Perinatal Outcome in Patients with Diabetes in Pregnancy and One Previous Caesarean Section: A Prospective Observational Service Evaluation

Abstract

Background: To determine the perinatal outcome in patients attending Joint obstetric and diabetic clinic who had diabetes and one previous caesarean section.Methods: A prospective service evaluation was conducted in a secondary care hospital having approximately 5100 deliveries per year. The combined cesarean section rate during the study period for all pregnant women and for all diabetic patients were 31% and 60%, respectively. Patients attending joint obstetric diabetic clinic from July 2015 to July 2016 were considered for the study. Fifty five (55) patients with both pregestational diabetes and gestational diabetes requiring pharmacotherapy and one previous caesarean, out of 358 patients who attended the clinic, were identified. The perinatal care, including timing, mode of delivery and indication for Cesarean section, maternal and neonatal outcomes were studied.Results: Out of 55 women, 8 (15%) had type 2 diabetes mellitus and 47 (85%) had gestational diabetes mellitus requiring pharmacotherapy. Initially, during antenatal follow up, 23 women (41%) were planned for vaginal birth after caesarean and 32(59%) were planned for elective cesarean section. Seven (7) women (13%) had a successful vaginal birth after cesarean section. These women had no additional risk factors and delivery was uneventful. Forty eight (48) women (87%) had cesarean section (elective, 60% and emergency, 27%). Eleven (75%) out of these 15 emergency cesarean section patients had additional risk factors that contributed to the decision for cesarean section. Most of the maternal complications 13/55 (23%) were in the cesarean section group and the majority were from emergency cesarean section group. Fifteen out of the fifty five cases (27%) were due to intra-uterine growth restriction, preeclampsia, eclampsia, abruption and postpartum hemorrhage. Similarly in all neonatal complications 14/55 (25%) were from the Cesarean section group (2 cases of small for gestational age, 6 cases of respiratory distress syndrome, 6 cases of Large for date). Among the 8 type 2 diabetes mellitus patients, 7 delivered by Cesarean section (4 emergencies and 3 elective) and only one had a successful vaginal birth after cesarean section. All 4 of the emergency Cesarean cases had additional risk factors.Conclusion: We found an exceptionally high caesarean section rate of 87% in our study which is almost twice as high as was found in the general diabetic pregnant population from other studies. Our study is the first of its kind to determine the cesarean section rate and perinatal outcome in combined pregestational and gestational diabetic patients requiring medical treatment and with one prior cesarean section. This study highlights the need for multi-centered studies to determine the optimal cesarean section rate that affords the lowest perinatal and maternal morbidity and mortality and also on how to modify these confounding factors so as to decrease the high caesarean section rate amongst this high risk group of patients.