Diabetes Pregnancy Outcomes Research Articles

Using technology to improve diabetes pregnancy outcomes

Using technology to improve diabetes pregnancy outcomes

Treating to Target Glycaemia in Type 2 Diabetes Pregnancy.

There is an increasing awareness that in those who develop early-onset (18-39 years) adult type 2 diabetes, an increase in insulin resistance, deterioration in beta-cell, and clustering of cardiovascular risk factors are particularly pronounced. Pregnant women with type 2 diabetes have additional risk factors for serious adverse pregnancy outcomes as well as added barriers regarding healthcare access before, during, and after pregnancy. Compared to pregnant women with type 1 diabetes, those with type 2 diabetes are older, have higher body mass index (BMI), with more metabolic comorbidities and concomitant medications, are more likely to belong to minority ethnic groups, and live in the highest areas of socio-economic deprivation. Approximately, one in seven pregnant women with type 2 diabetes (median age 34 years) are taking ACE-inhibitors, statins (13%), and/or other potentially harmful diabetes therapies (7%). Fewer than one in four are taking a high dose of folic acid before pregnancy, which may suggest that planning for pregnancy is not a priority for women themselves, their healthcare professionals, or the healthcare system. Knowledge of the epidemiology, pathophysiology, and unique management considerations of early-onset type 2 diabetes is essential to providing evidence-based care to pregnant women with type 2 diabetes. This narrative review will discuss contemporary data regarding type 2 diabetes pregnancy outcomes and the increasing recognition that different types of diabetes may require different treatment strategies before, during, and after pregnancy.

Glucose and Calcium Profile in Infants of Diabetic and Nondiabetic mothers- A Comparative Study

Background: Diabetes is one of the commonest and most important metabolic disorders that affect the health of pregnant women and infants. Diabetic mellitus is one of the most common metabolic disorders complicating pregnancy. The neonatal mortality rate is over five times that of nondiabetic mothers and is higher irrespective of birth weight and gestational age. There has been significant improvement in the outcome of diabetic pregnancies largely due to better metabolic control before and during pregnancy and vigorous neonatal care in developed countries. The management in our country still poses a major challenge.
 Methods: This case-control study was designed to find out the association between an infant's hypoglycemia and hypocalcemia with maternal diabetes. For the research, a total of 300 neonates were selected, where cases were selected from infants of diabetic mothers, and the control group was selected from infants of nondiabetic mothers. The mothers were interviewed by specific questionnaire, selected neonates were examined, and some biochemical tests were done to find out the outcome.
 Results: The study included 300 neonates of diabetic and nondiabetic mothers. The mean age of the Mothers of these neonates was 25.36 (SD±5.50) years. Among diabetic mothers 115(76%) had GDM and 36(23.8%) had PGDM. It is revealed that 83 (55%) of 150 mothers took insulin as the treatment. Hypoglycemia in neonates of diabetic and nondiabetic mothers right after birth at their first ½ hour of age 111 (37%). Hypoglycemia was found in 94 (62.3%) of infants of the diabetic mother than only 17(11.4%) in infants of the nondiabetic mother. Where the p-value is <0.001, which explains developing hypoglycemia in the infant of a diabetic mother is higher than nondiabetic mother. The number of hypocalcemic infants of the diabetic mother was 34 (22.5%), while hypocalcemic infants of the nondiabetic mother were only 8 (5.4%), which is significantly (p-value <0.001) lower.
 Conclusions: Hypoglycemia and hypocalcemia in infants were directly associated with the presence of diabetes during pregnancy. In spite of intensive management of maternal diabetes, the infants of diabetic mothers continue to be a high-risk population. Among the pregnancies complicated by diabetes, GDM continues to have a major contribution. Hypoglycemia remains the most common biochemical abnormality, followed by hypocalcemia. Therefore, this pregnancy complication will require increased re- sources to manage appropriate glycemic control during pregnancy and reduce adverse perinatal outcomes.
 TAJ 2022; 35: No-2: 93-102

Maternal and perinatal outcome of pre-eclampsia in patients with gestational diabetes mellitus

