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Haines AJ, Mackenzie L, Honey A, Middleton PG. Occupations and balance during the transition to motherhood with a lifetime chronic illness: A scoping review examining cystic fibrosis, asthma, and Type-1 diabetes. Aust Occup Ther J 2023; 70:730-744. [PMID: 37524324 DOI: 10.1111/1440-1630.12899] [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: 10/26/2022] [Revised: 06/30/2023] [Accepted: 07/08/2023] [Indexed: 08/02/2023]
Abstract
INTRODUCTION Throughout the transition to motherhood, changes are experienced across a woman's physical, mental, social, and occupational self. Maternal chronic illness adds the complexity of increased healthcare needs and navigating a high-risk, medicalised pregnancy, birth, and post-natal period. Literature concerning motherhood transitions in chronic illness generally focusses on the mother's medical health and pregnancy outcomes; little is known about the impacts on women's occupations, balance, and quality of life. Understanding these issues may help support women in a more tailored and holistic way. OBJECTIVE This scoping review aims to gather, analyse, and synthesise existing empirical research on occupational engagement and occupational balance as they impact on wellbeing and quality of life in women with a lifetime chronic illness before and during pregnancy and in early motherhood. METHOD The review follows the nine-stage framework described in the Joanna Briggs Institute Manual for Evidence Synthesis (2020). Five databases were searched: Embase, Medline, PsycINFO, CINAHL, Scopus, and OT Seeker. Data were extracted and examined via content analysis, described in narrative synthesis, summarised into a conceptual framework, and tabulated. FINDINGS A total of 8,655 papers were discovered on initial search. Following title and abstract screening, 220 full-text studies were assessed for eligibility, and 46 papers were finally included. Analysis generated four major themes: The Disrupted Transition Journey; Adaptation, Compromise and Choice; Outcomes; and Drawing on What's Available. The themes were conceptualised into a framework to explain how women sought to balance motherhood and illness-related occupations. Adequate access to information, social support, expert care, and financial resources improved both quality of life and healthcare compliance. CONCLUSION Findings of this scoping review deepen the understanding of occupational balance during the transition to motherhood in the context of lifetime chronic illness. Healthcare providers and supportive family and friends can use this knowledge to adapt their approach to assisting women with chronic illness on the motherhood journey. These findings may also inform further inquiry into the scope of occupational therapy practice with this population.
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Affiliation(s)
- Alena Jane Haines
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Lynette Mackenzie
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Anne Honey
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Peter G Middleton
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Centre for Investigation and Treatment of Respiratory Infections in Children and Adults, Westmead Campus, Westmead, New South Wales, Australia
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Egan AM, Brassill MJ, Brosnan E, Carmody L, Clarke H, Coogan Kelly C, Culliney L, Durkan M, Fenlon M, Ferry P, Hanlon G, Higgins T, Hoashi S, Khamis A, Kinsley B, Kinsley T, Kirwan B, Liew A, McGurk C, McHugh C, Murphy MS, Murphy P, O'Halloran D, O'Mahony L, O'Sullivan E, Nolan M, Peter M, Roberts G, Smyth A, Todd M, Tuthill A, Wan Mahmood WA, Yousif O, P Dunne F. An Irish National Diabetes in Pregnancy Audit: aiming for best outcomes for women with diabetes. Diabet Med 2020; 37:2044-2049. [PMID: 30710451 DOI: 10.1111/dme.13923] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/30/2019] [Indexed: 12/16/2022]
Abstract
AIMS The purpose of this study was to identify the number of pregnancies affected by pre-gestational diabetes in the Republic of Ireland; to report on pregnancy outcomes and to identify areas for improvement in care delivery and clinical outcomes. METHODS Healthcare professionals caring for women with pre-gestational diabetes during pregnancy were invited to participate in this retrospective study. Data pertaining to 185 pregnancies in women attending 15 antenatal centres nationally were collected and analysed. Included pregnancies had an estimated date of delivery between 1 January and 31 December 2015. RESULTS The cohort consisted of 122 (65.9%) women with Type 1 diabetes and 56 (30.3%) women with Type 2 diabetes. The remaining 7 (3.8%) pregnancies were to women with maturity-onset diabetes of the young (MODY) (n = 6) and post-transplant diabetes (n = 1). Overall women were poorly prepared for pregnancy and lapses in specific areas of service delivery including pre-pregnancy care and retinal screening were identified. The majority of pregnancies 156 (84.3%) resulted in a live birth. A total of 103 (65.5%) women had a caesarean delivery and 58 (36.9%) infants were large for gestational age. CONCLUSIONS This audit identifies clear areas for improvement in delivery of care for women with diabetes in the Republic of Ireland before and during pregnancy.
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Affiliation(s)
- A M Egan
- University Hospital Galway, Galway, Republic of Ireland
| | - M J Brassill
- South Tipperary General Hospital, Clonmel, Republic of Ireland
| | - E Brosnan
- Mayo University Hospital, Castlebar, Republic of Ireland
| | - L Carmody
- University Hospital Galway, Galway, Republic of Ireland
| | - H Clarke
- Portiuncla University Hospital, Ballinasloe, Republic of Ireland
| | - C Coogan Kelly
- St Luke's General Hospital, Kilkenny, Republic of Ireland
| | - L Culliney
- Cork University Hospital, Cork, Republic of Ireland
| | - M Durkan
- Bon Secours Hospital, Cork, Republic of Ireland
| | - M Fenlon
- Wexford General Hospital, Wexford, Republic of Ireland
| | - P Ferry
- Letterkenny University Hospital, Letterkenny, Republic of Ireland
| | - G Hanlon
- St Luke's General Hospital, Kilkenny, Republic of Ireland
| | - T Higgins
- University Hospital Kerry, Tralee, Republic of Ireland
| | - S Hoashi
- Midland Regional Hospital, Mullingar, Republic of Ireland
| | - A Khamis
- Letterkenny University Hospital, Letterkenny, Republic of Ireland
| | - B Kinsley
- Coombe Women and Infants University Hospital, Dublin, Republic of Ireland
| | - T Kinsley
- Coombe Women and Infants University Hospital, Dublin, Republic of Ireland
| | - B Kirwan
- University Hospital Galway, Galway, Republic of Ireland
| | - A Liew
- Portiuncla University Hospital, Ballinasloe, Republic of Ireland
| | - C McGurk
- St Luke's General Hospital, Kilkenny, Republic of Ireland
| | - C McHugh
- Sligo University Hospital, Sligo, Republic of Ireland
| | - M S Murphy
- South Infirmary Victoria University Hospital, Cork, Republic of Ireland
| | - P Murphy
- Cork University Hospital, Cork, Republic of Ireland
| | - D O'Halloran
- Cork University Hospital, Cork, Republic of Ireland
| | - L O'Mahony
- Cork University Hospital, Cork, Republic of Ireland
| | | | - M Nolan
- University Hospital Kerry, Tralee, Republic of Ireland
| | - M Peter
- University Hospital Waterford, Waterford, Republic of Ireland
| | - G Roberts
- University Hospital Waterford, Waterford, Republic of Ireland
| | - A Smyth
- Coombe Women and Infants University Hospital, Dublin, Republic of Ireland
| | - M Todd
- Mayo University Hospital, Castlebar, Republic of Ireland
| | - A Tuthill
- Cork University Hospital, Cork, Republic of Ireland
| | - W A Wan Mahmood
- Coombe Women and Infants University Hospital, Dublin, Republic of Ireland
| | - O Yousif
- Wexford General Hospital, Wexford, Republic of Ireland
| | - F P Dunne
- University Hospital Galway, Galway, Republic of Ireland
