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.

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.

Impact of ethnicity on gestational diabetes identified with the WHO and the modified International Association of Diabetes and Pregnancy Study Groups criteria: a population-based cohort study.

OBJECTIVE: The International Association of Diabetes and Pregnancy Study Groups (IADPSG) recently proposed new criteria for diagnosing gestational diabetes mellitus (GDM). We compared prevalence rates, risk factors, and the effect of ethnicity using the World Health Organization (WHO) and modified IADPSG criteria. METHODS: This was a population-based cohort study of 823 (74% of eligible) healthy pregnant women, of whom 59% were from ethnic minorities. Universal screening was performed at 28±2 weeks of gestation with the 75 g oral glucose tolerance test (OGTT). Venous plasma glucose (PG) was measured on site. GDM was diagnosed as per the definition of WHO criteria as fasting PG (FPG) ≥7.0 or 2-h PG ≥7.8 mmol/l; and as per the modified IADPSG criteria as FPG ≥5.1 or 2-h PG ≥8.5 mmol/l. RESULTS: OGTT was performed in 759 women. Crude GDM prevalence was 13.0% with WHO (Western Europeans 11%, ethnic minorities 15%, P=0.14) and 31.5% with modified IADPSG criteria (Western Europeans 24%, ethnic minorities 37%, P< 0.001). Using the WHO criteria, ethnic minority origin was an independent predictor (South Asians, odds ratio (OR) 2.24 (95% confidence interval (CI) 1.26-3.97); Middle Easterners, OR 2.13 (1.12-4.08)) after adjustments for age, parity, and prepregnant body mass index (BMI). This increased OR was unapparent after further adjustments for body height (proxy for early life socioeconomic status), education and family history of diabetes. Using the modified IADPSG criteria, prepregnant BMI (1.09 (1.05-1.13)) and ethnic minority origin (South Asians, 2.54 (1.56-4.13)) were independent predictors, while education, body height and family history had little impact. CONCLUSION: GDM prevalence was overall 2.4-times higher with the modified IADPSG criteria compared with the WHO criteria. The new criteria identified many subjects with a relatively mild increase in FPG, strongly associated with South Asian origin and prepregnant overweight.

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.

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.

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.

Pregestational diabetes.

The prevalence of preexisting diabetes in pregnancy is increasing largely because of an increase in type 2 diabetes. Outcomes of diabetic pregnancies for mother and newborn have improved greatly in recent decades from advances in understanding the disease process, improved education, and new treatment modalities delivered in a team approach. Nausea and vomiting from pregnancy and pregnancy-associated insulin resistance can make glycemic control a challenge. Care of women with preexisting diabetes demands careful monitoring in the preconception, prenatal, and peripartum periods.

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.

Diabetes e gestação: perfil clínico e laboratorial em pré-natal de alto risco / Diabetes and pregnancy: clinical profile in high-risk prenatal care

Introdução: O diabetes é complicação clínica frequente na gestação e sua prevalência vem aumentando nos últimos anos. Objetivo: Analisar a frequência dos tipos de diabetes na gestação, as características clínicas das gestantes e alguns desfechos materno-fetais, em pré-natal de alto risco. Método: Estudo retrospectivo de revisão dos prontuários eletrônicos de mulheres com diabetes e gestação atendidas no período de janeiro 2009 a junho 2010 no Hospital de Clínicas de Porto Alegre (HCPA). Resultados: Nesse período, 173 gestantes foram atendidas no ambulatório de gestação e diabetes, no total de 1459 consultas. O diabetes gestacional ocorreu em 84% das gestantes, 8% apresentaram diabetes tipo 2, 6%, diabetes tipo 1 e 2%, outros tipos. As mulheres com diabetes gestacional apresentaram HbA1c inferior às demais. A maioria das pacientes iniciou o pré-natal após o primeiro trimestre. A taxa geral de cesariana foi de 56%, tendo sido mais frequente no diabetes tipo 1. O recém-nascido foi considerado pequeno para a idade gestacional em 9% dos casos, e grande em 13%, sem diferença entre os tipos de diabetes. Nas mulheres com diabetes gestacional, o peso do recém-nascido correlacionou-se positivamente com o índice de massa corporal, glicemia de jejum ao diagnóstico e HbA1c da mãe. Conclusão: O diabetes associado à gestação é motivo frequente de atendimento no pré-natal especializado do HCPA, sendo a maioria diabetes gestacional. Nesses casos, obesidade e pior controle glicêmico associaram-se com o peso fetal aumentado. As gestantes chegam tardiamente ao centro de tratamento, com controle metabólico aquém do recomendado.

Background: Gestational diabetes is a common complication of pregnancy and its prevalence has increased in the last years. Aim: To describe the frequency of different types of diabetes, maternal clinical characteristics, and pregnancy outcomes in pregnant diabetic women who received prenatal care at a high-risk prenatal center. Method: Review of medical records of pregnant diabetic women who received prenatal care between January 2009 and June 2010 at Hospital de Clínicas de Porto Alegre (HCPA). Results: In this period, 173 pregnant diabetic women received prenatal care; 1,459 medical visits were made. Gestational diabetes was diagnosed in 84% of the women, 8% had type 2 diabetes, 6% had type 1 diabetes, and 2% had other types of diabetes. Women with gestational diabetes had lower HbA1c than the other diabetic groups. Most patients started the prenatal care after the first quarter. The global frequency of cesarean section was 56% but it was more frequent among type 1 diabetics. Newborns were small for gestational age in 9% of the cases and large for gestational age in 13%, without significant differences between different types of diabetes. In gestational diabetic women, birth weight was associated with mother’s body mass index, fasting glycemia at diagnosis, and HbA1c. Conclusion: Diabetes associated with pregnancy is a frequent reason for prenatal care at HCPA; gestational diabetes is the most frequent type of diabetes and, in these women, maternal obesity and worst glycemic control adversely influenced fetal birth weight. Patients arrive with a suboptimal glycemic control and start their treatment with undesirable delay.

