Planned vaginal and planned cesarean delivery outcomes in pregnancies complicated with pregestational type 1 diabetes - A three-year academic tertiary hospital cohort study.

BACKGROUND: Finland has the world's highest incidence of 62.5/100000 of diabetes mellitus type 1 (DM1) with approximately 400 (1%) DM1 pregnancies annually. Pregnancies complicated by DM1 are accompanied with increased risk for perinatal morbidity and mortality. Timing and mode of delivery are based on the risk of complications, yet the data on labor induction is limited. The aim of this study was to compare delivery outcomes in planned vaginal (VD) and planned cesarean deliveries (CD) in late preterm and term DM1 pregnancies, and to evaluate the feasibility of labor induction. MATERIALS AND METHODS: Pregnant women with DM1, live singleton fetus in cephalic presentation ≥34 gestational weeks delivering in Helsinki University Hospital between January 1st 2017 and December 31st 2019 were included. The primary outcome were the rates of adverse maternal and perinatal outcome. The study population was classified according to the 1980-revised White's classification. Statistical analyses were performed by IBM SPSS Statistics for Windows. RESULTS: Two hundred four women were included, 59.8% (n = 122) had planned VD. The rate of adverse maternal outcome was 27.5% (n = 56), similar between the planned modes of delivery and White classes. The rate of perinatal adverse outcome was 38.7% (n = 79), higher in planned CD (52.4% vs. 29.5%;p = 0.001). The most common adverse perinatal event was respiratory distress (48.8% vs. 23.0%;p <  0.001). The rate of adverse perinatal outcome was higher in White class D + Vascular compared to B + C (45.0% vs. 25.0%, OR after adjustment by gestational age 2.34 [95% CI 1.20-4.50];p = 0.01). The total rate of CD was 63.7% (n = 130), and 39.3% (n = 48) in planned VD. Women with White class D + Vascular more often had emergency CD compared to White Class B + C (48.6% vs. 25.0%;p = 0.009). The rate of labor induction was 51%, being 85.2% in planned VD. The rate of VD in induced labor was 58.7% (n = 61) and the rate of failed induction was 14.1% (n = 15). CONCLUSION: Planned VD was associated with lower rate of adverse perinatal outcome compared to planned CS, with no difference in the rates of adverse maternal outcome. Induction of labor may be feasible option but should be carefully considered in this high-risk population.

Diabetes mellitus in pregnancy: an update on the current classification and management.

BACKGROUND: Diabetes mellitus is a common medical disorder in pregnancy. It contributes particularly to perinatal morbidity/mortality, and maternal morbidity. This review aims at improving maternal and neonatal health care especially in Sub-Saharan Africa by improving the knowledge of health practitioners on current evidences in the classification and management of diabetes mellitus in pregnancy. METHODS: Relevant texts as well as online data bases including Pubmed, Google scholar, and African journal online, were searched for literatures related to the subject. RESULTS: Classification of diabetes in pregnancy has been revised to reflect the various aetiological factors. Also, the diagnostic value of fasting plasma glucose has been lowered to mark the point at which dramatic increase in the microvascular complications of diabetes mellitus occurs. Morbidity and mortality associated with the condition would be reduced through proper management that involves preconception care, early antenatal booking, dedicated multidisciplinary antenatal care, and delivery in a center with neonatal facility. Furthermore, some oral glucose lowering agents have shown some safety after the first trimester and they have been found to give comparable result to insulin therapy. CONCLUSION: The classification of diabetes mellitus in pregnancy has been revised. Its optimal management should involve multi-disciplinary inputs and may include oral hypoglycaemic agents. Knowledge of these by clinicians would improve maternal and neonatal health.

Pregnancy and diabetes management: advances and controversies.