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Wahabi HA, Fayed A, Esmaeil S, Elmorshedy H, Titi MA, Amer YS, Alzeidan RA, Alodhayani AA, Saeed E, Bahkali KH, Kahili-Heede MK, Jamal A, Sabr Y. Systematic review and meta-analysis of the effectiveness of pre-pregnancy care for women with diabetes for improving maternal and perinatal outcomes. PLoS One 2020; 15:e0237571. [PMID: 32810195 PMCID: PMC7433888 DOI: 10.1371/journal.pone.0237571] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 07/30/2020] [Indexed: 12/17/2022] Open
Abstract
Background Pre-gestational diabetes mellitus is associated with increased risk of maternal and perinatal adverse outcomes. This systematic review was conducted to evaluate the effectiveness and safety of pre-conception care (PCC) in improving maternal and perinatal outcomes. Methods Databases from MEDLINE, EMBASE, WEB OF SCIENCE, and Cochrane Library were searched, including the CENTRAL register of controlled trials, and CINHAL up until March 2019, without any language restrictions, for any pre-pregnancy care aiming at health promotion, glycemic control, and screening and treatment of diabetes complications in women with type I or type II pre-gestational diabetes. Trials and observational studies were included in the review. Newcastle-Ottawa scale and the Cochrane collaboration methodology for data synthesis and analysis were used, along with the GRADE tool to evaluate the body of evidence. Results The search identified 8500 potentially relevant citations of which 40 reports of 36 studies were included. The meta-analysis results show that PCC reduced congenital malformations risk by 71%, (Risk ratio (RR) 0.29; 95% CI: 0.21–0.40, 25 studies; 5903 women; high-certainty evidence). The results also show that PCC may lower HbA1c in the first trimester of pregnancy by an average of 1.27% (Mean difference (MD) 1.27; 95% CI: 1.33–1.22; 4927 women; 24 studies, moderate-certainty evidence). Furthermore, the results suggest that PCC may lead to a slight reduction in the risk of preterm delivery of 15%, (RR 0.85; 95% CI: 0.73–0.99; nine studies, 2414 women; moderate-certainty evidence). Moreover, PCC may result in risk reduction of perinatal mortality by 54%, (RR 0.46; 95% CI: 0.30–0.73; ten studies; 3071 women; moderate-certainty evidence). There is uncertainty about the effects of PCC on the early booking for antenatal care (MD 1.31; 95% CI: 1.40–1.23; five studies, 1081 women; very low-certainty evidence) and maternal hypoglycemia in the first trimester, (RR 1.38; 95% CI: 1.07–1.79; three studies; 686 women; very low- certainty evidence). In addition, results of the meta-analysis indicate that PCC may lead to 48% reduction in the risk of small for gestational age (SGA) (RR 0.52; 95% CI: 0.37–0.75; six studies, 2261 women; moderate-certainty evidence). PCC may reduce the risk of neonatal admission to intensive care unit (NICU) by 25% (RR 0.75; 95% CI: 0.67–0.84; four studies; 1322 women; moderate-certainty evidence). However, PCC may have little or no effect in reducing the cesarean section rate (RR 1.02; 95% CI: 0.96–1.07; 14 studies; 3641 women; low-certainty evidence); miscarriage rate (RR 0.86; 95% CI: 0.70–1.06; 11 studies; 2698 women; low-certainty evidence); macrosomia rate (RR 1.06; 95% CI: 0.97–1.15; nine studies; 2787 women, low-certainty evidence); neonatal hypoglycemia (RR 0.93; 95% CI: 0.74–1.18; five studies; 880 women; low-certainty evidence); respiratory distress syndrome (RR 0.78; 95% CI: 0.47–1.29; four studies; 466 women; very low-certainty evidence); or shoulder dystocia (RR 0.28; 95% CI: 0.07–1.12; 2 studies; 530 women; very low-certainty evidence). Conclusion PCC for women with pre-gestational type 1 or type 2 diabetes mellitus is effective in improving rates of congenital malformations. In addition, it may improve the risk of preterm delivery and admission to NICU. PCC probably reduces maternal HbA1C in the first trimester of pregnancy, perinatal mortality and SGA. There is uncertainty regarding the effects of PCC on early booking for antenatal care or maternal hypoglycemia during the first trimester of pregnancy. PCC has little or no effect on other maternal and perinatal outcomes.
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Affiliation(s)
- Hayfaa A. Wahabi
- Research Chair for Evidence-Based Healthcare and Knowledge Translation, King Saud University, Riyadh, Saudi Arabia
- Department of Family and Community Medicine, King Saud University Medical City and College of Medicine, Riyadh, Saudi Arabia
| | - Amel Fayed
- College of Medicine, Clinical Department, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
- High Institute of Public Health, Alexandria University, Alexandria, Egypt
- * E-mail:
| | - Samia Esmaeil
- Research Chair for Evidence-Based Healthcare and Knowledge Translation, King Saud University, Riyadh, Saudi Arabia
| | - Hala Elmorshedy
- College of Medicine, Clinical Department, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
- High Institute of Public Health, Alexandria University, Alexandria, Egypt
| | - Maher A. Titi
- Research Chair for Evidence-Based Healthcare and Knowledge Translation, King Saud University, Riyadh, Saudi Arabia
- Patient Safety Unit, Quality Management Department, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Yasser S. Amer
- Research Chair for Evidence-Based Healthcare and Knowledge Translation, King Saud University, Riyadh, Saudi Arabia
- Clinical Practice Guidelines Unit, Quality Management Department, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Rasmieh A. Alzeidan
- Cardiac Science Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Abdulaziz A. Alodhayani
- Department of Family and Community Medicine, King Saud University Medical City and College of Medicine, Riyadh, Saudi Arabia
| | - Elshazaly Saeed
- Prince Abdulla bin Khaled Coeliac Disease Research Chair, King Saud University, Riyadh, Saudi Arabia
| | | | - Melissa K. Kahili-Heede
- John A. Burns School of Medicine, Health Sciences Library, University of Hawaii at Manoa, Honolulu, HI, United States of America
| | - Amr Jamal
- Research Chair for Evidence-Based Healthcare and Knowledge Translation, King Saud University, Riyadh, Saudi Arabia
- Department of Family and Community Medicine, King Saud University Medical City and College of Medicine, Riyadh, Saudi Arabia
| | - Yasser Sabr
- Department of Obstetrics and Gynecology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Egan AM, Galjaard S, Maresh MJA, Loeken MR, Napoli A, Anastasiou E, Noctor E, de Valk HW, van Poppel M, Todd M, Smith V, Devane D, Dunne FP. A core outcome set for studies evaluating the effectiveness of prepregnancy care for women with pregestational diabetes. Diabetologia 2017; 60:1190-1196. [PMID: 28409213 PMCID: PMC5487596 DOI: 10.1007/s00125-017-4277-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 03/13/2017] [Indexed: 12/30/2022]
Abstract
AIMS/HYPOTHESIS The aim of this study was to develop a core outcome set (COS) for trials and other studies evaluating the effectiveness of prepregnancy care for women with pregestational (pre-existing) diabetes mellitus. METHODS A systematic literature review was completed to identify all outcomes reported in prior studies in this area. Key stakeholders then prioritised these outcomes using a Delphi study. The list of outcomes included in the final COS were finalised at a face-to-face consensus meeting. RESULTS In total, 17 outcomes were selected and agreed on for inclusion in the final COS. These outcomes were grouped under three domains: measures of pregnancy preparation (n = 9), neonatal outcomes (n = 6) and maternal outcomes (n = 2). CONCLUSIONS/INTERPRETATION This study identified a COS essential for studies evaluating prepregnancy care for women with pregestational diabetes. It is advocated that all trials and other non-randomised studies and audits in this area use this COS with the aim of improving transparency and the ability to compare and combine future studies with greater ease.