Background: Pre-eclampsia is a leading cause of maternal mortality in Bangladesh. The most common problem of the gestational diabetic mother is increased incidence of pre-eclampsia. The aim of the study was to compare the maternal and perinatal outcome of diabetic pregnancy complicated with pre-eclampsia and without preeclampsia.
 Methods: This was a prospective observational study including 70 gestational diabetes mellitus (GDM) cases with pre-eclampsia and 70 patients with GDM without pre-eclampsia admitted in Obstetrics and Gynaecology Department of BIRDEM General Hospital-2. A detailed history was taken, and relevant data were collected through interview in a structured questionnaire and analyses were done according to objectives of the study.
 Results: In this study, 82% patients were delivered by Caesarean section in the study group (pre-eclampsia) and 72% patients were delivered by Caesarean section in the control group (p value 0.158). Rate of pre-term delivery was 55% in the studygroup and 32% in the control group (p value <0.001). In the study group percentage of intrauterine growth retardation (IUGR) was 11.4% and in control group proportion of percentage of IUGR was 1.4%. There was oligo-hydramnios in 32% subjects of the study group and 22% of control group (p value 3.32). In the study group 44% babies were low birth weight whereas in control group 8% were low birth weight (p value <0.001).
 Conclusion: The rates of pre-maturity and low birth weight were significantly higher among patients of GDM with pre-eclampsia in comparison to patients with GDM without pre-eclampsia.
 BIRDEM Med J 2022; 12(2): 106-110

407 Accelerated fetal abdominal circumference growth velocity (ACGV): a predictor of adverse outcomes in diabetic pregnancies

Diabetes mellitus in pregnancy is associated with an increased risk of fetal macrosomia and profound perinatal morbidity and mortality. Current prediction methods for macrosomia, including third trimester estimated fetal weight (tEFW), have poor sensitivity. Other modalities like the use of abdominal circumference (AC) have been used but still fare poorly in predicting outcomes. Our objective was to investigate the predictive ability of the change in the AC over time, or AC growth velocity (ACGV), for fetal macrosomia and adverse perinatal outcomes. In this retrospective cohort study, 312 subjects with either pre-gestational diabetes (PGD) or gestational diabetes mellitus (GDM) with documented ultrasounds at 19w0d – 21w6d and 35w0d – 36w6d from 2013-2019 were analyzed. ACs at these intervals were used to calculate ACGV. ACGV ≥90th percentile was considered accelerated and was compared to tEFW ≥90th percentile. Chi square tests were used for categorical variables and area under the receiver operator curves (AUC) were calculated for ACGV and tEFW. Of the 312 patients, 39.4% had PGD and 60.6% had GDM. An accelerated ACGV (aACGV) was predictive of several clinically important adverse outcomes in diabetic pregnancies (see Table 1) and was a significantly better predictor for large for gestational age (LGA) babies in women with PGD as compared to women with GDM (AUC 0.86 vs 0.74, p=0.03). When comparing aACGV with tEFW, both performed similarly in their prediction of fetal macrosomia. tEFW was better at predicting LGA (AUC 0.84 vs 0.75, p=0.001), but aACGV was significantly better at predicting neonatal hypoglycemia (AUC 0.62 vs 0.56, p=0.04). Accelerated ACGV is an effective screening tool for predicting adverse outcomes in diabetic pregnancies and appears to fare better than tEFW for determining which neonates will require glycemic support after delivery. aACGV performed similarly to tEFW in predicting fetal macrosomia.

87 - Adverse Fetal and Neonatal Outcomes in Diabetic Pregnancies in Nova Scotia From 1988-2002 and 2003-2015

Pre-existing diabetes in pregnancy is related to adverse fetal and neonatal outcomes. We aimed to determine rates of these outcomes and changes over time among pregnancies associated with pre-existing diabetes in Nova Scotia (NS).