BACKGROUND: The treatment of diabetes in pregnancy has potentially far-reaching benefits for both pregnant women with diabetes and their children and may provide a cost-effective approach to the prevention of obesity, type 2 diabetes mellitus, and metabolic syndrome. Early and accurate diagnosis of diabetes in pregnancy is necessary for optimizing maternal and fetal outcomes. CONTENT: Optimal control of diabetes in pregnancy requires achieving normoglycemia at all stages of a woman's pregnancy, including preconception and the postpartum period. In this review we focus on new universal guidelines for the screening and diagnosis of diabetes in pregnancy, including the 75-g oral glucose tolerance test, as well as the controversy surrounding the guidelines. We review the best diagnostic and treatment strategies for the pregestational and intrapartum periods, labor and delivery, and the postpartum period, and discuss management algorithms as well as the safety and efficacy of diabetic medications for use in pregnancy. SUMMARY: Global guidelines for screening, diagnosis, and classification have been established, and offer the potential to stop the cycle of diabetes and obesity caused by hyperglycemia in pregnancy. Normoglycemia is the goal in all aspects of pregnancy and offers the benefits of decreased short-term and long-term complications of diabetes.

Development and evaluation of a standardized registry for diabetes in pregnancy using data from the Northern, North West and East Anglia regional audits.

OBJECTIVES: To develop and evaluate a standardized data set for measuring pregnancy outcomes in women with Type 1 and Type 2 diabetes and to compare recent outcomes with those of the 2002-2003 Confidential Enquiry into Maternal and Child Health. METHODS: Existing regional, national and international data sets were compared for content, consistency and validity to develop a standardized data set for diabetes in pregnancy of 46 key clinical items. The data set was tested retrospectively using data from 2007-2008 pregnancies included in three regional audits (Northern, North West and East Anglia). Obstetric and neonatal outcomes of pregnancies resulting in a stillbirth or live birth were compared with those from the same regions during 2002-2003. RESULTS: Details of 1381 pregnancies, 812 (58.9%) in women with Type 1 diabetes and 556 (40.3%) in women with Type 2 diabetes, were available to test the proposed standardized data set. Of the 46 data items proposed, only 16 (34.8%), predominantly the delivery and neonatal items, achieved ≥ 85% completeness. Ethnic group data were available for 746 (54.0%) pregnancies and BMI for 627 (46.5%) pregnancies. Glycaemic control data were most complete-available for 1217 pregnancies (88.1%), during the first trimester. Only 239 women (19.9%) had adequate pregnancy preparation, defined as pre-conception folic acid and first trimester HbA(1c) ≤ 7% (≤ 53 mmol/mol). Serious adverse outcome rates (major malformation and perinatal mortality) were 55/1000 and had not improved since 2002-2003. CONCLUSIONS: A standardized data set for diabetes in pregnancy may improve consistency of data collection and allow for more meaningful evaluation of pregnancy outcomes in women with pregestational diabetes.

White's classification of diabetes in pregnancy in the 21st century: is it still valid?

White's classification system (WCS) was created 60 years ago to identify diabetic (DM) pregnancies at increased risk for perinatal morbidity and mortality. Our objective was to assess the association between WCS and adverse pregnancy outcome (APO) in contemporary DM pregnancies. We studied diabetic women with singleton pregnancies who delivered at >20 weeks at a single institution over a 1-year period (2007 to 2008). Perinatal outcomes were compared between WCS groups. APO was defined as any of the following: preterm birth <34 weeks, severe preeclampsia, shoulder dystocia, and neonatal respiratory disease. Presence of vascular disease was defined as presence of chronic hypertension, chronic renal insufficiency, retinopathy, coronary artery disease, or prior cerebrovascular event. One hundred ninety-six DM pregnancies met the criteria. No significant differences in APO existed between White's class groups among women with pregestational DM (32.7% class B versus 26.9% class C versus 57.1% class D to F; p = 0.46). Logistic regression revealed that vascular disease was associated with APO (odds ratio = 2.7, 95% confidence interval = 1.2 to 6.2). In our population, presence of vascular disease, rather than WCS, was a better predictor of APO in DM women.

Optimal insulin delivery for the pregnant diabetic patient.

