabetic nephropathy was defined as microalbuminuria, macroalbuminuria or end-stage renal disease.

RESULTS

Patients with prior pre-eclampsia had diabetic nephropathy more often than patients with a normotensive pregnancy (diabetic nephropathy vs normal albumin excretion rate: 41.9% vs 8.9%; p<0.001), whereas patients with a history of pregnancy-induced hypertension did not (10.3% vs 8.9%; p=0.81). CHD was more prevalent in patients with a history of pre-eclampsia than in patients with a normotensive pregnancy (12.2% vs. 2.2%; p=0.03). Pre-eclampsia (odds ratio [OR] 7.7, 95% CI 1.6-36.1; p=0.01) and HbA(1c) (OR 2.0, 95% CI 1.1-3.8; p<0.05) were associated with incident diabetic nephropathy even when adjusted for follow-up time, BMI, smoking, diabetes duration and age.

CONCLUSIONS/INTERPRETATION

These data suggest that a history of pre-eclamptic pregnancy but not pregnancy-induced hypertension is associated with an elevated risk of diabetic nephropathy.

Hypertension and the pregnancy complicated by diabetes

Diabetes is a frequent complication of pregnancy. Type 1 diabetes is associated with an increased incidence of preeclampsia and pregnancy-induced hypertension. When renal dysfunction is present, the incidence of these complications is remarkably increased. White's class, poor glycemic control during the first half of pregnancy, and early blood pressure elevation are also independent risk factors for developing preeclampsia. Whether gestational diabetes increases the background incidence of preeclampsia is still debated. Because therapeutic interventions such as low-dose aspirin and antioxidants have not been shown to be effective, preventive measures rely on tight blood glucose control, as well as adequate blood pressure treatment.

Microvascular complications and the diabetic pregnancy

Without strict glycemic control, diabetic pregnancies are frequently complicated by spontaneous abortion, stillbirth, or congenital malformation. Retrospective studies have been largely reassuring that pregnancy does not accelerate morbid outcomes in women with diabetic vascular disease. Improved outcomes of high-risk pregnancy in women with pregestational, type 1, or type 2 diabetes mellitus remain challenging, depending on a comprehensive and multidisciplinary team approach and extensive preconception counseling.

Is pregnancy a risk factor for microvascular complications? The EURODIAB Prospective Complications Study

AIMS

To examine the long-term influence of pregnancy on the development and progression of microvascular complications in Type 1 diabetes.

METHODS

In the EURODIAB Prospective Complications Study (PCS), 793 women potentially child bearing at baseline completed the follow-up (7.3 years) and 163 (21%) gave birth during the follow-up period. We compared risk factors [mean levels of age, duration of diabetes, HbA(1c), systolic blood pressure (SBP) and proportion giving birth] between those that did or did not develop microvascular complications during the follow-up period.

RESULTS

For the 425 childless women at baseline, 102 gave birth during follow-up. HbA(1c) was a significant risk factor for progression to microalbuminuria but age, duration of diabetes, systolic blood pressure or giving birth were not. Duration of diabetes and high HbA(1c) were significant risk factors for progression to proliferative retinopathy, whereas giving birth was not. Similar results were obtained for progression to any form of retinopathy. Giving birth was not significantly related to the incidence of neuropathy. Similar results were obtained for women with children at baseline giving birth during follow-up (n = 61/368).

CONCLUSIONS

In this European study, having a first or another pregnancy did not seem to be a risk factor for long-term progression of any microvascular complication. This is in accordance with the findings of the Diabetes Control and Complications Trial (DCCT).

