Birth outcomes in women with gestational diabetes managed by lifestyle modification alone: The PANDORA study

AIMS

To assess outcomes of women in the Pregnancy and Neonatal Diabetes Outcomes in Remote Australia (PANDORA) cohort with gestational diabetes mellitus (GDM) managed by lifestyle modification compared with women without hyperglycaemia in pregnancy.

METHODS

Indigenous (n = 97) and Europid (n = 113) women managed by lifestyle modification were compared to women without hyperglycaemia (n = 235). Multivariate linear and logistic regressions assessed whether GDM-lifestyle women had poorer outcomes compared to women without hyperglycaemia.

RESULTS

Women with GDM-lifestyle had higher body mass index and lower gestational weight gain than women without hyperglycaemia. On univariate analysis, gestational age at delivery was lower and induction rates were higher in women with GDM-lifestyle than without hyperglycaemia. On multivariable regression, GDM-lifestyle was associated with lower gestational age at delivery (by 0.73 weeks), lower birthweight z-score (by 0.26, p = 0.007), lower likelihood of large for gestational age (LGA) [OR (95% CI): 0.55 (0.28, 1.02), p = 0.059], and greater likelihood of labour induction [2.34 (1.49, 3.66), p < 0.001] than women without hyperglycaemia.

CONCLUSION

Women with GDM managed by lifestyle modification had higher induction rates and their offspring had lower birthweight z-scores, with a trend to lower LGA than those without hyperglycaemia in pregnancy. Further studies are indicated to explore reasons for higher induction rates.

Diabetes care in remote Australia: the antenatal, postpartum and inter-pregnancy period

BACKGROUND

Aboriginal and Torres Strait Islander women experience high rates of diabetes in pregnancy (DIP), contributing to health risks for mother and infant, and the intergenerational cycle of diabetes. By enhancing diabetes management during pregnancy, postpartum and the interval between pregnancies, the DIP Partnership aims to improve health outcomes and reduce risks early in the life-course. We describe a mixed methods formative study of health professional's perspectives of antenatal and post-partum diabetes screening and management, including enablers and barriers to care.

METHODS

Health professionals involved in providing diabetes care in pregnancy, from a range of health services across the Northern Territory, completed the survey (n = 82) and/or took part in interviews and/or focus groups (n = 62).

RESULTS

Qualitative findings highlighted factors influencing the delivery of care as reported by health professionals, including: whose responsibility it is, access to care, the baby is the focus and pre-conception care. The main challenges were related to: disjointed systems and confusion around whose role it is to provide follow-up care beyond six weeks post-partum. Quantitative findings indicated that the majority of health professionals reported confidence in their own skills to manage women in the antenatal period (62%, 40/79) and slightly lower rates of confidence in the postpartum interval (57%, 33/58).

CONCLUSION

These findings regarding whose role it is to provide postpartum care, along with opportunities to improve communication pathways and follow up care have informed the design of a complex health intervention to improve health systems and the provision of DIP related care.

Making stillbirths visible: a systematic review of globally reported causes of stillbirth

BACKGROUND

Stillbirth is a global health problem. The World Health Organization (WHO) application of the International Classification of Diseases for perinatal mortality (ICD-PM) aims to improve data on stillbirth to enable prevention.

OBJECTIVES

To identify globally reported causes of stillbirth, classification systems, and alignment with the ICD-PM.

SEARCH STRATEGY

We searched CINAHL, EMBASE, Medline, Global Health, and Pubmed from 2009 to 2016.

SELECTION CRITERIA

Reports of stillbirth causes in unselective cohorts.

DATA COLLECTION AND ANALYSIS

Pooled estimates of causes were derived for country representative reports. Systems and causes were assessed for alignment with the ICD-PM. Data are presented by income setting (low, middle, and high income countries; LIC, MIC, HIC).