It is now possible to virtually normalize ambient blood glucose levels in insulin-dependent diabetic women during pregnancy. Successful programs have been developed that utilize home blood glucose monitoring, physiologic delivery of insulin, and quantitation of caloric intake carefully matched to insulin dosage. The results of establishing normoglycemia throughout gestation appear to be a normalization of mortality and morbidity for both infant and mother. Pregnancy provides a need for continuous upward adjustment of insulin dose concomitant with the ongoing fetal and hormonal changes associated with gestation.

Assessing White's classification of pregestational diabetes in a contemporary diabetic population.

OBJECTIVE: To assess the validity of White's classification, including the role of chronic hypertension, in a contemporary diabetic population. METHODS: We performed a retrospective cohort study of all singleton pregnancies with pre-existing diabetes mellitus from 2008 to 2013. Adverse outcomes were compared across classes B, C, D, and vascular disease (R, F, H) and further stratified by the presence or absence of chronic hypertension. Outcomes examined were a composite perinatal outcome (stillbirth, neonatal death, shoulder dystocia, birth injury, seizures, requiring chest compressions or intubation at delivery, blood pressure support), small for gestational age (SGA), large for gestational age (LGA), macrosomia, shoulder dystocia, preterm delivery at less than 37 weeks of gestation, preeclampsia, and cesarean delivery. RESULTS: Of the 475 patients, the 1980 White's classification was significantly associated with SGA, LGA, macrosomia, preterm delivery, preeclampsia, and cesarean delivery (P≤.01). Within each White's class based on age or time since diagnosis alone, hypertension was significantly associated with a higher incidence of preeclampsia in class B (16% without hypertension compared with 32% with hypertension, P<.01) and C (22% compared with 40%, P=.04), SGA in C (4.7% compared with 21%, P<.01), preterm delivery in B (25% compared with 46%, P<.01) and C (35% compared with 58%, P=.01), and the composite neonatal outcome in B (7.9% compared with 17%, P=.03). The incidence of adverse outcomes in classes B and C with hypertension resembles the incidence of adverse outcomes in those with diabetes one class higher. CONCLUSION: The 1980 White's classification system, taking into consideration the presence of chronic hypertension, remains a useful system for counseling pregestational diabetic women regarding adverse pregnancy outcomes. LEVEL OF EVIDENCE: II.

Screening, management, and outcome of pregnancy in diabetic mothers.

During a 3.5-year period 94 latently and manifestly diabetic patients were treated in the State Maternity Hospital of Helsinki. Management of manifestly diabetic patients included strict control of maternal glucose metabolism based on plasma glucose values after meals and on fasting plasma glucose values, early hospitalization, and delivery near term to avoid infant morbidity due to prematurity. Fetal surveillance was based primarily on daily nonstress fetal heart rate monitoring and frequent urinary estriol determinations. Hypertensive disorders were encountered in 33% of patients in class A and 24% of patients in classes B through F; urinary tract infections were found in 17% and repeated maternal hypoglycemic episodes were found in 20% of manifestly diabetic mothers. Diabetic retinopathy showed variable progression during pregnancy in 50% of cases and unchanged in the remaining 50%; only 16% of patients with hypertensive retinopathy showed progression on reexamination. The perinatal mortality was 1.1%. Delivery by cesarean section was performed in 55.3% of cases. The duration of gestation at the moment of delivery was 38.9 weeks in class A and progressively less in classes B through F according to the severity of the diabetic disorder. The following percentages reflecting infant morbidity were encountered: respiratory distress syndrome 5.3%; neonatal hypoglycemia, 10.6%; hyperbilirubinemia, 8.5%; hypocalcemia, 5.3%; and the aspiration syndrome, 5.3%. Two infants had congenital anomalies: 1 had hypospadias and the other had aortic coarctation.

Maternal outcome in class H diabetes mellitus.

The term class H diabetes mellitus has recently been used to describe pregnant diabetic women with ischemic heart disease. In such patients, the risks of abortion may approach those of continuing the gestation. Because significant cardiac disease can occur with diabetes of even recent onset, a baseline electrocardiogram is thus recommended for all pregnant diabetic women. Review of the literature reveals 11 cases, 8 of which resulted in maternal death. The authors have successfully treated a class H diabetic woman who delivered a healthy infant at 36 weeks' gestation.

