Quantitative assessment of the effect of pre-gestational diabetes and risk of adverse maternal, perinatal and neonatal outcomes

Impact of continuous glucose monitoring on pregnancy outcomes in women with pregestational diabetes

AIMS

This study aims to evaluate the impact of continuous glucose monitoring (CGM) on pregnancy outcomes in women with pregestational diabetes mellitus (PGDM).

METHODS

A retrospective cohort study was conducted on 387 pregnant women with PGDM at Virgen del Rocío University Hospital in Seville, spanning from 2016 to 2022. The patients were categorized into two groups: 212 women who used continuous glucose monitoring (CGM) and 175 women who self-monitoring of blood glucose (SMBG). The study evaluated maternal characteristics, pregnancy complications, delivery methods, neonatal outcomes, and congenital anomalies.

RESULTS

The CGM group exhibited lower weight gain during pregnancy (9.6 kg vs. 10.0 kg, p = 0.02) and required fewer prenatal visits (7 vs. 8, p = 0.01). The rate of cesarean sections was significantly lower in the CGM group (53.1% vs. 58.2%, p = 0.03), and the incidence of macrosomia was reduced (12.9% vs. 22.2%, p = 0.04). There were no significant differences in congenital anomalies, intrauterine fetal deaths, or neonatal deaths between the groups.

CONCLUSIONS

CGM in pregnant women with PGDM is associated with better pregnancy outcomes, including reduced cesarean section rates and lower incidence of macrosomia. These findings support the wider implementation of CGM for improved maternal and fetal health in PGDM pregnancies.

Perinatal and neonatal outcomes of high-risk asymptomatic women from a specialist preterm birth surveillance clinic

OBJECTIVES

To report the perinatal outcomes of high-risk asymptomatic women who attended a specialist preterm surveillance clinic (PSC) to undergo screening for spontaneous preterm birth (PTB) in Ireland.

METHODS

Single center, retrospective cohort study of asymptomatic high risk women who attended the PSC between January 2019 and December 2022. A comprehensive database of all patients who attended the clinic during the study period was constructed and analyzed. Overall outcomes were reported, and stratified per the occurrence of preterm or term birth. Iatrogenic PTBs were included in the outcome data.

RESULTS

Following exclusions for loss-to-follow-up, 762 cases were analyzed, constituting 2262 PSC visits. Of those, 183 women were prescribed progesterone (24.0 %), and 100 women underwent cervical cerclage (13.1 %) to prevent spontaneous PTB. Overall, 2.4 %, 6.2 % and 18.6 % of participants gave birth prior to 30 weeks, 34 weeks, and 37 weeks, respectively. The median gestational age at birth for the entire cohort was 38.6 weeks (inter-quartile range (IQR) 37.2-39.6 weeks). Women who delivered < 37 weeks were significantly more likely to be smokers (p = 0.030), have a previous spontaneous PTB (p = 0.016), have multiple pregnancies (p < 0.001), type 1 or 2 diabetes (p = 0.044), or have a previous full dilatation caesarean section birth (p = 0.024). Infants born prior to 37 weeks were more likely to have a lower median birthweight (2270 vs 3300 g, p < 0.001), be admitted to a neonatal intensive care unit (53.8 % vs 2.3 %, p < 0.001) or experience short-term morbidity, including respiratory support (38.0 % vs 1.6 %, p < 0.001).

CONCLUSIONS

Over 80% of women deemed to be at high risk of PTB gave birth at term gestations following attendance at a PSC during pregnancy. Most women can be successfully managed without interventions, instead employing a policy of serial cervical surveillance, to identify those at greatest risk of PTB.

Autoimmune diseases and adverse pregnancy outcomes: an umbrella review

BACKGROUND

There is a high prevalence of autoimmune conditions in women specially in the reproductive years; thus, the association with adverse pregnancy outcomes has been widely studied. However, few autoimmune conditions/adverse outcomes have been studied more than others, and this umbrella review aims to consolidate existing knowledge in this area with the aim to provide new knowledge and also identify gaps in this research area.

METHODS

Medline, Embase, and Cochrane databases were searched from inception to December 2023. Screening, data extraction, and quality appraisal (AMSTAR 2) were done by two independent reviewers. Data were synthesised narratively and quantitatively. Relative risks (RR)/odds ratio (OR) with 95% confidence intervals were reported.

