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American Journal of Obstetrics &... Oct 2023The American College of Obstetricians and Gynecologists recommends delivery in the 39th week of pregnancy for patients with pregestational and medication-controlled...
BACKGROUND
The American College of Obstetricians and Gynecologists recommends delivery in the 39th week of pregnancy for patients with pregestational and medication-controlled gestational diabetes with consideration for earlier delivery among those with poor glucose control.
OBJECTIVE
We sought to evaluate the impact of birth before 39 weeks' gestation exclusively for diabetes-related indications on neonatal outcomes and clinician rationale for these recommendations.
STUDY DESIGN
This was a retrospective cohort study of all singleton, nonanomalous pregnancies complicated by diabetes. Patients were identified through an obstetrical database containing information of 90,185 births from 2011 to 2021. Patients who delivered in a given week of gestation exclusively for diabetes-related indications were compared with ongoing pregnancies. Recommended births for other obstetrical indications were excluded from the diabetes-related indications cohorts. The primary outcome was neonatal intensive care unit admission. Secondary outcomes included neonatal intensive care unit length of stay, stillbirth, neonatal death, hypoglycemia, respiratory distress syndrome, and shoulder dystocia. For all births before 39 weeks' gestation, the electronic medical records were reviewed to confirm the rationale for the intervention for a diabetes-indicated condition.
RESULTS
From the 90,185 recorded births that occurred in 2011 to 2021, 4750 patients with diabetes were identified. Of those, 30.5% (n=1449) had a recommended birth for a diabetes-related indications with 2.2% of those (n=32) occurring at 36 weeks' gestation, 7.9% (n=114) at 37 weeks' gestation, 9.7% (n=141) at 38 weeks' gestation, and 63.0% (n=913) at 39 weeks' gestation. Births that occurred at 36 and 37 weeks' gestation exclusively for diabetes-related indications had higher rates of neonatal intensive care unit admission than the respective ongoing pregnancies (62.5% vs 8.7%; P<.001 and 25.4% vs 7.2%; P<.001). There was no difference in neonatal intensive care unit admission for births at 38 or 39 weeks' gestation when compared with ongoing pregnancy. For neonates born at 36 and 37 weeks' gestation in comparison with ongoing pregnancies, the median neonatal intensive care unit length of stay was 11.0 vs 2.8 days, (P<.001) and 4.4 vs 2.6 days (P=.026), respectively. There were significantly increased rates of neonatal hypoglycemia and respiratory distress syndrome among births that occurred at 36, 37, and 38 weeks' gestation when compared with ongoing pregnancies. There were no differences in the rate of stillbirth in this cohort. Primary factors cited for early birth were poor glycemic control (71.4%), recommendation by a maternal-fetal medicine specialist (38.7%), and suspected fetal macrosomia (27.9%). Overall, 46.7%, 32.8%, and 20.6% of patients had 1, 2, or ≥3 indications, respectively, listed as rationale for early birth. Overall, few objective measures were used to recommend birth before 39 weeks' gestation owing to diabetes.
CONCLUSION
In pregnancies complicated by diabetes, early birth exclusively for diabetes-related indications was associated with increased neonatal intensive care unit admission and length of stay and with neonatal morbidity. Little objective data are documented by clinicians to support their recommendations for early birth associated with diabetes. Additional clinical guidelines are needed to define suboptimal glucose control necessitating birth before 39 weeks' gestation.
Topics: Pregnancy; Infant, Newborn; Female; Humans; Stillbirth; Retrospective Studies; Blood Glucose; Diabetes, Gestational; Respiratory Distress Syndrome; Hypoglycemia
PubMed: 37567447
DOI: 10.1016/j.ajogmf.2023.101129 -
Journal of Clinical Medicine Mar 2024Recommendations for weight gain during pregnancy are based on pre-pregnancy body mass index (BMI). Pregnancy is a risk factor for excessive weight gain and many... (Review)
Review
Recommendations for weight gain during pregnancy are based on pre-pregnancy body mass index (BMI). Pregnancy is a risk factor for excessive weight gain and many endocrine problems, making it difficult to return to pre-pregnancy weight and increasing the risk of postpartum obesity and, consequently, type 2 diabetes and metabolic syndrome. Both excessive gestational weight gain (EGWG) and obesity are associated with an increased risk of gestational hypertension, pre-eclampsia, gestational diabetes, cesarean section, shoulder dystocia, and neonatal macrosomia. In the long term, EGWG is associated with increased morbidity and mortality, particularly from diabetes, cardiovascular disorders, and some cancers. This study aims to present recommendations from various societies regarding weight gain during pregnancy, dietary guidance, and physical activity. In addition, we discuss the pathophysiology of this complication and the differential diagnosis in pregnant women with EGWG. According to our research, inadequate nutrition might contribute more significantly to the development of EGWG than insufficient physical activity levels in pregnant women. Telehealth systems seem to be a promising direction for future EGWG prevention by motivating women to exercise. Although the importance of adequate pre-pregnancy weight and weight gain during pregnancy is well known, an increasing number of women gain excessive weight during pregnancy.
