DIAB-6537; No. of Pages 6 diabetes research and clinical practice xxx (2016) xxx–xxx
Contents available at ScienceDirect
Diabetes Research and Clinical Practice journ al h ome pa ge : www .elsevier.co m/lo cate/diabres
Pregnancy outcome in pregnancies complicated with gestational diabetes mellitus and late preterm birth Amir Aviram a,b, Liora Guy a,b, Eran Ashwal a,b, Liran Hiersch a,b, Yariv Yogev a,b, Eran Hadar a,b,* a b
Helen Schneider Hospital for Women, Rabin Medical Center, Petah-Tikva, Israel The Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Tel-Aviv, Israel
article info
abstract
Article history:
Aim: To assess pregnancy outcome among women with gestational diabetes mellitus (GDM)
Received 18 July 2015
delivering at the late preterm period.
Received in revised form
Methods: Retrospective observational cohort of all women with GDM who delivered a
15 October 2015
singleton fetus at the late preterm birth period (34 + 0/7 to 36 + 6/7 weeks of gestation).
Accepted 24 December 2015
The study group included all women diagnosed with GDM and were compared to a control
Available online xxx
group of women delivering at the same gestational age period but without known GDM.
Keywords:
GDM and 1717 (92.9%) were not. Women with GDM had a lower rate of spontaneous vaginal
Gestational diabetes mellitus
delivery (45.5% vs. 62.9%, p < 0.001) and a higher rate of cesarean delivery (50.8% vs. 31.8%,
Results: 1849 women were included in the study, of whom 132 (7.1%) were diagnosed with
Late
p < 0.001). GDM diagnosis incurs an adjusted ratio of 1.82 for cesarean delivery (95% CI 1.24–
Preterm birth
2.66, p = 0.002). Neonates of mothers with GDM had significant higher mean birth weight and
Neonatal Outcome
birth weight percentile, including higher rate of large-for-gestational age newborns. There were no differences in mortality or other parameters for neonatal morbidity. Conclusion: according to our data, late preterm occurring in women with GDM does not confer an increased risk for neonatal complications. # 2016 Elsevier Ireland Ltd. All rights reserved.
1.
Introduction
Gestational diabetes mellitus (GDM) complicates approximately 10% of all pregnancies [1]. It is associated with short and long term adverse outcome for the mother, fetus and newborn [2]. One of the potential contributors to diabetes associated morbidity is preterm birth (PTB)—either spontaneous or medically indicated. Although some investigators did
not report an increased risk for PTB among women with GDM [3,4], others demonstrated that GDM by itself is a risk factor for prematurity [5–8]. The overall rate of PTB, as well as late PTB (between 34 + 0/7 and 36 + 6/7 weeks of gestation), has been rising steadily in the last decades. This is attributed mainly to medical interventions such as early cesarean deliveries and inductions of labor [9]. Compared to term infants, late preterm newborns are at a higher risk for cerebral palsy (CP), intra ventricular
* Corresponding author at: The Helen Schneider Hospital for Women, Rabin Medical Center, Zabotinsky Street, Petach-Tikva 49100, Israel. Tel.: +972 3 9377400; fax: +972 3 5038189. E-mail address: [email protected] (E. Hadar). http://dx.doi.org/10.1016/j.diabres.2015.12.018 0168-8227/# 2016 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: Aviram A, et al. Pregnancy outcome in pregnancies complicated with gestational diabetes mellitus and late preterm birth. Diabetes Res Clin Pract (2016), http://dx.doi.org/10.1016/j.diabres.2015.12.018
DIAB-6537; No. of Pages 6
2
diabetes research and clinical practice xxx (2016) xxx–xxx
hemorrhage (IVH), respiratory morbidity, hypoglycemia, jaundice and death [10,11]. Overall, for late PTB, morbidity rates double for each additional week below 37 weeks of gestation. GDM is an independent risk factor for respiratory morbidity even after 34 weeks of gestation [12], with a 3–4 increase in complications among infants of mothers with diabetes in pregnancy [13]. Moreover, the occurrence of respiratory morbidity among late PTB newborns is higher than in term infants [14], with a 5–9 fold increase in need for ventilation [15]. Paucity of data exists regarding the implications of GDM combined with late PTB on obstetrical and neonatal outcome [16]. Therefore we aimed to assess pregnancy outcome among women with GDM delivering at the late preterm period, and to investigate whether they have a synergistic additive effect on obstetrical and neonatal outcomes.
2.
