Pre-existing diabetes, maternal glycated haemoglobin, and the risks of fetal and infant death: a population-based study.
ABSTRACT Pre-existing diabetes is associated with an increased risk of stillbirth, but few studies have excluded the effect of congenital anomalies. This study used data from a long-standing population-based survey of women with pre-existing diabetes to investigate the risks of fetal and infant death and quantify the contribution of glycaemic control.
All normally formed singleton offspring of women with pre-existing diabetes (1,206 with type 1 diabetes and 342 with type 2 diabetes) in the North of England during 1996-2008 were identified from the Northern Diabetes in Pregnancy Survey. RRs of fetal death (≥20 weeks of gestation) and infant death were estimated by comparison with population data from the Northern Perinatal Morbidity and Mortality Survey. Predictors of fetal and infant death in women with pre-existing diabetes were examined by logistic regression.
The prevalence of fetal death in women with diabetes was over four times greater than in those without (RR 4.56 [95% CI 3.42, 6.07], p < 0.0001), and for infant death it was nearly doubled (RR 1.86 [95% CI 1.00, 3.46], p = 0.046). There was no difference in the prevalence of fetal death (p = 0.51) or infant death (p = 0.70) between women with type 1 diabetes and women with type 2 diabetes. There was no evidence that the RR of fetal and infant death had changed over time (p = 0.95). Increasing periconception HbA1c concentration above 49 mmol/mol (6.6%) (adjusted odds ratio [aOR] 1.02 [95% CI 1.00, 1.04], p = 0.01), prepregnancy retinopathy (aOR 2.05 [95% CI 1.04, 4.05], p = 0.04) and lack of prepregnancy folic acid consumption (aOR 2.52 [95% CI 1.12, 5.65], p = 0.03) were all independently associated with increased odds of fetal and infant death.
Pre-existing diabetes is associated with a substantially increased risk of fetal and infant death in normally formed offspring, the effect of which is largely moderated by glycaemic control.
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ABSTRACT: Women with preexisting (type 1 or type 2) diabetes experience an increased risk of serious adverse pregnancy outcomes. It is not known, however, how these risks change between the first and second pregnancy and whether there is an increased risk of recurrence. This study describes the absolute risks and recurrence of serious adverse pregnancy outcomes in 220 women with preexisting diabetes. A total of 440 pregnancies occurring in 220 women with preexisting diabetes who delivered successive singleton pregnancies in the North of England during 1996-2008 were identified from the Northern Diabetes in Pregnancy Survey (NorDIP). Predictors of serious adverse outcome were estimated by competing-risks regression. Sixty-seven first pregnancies (30.5%) ended in serious adverse outcome, including 14 (6.4%) with congenital anomalies and 53 (24.1%) additional fetal or infant deaths. Thirty-seven second pregnancies (16.8%) ended in serious adverse outcome-half the rate among first pregnancies (P = 0.0004)-including 21 (9.5%) with congenital anomalies and 16 (7.3%) additional fetal or infant deaths. Serious adverse outcomes in the second pregnancy occurred twice as frequently in women who experienced a previous adverse outcome than in those who did not (26.9% vs. 12.4%, P = 0.004), but previous adverse outcome was not associated with preparation for the following pregnancy. Serious adverse outcomes are less common in the second pregnancies of women with preexisting diabetes, although the risk is comparable in those whose first pregnancy ends in adverse outcome. Reducing the risk of recurrence may require more support in the immediate period after an adverse pregnancy outcome. © 2015 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered.Diabetes Care 01/2015; DOI:10.2337/dc14-1888 · 8.57 Impact Factor
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ABSTRACT: During a pregnancy complicated by diabetes, the human placenta undergoes a number of functional and structural pathologic changes, such as increased placental weight and increased incidence of placental lesions including villous maturational defects and fibrinoid necrosis. The pathologic findings reported have differed among studies, potentially reflecting differences in type of diabetes, study methodology, or glycemic control of study participants. Alternatively, these discrepancies may represent different biologic adaptations to distinct metabolic diseases. We conducted a comprehensive review of English language citations in Pubmed and Embase using the keywords "diabetes", "placenta", AND "pathology". Abstracts were reviewed for relevance then full-text articles were reviewed in order to extract a comprehensive summary of current pathological findings associated with pregestational and gestational diabetes mellitus, as well as an understanding of the impact of glycemic control on placental pathology. Placental abnormalities most consistently associated with maternal diabetes are an increased incidence of villous immaturity, increased measures of angiogenesis, and increased placental weight. The literature suggests that, despite similarities in placental abnormalities, differences in placental pathology may reflect differences in pathophysiology among different types of diabetes. Consequently, standardization of terminology used to define placental lesions is warranted. Moreover, further research is needed to investigate the impact of pathophysiology, glycemic control and clinical factors, such as infant sex, weight and race, on placental structure and function. Copyright © 2014 Elsevier Ltd. All rights reserved.Placenta 12/2014; 36(2). DOI:10.1016/j.placenta.2014.11.021 · 3.29 Impact Factor
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ABSTRACT: Glycated hemoglobin (HbA1c) is a special fragment formed by the binding of glucose to the C chain or D chain of hemoglobin A and as a result of non-enzymatic catalysis of mature hemoglobin and glucose, which is an indicator used to evaluate the blood glucose control in diabetes mellitus (DM) patients. Recent researches indicated that HbA1c could be applied in gestational diabetes mellitus (GDM) and pregnancy combined DM, and increasing of HbA1c was close associated with adverse outcomes of women with pregnancy combined DM and GDM. HbA1c was reported to have a significant importance in monitoring congenital malformation, abortion, perinatal mortality, preeclampsia, postpartum abnormal glucose metabolism, vascular complications and so on, which could be a test item during the second trimester. Sensitivity of HbA1c in diagnoses of DM is lower than oral glucose tolerance test (OGTT), thus OGTT is still the golden standard of GDM. Emphasis should be put on standardization of detection and threshold of HbA1c and establishment of HbA1c normal ranges of different trimesters, when HbA1c is used to diagnose pregnancy combined DM and GDM, and evaluate effects of treatments.International Journal of Clinical and Experimental Medicine 01/2014; 7(12):4653-9. · 1.42 Impact Factor