PubMed: 38592297
DOI: 10.3390/jcm13051461 -
Journal of Obstetrics and Gynaecology :... Dec 2023To establish and verify a model for labour dystocia occurring in the active phase, this study retrospectively analysed the clinical data of primiparas with singleton...
To establish and verify a model for labour dystocia occurring in the active phase, this study retrospectively analysed the clinical data of primiparas with singleton cephalic full-term foetuses, who had delivered after a trial of labour. The Chi-square test, -test, Mann-Whitney U test and multivariate logistic regression analysis were used for statistical analysis. Based on the model a nomogram was established using the R programming language. Multivariate logistic regression analysis showed that the foetal abdominal circumference, premature rupture of membranes (PROM), prolonged latent phase, foetal station and foetal position at the early stage of the active phase were independent factors influencing labour dystocia occurring in the active phase. The established model could effectively and accurately support clinicians in the early identification of labour dystocia to improve maternal and infant outcomes.Impact statement Labour dystocia occurring during the active phase of the first stage, is the most commonly diagnosed as labour aberration. Previous studies have suggested that maternal age, body mass index, macrosomia and abnormal foetal position are the independent risk factors for labour dystocia. However, only the risk factors were reported, and few prediction models were established. This study uses data in the real world to establish a prediction model of full-term singleton primipara with labour dystocia occurring in the active phase by logistic regression analysis. Foetal abdomen circumference, PROM, prolonged latent phase, the foetal station and foetal position at the early stage of the active phase are independent factors influencing labour dystocia that occurs in the active phase. In addition, a nomogram is established as a visual graph to predict the probability of it. The nomogram based on the predictive model discarded complicated calculations and presented an easy visual graph-based method to predict the probability of labour dystocia occurring in the active phase. It helps to introduce interventions that could reduce the CS rate and occurrence of adverse maternal and foetal outcomes to ensure the safety of mothers and infants.
Topics: Female; Pregnancy; Humans; Retrospective Studies; Labor, Obstetric; Dystocia; Maternal Age; Fetal Macrosomia
PubMed: 36789884
DOI: 10.1080/01443615.2023.2174837 -
Journal of Perinatal Medicine Nov 2023Shoulder dystocia is a peracute mechanical dystocia and a prepartum, usually unpredictable, life-threatening entity with significant forensic implications due to...
BACKGROUND
Shoulder dystocia is a peracute mechanical dystocia and a prepartum, usually unpredictable, life-threatening entity with significant forensic implications due to significantly poor perinatal outcome, especially permanent disability or perinatal death.
CONTENT
To better objectify the graduation and to include other important clinical parameters, we believe it is appropriate to present a proposal for a complete perinatal weighted graduation of shoulder dystocia, based on several years of numerous other and our own clinical and forensic studies and thematic biobibliography. Obstetric maneuvers, neonatal outcome, and maternal outcome are three components, which are evaluated according to the severity of 0-4 proposed components. Thus, the gradation is ultimately in four degrees according to the total score: I. degreee, score 0-3: slightly shoulder dystocia with simple obstetric interventions, but without birth injuries; II. degree, score 4-7: mild shoulder dystocia resolved by external, secondary interventions and minor injuries; III. degree, score 8-10: severe shoulder dystocia with severe peripartum injuries; IV. degree, score 11-12: extremely difficult, severe shoulder dystocia with ultima ratio interventions applied and resulting extremely severe injuries with chronic disability, including perinatal death.
SUMMARY
As a clinically evaluated graduation, it certainly has an applicable long-term anamnestic and prognostic component for subsequent pregnancies and access to subsequent births, as it includes all relevant components of clinical forensic objectification.