SUN-642 Paracetamol May Increase Cardiac Congenital Malformations Risk in Prediabetic Pregnancy Women

ABSTRACTHyperglycemia can influence the development of the fetal heart, affecting both its structure and its function. Prospective and retrospective cohort studies have demonstrated an increased risk of congenital abnormalities with gestational diabetes. This observation is probably related to the inclusion of women with unrecognized type 2 diabetes (Allen, 2007, Pasarella, 2013).Substantial literature indicates that diabetes in pregnant rats and mice induces embryo lethality, growth retardation, and a variable incidence of birth defects. Then, the maintenance of normal concentrations of metabolites from all nutrient classes may be important for prevention of adverse fetal outcome in diabetic pregnancy.Acetaminophen overdose is the most often cause of acute liver injury and obese women are in particular risk, because is able to induce mitochondrial oxidative stress (Rousar, 2012). Acetaminophen (Paracetamol) over doses decreased embryonic low-molecular-weight thiols (glutathione and cysteine), compounds that play a vital role in the detoxication of exogenous and endogenous chemicals (Mitchell, 1973, Beck, 2001, Rousar, 2012, rev).The apparent safety of Paracetamol drug, a useful analgesic only (with no anti-inflammatory properties) (Neto, 2004; Hamlyn, 1978, Ucheya, 2006, Bessems, 2001) is compromized by its widespread and extensive chronic use, particularly in Peruvian population- Paracetamol though considered safe at a considerable low dose, especially in women, could cause kidney derangement and cardiac malformations during pregnant state (Ucheya, 2006), if the drug is ingested in the first trimester. Major congenital malformations, including those affecting the cardiovascular system, remain the leading cause of mortality and morbidity in infants of diabetic mothers (Pinter, 2001). Thus, there is an overcome potential maternal acetaminophen (paracetamol) toxicity (Horowitz, 1997).

A Prospective Study of the Neonatal Outcome in Diabetic Pregnancies

A Prospective Study of the Neonatal Outcome in Diabetic Pregnancies

Real-Time Change-Point Detection Algorithm with an Application to Glycemic Control for Diabetic Pregnant Women

Glycemic control in pregnancies of diabetic women is still suboptimal; birth defects and late miscarriages (i.e., second trimester miscarriages) are much more common in diabetic pregnancies than in the general population. This paper presents a pilot study for real-time detection of dangerous changes in glucose level, namely such that are associated with birth defects or miscarriage during the first trimester of pregnancy. Its main goals are to present an algorithm and to verify that it has practical potential to notify early enough of an increased risk of adverse outcomes in diabetic pregnancies. The study included eight women with type 1 diabetes who wore a Continuous Glucose Monitor (CGM; a device that reads and transmits the glucose level every five minutes) during the entire first trimester. Nonparametric change-point detection methods were applied on CGM data; results show evidence that an increase in glucose variability is associated with heightened risk for late miscarriage, and that this change could have been detected early enough to reduce fluctuations. By contrast, standard indicators for glycemic control in pregnancy failed to identify this peril.

Paracetamol and Cardiac Congenital Malformations in Prediabetic Pregnancy Women

Hyperglycemia can influence the development of the fetal heart, affecting both its structure and its function. Prospective and retrospective cohort studies have demonstrated an increased risk of congenital abnormalities with gestational diabetes. This observation is probably related to the inclusion of women with unrecognized type 2 diabetes [1, 2]. Substantial literature indicates that diabetes in pregnant rats and mice induces embryo lethality, growth retardation and a variable incidence of birth defects. Then, the maintenance of normal concentrations of metabolites from all nutrient classes may be important for prevention of adverse fetal outcome in diabetic pregnancy. Acetaminophen overdose is the most often cause of acute liver injury and obese women are in particular risk, because is able to induce mitochondrial oxidative stress [3]. Acetaminophen (Paracetamol) over doses decreased embryonic low-molecularweight thiols (glutathione and cysteine), compounds that play a vital role in the detoxication of exogenous and endogenous chemicals [3-5]. The apparent safety of Paracetamol drug, a useful analgesic only (with no anti-inflammatory properties) is compromised by its widespread and extensive chronic use, particularly in Peruvian population, where its analgesic is doing without control [6-9]. In fact, paracetamol though considered safe at a considerable low dose, especially in women could cause kidney derangement and cardiac malformations during pregnant state if the drug is ingested in the first trimester [8]. Major congenital malformations, including those affecting the cardiovascular system, remain the leading cause of mortality and morbidity in infants of diabetic mothers [10]. Thus, there is overcome potential maternal acetaminophen (paracetamol) toxicity [11].