Materials and methods
We conducted a retrospective observational cohort study of all women who delivered at a single, university affiliated medical center from 2009 to 2014, at the late preterm birth period (34 + 0/7 to 36 + 6/7 weeks of gestation) with GDM. The study was approved by the local institutional review board.
2.1.
Study population
Eligibility was limited to pregnant women with singleton pregnancies, delivering at the late preterm period, between 34 + 0/7 and 36 + 6/7 weeks of gestation. Women with a fetus or a newborn having confirmed chromosomal and/or structural congenital anomalies were excluded, as well as gravidas with pre-gestational diabetes. The study group included all women diagnosed with GDM and were compared to a control group of women delivering at the same gestational age period but without known GDM.
2.2.
Data collection
Data were retrieved from the comprehensive computerized databases of the delivery ward and fetal-maternal diabetes clinic, and cross tabulated using an individualized identification number per woman. Data from the neonatal unit and the neonatal intensive care unit (NICU) were integrated into the delivery room database using the unique admission number assigned to each parturient and her offspring. Collected data included demographical data as well as obstetrical data, sonographic biometric measurements, labor and delivery outcome and neonatal data.
2.3.
Carpenter and Coustan’s criteria [18]. Women diagnosed with GDM were referred to a multidisciplinary specialized clinic, and were treated with appropriate diet and lifestyle modification, combined with either Glyburide or Insulin, if glycemic control is no achieved. Birth weight percentile was calculated using gender specific local population based birth weight curves [19]. Large for gestational age babies were defined as newborns with birth weight above the 90th percentile for gestational age. Hypertension present at or prior to 20 weeks of gestation that did not progress to preeclampsia–toxemia was classified as chronic hypertension. After 20 weeks of gestation, hypertensive disorders in pregnancy were categorized according to the international society for the study of hypertension in pregnancy guidelines [20]. Oligohydramnion and polyhydramnios were diagnosed when amniotic fluid volume measurements were below 50 mm or above 250 mm, respectively [21]. Minor perineal laceration was considered as grade 1 or 2 perineal tears or episiotomy, and major perineal trauma was defined as grade 3 or 4 perineal tears. All neonatal outcomes were determined by the attending pediatrician according to international and national definitions. Composite neonatal adverse outcome was defined as one or more of the following: admission to the neonatal intensive care unit (NICU), neonatal asphyxia, seizures, hemorrhagic-ischemic encephalopathy (HIE), intraventricular hemorrhage (IVH), pH < 7.05, hypoglycemia (blood glucose levels < 40 mg/dl), respiratory distress syndrome (RDS), necrotizing enterocolitis (NEC), transient tachypnea of the newborn (TTN), meconium aspiration syndrome (MAS), neonatal sepsis or respiratory support. Composite respiratory adverse outcome was defined as one or more of the following: RDS, TTN and respiratory support by either continuous positive airway pressure (CPAP) or mechanical ventilation.
2.4.
Statistical analysis
Statistical analysis was performed using the SPSS software (IBM SPSS statistics version 20.0, Chicago, IL, USA). Comparison between continuous variables was performed with Students’ T-test, and categorical data were compared using x2 test or Fisher’s exact test. Multivariate logistic regression and adjusted odds ratios were calculated where appropriate. A probability value 140 mg/dl) followed by an abnormal 100 g oral glucose tolerance test (OGTT). Screening and diagnosis of GDM is universally performed at 24 to 28 weeks of gestation, and diagnosis was established according to
Overall, 39,573 women delivered a singleton non-anomalous baby in our institution during the study period. We excluded women with pre-gestational diabetes (n = 48) and those who delivered prior to 34 completed weeks of gestation (n = 1473) or beyond 37 completed weeks of gestation (n = 36,203). Thus, 1849 women were eligible for final analysis after implementing the exclusion criteria. Of the eligible women, 132/1849 (7.1%) were diagnosed with GDM and 1717/1849 (92.9%) were not diagnosed with GDM.