Topics: Pregnancy; Female; Infant, Newborn; Humans; Shoulder Dystocia; Shoulder; Perinatal Death; Dystocia; Birth Injuries; Delivery, Obstetric; Risk Factors
PubMed: 37329307
DOI: 10.1515/jpm-2022-0513 -
Journal of Patient-centered Research... 2023Anecdotally, there are attestations from clinicians of calcium carbonate being used successfully for laboring people experiencing labor dystocia. The goal of this... (Review)
Review
Anecdotally, there are attestations from clinicians of calcium carbonate being used successfully for laboring people experiencing labor dystocia. The goal of this narrative review was to provide a synopsis of pertinent literature on calcium use in obstetrics to explore the potential benefit of calcium carbonate as a simple and low-cost intervention for prevention or treatment of labor dystocia. To answer how calcium and carbonate physiologically contribute to myometrium contractility, we conducted a literature search of English-language peer-reviewed articles, with no year limitation, consisting of the keywords "calcium," "calcium carbonate," "calcium gluconate," "pregnancy," "hemorrhage," and variations of "smooth muscle contractility" and "uterine contractions." Though no overt evidence on calcium carbonate's ability to prevent labor dystocia was identified; relevant information was found regarding smooth muscle contractility, calcium's influence on uterine muscle contractility, and carbonate's potential impact on reducing amniotic fluid lactate levels to restore uterine contractility during labor. Studies reporting the potential effectiveness of calcium gluconate and sodium bicarbonate in preventing labor dystocia offer background, safety information, and rationale for a future randomized control trial to evaluate the ability of calcium carbonate to prevent labor dystocia and reduce rates of cesarean section.
PubMed: 37483561
DOI: 10.17294/2330-0698.2010 -
Obesity Reviews : An Official Journal... Jul 2024Maternal obesity and gestational diabetes mellitus (GDM) prevalence are increasing, with both conditions associated with adverse neonatal outcomes. This review aimed to... (Meta-Analysis)
Meta-Analysis Review
Maternal obesity and gestational diabetes mellitus (GDM) prevalence are increasing, with both conditions associated with adverse neonatal outcomes. This review aimed to determine the risk of adverse outcomes in women with obesity and GDM, compared with women with obesity alone. A systematic search identified 28 eligible articles. Meta-analysis was conducted using a random effects model, to generate pooled estimates (odds ratios, OR, or mean difference, MD). Compared with normal-weight controls, women with obesity had increased risks of large for gestational age (LGA, OR 1.98, 95% CI: 1.56, 2.52) and macrosomia (OR 2.93, 95% CI: 1.71, 5.03); the latter's risk almost double in women with obesity than GDM. Birth weight (MD 113 g, 95% CI: 69, 156) and shoulder dystocia (OR 1.23, 95% CI: 0.85, 1.78) risk was also higher. GDM significantly amplified neonatal risk in women with obesity, with a three- to four-fold risk of LGA (OR 3.22, 95% CI: 2.17, 4.79) and macrosomia (OR 3.71, 95% CI: 2.76, 4.98), as well as higher birth weights (MD 176 g, 95% CI: 89, 263), preterm delivery (OR 1.49, 95% CI: 1.25, 1.77), and shoulder dystocia (OR 1.99, 95% CI: 1.31, 3.03), when compared with normal-weight controls. Our findings demonstrate that maternal obesity increases serious neonatal adverse risk, magnified by the presence of GDM. Effective strategies are needed to safeguard against neonatal complications associated with maternal obesity, regardless of GDM status.
Topics: Humans; Pregnancy; Diabetes, Gestational; Female; Infant, Newborn; Pregnancy Outcome; Fetal Macrosomia; Birth Weight; Obesity, Maternal; Risk Factors; Obesity; Pregnancy Complications; Shoulder Dystocia
PubMed: 38679418
DOI: 10.1111/obr.13747 -
International Journal of Gynaecology... Aug 2023To examine recent incidence trends and characteristics of shoulder dystocia.
OBJECTIVE
To examine recent incidence trends and characteristics of shoulder dystocia.
METHODS
This is a retrospective cohort study querying the Healthcare Cost and Utilization Project's National Inpatient Sample. The study population included 9 913 838 vaginal deliveries for national estimates from January 2016 to December 2019. The main outcome measure was the diagnosis of shoulder dystocia. A binary logistic regression model was used to identify characteristics of shoulder dystocia in multivariable analysis.