RESULTS

Thirty-two reviews were included consisting of 709 primary studies. The review reported the association between 12 autoimmune conditions and 16 adverse pregnancy outcomes. Higher risk of miscarriage is reported in women with Sjögren's syndrome RR 8.85 (95% CI 3.10-25.26) and systemic lupus erythematosus (SLE) OR 4.90 (3.10-7.69). Pre-eclampsia was reported higher in women with type 1 diabetes mellitus (T1DM) OR 4.19 (3.08-5.71) and SLE OR 3.20 (2.54-4.20). Women reported higher risk of diabetes during pregnancy with inflammatory bowel disease (IBD) OR 2.96 (1.47-5.98). There was an increased risk of intrauterine growth restriction in women with systemic sclerosis OR 3.20 (2.21-4.53) and coeliac disease OR 1.71 (1.36-2.14). Preterm birth was associated with T1DM OR 4.36 (3.72-5.12) and SLE OR 2.79 (2.07-3.77). Low birth weight babies were reported in women with women with SLE or systemic sclerosis OR 5.95 (4.54-7.80) and OR 3.80 (2.16-6.56), respectively. There was a higher risk of stillbirth in women with T1DM OR 3.97 (3.44-4.58), IBD OR 1.57 (1.03-2.38), and coeliac disease OR 1.57 (1.17-2.10). T1DM in women was associated with 32% lower odds of small for gestational age baby OR 0.68 (0.56-0.83).

CONCLUSIONS

Pregnant women with autoimmune conditions are at a greater risk of developing adverse pregnancy outcomes. Further research is required to develop better preconception to postnatal care for women with autoimmune conditions.

The association between bacteriuria and adverse pregnancy outcomes: a systematic review and meta-analysis of observational studies

BACKGROUND

Antibiotics for bacteriuria and urinary tract infection are commonly prescribed during pregnancy to avoid adverse pregnancy outcomes. The aim of this study was to evaluate the association between significant bacteriuria in pregnancy and any of the four pregnancy outcomes: preterm delivery; low birth weight; small for gestational age; and preterm labour.

METHODS

Systematic review with meta-analysis of observational studies. We searched PubMed, EMBASE, the Cochrane CENTRAL library, and Web of Science for observational studies published before 1 March 2022. The risk of bias was assessed using the Newcastle-Ottawa scale. Study identification, data extraction and risk-of-bias assessment was performed by two independent authors. We combined the included studies in meta-analyses and expressed results as ORs with 95% CIs (Prospero CRD42016053485).

RESULTS

We identified 58 studies involving 421 657 women. The quality of the studies was mainly poor or fair. The pooled, unadjusted OR for the association between any significant bacteriuria and: (i) preterm delivery was 1.62 (95% CI: 1.30-2.01; 27 studies; I2 = 61%); (ii) low birth weight was 1.50 (95% CI: 1.30-1.72; 47 studies; I2 = 74%); (iii) preterm labour was 2.29 (95% CI: 1.53-3.43; 3 studies; I2 = 0%); and (iv) small for gestational age was 1.33 (95% CI: 0.88-2.02; 7 studies; I2 = 54%). Four studies provided an adjusted OR, but were too diverse to combine in meta-analysis.

CONCLUSIONS

This systematic review identified an association between significant bacteriuria in pregnancy and the three complications: preterm delivery; low birth weight; and preterm labour. However, the quality of the available evidence is insufficient to conclude whether this association is merely due to confounding factors. There is a lack of high-quality evidence to support active identification and treatment of bacteriuria in pregnancy.

Optimizing preconception care and interventions for improved population health

There is growing literature indicating that optimal preconception health is associated with improved reproductive, perinatal, and pediatric outcomes. Given that preconception care is recommended for all individuals planning a pregnancy, medical providers and public health practitioners have a unique opportunity to optimize care and improve health outcomes for reproductive-aged individuals. Knowledge of the determinants of preconception health is important for all types of health professionals, including policy makers. Although some evidence-based recommendations have already been implemented, additional research is needed to identify factors associated with favorable health outcomes and to ensure that effective interventions are made in a timely fashion. Given the largely clinical readership of this journal, this piece is primarily focused on clinical care. However, we acknowledge that optimizing preconception health for the entire population at risk of pregnancy requires broadening our strategies to include population-health interventions that consider the larger social systems, structures, and policies that shape individual health outcomes.

Maternal-fetal outcomes of pregnant women with type 1 diabetes treated with continuous subcutaneous insulin infusion or multiple daily injections during pregnancy - A Brazilian health care referral center cohort study

Objective

Pregnant women with type 1 diabetes (T1D) have an increased risk of maternal-fetal complications. Regarding treatment, continuous subcutaneous insulin infusion (CSII) has advantages compared to multiple daily injections (MDI), but data about the best option during pregnancy are limited. This study's aim was to compare maternal-fetal outcomes among T1D patients treated with CSII or MDI during pregnancy.

Subjects and methods

This study evaluated 174 pregnancies of T1D patients. Variables of interest were compared between the groups (CSII versus MDI), and logistic regression analysis was performed (p < 0.05).

Results

Of the 174 included pregnancies, CSII was used in 21.3% (37) and MDI were used in 78.7% (137). HbA1c values improved throughout gestation in both groups, with no difference in the first and third trimesters. The frequency of cesarean section was significantly higher in the CSII group [94.1 vs. 75.4%, p = 0.017], but there was no significant difference in the frequency of other complications, such as miscarriage, premature delivery and preeclampsia. The mean birth weight and occurrence of neonatal complications were also similar, except for the proportion of congenital malformations, which was significantly lower in the CSII group [2.9 vs. 15.6%, p = 0.048]. In regression analysis, the association of CSII with cesarean section and malformations lost significance after adjusting for HbA1c and other covariates of interest.

