ObjectivesTo investigate the association between the mode of birth and adverse neonatal outcomes of macrosomic (birth weight ≥4000 g) and non-macrosomic (birth weight <4000 g) live-born term ...singletons in vertex presentation (TSV) born to mothers with diabetes (pre-existing and gestational diabetes mellitus (GDM)).DesignA population-based retrospective cohort study.SettingNew South Wales, Australia.PatientsAll live-born TSV born to mothers with diabetes from 2002 to 2012.InterventionComparison of neonatal outcomes by mode of birth (prelabour caesarean section (CS) and planned vaginal birth resulted in intrapartum CS, non-instrumental or instrumental vaginal birth).Main outcome measuresFive-minute Apgar score <7, admission to neonatal intensive care unit (NICU) or special care nursery (SCN) and the need for resuscitation.ResultsAmong the 48 882 TSV born to mothers with diabetes, prelabour CS was associated with a significant increase in the rate of admission to NICU/SCN compared with planned vaginal birth.For TSV born to mothers with pre-existing diabetes, compared with non-instrumental vaginal birth, instrumental vaginal birth was associated with increased odds of the need for resuscitation in macrosomic (adjusted ORs (AOR) 2.6; 95% CI (1.2 to 7.5)) and non-macrosomic TSV (AOR 3.3; 95% CI (2.2 to 5.0)).For TSV born to mothers with GDM, intrapartum CS was associated with increased odds of the need for resuscitation compared with non-instrumental vaginal birth in non-macrosomic TSV (AOR 2.3; 95% CI (2.1 to 2.7)). Instrumental vaginal birth was associated with increased likelihood of requiring resuscitation compared with non-instrumental vaginal birth for both macrosomic (AOR 2.3; 95% CI (1.7 to 3.1)) and non-macrosomic (AOR 2.5; 95% CI (2.2 to 2.9)) TSV.ConclusionPregnant women with diabetes, particularly those with suspected fetal macrosomia, need to be aware of the increased likelihood of adverse neonatal outcomes following instrumental vaginal birth and intrapartum CS when planning mode of birth.
Recent research has demonstrated that mutations of the hepatocyte nuclear factor 4‐alpha (HNF4A) gene are associated with neonatal hyperinsulinaemic hypoglycaemia. Mutations of this gene also cause ...one of the subtypes of monogenic diabetes, a form of diabetes formerly known as maturity‐onset diabetes of the young. This article describes a family discovered to have a novel frame‐shift mutation of the HNF4A gene in the setting of early‐onset maternal diabetes and severe neonatal hyperinsulinaemic hypoglycaemia. The implications of a diagnosis of HNF4A gene mutation for obstetric and paediatric practice are discussed.
This paper articulates the importance of accurately identifying maternity services. It describes the process and challenges of identifying the number, level and networks of rural and remote maternity ...services in public hospitals serving communities of between 1000 and 25000 people across Australia, and presents the findings of this process.
Health departments and the national government's websites, along with lists of public hospitals, were used to identify all rural and remote Australian public hospitals offering maternity services in small towns. State perinatal reports were reviewed to establish numbers of births by hospital. The level of maternity services and networks of hospitals within which services functioned were determined via discussion with senior jurisdictional representatives.
In all, 198 rural and remote public hospitals offering maternity services were identified. There were challenges in sourcing information on maternity services to generate an accurate national picture. The nature of information about maternity services held centrally by jurisdictions varied, and different frameworks were used to describe minimum requirements for service levels. Service networks appeared to be based on a combination of individual links, geography and transport infrastructure.
The lack of readily available centralised and comparable information on rural and remote maternity services has implications for policy review and development, equity, safety and quality, network development and planning. Accountability for services and capacity to identify problems is also compromised.
To develop a risk “engine” or calculator, integrating the risks of hyperglycemia, maternal BMI and other basic demographic data commonly available at the time of the pregnancy oral glucose tolerance ...test (OGTT), to predict an individual’s absolute risk of specific adverse pregnancy outcomes.
Data from the Brisbane HAPO cohort was analysed using logistic regression to determine the relationship between four clinical outcomes (primary CS, birth injury, large-for-gestational age, excess neonatal adiposity) with different combinations of OGTT results and maternal demographics (age, height, BMI, parity). Existing sets of international GDM diagnostic criteria were also applied to the cohort.
191 (15.3%) women were diagnosed as GDM by one or more existing criteria. All international criteria performed poorly compared to risk models utilising OGTT results only, or OGTT results in combination with maternal demographics.