MAIN RESULTS

Eighty-five reports from 50 countries (489 089 stillbirths) were included. The most frequent categories were Unexplained, Antepartum haemorrhage, and Other (all settings); Infection and Hypoxic peripartum (LIC), and Placental (MIC, HIC). Overall report quality was low. Only one classification system fully aligned with ICD-PM. All stillbirth causes mapped to ICD-PM. In a subset from HIC, mapping obscured major causes.

CONCLUSIONS

There is a paucity of quality information on causes of stillbirth globally. Improving investigation of stillbirths and standardisation of audit and classification is urgently needed and should be achievable in all well-resourced settings. Implementation of the WHO Perinatal Mortality Audit and Review guide is needed, particularly across high burden settings.

FUNDING

HR, SH, SHL, and AW were supported by an NHMRC-CRE grant (APP1116640). VF was funded by an NHMRC-CDF (APP1123611).

TWEETABLE ABSTRACT

Urgent need to improve data on causes of stillbirths across all settings to meet global targets.

PLAIN LANGUAGE SUMMARY

Background and methods Nearly three million babies are stillborn every year. These deaths have deep and long-lasting effects on parents, healthcare providers, and the society. One of the major challenges to preventing stillbirths is the lack of information about why they happen. In this study, we collected reports on the causes of stillbirth from high-, middle-, and low-income countries to: (1) Understand the causes of stillbirth, and (2) Understand how to improve reporting of stillbirths. Findings We found 85 reports from 50 different countries. The information available from the reports was inconsistent and often of poor quality, so it was hard to get a clear picture about what are the causes of stillbirth across the world. Many different definitions of stillbirth were used. There was also wide variation in what investigations of the mother and baby were undertaken to identify the cause of stillbirth. Stillbirths in all income settings (low-, middle-, and high-income countries) were most frequently reported as Unexplained, Other, and Haemorrhage (bleeding). Unexplained and Other are not helpful in understanding why a baby was stillborn. In low-income countries, stillbirths were often attributed to Infection and Complications during labour and birth. In middle- and high-income countries, stillbirths were often reported as Placental complications. Limitations We may have missed some reports as searches were carried out in English only. The available reports were of poor quality. Implications Many countries, particularly those where the majority of stillbirths occur, do not report any information about these deaths. Where there are reports, the quality is often poor. It is important to improve the investigation and reporting of stillbirth using a standardised system so that policy makers and healthcare workers can develop effective stillbirth prevention programs. All stillbirths should be investigated and reported in line with the World Health Organization standards.

Preconception care for women with type 2 diabetes mellitus: A mixed-methods study of provider knowledge and practice

AIMS

Preconception care may decrease adverse pregnancy outcomes associated with pre-existing diabetes mellitus. Aboriginal Australians are at high risk of type 2 diabetes mellitus (T2DM), with earlier onset. We explored practitioner views on preconception care delivery for women with T2DM in the Northern Territory, where 31% of births are to Aboriginal women.

METHODS

Mixed-methods study including cross-sectional survey of 156 health practitioners and 11 semi-structured interviews.

RESULTS

Practitioners reported low attendance for preconception care however, 51% provided counselling on an opportunistic basis. Rural/remote practitioners were most likely to find counselling feasible. The majority (69%) utilised appropriate guidelines and addressed lifestyle modifications including smoking (81%), weight management (79%), and change medications appropriately such as ceasing ACE inhibitors (69%). Fewer (40%) prescribed the recommended dose of folate (5mg) or felt comfortable recommending delaying pregnancy to achieve optimal preconception glucose control (42%). Themes identified as barriers to care included the complexity of care setting and infrequent preconception consultations. There was a focus on motivation of women to make informed choices about conception, including birth spacing, timing and contraception. Preconception care enablers included cross-cultural communication, a multi-disciplinary care team and strong client-based relationships.