Conclusion

In this study, we observed a higher frequency of cesarean section and a lower occurrence of congenital malformations in the CSII group, but the adjusted results might indicate that these associations are influenced by glycemic control.

Maternal residential area effects on preterm birth, low birth weight and caesarean section in Australia: A systematic review

INTRODUCTION

In Australia, area of residence is an important health policy focus and has been suggested as a key risk factor for preterm birth (PTB), low birth weight (LBW) and cesarian section (CS) due to its influence on socioeconomic status, access to health services, and its relationship with medical conditions. However, there is inconsistent evidence about the relationship of maternal residential areas (rural and urban areas) with PTB, LBW, and CS. Synthesising the evidence on the issue will help to identify the relationships and mechanisms for underlying inequality and potential interventions to reduce such inequalities in pregnancy outcomes (PTB, LBW and CS) in rural and remote areas.

METHODS

Electronic databases, including MEDLINE, Embase, CINAHL, and Maternity & Infant Care, were systematically searched for peer-reviewed studies which were conducted in Australia and compared PTB, LBW or CS by maternal area of residence. Articles were appraised for quality using JBI critical appraisal tools.

RESULTS

Ten articles met the eligibility criteria. Women who lived in rural and remote areas had higher rates of PTB and LBW and lower rate of CS compared to their urban and city counterparts. Two articles fulfilled JBI's critical appraisal checklist for observational studies. Compared to women living in urban and city areas, women living in rural and remote areas were also more likely to give birth at a younger age (<20 years) and have chronic diseases such as hypertension and diabetes. They were also less likely to have higher levels of completing university degree education, private health insurance and births in private hospitals.

CONCLUSIONS

Addressing the high rate of pre-existing and/or gestational hypertension and diabetes, limited access of health services and a shortage of experienced health staff in remote and rural areas are keys to early identification and intervention of risk factors of PTB, LBW, and CS.

Diabetes and anti-diabetic interventions and the risk of gynaecological and obstetric morbidity: an umbrella review of the literature

BACKGROUND

Diabetes has reached epidemic proportions in recent years with serious health ramifications. The aim of this study was to evaluate the strength and validity of associations between diabetes and anti-diabetic interventions and the risk of any type of gynaecological or obstetric conditions.

METHODS

Design: Umbrella review of systematic reviews and meta-analyses.

DATA SOURCES

PubMed, Medline, Embase, Cochrane Database of Systematic Reviews, manual screening of references.

ELIGIBILITY CRITERIA

Systematic reviews and meta-analyses of observational and interventional studies investigating the relationship between diabetes and anti-diabetic interventions with gynaecological or obstetric outcomes. Meta-analyses that did not include complete data from individual studies, such as relative risk, 95% confidence intervals, number of cases/controls, or total population were excluded.

DATA ANALYSIS

The evidence from meta-analyses of observational studies was graded as strong, highly suggestive, suggestive or weak according to criteria comprising the random effects estimate of meta-analyses and their largest study, the number of cases, 95% prediction intervals, I2 heterogeneity index between studies, excess significance bias, small study effect and sensitivity analysis using credibility ceilings. Interventional meta-analyses of randomised controlled trials were assessed separately based on the statistical significance of reported associations, the risk of bias and quality of evidence (GRADE) of included meta-analyses.

RESULTS

A total of 117 meta-analyses of observational cohort studies and 200 meta-analyses of randomised clinical trials that evaluated 317 outcomes were included. Strong or highly suggestive evidence only supported a positive association between gestational diabetes and caesarean section, large for gestational age babies, major congenital malformations and heart defects and an inverse relationship between metformin use and ovarian cancer incidence. Only a fifth of the randomised controlled trials investigating the effect of anti-diabetic interventions on women's health reached statistical significance and highlighted metformin as a more effective agent than insulin on risk reduction of adverse obstetric outcomes in both gestational and pre-gestational diabetes.

CONCLUSIONS

Gestational diabetes appears to be strongly associated with a high risk of caesarean section and large for gestational age babies. Weaker associations were demonstrated between diabetes and anti-diabetic interventions with other obstetric and gynaecological outcomes.

TRIAL REGISTRATION

Open Science Framework (OSF) (Registration https://doi.org/10.17605/OSF.IO/9G6AB ).