The risk engine’s empirical performance on receiver – operator curve analysis was superior to the existing GDM diagnostic criteria tested. This concept shows promise for use in clinical practice, but further development is required.
Fetal Growth Spurt and Pregestational Diabetic Pregnancy
Shell Fean Wong , MD 1 ,
Fung Yee Chan , MD 1 ,
Jeremy J.N. Oats , MD 2 and
David H. McIntyre , MD 3
1 Department of Maternal Fetal Medicine, ...Mater Mothers’ Hospital, South Brisbane, Queensland, Australia
2 Department of Obstetrics and Gynecology, Mater Mothers’ Hospital, South Brisbane, Queensland, Australia
3 Department of Endocrinology, Mater Mothers’ Hospital, South Brisbane, Queensland, Australia
Abstract
OBJECTIVE —To assess the timing of fetal growth spurt among pre-existing diabetic pregnancies (types 1 and 2) and its relationship with
diabetic control. To correlate fetal growth acceleration with factors that might influence fetal growth.
RESEARCH DESIGN AND METHODS —This retrospective study involved all pregestational diabetic pregnancies delivered at a tertiary obstetric hospital in Australia
between 1 January 1994 and 31 December 1999. Pregnancies with major congenital fetal anomalies, multiple pregnancies, small-for-gestational-age
pregnancies (<10th centile), and those that were terminated before 20 weeks were excluded. In this cohort, pregnancies delivered
at term had at least four ultrasound scans performed. The first scans were performed before 14 weeks of gestation and were
regarded as dating scans. Abdominal circumference measurements were retrieved from the ultrasound reports. The z -scores for abdominal circumferences, according to the gestational age, were calculated. The gestations when the ultrasound
scans were performed were stratified at four weekly intervals beginning at 18 weeks and continuing through the rest of the
study. Majority of these diabetic pregnancies had ultrasound scans performed at 18, 28, 32, and 36 weeks. The abdominal circumference
z -scores for pregnancies with large-for-gestational-age (LGA) babies (>90th centile for gestation) were compared with babies
with normal birth weights.
RESULTS —A total of 101 diabetic pregnancies were included. Diabetic mothers, who had LGA babies, had significantly higher prepregnancy
body weight and BMI ( P < 0.05). There were no differences in maternal age or parity among the two groups. There were also no differences in the
first-, second-, and third-trimester HbA 1c levels between the two groups. The abdominal circumference z -scores were significantly higher for LGA babies from 18 weeks and thereafter. The differences increased progressively as
the gestation advanced. Maximum difference was noted in the third trimester (30–38 weeks).
CONCLUSIONS —Fetal growth acceleration in LGA fetuses of diabetic mothers starts in the second trimester, from as early as 18 weeks. In
this study, glucose control did not appear to have a direct effect on the incidence of LGA babies, and such observation might
result from the effects of other confounding factors.
AC, abdominal circumference
LGA, large-for-gestational-age
Footnotes
Address correspondence and reprint requests to Shell Fean Wong, Department of Maternal Fetal Medicine, Mater Mothers’ Hospital,
Raymond Terrace, South Brisbane, QLD 4101, Australia. E-mail: shellwong{at}hotmail.com .
Received for publication 19 November 2001 and accepted in revised form 5 July 2002.
A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances.
DIABETES CARE
The Hyperglycemia and Adverse Pregnancy Outcome (HAPO) Study showed significant perinatal risks at levels of maternal hyperglycemia below values that are diagnostic for diabetes. A Consensus Panel of ...the International Association of Diabetes and Pregnancy Study Groups (IADPSG) reviewed HAPO Study results and other work that examined associations of maternal glycemia with perinatal and long-term outcomes in offspring and published recommendations for diagnosis and classification of hyperglycemia in pregnancy in 2010. Subsequently, some commentaries and debate challenged the IADPSG recommendations. In this review, we provide details regarding some points that were considered by the IADPSG Consensus Panel but not published and address the following issues: 1) what should be the frequency of gestational diabetes mellitus (GDM); 2) were appropriate outcomes and odds ratios used to define diagnostic thresholds for GDM; 3) to improve perinatal outcome, should the focus be on GDM, obesity, or both; 4) should results of randomized controlled trials of treatment of mild GDM influence recommendations for diagnostic thresholds; and, 5) other issues related to diagnosis of GDM. Other groups are independently considering strategies for the diagnosis of GDM. However, after careful consideration of these issues, we affirm our support for the recommendations of the IADPSG Consensus Panel.
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