RESULTS
Shoulder dystocia was reported in 228 120 deliveries (23.0 per 1000). The incidence of shoulder dystocia increased from 21.0 to 24.6 per 1000 deliveries during the 4-year study period (17.1% relative increase, P < 0.001). In a multivariable analysis, the recent year of delivery remained an independent factor for shoulder dystocia: adjusted odds ratio (aOR) compared with 2016, 1.09 (95% confidence interval [CI], 1.08-1.11), 1.13 (95% CI, 1.12-1.14), and 1.18 (95% CI, 1.16-1.19) for 2017, 2018, and 2019, respectively. Large for gestational age (aOR 4.33 [95% CI, 4.25-4.40]), diabetes mellitus (pregestational aOR, 4.78 [95% CI, 4.63-4.94], and gestational aOR, 1.69 [95% CI, 1.66-1.71]), and vacuum-assisted delivery (aOR, 2.18 [95% CI, 2.15-2.21]) exhibited the largest risks for shoulder dystocia.
CONCLUSION
This national-level analysis identified various risk factors for shoulder dystocia and demonstrated that shouder dystocia cases are increasing gradually in the United States.
Topics: Pregnancy; Female; Humans; United States; Shoulder Dystocia; Retrospective Studies; Incidence; Shoulder; Delivery, Obstetric; Dystocia; Risk Factors
PubMed: 36707062
DOI: 10.1002/ijgo.14699 -
Equine Veterinary Journal Jan 2024Mare and foal survival are increased with prompt dystocia management. Data regarding mortality outcomes in mares and foals, when mares are recumbent at admission for...
BACKGROUND
Mare and foal survival are increased with prompt dystocia management. Data regarding mortality outcomes in mares and foals, when mares are recumbent at admission for dystocia resolution, are scarce.
OBJECTIVES
To evaluate recumbency at hospital admission as a risk factor for survival of mares and foals following dystocia management. Subsequent mare fertility was also evaluated.
STUDY DESIGN
Retrospective cohort.
METHODS
Data were obtained from medical records at Rood and Riddle Equine Hospital of mares with dystocia between 1995 and 2018. Mare signalment, ambulation status, survival data and foaling records were collected. The proportion of mare survival and mare fertility were analysed using chi-squared tests. Foal survival was analysed using Fisher's exact test. Odds ratios were calculated using multivariable logistic regression.
RESULTS
There were 1038 ambulatory mares and 41 recumbent mares included in the analysis. Survival rates after dystocia resolution were 90.5% (977/1079) in mares and 37.3% (402/1079) in foals. Ambulatory mares had higher odds of survival (OR 6.93, 95% CI: 3.25-14.78, p < 0.001) than recumbent mares. Foals delivered from ambulatory mares had higher odds of survival (OR 22.7, 95% CI: 3.11-165.44, p = 0.002) compared with foals delivered from recumbent mares. Fertility was not statistically different for surviving Thoroughbred mares within 3 years following dystocia resolution between ambulatory and recumbent mares.
MAIN LIMITATIONS
Retrospective study design and small case number of recumbent mares.
CONCLUSIONS
Mare and foal survival was significantly decreased when mares with dystocia were recumbent at hospital admission. Subsequent fertility, as defined for this study, of surviving mares was not affected by ambulation status at the time of dystocia resolution.
Topics: Pregnancy; Animals; Horses; Female; Retrospective Studies; Horse Diseases; Dystocia; Hospitals; Odds Ratio
PubMed: 37227213
DOI: 10.1111/evj.13956 -
American Journal of Obstetrics and... Oct 2023Among guidelines on gestational diabetes mellitus, there is an incongruity about the threshold of maternal hyperglycemia to diagnose gestational diabetes mellitus.
BACKGROUND
Among guidelines on gestational diabetes mellitus, there is an incongruity about the threshold of maternal hyperglycemia to diagnose gestational diabetes mellitus.
OBJECTIVE
This study aimed to ascertain the association between continuous glucose monitoring metrics and adverse outcomes among individuals undergoing gestational diabetes mellitus screening.