Associations Between Preconception Glycemia and Preterm Birth: The Potential Role of Health Care Access and Utilization

Background: Preconception diabetes is strongly associated with adverse birth outcomes. Less is known about the effects of elevated glycemia at levels below clinical cutoffs for diabetes. In this study, we estimated associations between preconception diabetes, prediabetes, and hemoglobin A1c (HbA1c) on the risk of preterm birth, and evaluated whether associations were modified by access to or utilization of health care services. Materials and Methods: We used data from Add Health, a US prospective cohort study with five study waves to date. At Wave IV (ages 24-32), glucose and HbA1c were measured. At Wave V (ages 32-42), women with a live birth reported whether the baby was born preterm. The analytic sample size was 1989. Results: The prevalence of preterm birth was 13%. Before pregnancy, 6.9% of women had diabetes, 23.7% had prediabetes, and 69.4% were normoglycemic. Compared to the normoglycemic group, women with diabetes had 2.1 (confidence interval [95% CI]: 1.5-2.9) times the risk of preterm birth, while women with prediabetes had 1.3 (95% CI: 1.0, 1.7) times the risk of preterm birth. There was a nonlinear relationship between HbA1c and preterm birth such that risk of preterm birth emerged after HbA1c = 5.7%, a standard cutoff for prediabetes. The excess risks of preterm birth associated with elevated HbA1c were four to five times larger among women who reported unstable health care coverage and among women who used the emergency room as usual source of care. Conclusion: Our findings replicate prior research showing strong associations between preconception diabetes and preterm birth, adding that prediabetes is also associated with higher risk. Policies and interventions to enhance access and utilization of health care among women before pregnancy should be examined.

Glycaemic control and novel technology management strategies in pregestational diabetes mellitus

Introduction

Pregestational diabetes (PGDM) is an increasingly common and complex condition that infers risk to both mother and infant. To prevent serious morbidity, strict glycaemic control is essential. The aim of this review is to review the glucose sensing and insulin delivering technologies currently available for women with PGDM.

Methods

We reviewed online databases for articles relating to technology use in pregnancy using a combination of keywords and MeSH headings. Relevant articles are included below.

Results

A number of technological advancements have improved care and outcomes for women with PGDM. Real time continuous glucose monitoring (rtCGM) offers clear advantages in terms of infants size and neonatal intensive care unit admissions; and further benefits are seen when combined with continuous subcutaneous insulin delivery (insulin pump) and algorithms which continuously adjust insulin levels to glucose targets (hybrid closed loop). Other advancements including flash or intermittent scanning CGM (isCGM) and stand-alone insulin pumps do not confer as many advantages for women and their infants, however they are increasingly used outside of pregnancy and many women enter pregnancy already using these devices.

Discussion

This article offers a discussion of the most commonly used technologies in pregnancy and evaluates their current and future roles.

Overt diabetes imposes a comparable burden on outcomes as pregestational diabetes: a cohort study

BACKGROUND

Women with diabetes first diagnosed during pregnancy (overt diabetes) may be at the same risk level of adverse outcomes as those with known pregestational diabetes. We compared pregnancy outcomes between these groups.

METHODS

We evaluated pregnant women with type 2 diabetes, pregestational or overt diabetes, attending high risk antenatal care in two public hospitals in Southern Brazil, from May 20, 2005 to June 30, 2021. Outcomes were retrieved from electronic medical records. Risk of adverse outcomes, expressed as relative risk (RR) and 95% confidence interval (CI), were calculated using Poisson regression with robust estimates.

RESULTS

Of 618 women, 33% were labelled as having overt diabetes and 67%, pregestational diabetes. Baseline maternal characteristics were similar: there was a slight, non-clinically relevant, difference in maternal age (33 ± 5.7 years in women with pregestational diabetes vs. 32 ± 6.0 years in women with overt diabetes, p = 0.004); and women with overt diabetes reported smoking almost twice compared to those with pregestational diabetes (12.3% vs. 6.5%, p = 0.024). There were no relevant differences between the groups regarding pregnancy outcomes, although there was a trend of higher neonatal intensive care admission in the group of women with pregestational diabetes (45.2% vs. 36.1%, p = 0.051).

CONCLUSIONS

Overt diabetes was diagnosed in one third of this cohort of pregnant women with hyperglycemia. Their pregnancy outcomes were similar to those of women with pregestational diabetes and were mostly related to maternal demographic characteristics and metabolic control. A call to action should be made to identify women of childbearing age at risk for pre-pregnancy diabetes; to detect hyperglycemia before conception; and to implement timely preconception care to all women with diabetes.

Mild periconceptional hyperglycemia: predictor of adverse fetomaternal outcomes in gestational diabetes?

AIM

To clarify whether mild first trimester hyperglycaemia (characteristic of early-onset GDM) is associated with higher incidence of congenital malformations and other adverse fetomaternal outcomes compared to women with second trimester hyperglycaemia (later-onset GDM).

DESIGN AND METHODS

We analyzed the Portuguese National GDM database, containing data collected between 2011 and 2017. Two study groups were defined: Group 1-Women with GDM diagnosed during the first trimester (with fasting glycemia ≥ 92 and < 126 mg/dL); Group 2-Women with GDM diagnosed after the first 12 weeks of gestation, with either fasting glycemia or oral glucose tolerance test, according to the International Association of Pregnancy and Diabetes Study Group criteria. The fetomaternal characteristics of each group were compared.