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Affiliation(s)
- Aoife M Egan
- Galway Diabetes Research Centre, Department of Medicine, National University of Ireland Galway, Galway, Ireland.
| | - Sander Galjaard
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Prenatal Medicine, Erasmus MC, University Medical Centre Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, the Netherlands.
| | - Michael J A Maresh
- Department of Obstetrics, St Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Mary R Loeken
- Section of Islet Cell and Regenerative Biology, Joslin Diabetes Center, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Angela Napoli
- Department of Clinical and Molecular Medicine, S. Andrea University Hospital, Sapienza, University of Rome, Rome, Italy
| | - Eleni Anastasiou
- Department of Endocrinology & Diabetes Center Alexandra Hospital, Athens, Greece
| | - Eoin Noctor
- Department of Endocrinology, University Hospital Limerick, Limerick, Ireland
| | - Harold W de Valk
- Department of Internal Medicine, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Mireille van Poppel
- Institute of Sport Science, University of Graz, Graz, Austria
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, VU University Medical Centre, Amsterdam, the Netherlands
| | - Marie Todd
- Department of Medicine, Mayo University Hospital, Castlebar, Ireland
| | - Valerie Smith
- School of Nursing & Midwifery, Trinity College Dublin, Dublin, Ireland
- School of Nursing & Midwifery, National University of Ireland Galway, Galway, Ireland
| | - Declan Devane
- School of Nursing & Midwifery, National University of Ireland Galway, Galway, Ireland
- Health Research Board - Trials Methodology Research Network (HRB-TMRN), Galway, Ireland
| | - Fidelma P Dunne
- Galway Diabetes Research Centre, Department of Medicine, National University of Ireland Galway, Galway, Ireland
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Webster P, Lightstone L, McKay DB, Josephson MA. Pregnancy in chronic kidney disease and kidney transplantation. Kidney Int 2017; 91:1047-1056. [PMID: 28209334 DOI: 10.1016/j.kint.2016.10.045] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 09/28/2016] [Accepted: 10/06/2016] [Indexed: 12/20/2022]
Abstract
Chronic kidney disease (CKD) affects up to 6% of women of childbearing age in high income countries, and is estimated to affect 3% of pregnant women. Advanced renal dysfunction, proteinuria, hypertension, and poorly controlled underlying primary renal disease are all significant risks for adverse maternal, fetal, and renal outcomes. In order to achieve the best outcomes, it is therefore of paramount importance that these pregnancies are planned, where possible, to allow the opportunity to counsel women and their partners in advance and to optimize these risks. These pregnancies should be deemed high risk and they require close antenatal monitoring from an expert multidisciplinary team. We discuss the effect of pregnancy on CKD, and also current guidelines and literature with specific reference to transplantation, autoimmune disease, and medication use in pregnancy. We also discuss the benefits of prepregnancy counseling and give practical recommendations to advise pregnant women with renal disease.
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Affiliation(s)
- Philip Webster
- Section of Renal Medicine and Vascular Inflammation, Department of Medicine, Imperial College London, United Kingdom
| | - Liz Lightstone
- Section of Renal Medicine and Vascular Inflammation, Department of Medicine, Imperial College London, United Kingdom
| | - Dianne B McKay
- Division of Nephrology, Department of Medicine, University of California, San Diego, California, USA
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Egan AM, Dunne FP. Pre-pregnancy care for women with diabetes mellitus. Br J Hosp Med (Lond) 2016; 77:C191-C193. [PMID: 27937031 DOI: 10.12968/hmed.2016.77.12.c191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- A M Egan
- Specialist Registrar, Galway Diabetes Research Centre, National University of Ireland Galway and Diabetes Day Centre, University Hospital Galway, Galway, Ireland
| | - F P Dunne
- Consultant Endocrinologist, Galway Diabetes Research Centre, National University of Ireland Galway and University Hospital Galway, Galway, Ireland
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Egan AM, Danyliv A, Carmody L, Kirwan B, Dunne FP. A Prepregnancy Care Program for Women With Diabetes: Effective and Cost Saving. J Clin Endocrinol Metab 2016; 101:1807-15. [PMID: 26918293 DOI: 10.1210/jc.2015-4046] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Only a minority of women with diabetes attend prepregnancy care service and the economic effects of providing this service are unclear. OBJECTIVE The objective of the study was to design, put into practice, and evaluate a regional prepregnancy care program for women with types 1 and 2 diabetes. DESIGN This was a prospective cohort and cost-analysis study. SETTING The study was conducted at antenatal centers along the Irish Atlantic Seaboard. PARTICIPANTS Four hundred fourteen women with type 1 or 2 diabetes participated in the study. INTERVENTIONS The intervention for the study was a newly developed prepregnancy care program. MAIN OUTCOME MEASURES The program was assessed for its effect on the risk of adverse pregnancy outcomes. The difference between program delivery cost and the excess cost of treating adverse outcomes in nonattendees was evaluated. RESULTS In total, 149 (36%) attended: this increased from 19% to 50% after increased recruitment measures in 2010. Attendees were more likely to take preconception folic acid (97.3% vs 57.7%, P < .001) and less likely to smoke (8.7% vs 16.6%, P = .03) or take potentially teratogenic medications at conception (0.7 vs 6.0, P = .008). Attendees had lower glycated hemoglobin levels throughout pregnancy (first trimester glycated hemoglobin 6.8% vs 7.7%, P < .001; third trimester glycated hemoglobin 6.1% vs 6.5%, P = .001), and their offspring had lower rates of serious adverse outcomes (2.4% vs 10.5%, P = .007). The adjusted difference in complication costs between those who received prepregnancy care vs usual antenatal care only is €2578.00. The average cost of prepregnancy care delivery is €449.00 per pregnancy. CONCLUSIONS This regional prepregnancy care program is clinically effective. The cost of program delivery is less than the excess cost of managing adverse pregnancy outcomes.
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Affiliation(s)
- Aoife M Egan
- Galway Diabetes Research Centre (A.M.E., L.C., B.K., F.P.D.) and Department of Economics (A.D.), National University of Ireland Galway, Galway, Ireland
| | - Andriy Danyliv
- Galway Diabetes Research Centre (A.M.E., L.C., B.K., F.P.D.) and Department of Economics (A.D.), National University of Ireland Galway, Galway, Ireland
| | - Louise Carmody
- Galway Diabetes Research Centre (A.M.E., L.C., B.K., F.P.D.) and Department of Economics (A.D.), National University of Ireland Galway, Galway, Ireland
| | - Breda Kirwan
- Galway Diabetes Research Centre (A.M.E., L.C., B.K., F.P.D.) and Department of Economics (A.D.), National University of Ireland Galway, Galway, Ireland
| | - Fidelma P Dunne
- Galway Diabetes Research Centre (A.M.E., L.C., B.K., F.P.D.) and Department of Economics (A.D.), National University of Ireland Galway, Galway, Ireland
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Abstract
Pregestational diabetes is a common medical complication of pregnancy and preconception planning is an essential component of care for affected women of childbearing age. Once pregnant, structured care in a multidisciplinary team setting is necessary to ensure optimal outcomes. Although significant progress has been made, these women and their offspring remain to have a significantly elevated risk of multiple adverse complications. Structured programmes using information technology and enabling access to novel technologies may facilitate our goal of ensuring an outcome closer to that of a pregnancy unaffected by diabetes.