Glomerular structural changes in pregnant, diabetic, and pregnant-diabetic rats

Kidneys enlarge both during pregnancy and in diabetes. The enlargement and morphology of glomeruli was studied during pregnancy and in diabetes in order to examine possible similarities, differences, and interactions in the growth in these conditions. Morphometric investigations were performed on glomeruli in pregnant rats, in rats with 2 weeks' diabetes, and in pregnant-diabetic rats. Kidneys were enlarged 22% in the midterm pregnant rats compared with controls, 74% in diabetic rats, and a further 21% in pregnant-diabetic rats. Glomerular volume was enlarged by 26% during midterm pregnancy in normal animals. Diabetes induced an enlargement in glomerular volume of 58% and a further 18% in midterm diabetic animals due to pregnancy. Within the glomerulus, pregnancy in normal animals induced minor non-significant changes. Diabetes induced significant increase in several parameters: mesangial volume and cell volume, capillary and glomerular basement membrane volume, capillary wall surface area, foot process width, filtration slit length, and nuclear number. Pregnancy in diabetic animals induced no significant additional changes. In conclusion, kidney enlargement in pregnancy shows very few glomerular changes in either normal or diabetic animals. Enlargement of glomeruli in diabetes involves hypertrophy and hyperplasia concurrent with several morphological changes within the glomerulus.

Diabetes mellitus in pregnancy

This article reviews normal and abnormal carbohydrate metabolism in pregnancy, with an emphasis on the challenges that are faced by those who care for the pregnant woman who has hyperglycemia. The growing problem of type 2 diabetes in pregnancy, the controversial use of oral antihyperglycemic agents for the treatment of gestational diabetes, and the long-term issue of diabetes prevention in those whose hyperglycemia resolves postpartum are also addressed.

Diabetic management in high risk patients (pregnancy, insulin pumps)

During the past decades our understanding about the clinical impact of diabetes has changed. We now know for certain that a good (read : near normal) glycemic control is necessary to prevent chronic complications of this disease in women regardless of the type of diabetes. Pregnancy is a specific situation whereby a "near normal" control is wanted not only for the patient but also for the fetus. Several studies have shown a correlation beween glycemic control and complications of pregnancy. Reaching optimal glycemic control is mandatory even before the pregnancy starts, considering the time window of occurance of the severe foetal congenital malformations (first weeks of pregnancy). The role of pre-conception care is emphasized. Optimal control in type 1 and type 2 diabetic patients can best be reached through intensive insulin therapy, but reaching normoglycemia is mainly limited by the occurence of hypoglycemia. The introduction of the new insulin analogues is an important step in our arsenal to achieve control using multiple daily insulin injections, but Novorapid and Lantus have not yet been approved for use in pregnancy. Insulin pumps are often used in pregnant patients, allowing an even better glycemic control with less hypoglycemia. An absolute requirement for CSII therapy to be successful is patient education and motivation by an experienced team.

Use of angiotensin-converting enzyme inhibitors in patients with diabetic nephropathy

Diabetic nephropathy is the most common cause of end-stage renal failure in the Western world. It accounts for 15-25% of all renal failure in patients requiring chronic dialysis. About 20% of patients with insulin-dependent diabetes and less than 15% of patients with non-insulin-dependent diabetes develop clinically significant nephropathy. The prevalence of diabetic nephropathy in pregnant patients with insulin-dependent diabetes is estimated to be 6%. Angiotensin converting enzyme (ACE) inhibitors are the drug of choice in treating women with diabetic nephropathy. In addition, many of these drugs may be started before conception. Unfortunately, these agents might be fetotoxic when taken during pregnancy. This article reviews the epidemiology and natural history of diabetic nephropathy, discusses the renoprotective effect of ACE inhibitors, reviews the effect of ACE inhibitors on fetomaternal outcome when used prior to and during pregnancy in women with diabetic nephropathy and discusses the new class of drugs, angiotensin II receptor antagonists, in the management of diabetics who have or are prone to developing diabetic nephropathy.

Pregnancy outcome and progression of diabetic nephropathy. What's next?

OBJECTIVES

The first objective was to assess the association of renal function with maternal and fetal pregnancy outcome in women with diabetic nephropathy. The second objective was to examine the feasibility of a multicenter surveillance program to determine the rates of maternal and fetal pregnancy complications in women with diabetic nephropathy, and to study the effect of pregnancy on the natural history of diabetic renal disease.