CONCLUSIONS

Health practitioners are keen to provide preconception counselling and reported knowledge of evidence-based guidelines. Improvements are needed in recommending high dose folate and optimising glucose control. Cross-cultural communication and team-based care were reported as fundamental to successful preconception care in women with T2DM. Continued education and policy changes are required to support practitioners in opportunities to enhance pregnancy planning.

Effects of continuity of care by a primary midwife (caseload midwifery) on caesarean section rates in women of low obstetric risk: the COSMOS randomised controlled trial

OBJECTIVE

To determine whether primary midwife care (caseload midwifery) decreases the caesarean section rate compared with standard maternity care.

DESIGN

Randomised controlled trial.

SETTING

Tertiary-care women's hospital in Melbourne, Australia.

POPULATION

A total of 2314 low-risk pregnant women.

METHODS

Women randomised to caseload received antenatal, intrapartum and postpartum care from a primary midwife with some care by 'back-up' midwives. Women randomised to standard care received either midwifery or obstetric-trainee care with varying levels of continuity, or community-based general practitioner care.

MAIN OUTCOME MEASURES

PRIMARY OUTCOME

caesarean birth. Secondary outcomes included instrumental vaginal births, analgesia, perineal trauma, induction of labour, infant admission to special/neonatal intensive care, gestational age, Apgar scores and birthweight.

RESULTS

In total 2314 women were randomised-1156 to caseload and 1158 to standard care. Women allocated to caseload were less likely to have a caesarean section (19.4% versus 24.9%; risk ratio [RR] 0.78; 95% CI 0.67-0.91; P = 0.001); more likely to have a spontaneous vaginal birth (63.0% versus 55.7%; RR 1.13; 95% CI 1.06-1.21; P < 0.001); less likely to have epidural analgesia (30.5% versus 34.6%; RR 0.88; 95% CI 0.79-0.996; P = 0.04) and less likely to have an episiotomy (23.1% versus 29.4%; RR 0.79; 95% CI 0.67-0.92; P = 0.003). Infants of women allocated to caseload were less likely to be admitted to special or neonatal intensive care (4.0% versus 6.4%; RR 0.63; 95% CI 0.44-0.90; P = 0.01). No infant outcomes favoured standard care.

CONCLUSION

In settings with a relatively high baseline caesarean section rate, caseload midwifery for women at low obstetric risk in early pregnancy shows promise for reducing caesarean births.

318. POLYURIA IN PREGNANCY - CHALLENGES OF DIAGNOSIS!

Increased urinary frequency is a widely experienced symptom in pregnancy; true polyuria is less common and can have a number of causes. It is essential, however that it should be recognized and appropriately investigated, as it may be potentially life threatening to mother and fetus. Diabetes insipidus (DI) is a rare complication of pregnancy. It can be the first presentation of pre-gestational DI, gestational DI or DI associated with acute fatty liver of pregnancy. The latter conditions are illustrated by the following two clinical cases. Osmotic homeostasis can be altered in pregnancy due to resetting of the osmostat and degradation of vasopressin by vasopressinase secreted by the placenta in increasing quantities in the 2nd and 3rd trimesters. Liver failure results in the availability of higher circulating levels of vasopressinase. These cases highlight the difficulties and importance of diagnosis and treatment. Pregnant women often report polyuria during the 3rd trimester. It is important to have a high level of clinical suspicion for the pathological causes, despite the non-specific presentation as underlying conditions can have catastrophic sequelae.

Clinical pathways involving general practice--a new approach to integrated health care?

The Mater Mothers' Hospital, South Brisbane recently identified a number of difficulties with the maternity share-care program it runs with 1100 local GPs. This paper describes an integration approach developed at the Mater which has addressed these problems via the use of clinical management guidelines across the whole episode of care, the provision of a patient held record/pathway as a clinical practice prompt, clear communication and information management protocols between hospital and general practice, and the provision of continuing medical education for share-care practitioners.

