Q.28What are the criteria for admission to intensive/special care?

Bibliographic InformationStudy Type & Evidence LevelNumber of PatientsPatient CharacteristicsIntervention & ComparisonFollow-up & Outcome MeasuresEffect SizeStudy SummaryReviewer Comments
Modanlou,HD.; Dorchester,WP.

1987 322
Study Type: Cross- sectional

Evidence level: 3
10,369 deliveries between 1984–1985Women who delivered during 1984 1985 in Miller Children's Hospital in California.

Country: USA
Intervention: No intervention, assessment of risk factors.

Comparison:
Follow-up period: No follow-up (cross- sectional study).

Outcome Measures: Delivery via:
  1. Vaginal vertex
  2. Breech vagina
  3. Repeat caesarean section
  4. Primary caesarean section
The study shows that diabetes is one of the diseases associated with increased caesarean section, resuscitation with positive pressure ventilation and low 1 and 5 minute Apgar score.

Diabetes, hypertension, premature labour, prolonged rupture of membrane and postdate were more common in women who underwent primary caesarean sections thanin vaginal vertex births (P < 0.001).

Very low Apgar score ( ≤ 3) at 1 and 5 minutes was significantly more frequent in primary and repeat caesarean sections than in vaginal vertex births (P < 0.01).

Resuscitation with positive pressure ventilation was more frequent in primary and repeat caesarean sections than in vaginal vertex births (P = 0.001).
Given that diabetes is associated with many of the poor pregnancy outcomes, there is a need for a well trained neonatal team to be present for operative deliveries.
Dalgic N;Ergenekon E;Soysal S;Koc E;Atalay Y;Gucuyener K;

2002 Mar 361
Study Type: Cohort

Evidence level: 2+
Exposure arm 94

Comparison arm – 0
Infants admitted to neonatal intensive care for hypoglycaemia

Country: Turkey
Intervention: Neuro- developmental outcome

Comparison: none
Follow-up period: 2 years

Outcome Measures: risk factors of neonatal hypoglycaemia and their frequencies

Long-term neurodevelopmental outcome of promptly treated neonatal hypoglycaemia
Premature – 51.1% maternal diabetes or gestational diabetes – 34.1%

SGA - 12.8%
no known risk factor - 26.6%

48 infants underwent psychometric evaluation:

2 showed motor deficit at 6 months
1 showed language deficit at 24 months
Routine screening for hypoglycaemia should be carried out on admission of high risk infants to intensive care.

Clinicians need to be taught which populations are high risk, but neonatal hypoglycaemia may occur in low-risk populations as well

Early action can prevent long- term complications
This was not a true cohort study as there was no comparison group. The statistical analyses were very basic and the sample size was too small to make the results generalisable.
Teramo K;Kari MA; Eronen M;Markkanen H;Hiilesmaa V;

2004 Oct 360
Study Type: Case- control

Evidence level: 2+
Cases - 157 women with type 1 diabetes delivered by caesarean section (CS) before the onset of labour had an amniotic fluid sample taken

Controls - 19 healthy, non- smoking women delivered by elective CS
Women with type 1 diabetes with at least one childbirth

Country: Finland
Intervention: amniotic fluid erythropoietin (EPO) levels

Comparison: Amniotic fluid EPO levels
Follow-up period:

Outcome Measures: umbilical artery pH and pO2 fetal macrosomia neonatal hypoglycaemia cardiomyopathy hyperbilirubinaemia admission to neonatal intensive care
Newborn infants in high EPO group were significantly more macrosomic (P = 0.0005) and acidotic (P < 0.0001), had significantly lower pO2 levels (P < 0.0001) than newborns in the medium and low group.

Neonatal hypoglycaemia (P < 0.0001), admission to neonatal intensive care (P = 0.03) and hyperbilirubinaemia (P = 0.002) occurred significantly more often in the high EPO group

EPO was independently related to low pH (P < 0.0001) and neonatal hypoglycaemia (P = 0.002) after adjustment.
Further studies are needed to evaluate the clinical usefulness of antenatal amniotic fluid EPO measurements in pregnancies complicated by diabetesThe authors needed to be clearer about the outcomes being measured
Halliday,H.L.

1981 363
Study Type: Other

Evidence Level: 3
Intervention: To determine the association between poorly controlled maternal diabetes and cardiomyopathy

Comparison:
Comparisons between LGA infants and AGA infants
12

Group 1 – 10 LGA infants

Group 2 – 2 AGA infants
Newborn infants with respiratory distress and cardiomegaly

Country: United States Ireland
Hypertrophic cardiomyopathyIncidence of hypertrophic cardiomyopathy in LGA group 100%. (cardiomyopathy only persisted for 2 weeks)

Incidence of hypertrphic cardiomyopathy in AGA group 0%
The authors are unsure whether the presence of hypertrophic cardiomyopathy could explain the respiratory difficulty observed in the infants. They felt that structural congenital heart disease could not explain the myocardial hypertrophy observedThis study is small, poorly designed and the association shown cannot be supported statistically
Watson D;Rowan J;Neale L;Battin MR;

2003 Dec

364
Study Type: Other

Evidence Level: 2+
Intervention: Admissions to NICU

Comparison: none
Records of 136 infantsInfants admitted to neonatal intensive care unit whose mothers had gestational diabetes or type 2 diabetes

Country: New Zealand
Mode of delivery gestational age prematurity birthweight hypoglycaemia respiratory distress congential anomaly days in NICUMost common indications for admission to NICU:

hypoglycaemia − 51% respiratory distress - 40% pre-term delivery 46%

Difference in rates of respiratory distress in pre-term infants (39%) and term infants (43%) was not significant P = 0.34

Birthweights among infants of women with type 2 diabetes were significantly higher (P < 0.05) than for the IGT group and significantly more common than in the IGT or normal group (P < 0.05)
Pre-term delivery is an important contributing factor to high neonatal morbidity in women with type 3 diabetes and gestational diabetesThe number of records used for the study are small, but the results are consistent with other evidence
Cordero,L.; Treuer,S.H.; Landon,M.B.; Gabbe,S.G.

/ /1998

362
Study Type: Other

Evidence Level: 2+
Intervention:
Factors affecting admission of infants to NICU

Comparison:
530 infants born to 332 women with gestational diabetes and 177 women with type 1 diabetesInfants born to mothers with gestational diabetes or type 1 diabetes

Country: United States
NICU admissions respiratory distress syndrome (RDS) congenital malformations intrauterine fetal growth hypoglycaemia other morbidities247 infants admitted to NICU.
Of these:

31% had gestational age <33 weeks

9% had congenital malformations

4% had miscellaneous conditions

42% had a gestational age >34 weeks and respiratory distress syndrome

1% had hypoglycaemia as the only diagnosis

Of 244 infants admitted to ‘well baby’ nurseries:

27 presented with RDS as the main reason for transfer to the NICU

43 presented with hypoglycaemia as the main reason for transfer to NICU
The use of guidelines must be flexible enough to allow the best care assignments for infants of mothers with gestational diabetes, while preventing delays in the recognition of neo-natal morbidities

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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