The Influence of Hyperglycemia on the Outcome of Diabetic Pregnancies

Abstract At the beginning of the last century, the association between diabetes mellitus and pregnancy was credited with a high risk of complications and mortality. However, nowadays, such issue no longer bears such a pessimistic approach. Planning the pregnancy during a period of optimal metabolic control and careful monitoring of the pregnant woman significantly reduces maternal and fetal mortality. The most important aspects of fetal pathology are: intrauterine fetal death, congenital malformations, growing disorders (macrosomia or delays in growing), neonatal hypoglycemia, respiratory distress syndrome, hypertrophic cardiomyopathy etc. The fetus’s viability is significantly impacted if a quality maternal glycemic control is not obtained at least 3 months prior to birth, as well as throughout the entire pregnancy term (particularly during the first 10 weeks, term during which organogenesis is completed). This systematic review of scientific literature aims to summarize the pathogenic ways in which hyperglycemia may influence the fetus of women with Diabetes Mellitus.

English

Extract of Ocimum gratissimum (OG), also known as scent leaf, is popularly used to treat diabetes mellitus and its hypoglycaemic activity has been confirmed by in vivo studies. The aim was to investigate the effect of this extract on placenta development and birth outcome in diabetic pregnancy. Forty two pregnant rats weighing 150-200 g were used. They were divided into control and extract treated diabetic and non-diabetic groups with 6 rats in each subgroup. Extract treated groups were administered 200 and 400 mg/kg of ethanolic extract of OG orally after the induction of diabetes by administration of alloxan monohydrate after an overnight fast. Treatment commenced in the second trimester and lasted till end of pregnancy. On day 18 of pregnancy, 3 rats from each group were sacrificed and placentae harvested and weighed. On the day of delivery, birth weight and other parameters were recorded. Results show that OG administration caused a significant decrease in placental weights, birth weights, litter sizes and placental-birth weight ratio in both diabetic and non-diabetic pregnancy. In conclusion, the observed decrease in placenta-birth weight ratios may suggest a protective beneficial effect of this extract against macrosomia in diabetic pregnancies and increased risk of cardiovascular disease later in life. Key words: Ocimum gratissimum, gestational diabetes, placenta-birth weight ratio, pregnancy outcome, postnatal growth.

Diabetes and Pregnancy

Diabetes and Pregnancy

Assessment of fetal myocardial performance index in women with pregestational and gestational diabetes mellitus.

Fetal cardiac left ventricular function in pregnant women with pregestational or gestational diabetes mellitus was investigated by exploring fetal myocardial performance index (MPI) and E wave/A wave peak velocity (E/A) ratio. Seventy pregnant women with either pregestational or gestational diabetes mellitus and with no other systemic or pregnancy related disorders were compared with 70 gestational age matched healthy controls by means of fetal left ventricular MPI and E/A ratio. Opening and closing clicks of the mitral and aortic valves were used to define the three time periods: ejection time (ET), isovolumetric contraction time (ICT) and isovolumetric relaxation time (IRT), which were employed in the calculation of MPI (MPI = [ICT + IRT]/ET). Statistical analyses were conducted using receiver operating characteristic analysis and independent two-sample t, Mann-Whitney U and chi-square tests. Fetal left ventricular MPI values were significantly higher in the diabetic group compared with controls (0.56 ± 0.09 vs 0.36 ± 0.04, P < 0.001), whereas E/A ratio was lower (0.66 ± 0.11 vs 0.69 ± 0.09, P = 0.049). The adverse perinatal outcome rate was also higher in the diabetic group. Receiver operating characteristic analysis revealed > 0.39 as the optimal cut-off level for MPI in perinatal adverse outcome prediction (sensitivity: 90.9%, specificity: 47.7%, area under the curve: 0.690, 95% confidence interval: 0.598-0.782, P < 0.001). We conclude that fetuses of diabetic mothers have significant left ventricular systolic and diastolic dysfunction. MPI may be used in the prediction of adverse perinatal outcome in diabetic pregnancies.