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Affiliation(s)
- A M Egan
- From the Galway Diabetes Research Centre, National University of Ireland Galway, Newcastle, Galway, Ireland and
| | - H R Murphy
- Level 4 Metabolic Research Laboratories and NIHR Cambridge Biomedical Research Centre, University of Cambridge Wellcome Trust - MRC Institute of Metabolic Science, Cambridge, UK
| | - F P Dunne
- From the Galway Diabetes Research Centre, National University of Ireland Galway, Newcastle, Galway, Ireland and
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Egan AM, Smith V, Devane D, Dunne FP. Effectiveness of prepregnancy care for women with pregestational diabetes mellitus: protocol for a systematic review of the literature and identification of a core outcomes set using a Delphi survey. Trials 2015; 16:356. [PMID: 26272593 PMCID: PMC4536746 DOI: 10.1186/s13063-015-0894-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 07/31/2015] [Indexed: 11/15/2022] Open
Abstract
Background Women with pregnancy complicated by pregestational diabetes experience increased rates of adverse pregnancy outcomes. Prepregnancy care is the targeted support and additional care offered to those women who are planning pregnancy and is associated with improved outcomes. However, there is significant heterogeneity in the outcomes measured and reported in studies evaluating the effects of prepregnancy care, which makes meaningful comparison difficult. The aim of this article is to present a protocol for a study to develop a Core Outcome Set (COS) for trials and other studies evaluating the effectiveness of prepregnancy care for women with pregestational diabetes mellitus. Methods/Design This study will include a systematic review of the literature to identify outcomes that have previously been reported in studies evaluating prepregnancy care for women with pregestational diabetes. We will then prioritise these outcomes from the perspective of key stakeholders, including women with pregestational diabetes as well as clinicians, using a Delphi survey. A final consensus meeting will be held with stakeholders to review and finalise the outcomes. Discussion The expectation is that the COS will always be collected and reported in all clinical trials, audits of practice and other forms of research that involve prepregnancy care programs for women with pregestational diabetes. This will facilitate comparing and contrasting of studies and allow for combining of appropriate studies with the ultimate goal of improved patient care. Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-0894-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Aoife M Egan
- Galway Diabetes Research Centre, School of Medicine, National University of Ireland, Galway, Ireland.
| | - Valerie Smith
- School of Nursing & Midwifery, Trinity College Dublin, Dublin, Ireland. .,School of Nursing & Midwifery, National University of Ireland, Galway, Ireland.
| | - Declan Devane
- School of Nursing & Midwifery, National University of Ireland, Galway, Ireland. .,Saolta University Health Care Group, Galway, Ireland. .,Health Research Board - Trials Methodology Research Network (HRB-TMRN), Galway, Ireland.
| | - Fidelma P Dunne
- Galway Diabetes Research Centre, School of Medicine, National University of Ireland, Galway, Ireland. .,Saolta University Health Care Group, Galway, Ireland.
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Wahabi HA, Alzeidan RA, Esmaeil SA. Pre-pregnancy care for women with pre-gestational diabetes mellitus: a systematic review and meta-analysis. BMC Public Health 2012; 12:792. [PMID: 22978747 PMCID: PMC3575330 DOI: 10.1186/1471-2458-12-792] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Accepted: 09/14/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pre-gestational diabetes mellitus is associated with increased risk for maternal and fetal adverse outcomes. This systematic review was carried out to evaluate the effectiveness and safety of pre-pregnancy care in improving the rate of congenital malformations and perinatal mortality for women with pre-gestational diabetes mellitus. METHODS We searched the following databases, MEDLINE, EMBASE, WEB OF SCIENCE, Cochrane Library, including the CENTRAL register of controlled trials and CINHAL up to December 2011, without language restriction, for any pre-pregnancy care aiming at health promotion, glycemic control and screening and treatment of diabetes complications in women with type I or type II diabetes mellitus. Study design were trials (randomized and non-randomized), cohort and case-control studies. RESULTS Of the 2452 title scanned 54 full papers were retrieved of those 21 studies were included in this review. Twelve cohort studies at low and medium risk of bias, with 3088 women, were included in the meta-analysis. Meta-analysis suggested that pre-pregnancy care is effective in reducing congenital malformation, Risk Ratio (RR) 0.25 (95% CI 0.16-0.37), number needed to treat (NNT) 19 (95% CI 14-24), and perinatal mortality RR 0.34 (95% CI 0.15-0.75), NNT = 46 (95% CI 28-115). Pre-pregnancy care lowers glycosylated hemoglobin A1c (HbA1c) in the first trimester of pregnancy by an average of 1.92% (95% CI -2.05 to -1.79). However women who received pre-pregnancy care were at increased risk of hypoglycemia during the first trimester of pregnancy RR 1.51 (95% CI 1.15-1.99). CONCLUSION Pre-pregnancy care for women with pre-gestational type 1 or type 2 diabetes mellitus is effective in improving rates of congenital malformations, perinatal mortality and in reducing maternal HbA1C in the first trimester of pregnancy. Pre-pregnancy care might cause maternal hypoglycemia in the first trimester of pregnancy.
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Affiliation(s)
- Hayfaa A Wahabi
- Sheikh Bahmdan Chair of Evidence-based Healthcare and Knowledge Translation, College of Medicine, King Saud University, Riyadh, Saudi Arabia.
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Ejdesjö A, Wentzel P, Eriksson UJ. Influence of maternal metabolism and parental genetics on fetal maldevelopment in diabetic rat pregnancy. Am J Physiol Endocrinol Metab 2012; 302:E1198-209. [PMID: 22374754 DOI: 10.1152/ajpendo.00661.2011] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The purpose of this study was to investigate the influence of parental transgenerational genetics and maternal metabolic state on fetal maldevelopment in diabetic rat pregnancy. Rats from an inbred malformation-resistant (W) strain, and an inbred malformation-prone (L) strain, were cross-mated to produce two different F(1) hybrids, WL and LW. Normal (N) and manifestly diabetic (MD) WL and LW females were mated with normal males of the same F(1) generation to obtain WLWL and LWLW F(2) hybrids. Maternal diabetes increased malformation and resorption rates in both F(2) generations. MD-WLWL offspring had higher resorption rate but similar malformation rate compared with the MD-LWLW offspring. Malformed MD-WLWL offspring presented with 100% agnathia/micrognathia, whereas malformed MD-LWL offspring had 60% agnathia/micrognathia and 40% cleft lip and palate. The MD-WL dams showed increased β-hydroxybutyrate levels and alterations in concentrations of several amino acids (taurine, asparagine, citrulline, cystine, glutamic acid, leucine, tyrosine, and tryptophan) compared with MD-LW dams. Fetal glyceraldehyde-3-phosphate dehydrogenase (Gapdh) activity and gene expression were more altered in MD-WLWL than MD-LWLW. Fetal gene expression of reactive oxygen species (ROS) scavenger enzymes was diminished in MD-WLWL compared with MD-LWLW. Glial cell line-derived neurotrophic factor and Ret proto-oncogene gene expression was decreased in both MD-WLWL and MD-LWLW fetuses, whereas increased bone morphogenetic protein 4 and decreased Sonic hedgehog homolog expression was found only in MD-LWLW fetuses. Despite identical autosomal genotypes, the WL and LW dams gave birth to offspring with markedly different malformation patterns. Together with fetal differences in enzymatic activity and expression of Gapdh, ROS scavengers, and developmental genes, these results may suggest a teratological mechanism in diabetic pregnancy influenced by maternal metabolism and parental strain epigenetics.
