Abstract
Background: The recommended gestational age to deliver pregnancies complicated by diabetes ranges from 34 to 39 weeks of gestation. The objective of this study was to determine the optimal gestational age for delivery of patients with diabetes to minimize perinatal death.Methods: We extracted a population-based cohort of singleton, nonanomalous infants of diabetic pregnancies from the Missouri birth registry for the period January 1, 1989 to December 31, 2005 and compared perinatal outcomes of planned deliveries at 37, 38, 39, and 40 weeks to expectant management. Planned deliveries were identified by induction or cesarean delivery without documented medical or obstetric indications. The primary outcome was perinatal death, defined as stillbirth or neonatal death within 28 days of birth. Secondary outcomes were independent stillbirth, independent neonatal death, and a composite adverse neonatal event of assisted ventilation >30 minutes, birth injury, seizures, or 5-minute Apgar score ≤3. Groups were compared using t test and chi-square as appropriate.Results: In 4,905 diabetic pregnancies reaching 37 weeks, 1,012 (20.6%) patients were insulin dependent. Overall, the risk of perinatal death at any gestational age examined was low (3/1,000 births or lower), as was the risk of the adverse perinatal outcome (<2%). When only patients who were insulin dependent were included in the analysis, the risk of perinatal death at any gestational age remained low at 6 per 1,000 births or fewer.Conclusion: Delivery as early as 37 weeks is reasonable for women who have diabetes, although the absolute risk of perinatal death is low at 37 to 39 weeks.
Highlights
Insulin, home blood glucose monitoring, antenatal testing, and oral hypoglycemic agents have revolutionized the management of diabetes during pregnancy,[1] leading to drastic reductions in maternal and infant mortality attributable to diabetic complications
In 1925, the perinatal mortality rate of infants born to mothers with diabetes was 40/1,000 births, compared to a rate of approximately 5/1,000 births in 2000.1 Despite these improvements, the risk of stillbirth remains 3to 4-fold higher in patients with pregnancies complicated by diabetes compared to patients without diabetes.[2]
The American College of Obstetricians and Gynecologists (ACOG), the Society for MaternalFetal Medicine (SMFM), and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) provide a broad range of gestational ages at which delivering pregnancies complicated by diabetes may be appropriate—from 34 to 39 weeks of gestation— delivery at 39 weeks is recommended by all in the setting of well-controlled diabetes without vascular disease, and the ACOG in 2019 recommended a range of 36 to 39 weeks.[3,4,5]
Summary
Home blood glucose monitoring, antenatal testing, and oral hypoglycemic agents have revolutionized the management of diabetes during pregnancy,[1] leading to drastic reductions in maternal and infant mortality attributable to diabetic complications. Methods: We extracted a population-based cohort of singleton, nonanomalous infants of diabetic pregnancies from the Missouri birth registry for the period January 1, 1989 to December 31, 2005 and compared perinatal outcomes of planned deliveries at 37, 38, 39, and 40 weeks to expectant management. When only patients who were insulin dependent were included in the analysis, the risk of perinatal death at any gestational age remained low at 6 per 1,000 births or fewer. Conclusion: Delivery as early as 37 weeks is reasonable for women who have diabetes, the absolute risk of perinatal death is low at 37 to 39 weeks
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