Glucose intolerance during pregnancy. I. A reappraisal of alleged screening criteria.

This study was designed to examine various risk factors in regard to their correlation with carbohydrate intolerance and in relation to birthweight and well-being of the newborn. Of the various alleged prediabetic stigmata among a selected group of 390 women, only marked maternal overweight, diabetes in previous pregnancy, family history of diabetes at the sibling level, and accompanying maternal morbidity were associated with increased risk for both gestational carbohydrate intolerance and for morbidity in the newborn. In women over 30 years of age a definite increase in the incidence of carbohydrate intolerance was noted among this high-risk population. Multiplicity of screening criteria presented a significantly (P less than 0.001) greater risk for the development of carbohydrate intolerance and was seen to be positively (P less than 0.001) with increased perinatal morbidity.

Coronary artery disease in insulin-dependent diabetes mellitus of pregnancy (class H): a review of the literature.

Coronary heart disease and myocardial infarction are uncommon complications during pregnancy. Women with insulin-dependent diabetes mellitus (IDDM) have a much greater risk of serious coronary heart disease, but few cases of myocardial infarctions occurring during pregnancy have been reported. Significant maternal morbidity has been reported in half of these cases. This is a case of a myocardial infarction occurring at 21 weeks of gestation in a patient with class R/F IDDM and the subsequent pregnancy management as well as a review of the literature concerning Class H IDDM in pregnancy.

Diabetes complicating pregnancy.

Despite the well-documented relationship between morbidity in pregnancy and pregestational maternal diabetes, the corrected perinatal outcome is, in most series, equal to or better than that of the general reference obstetric population. No single aspect or element of contemporary management is responsible for this improvement; rather, a combination of interventions seems responsible. Targeting delivery early in term, improved compliance, better glycemic control during pregnancy, improved control at conception, improved neonatal care, family planning, and early screening for fetal abnormalities all likely contribute to improved outcome. The currently observed rates of perinatal mortality suggest that an irreducible minimum mortality rate may be reached; however, large disparities in access to care and treatment continue to result in a wide range in rates of morbidity and mortality, a fact that pertains to outcomes in general as well as to pregnancies complicated by diabetes. The identification of women with lesser degrees of hyperglycemia as diabetic by lowering the thresholds for glucose tolerance test abnormality suggests an importance of the diagnosis that is not supported by evidence of either related morbidity or therapeutic benefit. The extrapolation of risk to women with lesser degrees of hyperglycemia seems to have little basis, and the management of women with mild glucose intolerance as if they had overt diabetes is unwarranted. The excess of resources dedicated to the identification and monitoring of an increasing number of women with mild abnormalities of glucose metabolism should prompt a reevaluation of these practices. Perinatal benefits of this expenditure are difficult to document or nonexistent, and there is a predictable increase in iatrogenic morbidities associated with the diagnosis. The exception in the most recent recommendations is the addition of a random glucose measure to screen for the rare women with overt undiagnosed diabetes who presents for prenatal care, because these women are at increased risk of morbidities related to diabetes. A curious statement was made in the summary and recommendations of the fourth International Congress on Gestational Diabetes: "There remains a compelling need to develop diagnostic criteria for GDM [gestational diabetes mellitus] that are based on the specific relationships between hyperglycemia and risk of adverse outcome." If these relationships are undefined, what is the import of the diagnosis? At the author's center, application of the new diagnostic thresholds for the diagnosis of gestational diabetes mellitus has increased the incidence to over 6%. Without a clear expectation of benefit, this increase represents an unsupportable investment of resources. What are the prospects for improving understanding of the relationships between glucose intolerance and pregnancy risks? The direction of new guidelines and recommendations seems to be moving away from resolution of the relationships. The new criteria result in the diagnosis of gestational diabetes in an increasing number of women who were previously normal. It is easier to differentiate women at an extreme of hyperglycemia from normal. Investigations will be even less able to identify attributable effects of glucose intolerance in pregnancy with the inclusion of women with lesser degrees of hyperglycemia. As evidenced in O'Sullivan's original series, women with fasting hyperglycemia in pregnancy are still presumed to be at increased risk of fetal death. This risk factor remains important in clinical management if insulin treatment, fetal surveillance, and early term delivery can reduce the risk of fetal loss. At the author's center, the relationships among outpatient measures of fasting glycemia, glucose tolerance testing results, and perinatal outcomes are evaluated. Preliminary results suggest that fasting glycemia measured at the time of a 50-g glucose tolerance test is significantly correlated with and as sensitive and predictive of morbidity as the glucose tolerance test diagnosis of gestational diabetes. If these results are confirmed, it will be difficult to rationalize continued glucose tolerance testing.