RESULTS

A total of 18.518 pregnant women diagnosed with GDM were included which 34.4% of them belonged to Group 1. Pregnant women from this group were significantly younger and had a higher median BMI than the women from the other group. Overall, there was no significant differences in maternal morbidity parameters between groups. Non-evolutive pregnancies were significantly more frequent along the present gestation in the group 1 (1.1% vs. 0.1%, p < 0.001), as was fetal death (0.6% vs. 0.2%, p < 0.001). Congenital malformations did not differ significantly between groups (3.2% vs. 2.8%, p = 0.155).

CONCLUSIONS

The mild near conceptional hyperglycaemic state characteristic of an early-onset GDM seems to be associated with an increased prevalence of non-evolutive pregnancies and foetal deaths when compared to later-onset GDM.

Diabetes during Pregnancy: A Maternal Disease Complicating the Course of Pregnancy with Long-Term Deleterious Effects on the Offspring. A Clinical Review

In spite of the huge progress in the treatment of diabetes mellitus, we are still in the situation that both pregestational (PGDM) and gestational diabetes (GDM) impose an additional risk to the embryo, fetus, and course of pregnancy. PGDM may increase the rate of congenital malformations, especially cardiac, nervous system, musculoskeletal system, and limbs. PGDM may interfere with fetal growth, often causing macrosomia, but in the presence of severe maternal complications, especially nephropathy, it may inhibit fetal growth. PGDM may also induce a variety of perinatal complications such as stillbirth and perinatal death, cardiomyopathy, respiratory morbidity, and perinatal asphyxia. GDM that generally develops in the second half of pregnancy induces similar but generally less severe complications. Their severity is higher with earlier onset of GDM and inversely correlated with the degree of glycemic control. Early initiation of GDM might even cause some increase in the rate of congenital malformations. Both PGDM and GDM may cause various motor and behavioral neurodevelopmental problems, including an increased incidence of attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD). Most complications are reduced in incidence and severity with the improvement in diabetic control. Mechanisms of diabetic-induced damage in pregnancy are related to maternal and fetal hyperglycemia, enhanced oxidative stress, epigenetic changes, and other, less defined, pathogenic mechanisms.

Assessment of the effect of pregnancy planning in women with type 1 diabetes treated by insulin pump

BACKGROUND

Pregnant women with type 1 diabetes (T1D) have high risk of complications despite improved care based on technology advancements.

OBJECTIVE

To assess the effects of pregnancy planning on fetal and maternal outcomes in T1D women treated with continuous subcutaneous insulin infusion (CSII).

STUDY DESIGN

We retrospectively assessed maternal and neonatal outcomes in T1D women using CSII who had planned or unplanned pregnancies between 2002 and 2018. The study was done in two European countries with similar sustained programs for pregnancy planning over the study period.

RESULTS

Data from 107 pregnancies and newborn babies were collected. Seventy-nine pregnancies (73.8%) had been planned. HbA1c was lower in planned versus unplanned pregnancy before and during all three trimesters of pregnancy (p < 0.0001). Pregnancy planning was associated with a reduction in the occurrence of iatrogenic preterm delivery (RR 0.44, 95% CI 0.23-0.95; p = 0.01). Risk reduction persisted after adjustments for mother's age above 40 years and preeclampsia. High HbA1c before or during pregnancy was associated with an increased risk of iatrogenic preterm delivery (RR 3.05, 95% CI 1.78-5.22, p < 0.0001). Premature newborns needed intensive care more often than those at term (RR 3.10, 95% CI 1.53-4.31; p = 0.002).

CONCLUSIONS

Pregnancy planning in T1D women using CSII was associated with better glucose control and decreased risk of iatrogenic preterm delivery. Hence preconception care also improves pregnancy outcome in patients using an advanced mode of insulin delivery. Planned pregnancies could further benefit from the use of new metrics of glucose control.

Agreement Analysis between Sonographic Estimates and Birth Weight, by the WHO and Intergrowth-21st Tables, in Newborns of Diabetic Mothers

OBJECTIVE

 To analyze the agreement, in relation to the 90th percentile, of ultrasound measurements of abdominal circumference (AC) and estimated fetal weight (EFW), between the World Health Organization (WHO) and the International Fetal and Newborn Growth Consortium for the 21st Century (intergrowth-21st) tables, as well as regarding birth weight in fetuses/newborns of diabetic mothers.

METHODS

 Retrospective study with data from medical records of 171 diabetic pregnant women, single pregnancies, followed between January 2017 and June 2018. Abdominal circumference and EFW data at admission (from 22 weeks) and predelivery (up to 3 weeks) were analyzed. These measures were classified in relation to the 90th percentile. The Kappa coefficient was used to analyze the agreement of these ultrasound variables between the WHO and intergrowth-21st tables, as well as, by reference table, these measurements and birth weight.

