Q.23What special considerations in relation to spontaneous or planned preterm birth are appropriate for women with diabetes?

Bibliographic InformationStudy Type & Evidence LevelAim of StudyNumber of Patients & Patient CharacteristicsPopulation CharacteristicsOutcome measuresResults & CommentsStudy SummaryReviewer Comment
Mathiesen ER;Christensen AB;Hellmuth E;Hornnes P;Stage E;Damm P; 2002 Sep {Mathiesen, 2002 27426 /id}Study Type: Non-random intervention study. Evidence Level: 2+Intervention: An algorithm for administration of additional insulin during treatment with antenatal steroids16: 8 women received additional insulin according to algorithm, 8 received additional insulin based on individual glucose levels.Pregnant women with type 1 diabetes receiving antenatal steroids for fetal lung maturation.Blood glucose. Maternal hypoglycaemia (<3 mmol/l).Cohort 1 (control group):
Insulin dose (% increase from baseline).
Median (range).
Day 1: 6(0–40)
Day 2: 38(20–106)
Day 3: 36(25–125)
Day 4: 27(0–60)
Day 5 17(0–60)
Blood glucose. Median (range).
Day 1: 6.7 (3.5–23)
Day 2: 14.3 (6.6–15)
Day 3: 12.3 (10.5–13.4)
Day 4: 7.7 (5.4–11.1)
Day 5: 7.7 (5.3–11.1).
Intervention group:
Insulin dose (% increase from baseline).
Median (range).
Day 1: 27(0–40)
Day 2: 45 (3–147)
Day 3: 40 (16–19)
Day 4: 31(19–113)
Day 5: 11 (−6–40)
Blood glucose. Median (range).
Day 1: 7.7 (4.1–11.6)
Day 2: 8.2 (6.7–12.7) P < 0.05
Day 3: 9.6 (6.3–13.1) P < 0.05
Day 4: 7.0 (5.1–9.8)
Day 5: 7.4 (4.2–11.9).

The total number of hypoglycaemic episodes per woman ranged from 0–2 (median 0) in the intervention group and from 0–5 (median 0.5) in the control group.
The median blood glucose during the second and third day was significantly reduced in the intervention group (P < 0.05) and was close to acceptable levels.

An algorithm with the s.c. Insulin dose increased by up to 40% shortly after glucocorticoid treatment for lung maturation in pregnant women with diabetes prevents severe dysregulation of glycaemic control.
There were two perinatal deaths in the intervention group. An intrapartum death in week 27, 3 days after the first glucorticoid dose; and an antepartum death in wk 27 in a severely growth-restricted fetus (340 g) 17 days after the first glucocorticoid dose.
Kaushal, K; Gibson, J; Railton A; Hounsome B; New J; Young R; 2002.Study type: Case series
Evidence Level: 3
Protocol for improved glycaemic control following corticosteroid therapy in diabetic pregnancies. The protocol incorporates four graded sliding scales. The initial scale is selected according to the patient’s current s.c. insulin dose and advanced if blood glucose is ≥ 10.1 mmol/l for 2 consecutive hours.6 women receiving antenatal steroidsWomen receiving dexamethasone in maternity unit.Supplementary insulin requirement (median, range)
Blood glucose values
The median amount of supplementary IV insulin required was 74U (range 32– 88U); the median glucose values achieved were 5.8–8.9 mmol/l. 75% of glucose measurements were within an acceptable range of 4–10 mmol/l. enables routine ward staff to manage this effectively.Large amounts of supplementary IV? insulin are required to achieve even moderate control. This protocol
Bibliographic InformationStudy Type & Evidence LevelNumber of PatientsPatient CharacteristicsIntervention & ComparisonFollow-up & Outcome MeasuresEffect SizeStudy SummaryReviewer Comments
Lauszus,F.F.; Fuglsang,J.; Flyvbjerg,A.; Klebe,J.G.

2006

303
Study Type: Cohort

Evidence level: 2+
71 women with type 1 diabetesDuring six years (1993–1998), 198 out of 310 pregnancies with type 1 diabetes were enrolled prospectively by the Aarhus University Hospital in Denmark.

50 women were excluded due to albuminuria, 26 preeclampsia, 9 repeated pregnancies, 1 twin pregnancy and 40 due to insufficient clinical data.

Sufficient data was defined as available data on insulin dose, HbA1c, and albumin excretion rate in gestational week 12 and thereafter.

71 women with singleton pregnancies remained for this study.

Country: Denmark
Intervention:
HbA1c, insulin dose, and albumin excretion rate checks from week 12 in women with type 1 diabetes, and every second week thereafter.

Comparison:
Values from women without type 1 diabetes
Follow-up period:
Conception to delivery

Outcome Measures: Indicators of deterioration of diabetes during pregnancy:
  1. Progression of nephropathy
  2. Retinopathy
Adverse perinatal outcomes:
  1. Preeclampsia
  2. Preterm delivery
  3. Prematurity
  4. Inrauterine growth retardation
  5. Neonatal hypoglycaemia
The preterm rate was 23% and women delivering preterm showed higher HbA1c throughout pregnancy.

Univariate regression analysis showed HbA1c was the strongest predictor of preterm delivery from week 6 to 32.

The same association was observed in multivariate analysis which included insulin dose, body mass index (BMI), age, duration of diabetes, and diurnal blood pressure.

The risk of delivering preterm was more than 40% when HbA1c was above 7.7% in week 8.

Diurnal blood pressure was not found to be associated with preterm delivery.
The quality of glycaemic control in early and mid-pregnancy is a major, independent risk factor for preterm delivery in normoalbuminuric diabetic women without preeclampsia.

From: Evidence tables

Cover of Diabetes in Pregnancy
Diabetes in Pregnancy: Management of Diabetes and Its Complications from Preconception to the Postnatal Period.
NICE Clinical Guidelines, No. 63.
National Collaborating Centre for Women's and Children's Health (UK).
London: RCOG Press; 2008 Mar.
Copyright © 2008, National Collaborating Centre for Women’s and Children’s Health.

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