METHODS

In order to address the first objective, we analyzed data from women with type 1 diabetes and nephropathy enrolled in the Diabetes in Pregnancy Program at our institution. Women were assigned to one of three groups according to enrolment serum creatinine concentration: < or = 1.0 mg/dl, > 1.0 to 1.5 mg/dl and > 1.5 mg/dl. A pilot surveillance program at six centers included women experiencing pregnancy complicated by diabetic nephropathy. In both studies, medical and obstetric history, and maternal and neonatal outcomes, were recorded. Statistical analysis included chi2, logistic regression and analysis of variance.

RESULTS

There were 72 pregnancies in 58 women with diabetic nephropathy who enrolled in the pregnancy program. High serum creatinine concentration at enrolment was associated with delivery before 32 weeks' gestation, very low birth weight and increased incidence of neonatal hypoglycemia, independent of quantity of total urinary protein excretion and glycemic control in any trimester. To date, pilot surveillance data have been obtained from six centers on 16 women. Serum creatinine concentrations ranged from 0.4 to 1.1 mg/dl and creatinine clearance from 32 to 317 m/min. Gestational age at delivery ranged from 22 to 39 weeks.

CONCLUSIONS

High serum creatinine concentration at enrolment is a risk factor for adverse maternal and neonatal outcome, independent of quantity of total urinary protein excretion and glycemic control during any trimester. A multicenter surveillance program is needed, in order to study less frequent maternal and neonatal outcomes as well as the long-term effects of pregnancy on the natural course of diabetic renal disease.

Effect of pregnancy on microvascular complications in the diabetes control and complications trial. The Diabetes Control and Complications Trial Research Group

OBJECTIVE

To assess the effect of pregnancy on the development and progression of retinopathy and microalbuminuria in type 1 diabetes.

RESEARCH DESIGN AND METHODS

We conducted longitudinal analyses of the Diabetes Control and Complications Trial (DCCT), a multicenter controlled clinical trial that compared intensive treatment with conventional diabetes therapy and studied 180 women who had 270 pregnancies and 500 women who did not become pregnant during an average of 6.5 years of follow-up. Women assigned to the conventional treatment group were changed to intensive therapy if they were planning pregnancy or as soon as possible after conception. Fundus photography was performed every 6 months, and the urinary albumin excretion rate (AER) was measured annually.

RESULTS

Compared with nonpregnant women, pregnant women had a 1.63-fold greater risk of any worsening of retinopathy from before to during pregnancy (P < 0.05) in the intensive treatment group; the risk was 2.48-fold greater for pregnant vs. not pregnant women in the conventional group (P < 0.001). In the conventional group, the odds of > or =3-step progression from the baseline retinopathy level was >2.9-fold among pregnant vs. not pregnant women (P = 0.003). The odds ratio (OR) peaked during the second trimester (OR = 4.26, P = 0.001) and persisted as long as 12 months postpregnancy (OR = 2.87, P = 0.005). The level of AER during pregnancy in the intensive group, but not in the conventional group, was significantly elevated from the level at baseline, albeit in the normal range. Although individual patients had transient worsening of retinopathy during pregnancy, even to the proliferative level, at the end of the DCCT, mean levels of retinopathy and albuminuria in subjects who had become pregnant were similar to those in subjects who had not become pregnant within each treatment group.

CONCLUSIONS

Pregnancy in type 1 diabetes induces a transient increase in the risk of retinopathy; increased ophthalmologic surveillance is needed during pregnancy and the first year postpartum. The long-term risk of progression of early retinopathy and albumin excretion, however, does not appear to be increased by pregnancy.

Medical complications of diabetes mellitus in pregnancy

Many women with diabetes develop complications of their chronic disease that may have a tremendous impact on their quality of life and their ultimate prognosis. Because Type 1 diabetes often begins at a very early age, it is quite common for women in their child-bearing years to be affected by these complications. As described in this article, diabetic complications and pregnancy may significantly affect each other, but it is not always easy to predict the course of either and to counsel these patients accordingly. Nevertheless, it appears that only in rare occasions should women with diabetes be advised against pregnancy, and that in most situations, with careful and knowledgeable management, a favorable outcome of pregnancy can be expected both for the mother and her infant.

Risks of preeclampsia and adverse neonatal outcomes among women with pregestational diabetes mellitus. National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units

OBJECTIVES

This study was undertaken to determine the frequencies of preeclampsia and adverse neonatal outcomes among women with pregestational diabetes.