RESULTS

 The WHO study reported 21.6% large-for-gestational-age (LGA) newborns while the intergrowth-21st reported 32.2%. Both tables had strong concordances in the assessment of initial AC, final AC, and initial EFW (Kappa = 0.66, 0.72 and 0.63, respectively) and almost perfect concordance in relation to final EFW (Kappa = 0.91). Regarding birth weight, the best concordances were found for initial AC (WHO: Kappa = 0.35; intergrowth-21st: Kappa = 0.42) and with the final EFW (WHO: Kappa = 0.33; intergrowth- 21st: Kappa = 0.35).

CONCLUSION

 The initial AC and final EFW were the parameters of best agreement regarding birth weight classification. The WHO and intergrowth-21st tables showed high agreement in the classification of ultrasound measurements in relation to the 90th percentile. Studies are needed to confirm whether any of these tables are superior in predicting short- and long-term negative outcomes in the LGA group.

Prediction of stillbirth: an umbrella review of evaluation of prognostic variables

BACKGROUND

Stillbirth accounts for over 2 million deaths a year worldwide and rates remains stubbornly high. Multivariable prediction models may be key to individualised monitoring, intervention or early birth in pregnancy to prevent stillbirth.

OBJECTIVES

To collate and evaluate systematic reviews of factors associated with stillbirth in order to identify variables relevant to prediction model development.

SEARCH STRATEGY

MEDLINE, Embase, DARE and Cochrane Library databases and reference lists were searched up to November 2019.

SELECTION CRITERIA

We included systematic reviews of association of individual variables with stillbirth without language restriction.

DATA COLLECTION AND ANALYSIS

Abstract screening and data extraction were conducted in duplicate. Methodological quality was assessed using AMSTAR and QUIPS criteria. The evidence supporting association with each variable was graded.

RESULTS

The search identified 1198 citations. Sixty-nine systematic reviews reporting 64 variables were included. The most frequently reported were maternal age (n = 5), body mass index (n = 6) and maternal diabetes (n = 5). Uterine artery Doppler appeared to have the best performance of any single test for stillbirth. The strongest evidence of association was for nulliparity and pre-existing hypertension.

CONCLUSION

We have identified variables relevant to the development of prediction models for stillbirth. Age, parity and prior adverse pregnancy outcomes had a more convincing association than the best performing tests, which were PAPP-A, PlGF and UtAD. The evidence was limited by high heterogeneity and lack of data on intervention bias.

TWEETABLE ABSTRACT

Review shows key predictors for use in developing models predicting stillbirth include age, prior pregnancy outcome and PAPP-A, PLGF and Uterine artery Doppler.

Expression of ADP and TNF-α in patients with gestational diabetes mellitus and its relationship with pregnancy outcomes

Expression of adiponectin (ADP) and tumor necrosis factor-α (TNF-α) in patients with gestational diabetes mellitus and its relationship with pregnancy outcomes was explored. A total of 78 patients with gestational diabetes mellitus admitted to Qingpu Branch of Zhongshan Hospital Affiliated to Fudan University from June 2017 to December 2018 were enrolled as an experimental group, and further 70 healthy pregnant women in physical examination during the same period were enrolled as a control group. Concentrations of ADP and TNF-α were determined and compared between the two groups. The patients were divided into high ADP expression group (≥6.84), low ADP expression group (<6.84), high TNF-α expression group (≥6.17) and low TNF-α expression group (<6.17). Corresponding two groups were compared in terms of adverse pregnancy outcomes, respectively, and they were also compared with the control group. The clinical association between ADP and TNF-α was analyzed. TNF-α was highly expressed in the blood of patients with gestational diabetes mellitus, while ADP expression was low in the blood. The low expression of ADP was related to age, pregestational body mass index (BMI), gestational week, medical history and family history of diabetes mellitus (all P<0.05), and the high expression of TNF-α was related to age, pregestational BMI, gestational week, medical history, amniotic fluid volume, abortion history, and family history of diabetes mellitus (all P<0.05). The experimental group faced a higher risk of adverse pregnancy outcomes than the control group. Both ADP and TNF-α are abnormally expressed in the patients with gestational diabetes mellitus, and TNF-α is affected by more of the factors. The concentrations of ADP and TNF-α affect the pregnancy outcomes. It suggests that ADP and TNF-α can be used as indexes for predicating pregnancy outcomes, and for judging the disease conditions and treatment of patients.