STUDY DESIGN
This was a prospective study (from June 2020 to January 2022) of individuals who underwent 2-step gestational diabetes mellitus screening at ≤30 weeks of gestation. The participants wore a blinded continuous glucose monitoring device (Dexcom G6 Pro; Dexcom, Inc, San Diego, CA) for 10 days starting when they took the 50-g glucose challenge test. The primary outcome was a composite of adverse neonatal outcomes (large for gestational age, shoulder dystocia or neonatal injury, respiratory distress, need for intravenous glucose treatment for hypoglycemia, or fetal or neonatal death). The secondary neonatal outcomes included preterm birth, neonatal intensive care unit admission, hypoglycemia, mechanical ventilation or continuous positive airway pressure, hyperbilirubinemia, and hospital length of stay. The secondary maternal outcomes included weight gain during pregnancy, hypertensive disorders of pregnancy, induction of labor, cesarean delivery, and postpartum complications. Time within the target range (63-140 mg/dL), time above the target range (>140 mg/dL) expressed as a percentage of all continuous glucose monitoring readings, and mean glucose level were analyzed. The Youden index was used to choose the threshold of ≥10% for the time above the target range and association with adverse outcomes.
RESULTS
Of 136 participants recruited, data were available from 92 individuals (67.6%). The 2-step method diagnosed gestational diabetes mellitus in 2 individuals (2.2%). Continuous glucose monitoring indicated that 17 individuals (18.5%) had time above the target range of ≥10%. Individuals with time above the target range of ≥10% had a significantly higher likelihood of composite adverse neonatal outcomes than individuals with time above the target range of <10% (63% vs 18%; P=.001). Furthermore, compared with neonates born to individuals with time above the target range of <10%, neonates born to individuals with time above the target range of ≥10% had an increased likelihood for hypoglycemia (14.5% vs 47%; P=.009) and had a longer length of stay (2 vs 4 days; P=.03). No difference in maternal outcomes was noted between the groups.
CONCLUSION
In this prospective study of individuals undergoing gestational diabetes mellitus screening, a cutoff of the time above the target range of ≥10% using continuous glucose monitoring was associated with a higher rate of neonatal adverse outcomes. A randomized trial of continuous glucose monitoring vs 2-step screening for gestational diabetes mellitus to lower the rate of adverse outcomes is underway (identification number: NCT05430204).
Topics: Female; Humans; Pregnancy; Blood Glucose; Blood Glucose Self-Monitoring; Diabetes, Gestational; Hypoglycemia; Pregnancy Outcome; Premature Birth; Prospective Studies
PubMed: 37088275
DOI: 10.1016/j.ajog.2023.04.021 -
International Journal of Environmental... Oct 2023One in 20 births could be affected by hypermobile Ehlers-Danlos syndrome or Hypermobility Spectrum Disorders (hEDS/HSD); however, these are under-diagnosed and lacking...
One in 20 births could be affected by hypermobile Ehlers-Danlos syndrome or Hypermobility Spectrum Disorders (hEDS/HSD); however, these are under-diagnosed and lacking research. This study aimed to examine outcomes and complications in people childbearing with hEDS/HSD. A large online international survey was completed by women with experience in childbearing and a diagnosis of hEDS/HSD ( = 947, total pregnancies = 1338). Data were collected on demographics, pregnancy and birth outcomes and complications. Participants reported pregnancies in the UK ( = 771), USA ( = 364), Australia ( = 106), Canada ( = 60), New Zealand ( = 23) and Ireland ( = 14). Incidences were higher in people with hEDS/HSD than typically found in the general population for pre-eclampsia, eclampsia, pre-term rupture of membranes, pre-term birth, antepartum haemorrhage, postpartum haemorrhage, hyperemesis gravidarum, shoulder dystocia, caesarean wound infection, postpartum psychosis, post-traumatic stress disorder, precipitate labour and being born before arrival at place of birth. This potential for increased risk related to maternal and neonatal outcomes and complications highlights the importance of diagnosis and appropriate care considerations for childbearing people with hEDS/HSD. Recommendations include updating healthcare guidance to include awareness of these possible complications and outcomes and including hEDS/HSD in initial screening questionnaires of perinatal care to ensure appropriate consultation and monitoring can take place from the start.
Topics: Pregnancy; Infant, Newborn; Humans; Female; Joint Instability; Ehlers-Danlos Syndrome; Surveys and Questionnaires; Uterine Hemorrhage
PubMed: 37887695
DOI: 10.3390/ijerph20206957