patients with gestational diabetes (GDM) accelerated fetal Diabetes 28: Very tight versus tight control for diabetes in pregnancy (Cochrane review) …
The First World Congress On: Controversies in Obstetrics, Gynecology
Infertility Prague, Czech Republic - 1999
Can Macrosomia Be Prevented?
M Hod and S Aschkenazi
Perinatal Division and WHO Collaborating Center for Perinatal Care
Center For Womens Health At The Rabin Medical Center
Sackler School of Medicine,Tel-Aviv University, Petach Tiquva, Israel
Summary
Objective: To determine whether strict glycemic control during diabetic
pregnancy combined with elective early induction of labor reduces the rate
of macrosomia, birth trauma, and its influences on the C/S rate Materials
and Methods: Data were collected on the outcome of gestational diabetes
GDM from 1/1980 to 12/1998 We investigated the relationship between mode
of delivery, macrosomia 4000 g, perinatal morbidity and mortality to
maternal glycemic control and departmental delivery protocols Results:
Compared with results before implementation of our management policy there
was a statistically significant decline in the incidence of macrosomia
179 to 45 P005 Induction of labor increased from 15 to 35 of the
pregnancies, but the rate of C/S remained unchanged 206, and
178,
respectively Conclusion: Maintaining strict glycemic control and adhering
to early elective delivery have a significant effect on reducing the rate
of macrosomia, without affecting the rate of cesarean deliveries
Introduction
In patients with gestational diabetes GDM accelerated fetal growth
remains a major perinatal complication Macrosomia is permanent and has
been associated with an increased risk of birth trauma and cesarean
delivery rate Due to the tendency of accelerated fetal growth prolonging
gestation in diabetic pregnancy leads to an increase in absolute infant
size Our objective was to investigate the effectiveness of strict
metabolic control during pregnancy coupled with term 38 wks early
induction of labor based on estimated fetal weight in reducing macrosomia,
birth trauma and C/S rates
Materials and Methods
From 1 January 1980 to 31 December 1995 data were collected on the outcome
of GDM and normal pregnancies admitted to the department of Obstetrics and
Gynecology, Rabin Medical Center Patients represented the entire spectrum
of the Israeli population Specifically, we sought to determine the
relationship between perinatal macrosomia 4000g, management of
labor,
mode of delivery, and perinatal morbidity and mortality to maternal
glycemic control and departmental labor and delivery criteria
The classification, diagnosis, treatment and follow-up of patients with GDM
were performed according to the specific recommendations proposed by
American Diabetes Association 1 and the American College of Obstetrics
and Gynecology 2 During the study period 1980-1989, patients with
fasting glucose levels of 58mmol/L or postprandial levels of 78 mmol/L
were given insulin treatment Between 1990 and 1992, patients were also
instructed to aim maintain a plasma glucose level of 58 mmol/L As of 1993
insulin was started at fasting levels of 53 mmol/L and/or 2-h
postprandial levels of 66 mmol/l, and the glycemic goal was set at 53
mmol/L In addition, as of 1993, labor was induced at 38 weeks in all
patients with a suspected large for gestational age fetus LGA- estimated
fetal weight above the 90th percentile by vaginal application of
prostaglandin E2 pessaries 3 mg Elective cesarean section was performed
if the estimated fetal weight EFW was 4000 g
Results
During the 18 years of the study 82,979 women gave birth in our department
Of these 2045 246 were
diagnosed with GDM Labor induction rate in the
GDM patients was 35 compared with 10 in the non-GDM patients The
maintenance of strict metabolic control in the GDM patients combined with
the early induction of labor protocol was accompanied by rates of
macrosomia, LGA fetuses, shoulder dystocia, and cesarean births not
significantly higher than those for the non-GDM subjects as published in
reference 3 Macrosomia rates declined gradually from 179 to 88 and
45 in 1985-1992, 1992-1995 and 1998, respectively Overall C/S rates did
not alter significantly, 206, 16,2, 178, respectively Shoulder
dystocia rates declined but did not reach statistical significance 15,
06, in1985 compared with 1995 A similar trend was observed with
perinatal morbidity and mortality
Conclusion
We hypothesized that in the management of pregnancies with GDM combining
early detection and strict metabolic control with early induction of labor
near term- to avoid excessive fetal growth in utero, could lead to more
favorable perinatal outcome To test this assumption, we studied pregnancy
outcome in GDM patients compared with the non-GDM normal pregnant
population over a period of 18 years in which none, some, or all
of these
criteria were applied The results indicate a gradual and constant decline
in several important feto-maternal complications for comprehensive data,
see reference 3 During the last follow up period 1993-1998, the target
normoglycemic level was lowered to 53 mmol/L, strict metabolic control
was implemented, and labor was induced at a lower mean gestational age
according to the EFW It is only after applying all three aspects of the
management policy together that we succeeded to decrease the complications
occurring in GDM patients to rates that compared favorably with those
observed in the general non-GDM population
The main perinatal complication of GDM is accelerated fetal growth It
increases the risk of birth trauma and the likelihood of performing a
cesarean delivery Randomized controlled studies have assessed the effects
of primary dietary therapy in pregnancies with GDM 4 and very tight and
intensified glycemic control in women with insulin dependent pregnancies
5 These studies were not able to prove clear evidence of benefit in
perinatal outcome Similarly, two randomized controlled trials from the
Cochrane Pregnancy and Childbirth Group trials register 6 involving
313
women investigated the effects of a policy of early labor induction for
suspected fetal macrosomia on method of delivery and maternal or perinatal
morbidity Compared to expectant management, induction of labor for
suspected macrosomia did not reduce the risk of cesarean section or
instrumental delivery Perinatal morbidity was similar between groups
Contrary to the conflicting results regarding management of fetal
macrosomia, our study clearly demonstrates that although it might not be
sufficient to pursue one of the two approaches, by combining the two
management protocols and strictly implementing them together, the problem
of macrosomia can be overcome, achieving rates similar to the healthy non-
diabetic pregnant population This has been attainable at low cost and
minimal clinical recourses, without increasing the rate of cesarean or
instrumental deliveries, but merely by adhering and strictly implementing
tight glycemic control together with early induction of labor
References
1 National Diabetes Data Group: Classification and diagnosis for
diabetes mellitus and other categories of glucose intolerance
Diabetes 28:1037-1059, 1979
2 American college of
obstetrics and Gynecologists; Management of
diabetes mellitus in pregnancy AGOG Tech Bull 92;1-5,1986
3 HOD,M, et al, Antepartum management protocol; timing and mode of
delivery in gestational diabetes Diabetes care 21sup 2:B113-
117,1998
4 Walkinshaw SA Dietary regulation for gestational diabetes Cochrane
Review In: In: The Cochrane Library, issue 2,: Update Software,
Oxford, 1999
5 Walkinshaw SA Very tight versus tight control for diabetes in
pregnancy Cochrane review In: The Cochrane Library, issue 2,:
Update Software, Oxford, 1999
6 Irion O, Boulvain M Induction of labor for suspected fetal macrosomia
Cochrane Review In: The Cochrane Library, issue 2,: Update
Software, Oxford, 1999
Source:guidedog.org