Please cite this article in press as: Aviram A, et al. Pregnancy outcome in pregnancies complicated with gestational diabetes mellitus and late preterm birth. Diabetes Res Clin Pract (2016), http://dx.doi.org/10.1016/j.diabres.2015.12.018
DIAB-6537; No. of Pages 6
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diabetes research and clinical practice xxx (2016) xxx–xxx
Table 1 – Characteristics for women with or without GDM at late preterm birth. Parameter
GDM (n = 132)
Non GDM (n = 1717)
p Value
34.1 6.0 3.0 2.2 2.3 1.4 52 (39.4) 35.4 0.8 34 (25.8) 72 (54.5)
31.1 5.2 2.8 2.0 2.2 1.4 660 (38.4) 35.4 0.8 257 (15.0) 918 (53.5)
Contents available at ScienceDirect
Diabetes Research and Clinical Practice journ al h ome pa ge : www .elsevier.co m/lo cate/diabres
Pregnancy outcome in pregnancies complicated with gestational diabetes mellitus and late preterm birth Amir Aviram a,b, Liora Guy a,b, Eran Ashwal a,b, Liran Hiersch a,b, Yariv Yogev a,b, Eran Hadar a,b,* a b
Helen Schneider Hospital for Women, Rabin Medical Center, Petah-Tikva, Israel The Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Tel-Aviv, Israel
article info
abstract
Article history:
Aim: To assess pregnancy outcome among women with gestational diabetes mellitus (GDM)
Received 18 July 2015
delivering at the late preterm period.
Received in revised form
Methods: Retrospective observational cohort of all women with GDM who delivered a
15 October 2015
singleton fetus at the late preterm birth period (34 + 0/7 to 36 + 6/7 weeks of gestation).
Accepted 24 December 2015
The study group included all women diagnosed with GDM and were compared to a control
Available online xxx
group of women delivering at the same gestational age period but without known GDM.
Keywords:
GDM and 1717 (92.9%) were not. Women with GDM had a lower rate of spontaneous vaginal
Gestational diabetes mellitus
delivery (45.5% vs. 62.9%, p < 0.001) and a higher rate of cesarean delivery (50.8% vs. 31.8%,
Results: 1849 women were included in the study, of whom 132 (7.1%) were diagnosed with
Late
p < 0.001). GDM diagnosis incurs an adjusted ratio of 1.82 for cesarean delivery (95% CI 1.24–
Preterm birth
2.66, p = 0.002). Neonates of mothers with GDM had significant higher mean birth weight and
Neonatal Outcome
birth weight percentile, including higher rate of large-for-gestational age newborns. There were no differences in mortality or other parameters for neonatal morbidity. Conclusion: according to our data, late preterm occurring in women with GDM does not confer an increased risk for neonatal complications. # 2016 Elsevier Ireland Ltd. All rights reserved.
1.
Introduction
Gestational diabetes mellitus (GDM) complicates approximately 10% of all pregnancies [1]. It is associated with short and long term adverse outcome for the mother, fetus and newborn [2]. One of the potential contributors to diabetes associated morbidity is preterm birth (PTB)—either spontaneous or medically indicated. Although some investigators did
not report an increased risk for PTB among women with GDM [3,4], others demonstrated that GDM by itself is a risk factor for prematurity [5–8]. The overall rate of PTB, as well as late PTB (between 34 + 0/7 and 36 + 6/7 weeks of gestation), has been rising steadily in the last decades. This is attributed mainly to medical interventions such as early cesarean deliveries and inductions of labor [9]. Compared to term infants, late preterm newborns are at a higher risk for cerebral palsy (CP), intra ventricular
* Corresponding author at: The Helen Schneider Hospital for Women, Rabin Medical Center, Zabotinsky Street, Petach-Tikva 49100, Israel. Tel.: +972 3 9377400; fax: +972 3 5038189. E-mail address: [email protected] (E. Hadar). http://dx.doi.org/10.1016/j.diabres.2015.12.018 0168-8227/# 2016 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: Aviram A, et al. Pregnancy outcome in pregnancies complicated with gestational diabetes mellitus and late preterm birth. Diabetes Res Clin Pract (2016), http://dx.doi.org/10.1016/j.diabres.2015.12.018
DIAB-6537; No. of Pages 6
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diabetes research and clinical practice xxx (2016) xxx–xxx
hemorrhage (IVH), respiratory morbidity, hypoglycemia, jaundice and death [10,11]. Overall, for late PTB, morbidity rates double for each additional week below 37 weeks of gestation. GDM is an independent risk factor for respiratory morbidity even after 34 weeks of gestation [12], with a 3–4 increase in complications among infants of mothers with diabetes in pregnancy [13]. Moreover, the occurrence of respiratory morbidity among late PTB newborns is higher than in term infants [14], with a 5–9 fold increase in need for ventilation [15]. Paucity of data exists regarding the implications of GDM combined with late PTB on obstetrical and neonatal outcome [16]. Therefore we aimed to assess pregnancy outcome among women with GDM delivering at the late preterm period, and to investigate whether they have a synergistic additive effect on obstetrical and neonatal outcomes.
2.
Materials and methods
We conducted a retrospective observational cohort study of all women who delivered at a single, university affiliated medical center from 2009 to 2014, at the late preterm birth period (34 + 0/7 to 36 + 6/7 weeks of gestation) with GDM. The study was approved by the local institutional review board.