Diabetes mellitus in pregnancy.

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

Basis of the present classification of diabetes.

The present classification of diabetes most widely used is that recommended by the National Diabetes Data Group and subsequently endorsed by the World Health Organization. This classification is primarily a clinical classification of diabetes because in most instances the etiology is unknown. The need for a standardized classification arose out of the recognition that diabetes was a syndrome rather than a single disease and the different terminologies which emerged. While certain types of diabetes can be classified according to specific etiology or associations with specific syndromes, the vast majority cannot. Insulin-dependent and noninsulin-dependent diabetes usually represent syndromes whose etiopathology is believed to differ and their clinical characteristics are usually distinctive. As evidence of etiological heterogeneity has increased there has been a tendency to adopt the terms Type I and Type II diabetes to indicate different etiologies, although the original usage of these terms was as a clinical classification to differentiate between insulin dependent and non-insulin-dependent disease. At present the use of the four terms to describe the common types of diabetes leads to confusion, which could readily be resolved by arriving at agreed definitions for each of these terms. While the NDDG-WHO classification has served to standardize terminology and stimulate research into the different causes of diabetes, some further refinement of the classification, together with some additional definition of terms, should be considered. The classification of diabetes most widely used at the present time is that suggested by the National Diabetes Data Group (NDDG) in the United States in 1979, which was subsequently recommended by the World Health Organization (WHO) Expert Committee on Diabetes Mellitus in 1980. It should be stressed that this classification was intended to be a uniform framework for clinical and epidemiological research, and that the classification would almost certainly have to be modified on the basis of new knowledge in the future.

Limitations and problems of diabetes classification from an epidemiological point of view.

There are residual ambiguities between the two main current glycaemic definitions of the categories of DM, IGT and normal GT which should be resolved. IGT is clearly a highly heterogeneous category and could with advantage be resolved into its identifiable subsets though adequate data for this is not yet available. The concept of insulin dependency requires clearer definition for operational purposes. Biochemical parameters (e.g. C-peptide responses) may help. Attempts to combine clinical manifestations and pathogenic mechanisms in a single classification (e.g. IDDM/NIDD versus Type I/Type II) should be handled with care. If the term Type I is to be retained, it should be applied to a defined pathogenic process, not to a clinical type of DM. The term Type II is inadequately defined at present. IDDM and NIDDM, clinical descriptive terms, may be provoked by a variety of pathogenic mechanisms (i.e. they are 'heterogeneous'). They could be subclassified by mechanism (when known). More visibility should be given in classification to non-Europid forms of DM (e.g. 'Tropical or 'Nutritional' DM). A staging dimension should be recognised in classifications of DM. Future classifications will benefit from the incorporation of the presence or absence of susceptibility/resistance factors to diabetes itself or to its severe long term sequelae. There remain uncertainties about the definitions and clinical implications of gestational DM (and gestational IGT) not discussed above. It should be accepted that different user groups may need different subclassification of diabetes and glucose intolerance to meet their specific requirements and so long as this is made clear and definitions are adequate this should not be a problem. However, for the present, all groups should accept the proposed glycaemic definitions of DM or IGT for the purposes of comparability.

Significance of umbilical and uterine artery velocimetry in the well-controlled pregnant diabetic.