Progression of retinopathy in type 1 diabetic women during pregnancy.

Progression of diabetic retinopathy (DR) occurs at least temporarily during pregnancy and postpartum. The pathogenetic mechanisms of DR progression during pregnancy are not fully understood. Several factors related to metabolic changes (hyperglycaemia), diabetes itself (duration of diabetes before conception, baseline status of DR), pregnancy physiology (hypervolaemia and hypercoagulation, impaired retinal autoregulation) and pregnancy complications (pre-eclampsia) seem to play important roles in the progression of DR during pregnancy. On the other hand, systemic angiopoietic and vasoactive factors seem to have minor role in the deterioration of DR during that time period. Good glycaemic control, normotension, lack of nephropathy as well as lack of pre-proliferative/proliferative changes of DR are good prognostic factors as regards the progression of DR during pregnancy. However, pregnancy seems to have no long-term detrimental effects as regards the progression of DR unless it has proceeded to pre-proliferative and proliferative phases.

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.

Macular capillary blood flow velocity by blue-field entoptoscopy in diabetic and healthy women during pregnancy and the postpartum period.

PURPOSE: To study macular capillary blood flow velocity in diabetic and healthy women during pregnancy and the postpartum period. METHODS: A prospective study of 46 pregnant women with insulin-dependent diabetes and 11 healthy pregnant women was performed. Macular capillary blood flow velocity was measured by blue-field entoptic simulation. Diabetic retinopathy was graded from colour fundus photographs. RESULTS: In diabetic women, the macular capillary blood flow velocity was 0.94+/-0.27 mm/s (mean +/- SD) during the first trimester, 1.00+/-0.28 mm/s during the third trimester and 1.03+/-0.24 mm/s 3 months postpartum, compared with values of 0.71+/-0.20, 0.77+/-+/-0.20 and 0.82+/-0.19 mm/s, respectively, in healthy women (P=0.0026 between groups). Diabetic women with no or very mild retinopathy had lower macular capillary blood flow velocities than those with more severe retinopathy (P=0.0164), but higher velocities than healthy women (P=0.0167). An increase temporally from the first trimester to the postpartum period was observed in diabetic women (P=0.0294) but not in healthy (P=0.2449) women. CONCLUSIONS: According to our study macular capillary blood flow velocity is higher in diabetic than in healthy women during pregnancy and the postpartum period. Further, capillary blood flow velocity seems to depend on the grade of retinopathy in pregnant diabetic women. These data support the concept that capillary hyperperfusion may play a role in the development of diabetic retinopathy during pregnancy.

[Diabetes and pregnancy. Past, present, and future]. / Diabetes e gravidez. Passado, presente e futuro.

After the discovery of insulin and during almost an half of a century, physicians and researchers apply their efforts in a better knowledge to reduce the perinatal mortality of the offspring of the diabetic mother. The optimisation of glucose control--the main key of the management of diabetic pregnancy--and the new methods of fetal and neonatal surveillance allowed that in the end of XX century the perinatal mortality were close to the general population. Nevertheless the perinatal morbidity is still elevated. Several studies suggest that fetal hyperinsulinism, consequence major of the abnormal intra uterine milieu of the diabetic mother, could be the cause of such morbidity at short and long term. In this paper, gestational diabetes is specially analysed. In spite of a large amount of studies, there is until know no diagnostic test that allows us to identify the pregnant women with a higher risk for a bad outcome namely, macrosomia and their consequences like caesarean section, traumatic delivery and neonatal complications. The ideal test should give that kind of information. Thus some methods of fetal surveillance had been proposed complementary. At this moment the health care professionals that are working in the field of diabetes and pregnancy are waiting for the results of the prospective multicentric study (HAPO study), hoping that a consensus could be reached about such a test.

Placental pathology in relation to the White's classification of diabetes mellitus.

The objective of this study was to investigate various macroscopic and microscopic features of the placenta in pregnancies complicated by diabetes according to White's classification. A total of 148 placentas were studied. Sixty-five were from control patients and 83 from diabetic mothers. The diabetic mothers were further divided into three groups according to White's classification. There were 40 cases in White's group A and 36 cases in White's group B. There were 7 cases in White's groups C and D combined. Advanced maternal age and grandmultiparity were significantly higher in White A, White B and White C&D compared to the normal group. Mean weight of the mother was higher in White group A and group B compared to the control group and group C&D. The placental weight and neonatal weight were increased provided the diabetes was not complicated by vascular disease. With accompanying vascular disease the placental weight and neonatal weight were reduced compared to the controls. As a result of increased perinatal jeopardy the rate of operative delivery was higher in diabetic mothers. No major difference was observed in microscopic changes of placentas in different groups according to White's classification and the normal group.

Diabetes in pregnancy.

A number of risk factors exist for pregnant women with diabetes and their babies. Collaborative care can ensure that women with pre-existing diabetes, and those who develop diabetes during pregnancy, receive appropriate and individualised care.

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.