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Affiliation(s)
- A Ejdesjö
- Dept. of Medical Cell Biology, Biomedical Centre, PO Box 571, SE-75123 Uppsala, Sweden.
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12
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Preconception care for diabetic women for improving maternal and fetal outcomes: a systematic review and meta-analysis. BMC Pregnancy Childbirth 2010; 10:63. [PMID: 20946676 PMCID: PMC2972233 DOI: 10.1186/1471-2393-10-63] [Citation(s) in RCA: 133] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2010] [Accepted: 10/14/2010] [Indexed: 11/24/2022] Open
Abstract
Background Preexisting diabetes mellitus is associated with increased risk for maternal and fetal adverse outcomes. Despite improvement in the access and quality of antenatal care recent population based studies demonstrating increased congenital abnormalities and perinatal mortality in diabetic mothers as compared to the background population. This systematic review was carried out to evaluate the effectiveness and safety of preconception care in improving maternal and fetal outcomes for women with preexisting diabetes mellitus. Methods We searched the following databases, MEDLINE, EMBASE, WEB OF SCIENCE, Cochrane Library, including the CENTRAL register of controlled trials and CINHAL up to December 2009, without language restriction, for any preconception care aiming at health promotion, glycemic control and screening and treatment of diabetes complications in women of reproductive age group with type I or type II diabetes. Study design were trials (randomized and non-randomized), cohort and case-control studies. Of the 1612 title scanned 44 full papers were retrieved of those 24 were included in this review. Twelve cohort studies at low and medium risk of bias, with 2502 women, were included in the meta-analysis. Results Meta-analysis suggested that preconception care is effective in reducing congenital malformation, RR 0.25 (95% CI 0.15-0.42), NNT17 (95% CI 14-24), preterm delivery, RR 0.70 (95% CI 0.55-0.90), NNT = 8 (95% CI 5-23) and perinatal mortality RR 0.35 (95% CI 0.15-0.82), NNT = 32 (95% CI 19-109). Preconception care lowers HbA1c in the first trimester of pregnancy by an average of 2.43% (95% CI 2.27-2.58). Women who received preconception care booked earlier for antenatal care by an average of 1.32 weeks (95% CI 1.23-1.40). Conclusion Preconception care is effective in reducing diabetes related congenital malformations, preterm delivery and maternal hyperglycemia in the first trimester of pregnancy.
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14
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Abstract
Congenital malformations are more common in infants of diabetic women than in children of non-diabetic women. The etiology, pathogenesis and prevention of the diabetes-induced malformations have spurred considerable clinical and basic research efforts. The ultimate aim of these studies has been to obtain an understanding of the teratogenic process, which may enable precise preventive therapeutic measures in diabetic pregnancies. The results of the clinical and basic studies support the view of an early gestational induction of the malformations in diabetic pregnancy by a teratogenic process of multifactorial etiology. There may be possible targets for new therapeutic efforts revealed by the research work. Thus, future additions to the therapeutic efforts may include supplementation with antioxidants and/or folic acid, although more research is needed to delineate the dosages and compounds to be used. As the research into genetic predisposition for the teratogenic induction of malformations by maternal diabetes starts to reveal new genes and gene products involved in the etiology of the malformations, a set of new targets for intervention may arise.
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Affiliation(s)
- Ulf J Eriksson
- Department of Medical Cell Biology, Uppsala University, Biomedical Center, PO Box 571, SE-75123 Uppsala, Sweden.
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15
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Feig DS, Razzaq A, Sykora K, Hux JE, Anderson GM. Trends in deliveries, prenatal care, and obstetrical complications in women with pregestational diabetes: a population-based study in Ontario, Canada, 1996-2001. Diabetes Care 2006; 29:232-5. [PMID: 16443865 DOI: 10.2337/diacare.29.02.06.dc05-1482] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To describe recent trends in the proportion of deliveries in women with pregestational diabetes (PGD), their use of services, and diabetes-related obstetrical complications. RESEARCH DESIGN AND METHODS In this population-based retrospective cohort study, comprehensive administrative data were used to identify all women (with and without PGD) who gave birth in an Ontario, Canada, hospital from 1996 to 2001. Data on maternal complications and interventions were obtained from hospital discharge records; data on use of prenatal services were obtained from fee-for-service claims. RESULTS The proportion of deliveries in women with PGD increased steadily from 0.8% in 1996 to 1.2% in 2001 (P < 0.001). In 2001, women with PGD were more likely to be diagnosed with shoulder dystocia (adjusted odds ratio 2.00 [95% CI 1.55-2.58]), hypertension (4.13 [3.44-4.96]), and preeclampsia/eclampsia (4.44 [3.43-5.73]) and have higher rates of inductions (1.69 [1.52-1.88]) and caesarean sections (1.78 [1.60-1.98]) than women without PGD. In 2001, 50% of the women with PGD had a visit to a diabetes specialist during pregnancy and only 30% of women had claims for a prenatal retinal examination. Both of these rates have decreased over the study period. CONCLUSIONS Women with PGD now account for a larger proportion of deliveries. These women continue to have higher obstetrical complication and intervention rates than women without PGD and many do not receive recommended specialty care during pregnancy.
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Affiliation(s)
- Denice S Feig
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
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Sablock U, Lindow SW, Arnott PIE, Masson EA. Prepregnancy counselling for women with medical disorders. J OBSTET GYNAECOL 2002; 22:637-8. [PMID: 12554253 DOI: 10.1080/0144361021000020439] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Langer O. A spectrum of glucose thresholds may effectively prevent complications in the pregnant diabetic patient. Semin Perinatol 2002; 26:196-205. [PMID: 12099309 DOI: 10.1053/sper.2002.33962] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
This article outlines the probable positive relationship between levels of maternal glycemia and perinatal morbidity and mortality. A spectrum of different glucose thresholds can be established and used appropriately to prevent each complication. This article also outlines the concept of normality and what definitions of normality should be used to evaluate the relationship between the level of glycemia and perinatal outcome. Definitive conclusions are hampered by a lack of uniformity in definitions and interventions, and by a failure in some analyses to control for confounding variables. However, it is suggested that different levels of glycemia are required to prevent different diabetic complications. Thus, although it is not always possible to achieve targeted levels of glycemic control in all patients, any improvement will be beneficial because it will affect fetal complications associated with that glucose threshold.
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Affiliation(s)
- Oded Langer
- Department of Obstetrics and Gynecology, St Luke's-Roosevelt Hospital Center, New York, NY 10019, USA
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18
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Kalter H. Hyperglycemia and congenital malformations in insulin-dependent diabetes mellitus: a brief summary and evaluation. TERATOLOGY 2002; 65:97-101. [PMID: 11877769 DOI: 10.1002/tera.10024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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19
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Abstract
This article provides the reader with relevant information regarding the association between level of glycemia and perinatal outcome in preexisting diabetes. Although the glycemic profile is a continuum in nature, different thresholds of glucose are associated with fetal complications such as stillbirth, spontaneous abortion, congenital anomalies, fetal macrosomia, and metabolic and respiratory complications. For each complication, a different targeted threshold of normality is required. Thus, although it is not always possible to achieve optimal glycemic control in all patients, any improvement will be beneficial because it will reduce the rate of complications for a given glucose threshold.
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Affiliation(s)
- O Langer
- Department of Obstetrics and Gynecology, St. Luke's-Roosevelt Hospital Center, New York, NY 10019, USA.