Contemporary type 1 diabetes pregnancy outcomes: impact of obesity and glycaemic control.

To compare contemporary pregnancy outcomes in women with and without type 1 diabetes, and to examine the effects of obesity and glycaemic control on these outcomes. Historical cohort study in a specialist diabetes and maternity network in Victoria. All singleton births (at least 20 weeks' gestation), 2010-2013, were analysed: 107 pregnancies to women with type 1 diabetes and 27 075 pregnancies to women without diabetes. Women with type 2 diabetes or gestational diabetes were excluded. Data were extracted from the Birthing Outcomes System database; associations between type 1 diabetes and pregnancy outcomes were analysed by multivariable regression. Mode of birth; maternal and neonatal outcomes. The mean body mass index was higher for women with type 1 diabetes than for women without diabetes (mean, 27.3 kg/m(2) [SD, 5.0] v 25.7 kg/m(2) [SD, 5.9]; P = 0.01); the median gestation period for their babies was shorter (median, 37.3 weeks [IQR, 34.6-38.1] v 39.4 weeks [IQR, 38.4-40.4]; P <0.001) and they were more likely to be large for gestational age (LGA) (adjusted odds ratio [aOR], 7.9; 95% CI, 5.3-11.8). Women with type 1 diabetes were more likely to have had labour induced (aOR, 3.0; 95% CI, 2.0-4.5), a caesarean delivery (aOR, 4.6; 95% CI, 3.1-7.0), or a pre-term birth (aOR, 6.7; 95% CI, 4.5-10.0); their babies were more likely to have shoulder dystocia (aOR, 8.2; 95% CI, 3.6-18.7), hypoglycaemia (aOR, 10.3; 95% CI, 6.8-15.6), jaundice (aOR, 5.1; 95% CI, 3.3-7.7), respiratory distress (aOR, 2.5; 95% CI, 1.4-4.4) or to suffer perinatal death (aOR, 4.3; 95% CI, 1.9-9.9). In women with type 1 diabetes, greater obesity was associated with increased odds for an LGA baby or congenital malformation, and increased HbA1c levels were associated with pre-term birth and perinatal death. Women with type 1 diabetes, even when managed in a specialist setting, still experience adverse obstetric and neonatal outcomes. Poor glycaemic control is not wholly responsible for adverse outcomes, reinforcing the importance of other risk factors, such as obesity and weight gain.

Gene expression profiling of changes induced by maternal diabetes in the embryonic heart.

Cardiovascular defects are one of the most common congenital defects associated with maternal diabetes. Based on whole embryo gene expression microarray analysis, 11 genes were chosen for temporal expression analysis of diabetes-exposed hearts. The majority of the selected genes were deregulated in diabetes-exposed hearts compared to our controls at E13.5, E14.5, and E18.5. We showed increased hypoxia and HIF-1α protein levels in diabetes-exposed hearts at E10.5, which is a critical time point for the induction of developmental defects associated with diabetic embryopathy. Additionally, we found increased cardiac Vegfa levels that might trigger developmental abnormalities associated with diabetic embryopathy. Our results show that maternal diabetes affects the temporal expression pattern of gene encoding molecules involved in heart development and tissue remodelling and that these molecules might affect heart maturation processes and thus, the final outcome of diabetic pregnancies.

Outcome of Diabetic Pregnancies in a Tertiary Referral Centre, Varanasi.