2.1.
Study population
Eligibility was limited to pregnant women with singleton pregnancies, delivering at the late preterm period, between 34 + 0/7 and 36 + 6/7 weeks of gestation. Women with a fetus or a newborn having confirmed chromosomal and/or structural congenital anomalies were excluded, as well as gravidas with pre-gestational diabetes. The study group included all women diagnosed with GDM and were compared to a control group of women delivering at the same gestational age period but without known GDM.
2.2.
Data collection
Data were retrieved from the comprehensive computerized databases of the delivery ward and fetal-maternal diabetes clinic, and cross tabulated using an individualized identification number per woman. Data from the neonatal unit and the neonatal intensive care unit (NICU) were integrated into the delivery room database using the unique admission number assigned to each parturient and her offspring. Collected data included demographical data as well as obstetrical data, sonographic biometric measurements, labor and delivery outcome and neonatal data.
2.3.
Carpenter and Coustan’s criteria [18]. Women diagnosed with GDM were referred to a multidisciplinary specialized clinic, and were treated with appropriate diet and lifestyle modification, combined with either Glyburide or Insulin, if glycemic control is no achieved. Birth weight percentile was calculated using gender specific local population based birth weight curves [19]. Large for gestational age babies were defined as newborns with birth weight above the 90th percentile for gestational age. Hypertension present at or prior to 20 weeks of gestation that did not progress to preeclampsia–toxemia was classified as chronic hypertension. After 20 weeks of gestation, hypertensive disorders in pregnancy were categorized according to the international society for the study of hypertension in pregnancy guidelines [20]. Oligohydramnion and polyhydramnios were diagnosed when amniotic fluid volume measurements were below 50 mm or above 250 mm, respectively [21]. Minor perineal laceration was considered as grade 1 or 2 perineal tears or episiotomy, and major perineal trauma was defined as grade 3 or 4 perineal tears. All neonatal outcomes were determined by the attending pediatrician according to international and national definitions. Composite neonatal adverse outcome was defined as one or more of the following: admission to the neonatal intensive care unit (NICU), neonatal asphyxia, seizures, hemorrhagic-ischemic encephalopathy (HIE), intraventricular hemorrhage (IVH), pH < 7.05, hypoglycemia (blood glucose levels < 40 mg/dl), respiratory distress syndrome (RDS), necrotizing enterocolitis (NEC), transient tachypnea of the newborn (TTN), meconium aspiration syndrome (MAS), neonatal sepsis or respiratory support. Composite respiratory adverse outcome was defined as one or more of the following: RDS, TTN and respiratory support by either continuous positive airway pressure (CPAP) or mechanical ventilation.
2.4.
Statistical analysis
Statistical analysis was performed using the SPSS software (IBM SPSS statistics version 20.0, Chicago, IL, USA). Comparison between continuous variables was performed with Students’ T-test, and categorical data were compared using x2 test or Fisher’s exact test. Multivariate logistic regression and adjusted odds ratios were calculated where appropriate. A probability value 140 mg/dl) followed by an abnormal 100 g oral glucose tolerance test (OGTT). Screening and diagnosis of GDM is universally performed at 24 to 28 weeks of gestation, and diagnosis was established according to
Overall, 39,573 women delivered a singleton non-anomalous baby in our institution during the study period. We excluded women with pre-gestational diabetes (n = 48) and those who delivered prior to 34 completed weeks of gestation (n = 1473) or beyond 37 completed weeks of gestation (n = 36,203). Thus, 1849 women were eligible for final analysis after implementing the exclusion criteria. Of the eligible women, 132/1849 (7.1%) were diagnosed with GDM and 1717/1849 (92.9%) were not diagnosed with GDM.
Please cite this article in press as: Aviram A, et al. Pregnancy outcome in pregnancies complicated with gestational diabetes mellitus and late preterm birth. Diabetes Res Clin Pract (2016), http://dx.doi.org/10.1016/j.diabres.2015.12.018
DIAB-6537; No. of Pages 6
3
diabetes research and clinical practice xxx (2016) xxx–xxx
Table 1 – Characteristics for women with or without GDM at late preterm birth. Parameter
GDM (n = 132)
Non GDM (n = 1717)
p Value
34.1 6.0 3.0 2.2 2.3 1.4 52 (39.4) 35.4 0.8 34 (25.8) 72 (54.5)
31.1 5.2 2.8 2.0 2.2 1.4 660 (38.4) 35.4 0.8 257 (15.0) 918 (53.5)