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20
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Abstract
In spite of the widely accepted knowledge that elevated blood glucose levels in early pregnancy are associated with a significantly increased risk of birth defects in infants of women with established diabetes, the majority of diabetic women do not plan their pregnancies and enter pregnancy with inadequate blood glucose control. This article reviews the current research on circumstances and factors associated with unplanned diabetic pregnancies and offers recommendations to encourage effective pregnancy planning and preconception care among women with diabetes.
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Affiliation(s)
- E V Holing
- Department of Obstetrics and Gynecology, University of Washington, Seattle 98195-6460, USA.
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21
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Abstract
Diabetes mellitus complicates somewhere between 1 and 20% of all pregnancies worldwide. Women with all types of diabetes, including type 1 (insulin-dependent) and type 2 (non-insulin-dependent) diabetes mellitus, and gestational diabetes mellitus, as well as their infants, are at increased risk for a number of different complications. However, achieving and maintaining euglycemia throughout gestation has been demonstrated to reduce the risk of adverse outcome for both the mother and her offspring. Traditional management approaches use a combination of diet, exercise, intensive insulin regimens and multiple self monitored blood glucose determinations. There are a number of newer agents available to treat diabetes mellitus; however, their safety in pregnancy has not been thoroughly tested. Although the oral hypoglycaemic drugs are not customarily used during gestation in most of the US and Europe they have had considerable use in South Africa. Animal and human studies of the teratogenic effects of these drugs have yielded conflicting data and it is difficult to distinguish between the teratogenic effects of poor maternal metabolic control and the agents themselves. This article also addresses the current state of the knowledge regarding the drug safety of a variety of medications for conditions, including hypertension and preterm labour, commonly encountered in the management of the pregnant women with diabetes mellitus.
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Affiliation(s)
- E A Reece
- Temple University, School of Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, Philadelphia, Pennsylvania, USA
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22
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Abstract
The aim of the diabetes specialist is to provide a service to the pregnant diabetic woman so that she will present to her obstetrician with such well-controlled plasma glucose levels that her pregnancy will proceed without any diabetes-related problem, and she will be delivered of a normal baby, of normal size, at the normal full-term gestation, by the normal route. There are some problems in achieving this aim. The exact definition of hyperglycaemia in pregnancy is still a matter of dispute. Screening methods to identify the problem differ widely. Many centres have developed joint diabetes/antenatal clinics, but there are practical problems with such an approach. Pre-pregnancy counselling, and discussion of contraceptive measures is an important task for the diabetologist and requires up-to-date knowledge. Control of plasma glucose requires alteration of insulin doses as pregnancy proceeds. Mothers with retinal, renal or cardiac problems will need special care. The medical problems which develop, and the management of blood glucose during labour and delivery, mean that the diabetes team must be very adjacent to the obstetric service, and a centralised approach offers many advantages. The postpartum state, and the long-term outcome for both mother and baby, remain both an interest and a responsibility for the obstetric physician.
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Affiliation(s)
- D R Hadden
- Royal Victoria Hospital and Royal Maternity Hospital, Belfast, Northern Ireland, UK
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23
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Littley MD. Management of diabetic pregnancy. Postgrad Med J 1994; 70:610-9. [PMID: 7971624 PMCID: PMC2397735 DOI: 10.1136/pgmj.70.827.610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- M D Littley
- Department of Diabetes and Endocrinology, University Hospital of South Manchester, UK
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24
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Cox M, Whittle MJ, Byrne A, Kingdom JC, Ryan G. Prepregnancy counselling: experience from 1,075 cases. BRITISH JOURNAL OF OBSTETRICS AND GYNAECOLOGY 1992; 99:873-6. [PMID: 1450133 DOI: 10.1111/j.1471-0528.1992.tb14432.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To assess the activity of a prepregnancy counselling clinic in terms of investigations, counselling, treatment and subsequent pregnancy outcome. DESIGN Review of 1,075 couples attending over a nine year period. SETTING University Hospital offering a tertiary referral service for fetal medicine. SUBJECTS Couples referred to the clinic from a variety of sources. MAIN OUTCOME MEASURES Categories of referral, value of diagnostic tests, and subsequent pregnancy outcome. RESULTS The main categories of referral were: previous miscarriage (44.4%); previous fetal abnormality (19.6%); chronic maternal disease (22.3%); and others (13.7%). Routine investigations produced a low yield of abnormality (1%), in contrast to investigations selected for specific reasons (12%). Subsequent pregnancy outcome, which was unaltered in either the previous miscarriage or fetal abnormality groups, did improve in the chronic maternal disease group. CONCLUSIONS This study does not prove the value of prepregnancy counselling. However, it does illustrate the importance of making an accurate assessment of previous problems and current health as a means of determining both maternal and fetal risks in a subsequent pregnancy, a process which seems to lead to an improved outcome within selected groups. The importance of continuity of care in all couples, especially when there has been a previous adverse pregnancy outcome is emphasized.
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Affiliation(s)
- M Cox
- University Department of Midwifery, Queen Mother's Hospital, Yorkhill, Glasgow, UK
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25
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Abstract
Between 1 June 1986 and 31 August 1987 all 47 pregnant diabetic Tanzanian women attending Muhimbili Medical Centre, Dar es Salaam were seen and managed by a small team of interested physicians and obstetricians. Of the 50 pregnancies there were 44 (88%) live births, five (10%) perinatal deaths, and one (2%) spontaneous abortion. One child was born with a serious congenital abnormality. All five perinatal deaths were seen in women who presented late in pregnancy (three) or had poor blood glucose control (two). In 10 (36%) of the 28 pregnancies in the 25 patients with insulin-requiring diabetes, insulin requirements decreased greater than 8 U during the course of pregnancy. The present study suggests that with close supervision of the pregnant diabetic patient in Africa perinatal mortality rates approaching those seen in developed countries can be achieved, despite the lack of home blood glucose monitoring. Rates could be further reduced if medical services were more widely available, and if all patients were educated on the importance of early presentation in pregnancy.
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Affiliation(s)
- J K Lutale
- Department of Medicine, Muhimbili Medical Centre, University of Dar es Salaam, Tanzania
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26
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Hadden DR. Medical management of diabetes in pregnancy. BAILLIERE'S CLINICAL OBSTETRICS AND GYNAECOLOGY 1991; 5:369-94. [PMID: 1954719 DOI: 10.1016/s0950-3552(05)80103-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Combs CA, Kitzmiller JL. Spontaneous abortion and congenital malformations in diabetes. BAILLIERE'S CLINICAL OBSTETRICS AND GYNAECOLOGY 1991; 5:315-31. [PMID: 1954716 DOI: 10.1016/s0950-3552(05)80100-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The first few weeks after conception are a critical period for the embryo of a diabetic mother. If the mother is in good glycaemic control during this time, the risk of spontaneous abortion or major congenital malformation is low. Otherwise, the risk increases in proportion to the degree of blood glucose elevation. Glycohaemoglobin determination in the first trimester can be useful in retrospectively evaluating the degree of glycaemic control present around the time of conception and in roughly estimating the risk of spontaneous abortion or major malformation. For women with high risk, early prenatal diagnosis of congenital anomalies is warranted using detailed ultrasound examination, fetal echocardiography and alpha-fetoprotein determinations. Encouraging diabetic women to achieve strict control prior to conception should virtually eliminate the excess risk of spontaneous abortion or major malformation.