Preeclampsia in women with pregestational diabetes - a cohort study

Aims: To evaluate risk factors for preeclampsia (PE) in women with pregestational diabetes.Methods: Retrospective cohort study of women with pregestational diabetes cared for at a specialized prenatal care facility. Maternal characteristics at booking and during pregnancy were studied for their association with preeclampsia. Multivariable models were tested using Poisson regression with robust estimates; results were expressed as relative risk (RR) and 95% confidence interval (CI).Results: Preeclampsia was diagnosed in 62 of 206 women (30%, 95% CI 24-37%). Previous chronic hypertension was found in 53 subjects (26%; 95% CI 20-32%), of whom 41 (77%, 95% CI 64-88) were type 2 women. Type 1 diabetes, chronic hypertension, systolic blood pressure >124 mmHg at booking and gestational weight gain, either total or excessive for body mass index category, behaved as independent risk factors.Conclusions: In women with pregestational diabetes, some risk factors may predict PE, similar to those found in non-diabetic pregnant women. Two non-modifiable factors (type of diabetes and chronic hypertension) and two modifiable ones (systolic blood pressure levels and gestational weight gain) were found relevant in this cohort. A policy of close monitoring of blood pressure and weight gain, aiming adequate weight gain, may be added to current recommended measures. The high prevalence of PE in women with prepregnancy diabetes, especially those with initial pregnancy systolic blood pressure >124 mmHg, supports a policy of early institution of low dose aspirin. Further multicentric studies will help define the role of these risk factors as contributors to PE in pregestational diabetes.

Correlation between serum transforming growth factor β1, interleukin-6 and neonatal respiratory distress syndrome

Trend and correlation of transforming growth factor β1 (TGF-β1) and interleukin-6 (IL-6) in serum of children with neonatal respiratory distress syndrome (NRDS) were investigated. A total of 75 NRDS children born in the Xiangyang Central Hospital from July 2015 to August 2017 were analyzed retrospectively. A total of 45 NRDS premature infants who received pulmonary surfactant (PS) within 12 h after birth were treated as PS group, 30 who did not receive PS treatment as non-PS group, and 32 premature infants without NRDS in the same period were selected as control group. Serum levels of TGF-β1 and IL-6 were detected by enzyme linked immunosorbent assay (ELISA) at various time points after birth and their correlation was analyzed. The expression level of TGF-β1 in serum of children in PS group was significantly higher than that in control group on days 1 and 3 after birth (P<0.05). The expression level of TGF-β1 in non-PS group increased continuously with the increase of number of days and was significantly higher than that in control group on days 1, 3 and 7 after birth (P<0.05), and significantly higher than that in PS group on days 3 and 7 after birth (P<0.05). The analysis of the correlation between the severity of the disease and the expression levels of TGF-β1 and IL-6 showed that the expression levels were elevated with the increase of the disease severity. The expression levels of TGF-β1 and IL-6 were positively correlated with severity of the disease (r=0.7509, P<0.05; r=0.8056, P<0.05). The expression levels of TGF-β1 and IL-6 in PS and non-PS groups were positively correlated (r=0.9042, P<0.05; r=0.8905, P<0.05). The results showed that serum TGF-β1 and IL-6 were elevated in NRDS children, and there was a positive correlation between them.

Management of Preexisting Diabetes in Pregnancy: A Review

IMPORTANCE

The presence of preexisting type 1 or type 2 diabetes in pregnancy increases the risk of adverse maternal and neonatal outcomes, such as preeclampsia, cesarean delivery, preterm delivery, macrosomia, and congenital defects. Approximately 0.9% of the 4 million births in the United States annually are complicated by preexisting diabetes.

OBSERVATIONS

Women with diabetes have increased risk for adverse maternal and neonatal outcomes, and similar risks are present with type 1 and type 2 diabetes. Both forms of diabetes require similar intensity of diabetes care. Preconception planning is very important to avoid unintended pregnancies and to minimize risk of congenital defects. Hemoglobin A1c goals are less than 6.5% at conception and less than 6.0% during pregnancy. It is also critical to screen for and manage comorbid illnesses, such as retinopathy and nephropathy. Medications known to be unsafe in pregnancy, such as angiotensin-converting enzyme inhibitors and statins, should be discontinued. Women with obesity should be screened for obstructive sleep apnea, which is often undiagnosed and can result in poor outcomes. Blood pressure goals must be considered carefully because lower treatment thresholds may be required for women with nephropathy. During pregnancy, continuous glucose monitoring can improve glycemic control and neonatal outcomes in women with type 1 diabetes. Insulin is first-line therapy for all women with preexisting diabetes; injections and insulin pump therapy are both effective approaches. Rates of severe hypoglycemia are increased during pregnancy; therefore, glucagon should be available to the patient and close contacts should be trained in its use. Low-dose aspirin is recommended soon after 12 weeks' gestation to minimize the risk of preeclampsia. The importance of discussing long-acting reversible contraception before and after pregnancy, to allow for appropriate preconception planning, cannot be overstated.

CONCLUSIONS AND RELEVANCE

Preexisting diabetes in pregnancy is complex and is associated with significant maternal and neonatal risk. Optimization of glycemic control, medication regimens, and careful attention to comorbid conditions can help mitigate these risks and ensure quality diabetes care before, during, and after pregnancy.

Temporal changes in characteristics and outcomes among pregnant women with pre-gestational diabetes

OBJECTIVE

To evaluate pregnancy outcomes among women with pre-gestational diabetes.