The study was done to determine the maternal and fetal outcome of pregnancies complicated by maternal diabetes either Gestational Diabetes Mellitus (GDM) or preexisting (type 1 or type 2) diabetes over a period from March 2011 to Feb 2013 in a tertiary care hospital, Varanasi. This is a retrospective audit of the maternal and fetal outcome of women who presented to the Sir Sundar Lal Hospital, Department of Obstetrics and Gynaecology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India from March 2011 to Feb 2013, with GDM or pre-existing type 1 or type 2 Diabetes with pregnancy. The audit group comprised 65 pregnancies (67 babies), of whom 27 had preexisting diabetes and 38 cases developed gestational diabetes. Pregnant women who were found to be diabetic preconceptionally or in the first trimester were classified as 'pre-existing diabetes'. There were total of 65 diabetic women in this retrospective study, 39 women were GDM (60%) while 26 women (40%) were having pre-existing diabetes (24 type 1 diabetes and 2 women were in type 2 diabetes group). There were 35 multigravid women (53.85%) and 30 primigravid women (46.15%). There were 39 (60%) women on Insulin. There were 42 Lower Segment Caesarean Section (64.62%) and 23 Spontaneous Vaginal Delivery (35.38%). In fetal and neonatal complications, there were three still births, one case of intrapartum death, and one case of shoulder dystocia. Fetal anomalies were less frequent, one case of Gastroschisis with Hydrocephalus associated with Menigomyelocoele, there was one case of isolated Hydrocephalus, and there was also one case of Truncus arteriosus. The study analyses maternal and fetal complication in the GDM group and also preexisting diabetes group. In our centre, the 60% women were GDM while 40% were having pre-existing diabetes. Total rate of fetal/neonatal complication rate was 7.69% and of congenital anomaly rate it was 9.23%. Proportion of still birth, Intrauterine death, and congenital malformations was higher in the pre-existing diabetes group although the data are not large enough to draw a statistically significant conclusion. LSCS rate was little higher in the GDM group (69.23%) in comparison to the preexisting diabetes group where it was 57.69%. SVD (Spontaneous Vaginal Delivery) rate was 30.77% in GDM and 42.31% in the pre-existing diabetes group. HbA1c was within normal range 84.62% of GDM group while in 15.38% it was raised >6%. In the pre-existing diabetes group, only 19.23% of women had HbA1c within acceptable range and 80.77% had it >6. The aim of St Vincent Declaration is to 'achieve pregnancy outcome in the diabetic woman that is similar to that of the non-diabetic woman.' But, so far we have not been able to achieve this. Our HbA1c level is remarkably high in the pre-existing diabetes group. Only 3 out of 65 patients' women took Folic Acid periconceptionally. We need to work to achieve it our best. It is well known that insulin treatment during pregnancy results in reduction in the rate of macrosomia, fetal/neonatal, and maternal complications. Therefore, we need to use insulin judiciously and advocate its usage in the situations where it is needed.

Improving outcomes in diabetic pregnancies

Improving outcomes in diabetic pregnancies

674: Obesity does not worsen outcomes in diabetic pregnancies

women who were 13 at 6 mo or 1 yr, had a higher score at 1 mo compared to women who stayed screen negative (8 vs. 4) (p 0.001). Median EPDS at 6 and 12 mo PP were persistently higher for those who screened positive at 1 mo PP (9 vs 4 at each time point). Contrary to prior reports, being high risk for PPD at 1 mo was not associated with PP weight retention at 1 yr. However, high risk EPDS scores at 1 mo were associated with less maternal sleep at 6 mo PP, a higher likelihood of smoking (p .05), not using birth control (p .01), and becoming pregnant again by 6 mo PP (p .05). CONCLUSION: Postpartum depression signals a series of risks to the mother, including ongoing depression, inadequate sleep, smoking, and rapid repeat pregnancies. All are of high relevance to obstetric providers and demand additional focus and intervention.

Biomarkers of maternal diabetes and its complication in pregnancy

There are specific biomarkers – indicators of normal and abnormal processes – in diabetic pregnancies that predict the degree of diabetic control as well as embryonic and fetal growth and development. They can be detected in maternal blood, amniotic fluid or in the cord plasma of the newborn infant. While the cord plasma levels are of little clinical relevance because they do not allow us to interfere with the outcome of pregnancy, biomarkers in maternal blood or amniotic fluid may help us to better control the outcome of diabetic pregnancies. Important biomarkers in maternal blood are fasting glucose, HbA1c and IGFs. Relevant biomarkers in amniotic fluid are insulin, erythropoietin and markers of bone formation and resorption. Cord plasma biomarkers include IGFs, leptin, adiponectin, resistin, markers of oxidative stress and of hypoxia. Whether these biomarkers can be predictors of long term outcome in infants of diabetic mothers is yet to be determined.