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28
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Peck RW, Price DE, Lang GD, MacVicar J, Hearnshaw JR. Birthweight of babies born to mothers with type 1 diabetes: is it related to blood glucose control in the first trimester? Diabet Med 1991; 8:258-62. [PMID: 1828742 DOI: 10.1111/j.1464-5491.1991.tb01582.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
A retrospective study of 133 pregnancies in women with Type 1 diabetes was performed, and the 116 which progressed beyond 28 weeks were further analysed. Despite good maternal blood glucose control (mean (+/- SE) HbA1 levels 8.6 +/- 0.2% at the end of the first trimester; 6.9 +/- 0.2% at delivery; normal range 4.0-8.5%), 38% of babies had birthweights above the 90th centile and operative intervention occurred in 77 deliveries (66%). There was no significant correlation between birthweight and HbA1 level at any stage of pregnancy, but mothers with babies above the 90th centile for weight had a higher HbA1 at the end of the first trimester than mothers with babies below the 90th centile (9.3 +/- 0.5 vs 7.9 +/- 0.2%, p less than 0.05). In contrast there was no difference in the HbA1 levels at delivery (7.0 +/- 0.3 vs 6.8 +/- 0.2%). The perinatal mortality rate was 17.7 per 1000 births. The results confirm that in Type 1 diabetes large babies are common despite good blood glucose control, and suggest that maternal blood glucose control in the first trimester may be an important determinant of birthweight.
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Steel JM, Johnstone FD, Hepburn DA, Smith AF. Can prepregnancy care of diabetic women reduce the risk of abnormal babies? BMJ (CLINICAL RESEARCH ED.) 1990; 301:1070-4. [PMID: 2249069 PMCID: PMC1664221 DOI: 10.1136/bmj.301.6760.1070] [Citation(s) in RCA: 153] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To see whether a prepregnancy clinic for diabetic women can achieve tight glycaemic control in early pregnancy and so reduce the high incidence of major congenital malformation that occurs in the infants of these women. DESIGN An analysis of diabetic control in early pregnancy including a record of severe hypoglycaemic episodes in relation to the occurrence of major congenital malformation among the infants. SETTING A diabetic clinic and a combined diabetic and antenatal clinic of a teaching hospital. PATIENTS 143 Insulin dependent women attending a prepregnancy clinic and 96 insulin dependent women managed over the same period who had not received specific prepregnancy care. MAIN OUTCOME MEASURE The incidence of major congenital malformation. RESULTS Compared with the women who were not given specific prepregnancy care the group who attended the prepregnancy clinic had a lower haemoglobin AI concentration in the first trimester (8.4% v 10.5%), a higher incidence of hypoglycaemia in early pregnancy (38/143 women v 8/96), and fewer infants with congenital abnormalities (2/143 v 10/96; relative risk among women not given specific prepregnancy care 7.4 (95% confidence interval 1.7 to 33.2]. CONCLUSION Tight control of the maternal blood glucose concentration in the early weeks of pregnancy can be achieved by the prepregnancy clinic approach and is associated with a highly significant reduction in the risk of serious congenital abnormalities in the offspring. Hypoglycaemic episodes do not seem to lead to fetal malformation even when they occur during the period of organogenesis.
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Traub AI, Harley JM, Cooper TK, Maguiness S, Hadden DR. Is centralized hospital care necessary for all insulin-dependent pregnant diabetics? BRITISH JOURNAL OF OBSTETRICS AND GYNAECOLOGY 1987; 94:957-62. [PMID: 3689727 DOI: 10.1111/j.1471-0528.1987.tb02269.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
A retrospective population study in Northern Ireland examined the benefits of centralized care in insulin-dependent diabetic pregnancies. In the 5 years 1979-1983, there were 139, 250 deliveries in Northern Ireland and of these 221 pregnancies occurred in 187 insulin-dependent diabetic patients; 100 were managed entirely in peripheral maternity units, 61 were referred from a peripheral unit to the Royal Maternity Hospital, Belfast and 60 were managed entirely in this central referral hospital. The patients referred from the periphery had the worst past obstetric history with a combined perinatal mortality rate of 200 per 1000. During the study period the perinatal mortality rate was 107 for the referred pregnancies, 33 for those managed entirely in the peripheral units and 18 for those managed at the Royal Maternity Hospital. If those pregnancies terminated for fetal abnormality, and deaths beyond the perinatal period are included, the figures for total fetal loss were 15.5%, 5.5% and 7.1% respectively. Overall the major congenital malformation rate was 7.5%, and for the respective groups 6.5%, 3.0% and 13.0%. For the general population during the same period the perinatal mortality rate was 1.4% and the major congenital malformation rate was 2.5%. Thus it is suggested that only peripheral hospitals which can offer combined antenatal/endocrine care and with a neonatal intensive care unit should undertake the management of the pregnant diabetic.
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Affiliation(s)
- A I Traub
- Department of Midwifery and Gynaecology, Queen's University, Belfast
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32
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Abstract
Two hundred and thirty pregnancies were studied in 196 diabetic women. Seven women with babies found to have major malformations had a higher median first trimester haemoglobin A1 (12.9%) than the median HbA1 (10.8%) in those with normal babies (p = 0.06). No relationship was found between the occurrence of minor malformations and first trimester maternal haemoglobin A1. Two of the seven congenital malformations were diagnosed antenatally at a time when therapeutic abortion could be offered. Expert antenatal ultrasound scanning should be offered to all pregnant diabetic women as poor glycaemic control at the time of conception and organogenesis, as evidenced by raised first trimester HbA1, predisposes to congenital malformation.
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Dicker D, Feldberg D, Karp M, Yeshaya A, Samuel N, Goldman JA. Preconceptional diabetes control in insulin-dependent diabetes mellitus patients with continuous subcutaneous insulin infusion therapy. J Perinat Med 1987; 15:161-7. [PMID: 3656048 DOI: 10.1515/jpme.1987.15.2.161] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Preconceptional diabetes management is an important prerequisite for pregnancy planning and its value has been well-documented. Glucose control and the outcome of pregnancy, managed in the preconceptional period, with continuous subcutaneous insulin infusion therapy to those receiving insulin injections are compared. Fifty-two juvenile onset insulin dependent diabetic women contemplating pregnancy were regularly consulted by a diabetology team starting at least two months before conception. Glucose control was achieved by continuous subcutaneous insulin infusion pumps (CSIIP) in 18 patients, and 34 women received intensive insulin therapy (IIT). In both groups, normal glucose levels and normal HbA1 were achieved at conception, maintained during the period of organogenesis and throughout pregnancy. In view of the fact that perinatal results, such as the occurrence of malformations, mean gestational age, mean birth weight and neonatal complications were not significantly different in both groups, we believe that both methods are equally effective. Consequently, the less costly and yet effective IIT may be the method of choice, while the more expensive pump should be used mainly in selected cases.
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Affiliation(s)
- D Dicker
- Department of Obstetrics and Gynecology, Golda Meir Medical Center, Petah-Tikva, Israel
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Abstract
In 1979-80 a national survey of the incidence of congenital malformations in babies born to diabetic mothers in the United Kingdom was carried out by questionnaire. Of the 1034 mothers reported, 773 were known to have diabetes before the index pregnancy. The incidence of congenital malformations ws 7.1% which is significantly higher than the 2.1% in the offspring reported to the Office of Population, Censuses and Surveys (OPCS) for England and Wales in 1979-80. The increase was most pronounced for malformations of the heart, spine, lungs, and brain. In 40% of the diabetic mothers blood glucose was not recorded during the first trimester of pregnancy, and in this group the malformation rate was twice that in babies born of mothers who had had at least one reported blood glucose estimation during this time. We conclude that there is an urgent need to improve health education and supervision before and during pregnancy in all diabetic women if the prevalence of malformations amongst their offspring is to be reduced.