The measurement of umbilical and uterine artery velocity waveforms was used to study pregnancies complicated by diabetes. Continuous wave Doppler velocimetry was used to identify the umbilical and uterine artery velocity waveforms. A systolic:end diastolic ratio (S:D ratio) was calculated to analyze the obtained velocity waveforms. We treated 33 tightly controlled and monitored diabetic gravidas. The mean blood sugar value for this population was 95 +/- 8 mg/dL, and the mean umbilical artery S:D ratio was 2.5 +/- 0.3. That group of patients was compared to a group on which we reported previously. Statistically significant differences were found between the well-controlled and poorly controlled populations in third-trimester S:D ratios, number of stillbirths and neonatal morbidity. Uterine artery velocimetry allowed the identification of a patient who developed preeclampsia. This study seems to have indicated that umbilical and uterine artery velocimetry may have an adjunctive role in the surveillance of pregnancies complicated by diabetes.

[Diabetes and pregnancy: treatment and results (author's transl)]. / Die diabetische Schwangerschaft: Behandlung und Ergebnisse.

Pregnancy and delivery in 190 diabetic women are described. Obstetric, medical and neonatal guidelines for treatment are outlined and the following results are reported: 1. The delivery dates suggested by P. White were generally exceeded by 2 weeks. Group A was delivered at term, group B generally in the 38th week, group C between the 37th and 38th week and group D mostly in the 37th week of gestation. 2. Spontaneous delivery was achieved in 60% of the cases; Caesarean section was necessary in 33%, whilst the incidence of vacuum extraction was 5%. 3. The perinatal infant mortality rate in diabetic pregnancy decreased from 22.9% in 1970/71 to 2.7% in 1972/1976. 4. Perinatal mortality was related to the degree of severity of diabetes according to White's classification. 5. The percentage of PBSP cases was lowered from 32% to 24%. Perinatal mortality in the PBSP group decreased from 50% in 1970/71 to 19% in 1972/1976. 6. Hypoglycaemia occurred in 70% of 74 newborn infants submitted to intensive neonatal care. A true glucose value of less than 25 mg% was recorded in 30% of these cases. Hypocalcaemia was present in 16% cases, whilst 62% of the newborn infants suffered from respiratory distress syndrome. Cardiomegaly occurred in 28% of infants. 7. Development and prognosis are judged to be favourable in children of diabetic mothers.

Reclassification after delivery of diabetes in pregnancy.

Gestational diabetes mellitus (GDM) constitutes a risk factor for the development of non insulin-dependent diabetes mellitus (NIDDM). The search for parameters to provide discrimination between a high risk and a low risk for future development of NIDDM is today the aim of many investigations. The absence or presence of several factors such as glycemia during pregnancy and post partum, the need for insulin treatment, disorders of the pancreatic insulin secretion, the number of pregnancies, maternal obesity, the early diagnosis of GDM, the family history of diabetes mellitus, the race and immune disorders give rise to a very high relative risk (RR) of developing NIDDM. To know the degree of risk will allow a future appropriate clinical intervention to reduce the incidence of NIDDM and its economic cost.

[Gestational diabetes: the urgent need for a consensus]. / Diabète gestationnel: l'urgent besoin d'un consensus.

About 2% of all pregnant women are affected by gestational diabetes. Unfortunately there is no unanimity in considering the criteria for the definition, classification and screening of these patients. This work tries to sort out the principal elements to be found in the literature that could help to work out a consensus in this field. At the present time, one of the best definitions seems to be "any pregnant women in whom the onset or recognition of diabetes or impaired glucose tolerance occurs during pregnancy". So, gestational diabetes is not synonymous of White's Class A and it is suggested to restrict the White classification to the diabetic women who subsequently become pregnant. The diagnostic test to establish glucose intolerance will be the oral glucose tolerance test with 100 g glucose. Various sets of criteria have been suggested for the interpretation of this test but it is advisable to use normal values established by one of the prospective studies, either by O'Sullivan in the USA or by Pinget in France or by Abell in Australia. As far as screening is concerned, the most sensible, specific and easy strategy appears to estimate, in every pregnant woman, the plasma glucose level one hour after a load of 50 g and to restrict oral glucose tolerance tests to the pregnant women whose results is above 150 mg%.