Carbohydrate-deficient glycoprotein syndrome in a newborn with an unbalanced chromosomal translocation

Carbohydrate-deficient glycoprotein syndromes may occur as a primary result of distinct genetic disruption of the enzymes involved in processing the carbohydrate moeities of glycoproteins. They may also occur due to a number of secondary defects in glycosylation.

CONCLUSION

A female infant with an unbalanced chromosomal translocation [46,XX,der(21)t(17;21) (p13.1;q22.11)mat.ish der(21)t(17;21) (D17S375 x 3, D21S65-)] and with biochemical and clinical features of a carbohydrate deficient glycoprotein syndrome is reported. This chromosomal disruption is another secondary cause of the disorder.

Menstrual migraine: a double-blind trial of percutaneous estradiol

The present study investigated whether administration of percutaneous estradiol for the 7 days encompassing menstruation (the paramenstruum) would be effective in alleviating menstrual migraine. The study was a double-blind cross-over placebo comparison of percutaneous estradiol in gel form. Twenty-two women who suffered from regular recurring menstrual migraine were studied during 2 assessment menstrual cycles, 4 treatment cycles (2 of estradiol gel, 2 of placebo gel), and 1 follow-up (no treatment) cycle. Women completed daily records of the occurrence and severity of migraine and medication used. Eighteen women completed the study. There was a significant reduction in the frequency of migraine in the paramenstruum and in the amount of medication taken during use of percutaneous estradiol. Women expressed a significant preference for continuation of therapy with percutaneous estradiol.

Early onset pre-eclampsia: recognition of underlying renal disease

A follow up study of 84 patients with early onset pre-eclampsia (before 37 weeks' gestation) showed a high prevalence of underlying renal disease. Renal abnormalities were found in 33 of the 49 primiparas (67%) and in 22 of the 35 multiparas (63%). Two thirds of the multiparas with pre-eclampsia before 37 weeks with a diagnosis of either essential hypertension or renal disease had recurrent pre-eclampsia. Maternal morbidity and fetal mortality were greater in the group with early onset pre-eclampsia than in a group with late onset disease. Idiopathic pre-eclampsia occurred in 10% of primiparas in the early onset group, whereas it was the main condition in over three quarters of primiparas in the late onset group. A presumptive diagnosis of idiopathic pre-eclampsia is likely to be correct only in primiparas who develop the disease after 37 weeks of pregnancy; in all other cases careful search will almost certainly detect an underlying abnormality, predominantly renal.

Treatment of premenstrual syndrome. A double-blind trial of dydrogesterone

A double-blind randomised crossover trial of oral micronised progesterone and placebo had demonstrated that progesterone had beneficial effects over placebo for some mood and physical premenstrual symptoms. A further trial using identical methodology was carried out to assess whether dydrogesterone would have the same beneficial effects. Prospective assessment confirmed the presence of a premenstrual syndrome in 30 women. Of these, six withdrew during the 4 months of the study. Twenty-four women completed the double-blind crossover protocol. All women were interviewed premenstrually before treatment and in each month of treatment. They completed the Moos Menstrual Distress Questionnaire, Beck Depression Inventory, Spielberger State Anxiety Inventory, Mood Adjective Checklist and a Daily Symptom Record. Analysis of data found an overall beneficial effect of being treated for most variables. Further analysis showed that the most major effects occurred in the first 2 treatment months. This study could find no evidence that dydrogesterone was more effective than placebo in treating premenstrual complaints.

A controlled trial of fetal heart rate monitoring in a low-risk obstetric population

A controlled trial of fetal heart rate (FHR) monitoring in a low-risk obstetric population was carried out in 989 patients at the Mercy Maternity Hospital and Queen Victoria Medical Centre. The use of monitoring failed to demonstrate any improvement in perinatal outcome. Monitoring was associated with an increased intervention rate and a small increase in the number of babies who remained in the isolette beyond 3 days. This study does not support the view that FHR monitoring should be used in all labors. Further study in a larger sample is recommended.