STUDY DESIGN

This was a prospective observation of pregnancy outcomes among 462 women with pregestational diabetes mellitus (White classes B-F) and singleton pregnancies who were enrolled in a multicenter trial to compare low-dose aspirin with placebo for preeclampsia prevention. The main outcome measures were preeclampsia and neonatal outcomes.

RESULTS

Among 462 women with pregestational diabetes, 92 (20%) had preeclampsia. Preeclampsia frequency rose significantly with increasing severity of diabetes according to White classification (class B, 11%; class C, 22%; class D, 21%; class R plus class F, 36%; P <.0001). Preeclampsia was also more common among women who had proteinuria at baseline (28% vs 18%; odds ratio, 1.75; 95% confidence interval, 1.02-3.01). Frequency of preterm delivery at <35 weeks' gestation rose greatly with increasing severity of diabetes (P =.0002). Women with proteinuria at baseline were significantly more likely to be delivered at <35 weeks' gestation (29% vs 13%; odds ratio, 2.6; 95% confidence interval, 1.5-4.6) and to have small-for-gestational-age infants (14% vs 3%; odds ratio, 5. 4; 95% confidence interval, 2.7-17.7), and they were less likely to have large-for-gestational-age infants (14% vs 40%; odds ratio, 0.2; 95% confidence interval, 0.1-0.5).

CONCLUSION

Among women with pregestational diabetes mellitus, the frequency of preeclampsia rose with increasing severity of diabetes. Proteinuria early in pregnancy was associated with marked increases in adverse neonatal outcomes independent of preeclampsia development.

Risk factors, pregnancy complications, and prevention of hypertensive disorders in women with pregravid diabetes mellitus

OBJECTIVE

To review the rate, risk factors, and potential prevention of preeclampsia in women with pregravid diabetes mellitus.

METHODS

Detailed review of recent English literature describing pregnancy outcome in women with pregravid insulin-dependent diabetes mellitus (Type 1 diabetes). The primary focus of the review is risk factors for preeclampsia and potential methods suggested for prevention of preeclampsia. In addition, pitfalls in diagnosis of preeclampsia will be emphasized.

RESULTS

The reported rate of preeclampsia ranged from 9% to 66%. This rate increased with increased severity of diabetes by White's classification, with the highest rate reported in women with pregravid diabetic nephropathy. Risk factors identified for preeclampsia were nulliparity, chronic hypertension, microalbuminuria prior to pregnancy, nephropathy, and poor glycemic control early in pregnancy. There is lack of agreement among reports in the literature concerning criteria used to diagnose preeclampsia. There are two randomized trials that included women with Type 1 diabetes who were randomized to receive either low-dose aspirin or placebo. There was no reduction in the rate of preeclampsia with low-dose aspirin in either trial.

CONCLUSIONS

In women with pregravid Type 1 diabetes, the rates of preeclampsia and adverse neonatal outcome increase with increased severity of diabetes. Low-dose aspirin does not reduce rate of preeclampsia in such women. Further studies should address the role of good glycemic control prior to 20 weeks gestation and prevention of microalbuminuria.

Effect of medical therapy on progressive nephropathy: influence of pregnancy, diabetes and hypertension

Nephropathy is a complication of diabetes mellitus that can affect women in their reproductive years. This article reviews the effects on treatment on the main factors associated with short- and long-term complications in pregnant women with diabetic nephropathy. Tight glycemic control, adequate treatment of elevated blood pressure, and renal function in early pregnancy are the most significant predictors of maternal and perinatal outcomes. Contemporary methods of perinatal care and adequate treatment of blood pressure allow fetal survival rates of 95%. Furthermore, pregnancy per se does not appear to worsen the natural progression to end-stage renal disease for most women with renal insufficiency. However, patients with moderate to severe renal impairment may experience acceleration of renal disease.