METHODS

Retrospective analysis of pregnant women with type 1 or type 2 diabetes attending a university hospital in Brazil. Maternal characteristics and pregnancy outcomes were compared among deliveries between May 1, 2005, and December 31, 2010, and between January 1, 2011, and December 31, 2015. Risks were calculated by Poisson regression.

RESULTS

In total 220 women were included. Type 1 diabetes was more frequent in 2005-2010 than in 2011-2015, and type 2 diabetes was more frequent in 2011-2015 (P=0.005). History of macrosomia (P=0.011), hypertensive disorders of pregnancy (P=0.015), and pre-gestational excess weight (body mass index >25 kg/m² ; P=0.003) was more frequent in 2011-2015. For women with type 1 diabetes, pre-gestational weight (P=0.007) and glycated hemoglobin (P=0.026) were higher in 2011-2015. For women with type 2 diabetes, previous hypertensive disorders of pregnancy (P=0.032) were more prevalent and family history of diabetes (P<0.001) less prevalent in 2011-2015. Adverse pregnancy outcomes were similar for type 1 and type 2, and across both periods.

CONCLUSION

Type 2 diabetes became more common over the two time periods and women with type 1 diabetes had higher pre-gestational weight. Perinatal outcomes were similar.

He Tamariki Kokoti Tau-Tackling Preterm: a data-linkage methodology to explore the clinical care pathway in preterm deliveries

BACKGROUND

Significant health inequities exist around maternal and infant health for Māori, the indigenous people of Aotearoa New Zealand - and in particular around a premature (preterm) delivery. Māori babies are more likely to be born preterm (8.1%, compared to an overall rate of 7.4%) and they are more likely to have a preterm death. An essential part of redressing these disparities is to examine the clinical care pathway and outcomes associated with preterm deliveries. This paper describes a protocol utilising national and local health collections to enable such a study.

DESIGN

This is a retrospective cohort study comprising 5 years data pertaining to preterm deliveries from 2010 to 2014. These data are generated from linked national administrative and local health information collections to explore a range of neonatal outcomes and infant mortality in relation to the antenatal care pathway and known risk factors for preterm delivery. This study is being conducted within a Kaupapa Māori paradigm that dismisses victim blaming and seeks to intervene at structural levels to improve the health and wellbeing of Māori whānau (family).

SIGNIFICANCE OF THE STUDY

Our data-linkage methodology optimises the utility of New Zealand health collections to address a significant health issue. Our findings will fill the information gaps around the burden of preterm delivery by quantifying the incidence of preterm delivery and adverse neonatal and infant outcomes in Aotearoa New Zealand. It will explore access to evidenced based care including use of steroids before birth, and appropriate place of delivery. The results from this study will inform maternity care services to improve management of preterm deliveries - both locally and internationally. This in turn will improve the preterm sequela by reducing the long-term health burden and health inequities.

Comparing the risk of adverse pregnancy outcomes of Chinese patients with polycystic ovary syndrome with and without antiandrogenic pretreatment

OBJECTIVE

To evaluate the prevalence of adverse pregnancy outcomes in healthy Chinese women and to investigate whether these outcomes could be decreased in patients with polycystic ovary syndrome (PCOS) by ethinylestradiol/cyproterone acetate (EE/CPA) pretreatment.

DESIGN

Retrospective study.

SETTING

Medical university.

PATIENT(S)

Six thousand healthy women (group A) were selected from 24,566 pregnant women by randomized sampling. Four hundred forty-eight patients with PCOS without EE/CPA pretreatment were assigned to group B, and 222 patients with PCOS with 3 months of pretreatment to group C. All patients with PCOS had biochemical and/or clinical hyperandrogenism and conceived within 3 monthly ovulation inductions using clomiphene.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Gestational diabetes mellitus (GDM), pregnancy-induced hypertension (PIH), premature delivery (PD), and neonatal birth weight.

RESULT(S)

The prevalence of GDM, PIH, and PD was higher in group B than in groups A and C (A vs. B vs. C: GDM, 21.2% vs. 35.0% vs. 22.5%; PIH, 6.5% vs. 14.1% vs. 7.7%; PD, 5.4% vs. 8.6% vs. 6.8%). No significant difference was found in neonatal birth weight. After adjusting for age, pregestational body mass index, education level, and employment status, PCOS without pretreatment increased the risk of GDM (adjusted odds ratio [aOR] = 1.666; 95% confidence interval [CI], 1.340-2.072), PIH (aOR = 1.487; 95% CI, 1.093-2.023), and PD (aOR = 1.522; 95% CI 1.051-2.205), compared with healthy women. No increased risk was found in group C.

CONCLUSION(S)

In our highly selected study population, patients with PCOS are more likely to develop GDM, PIH, and PD. Pretreatment with EE/CPA was associated with a lower risk of GDM, PIH, and PD.