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Goldman JA, Dicker D, Feldberg D, Yeshaya A, Samuel N, Karp M. Pregnancy outcome in patients with insulin-dependent diabetes mellitus with preconceptional diabetic control: a comparative study. Am J Obstet Gynecol 1986; 155:293-7. [PMID: 3740144 DOI: 10.1016/0002-9378(86)90812-4] [Citation(s) in RCA: 117] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Forty-four of 75 pregnant women with juvenile-onset insulin-dependent diabetes, who attended a preconceptional clinic, were seen regularly by a diabetologic team. Glycemic control was obtained by intensified insulin therapy and monitored by blood glucose self-monitoring. When these patients were compared with a group of 31 nonattenders of the preconceptional clinic, in the former normoglycemia and normal hemoglobin A1 values were achieved before conception, whereas in the latter good control was reached by the second trimester. This group had also more maternal complications, such as preeclampsia, and higher cesarean section rates. Congenital anomalies were 9.6% among offspring of nonattenders, while none occurred in those with preconceptional counseling. We confirm the evidence accumulated in the recent literature that congenital malformations in pregnancy complicated by diabetes may be linked to disturbances in maternal metabolism during the period of embryogenesis. Consequently we concur with the recommendation that tight diabetic control is required before the patient attempts to conceive.
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Abstract
During the past decade, our major objective in the management of pregnancies complicated by diabetes mellitus has become normalization of maternal and, therefore, fetal glucose levels. For most women with insulin-dependent diabetes, this goal may be achieved through the use of multiple insulin injections combined with an appropriate dietary intake. The results of such therapy can now be accurately assessed by means of home glucose monitoring. Patients with gestational diabetes can be properly treated only if they are first identified. Therefore, all pregnant women should be tested for this disorder because screening based on past obstetric history or clinical criteria alone may miss up to 50% of patients with gestational diabetes. Between 1980 and 1984, the perinatal mortality rate reported in the American literature for more than 800 insulin-dependent patients was 21 per 1000, with more than 50% of these deaths resulting from major malformations. Such data emphasize the need to achieve maternal euglycemia before conception, as poor maternal control has been associated with teratogenesis. Prepregnancy assessment should also include a thorough evaluation of maternal vasculopathy.
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Crichton MA, Silverton LI. The sweeter side of life: A review of diabetes and its effects on pregnancy. Midwifery 1985. [DOI: 10.1016/s0266-6138(85)80017-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Mølsted-Pedersen L, Pedersen JF. Congenital malformations in diabetic pregnancies. Clinical viewpoints. ACTA PAEDIATRICA SCANDINAVICA. SUPPLEMENT 1985; 320:79-84. [PMID: 3869430 DOI: 10.1111/j.1651-2227.1985.tb10143.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
A consecutive series of 2,587 newborn infants of diabetic mothers treated during pregnancy and delivery in the period 1926 to 1983 has been analysed. The malformation rate was 6.6%. The series has been divided into five consecutive periods each comprising around 500 infants. During the first four periods the frequency of congenital malformations (CM) was remarkably constant also when related to the severity of the maternal diabetes. During the latest period from 1979 to 1983 a significant decrease in the frequency and severity of CM in infants of diabetic mothers was seen, most marked in the group with more severe maternal diabetes (White's classes D + F). One hundred and thirty-five insulin-dependent diabetic women with regular menstrual histories were examined by ultrasonic scanning in the 7th to 14th week of pregnancy. As judged by the crown-rump length 53 fetuses were smaller than normal. The term early growth delay is used for this phenomenon. Nine of the 135 fetuses had major CM and seven of them were smaller than normal in early pregnancy. These observations show that fetuses that are significantly smaller than normal in early pregnancy carry a higher risk of being malformed and suggest a common mechanism behind early growth delay and induction of abnormal embryogenesis.
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Thornton JR, Emmett PM, Heaton KW. Smoking, sugar, and inflammatory bowel disease. BMJ : BRITISH MEDICAL JOURNAL 1985; 290:1786-7. [PMID: 3924257 PMCID: PMC1415981 DOI: 10.1136/bmj.290.6484.1786-a] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Roundhill A, Jones DB. Obstetrical consultations in a community hospital. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 1984; 30:2103-2105. [PMID: 21279124 PMCID: PMC2154322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
This paper describes the pattern of obstetrical consultations in a family practice oriented obstetric service to a mixed urban/farming community of 60,000 living within a 60 km radius of a well-equipped community hospital. Over the past few years the annual number of deliveries has been 700-750. Referral patterns are affected by changing patterns of practice, availability of diagnostic techniques, and consumer expectations. Early risk assessment by the family physician is the key to improved prenatal care. More than 60% of obstetrical patients in this community are totally managed by family physicians; the remainder involve collaboration with a consultant at some stage. Indications for referral occur throughout the phases of pregnancy. The success of this family physician service is the result of good family physician/consultant relationships in the small community hospital.
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Heller SR, Lowe JM, Johnson IR, O'Brien PM, Clarke P, Symonds EM, Tattersall RB. Seven years experience of home management in pregnancy in women with insulin-dependent diabetes. Diabet Med 1984; 1:199-204. [PMID: 6242798 DOI: 10.1111/j.1464-5491.1984.tb01953.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Fifty-eight of a consecutive series of 75 pregnancies in women with insulin-dependent diabetes went into the third trimester. Diabetes was managed by home blood glucose monitoring and women were not routinely admitted at any stage before delivery. The mean number of in-patient days before delivery was 15 for the whole series but has been reduced to 9 during the past four years. Each woman performed an average of 171 blood glucose measurements during her pregnancy. Mean blood glucose (including post-prandial levels) fell significantly from 7.9 mmol/l in the first trimester to 7.3 in the second and 6.4 in the third. Mean percentage of haemoglobin A1 was within the normal range in the second and third trimesters. The cesarean section rate was high at 66% but there were no perinatal deaths. Three infants had congenital abnormalities. We conclude that home blood glucose monitoring is a safe and effective way of managing pregnant diabetic women as out-patients. The cost of meters and sticks is repaid many times over in the saving of hospital costs. In addition, home blood glucose monitoring is popular with the patients and many choose to continue it after delivery.
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Hollingsworth DR, Jones OW, Resnik R. Expanded care in obstetrics for the 1980s: preconception and early postconception counseling. Am J Obstet Gynecol 1984; 149:811-4. [PMID: 6465245 DOI: 10.1016/0002-9378(84)90596-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
This paper is an essay in which the suggestion is made to expand obstetric care during this decade to include preconception as well as early postconception counseling. The development of perinatal and neonatal medicine is traced and medical problems that might be improved by medical counseling before pregnancy occurs are tabulated. Diabetes is suggested as a prototype of a medical disorder for which preconception counseling would be helpful. The expansion of obstetric services into an area of preventive medicine might well begin in already established regional medical centers but should quickly expand to the offices of private obstetricians. In this broader interpretation of obstetric care, prevention of maternal and fetal or neonatal problems could decrease the cost of high-risk medical care.
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Hodges LC, Turner D. Preventing congenital tragedy: an opportunity for nursing. Health Care Women Int 1984; 5:211-22. [PMID: 6569865 DOI: 10.1080/07399338409515651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Kalter H, Warkany J. Medical progress. Congenital malformations: etiologic factors and their role in prevention (first of two parts). N Engl J Med 1983; 308:424-31. [PMID: 6337330 DOI: 10.1056/nejm198302243080804] [Citation(s) in RCA: 262] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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