Pregestational Diabetes Mellitus and Pregnancy

In a pregnancy complicated by diabetes the foetus is at increased risk of congenital malformations, macrosomia and stillbirth. For the mother, diabetes complications (retinopathy nephropathy) may worsen, and in this group there is a higher incidence of hypertension, pre-eclamptic toxaemia and intrauterine growth restriction. However, women with good control who are free of diabetic complications can expect a normal outcome.

Pregnancy in chronic renal insufficiency and end-stage renal disease

Childbearing is important to women with renal disease, but pregnancy has generally been regarded as very high risk in these women. In this review, an attempt is made to clarify the nature and severity of those risks in the settings of chronic renal insufficiency and end-stage renal disease, including dialysis patients and transplant recipients. Hypertension is the most common life-threatening problem in all three groups. A wide range of antihypertensive medications have been used, with angiotensin-converting enzyme inhibitors the only drugs absolutely contraindicated because of their association with neonatal anuria, pulmonary hypoplasia, and neonatal death. Women with serum creatinine levels of 1.4 mg/dL or greater are at risk for accelerated loss of renal function compared with women who don't become pregnant. Transplant recipients have a risk for loss of renal function similar to controls as long as renal function is well preserved. The frequency of conception is decreased in women with renal insufficiency and markedly decreased in dialysis patients (0.5% per year). Return of fertility is the rule in transplant recipients. Exposure to immunosuppressive drugs, including prednisone, azathioprine, cyclosporine, and tacrolimus, has not been associated with an increase in congenital anomalies. These drugs, particularly cyclosporine, have been associated with small-for-gestational-age babies. Transplant recipients are at risk for infections that have implications for the fetus, including cytomegalovirus, herpes simplex, and toxoplasmosis. All groups have an increased risk for prematurity and intrauterine growth restriction. The percentage of pregnancies resulting in surviving infants in women with renal insufficiency and transplant recipients ranges from 70% to 100%. For women who conceive after starting dialysis, the likelihood of a surviving infant is approximately 50%.

Pregnancy in diabetes

For patients with preconception diabetes, the most important aspect is the need for good glycemic control pre conception to lessen the risk of congenital malformations. Careful assessment of diabetes complications is essential prepregnancy. In the absence of major complications, good glycemic control gives the pregnant diabetic patient the same chance for a healthy baby as the rest of the population. Pregnancy alters carbohydrate tolerance, and thus gestational diabetes should be screened for and, when found, treated aggressively with dietary intervention, glucose monitoring, and insulin if good glycemic control has not been attained. These patients are at greatly increased risk for diabetes in the long term.

Statistical analysis of perinatal outcomes in pregnancy complicated with diabetes mellitus

OBJECTIVE

To evaluate the outcomes of pregnancies complicated with diabetes mellitus (DM) in the maternal and perinatal center of Tokyo Women's Medical College (TWMC), and compare the results with reports of other countries.

METHODS

A retrospective study of 482 cases of DM pregnancies were included over a 13-year period in a tertiary care hospital in Tokyo. Information were obtained from medical records of both mothers and babies.

RESULTS

The prevalence of pregnancies complicated with DM was 5.1%. Preeclampsia developed in 124 cases at a rate of 25.8%. Incidence of preterm delivery was 16.6%. Caesarean sections were performed in 36.7% patients. There were significant differences of caesarean section rates between diabetic complication group (retinopathy and nephropathy) and non-complication group (69.5% vs 30.5%, p < 0.0001), and between preterm and term deliveries (60.0% vs 32.1%, p < 0.0001). Maternal backgrounds significantly involved with preterm delivery were DM nephropathy and severe preeclampsia. Babies with heavy for gestational age (HGA) were observed at a rate of 21% in all. There were 3 perinatal deaths (intrauterine fetal deaths, IUFD) with the perinatal mortality rate of 6.1/1,000 births. The incidence of caesarean section and perinatal mortality rate of non-DM pregnancies in our center during the same study period were 16.3% and 7.7/1,000 births respectively.

CONCLUSIONS

The perinatal outcome in our study was better compared to other worldwide reports. With accurate perinatal management, perinatal mortality rate of DM pregnancies in the current study was almost same as that of non-DM pregnancies in our center. The main factors to promote adverse perinatal outcomes were presence of DM nephropathy and severe preeclampsia.