Division of Women & Child Health, The Aga Khan University, Stadium Road, PO Box 3500, Karachi, Pakistan.
BMC Public Health. 2011 Apr 13;11 Suppl 3(Suppl 3):S2. doi: 10.1186/1471-2458-11-S3-S2.
Diabetes during pregnancy is associated with significant risk of complications to the mother, fetus and newborn. We reviewed the potential impact of early detection and control of diabetes mellitus during pregnancy on stillbirths for possible inclusion in the Lives Saved Tool (LiST).
A systematic literature search up to July 2010 was done to identify all published randomized controlled trials and observational studies. A standardized data abstraction sheet was employed and data were abstracted by two independent authors. Meta-analyses were performed with different sub-group analyses. The analyses were graded according to the CHERG rules using the adapted GRADE criteria and recommendations made after assessing the overall quality of the studies included in the meta-analyses.
A total of 70 studies were selected for data extraction including fourteen intervention studies and fifty six observational studies. No randomized controlled trials were identified evaluating early detection of diabetes mellitus in pregnancy versus standard screening (glucose challenge test between 24th to 28th week of gestation) in pregnancy. Intensive management of gestational diabetes (including specialized dietary advice, increased monitoring and tailored dietary therapy) during pregnancy (3 studies: 3791 participants) versus conventional management (dietary advice and insulin as required) was associated with a non-significant reduction in the risk of stillbirths (RR 0.20; 95% CI: 0.03-1.10) ('moderate' quality evidence). Optimal control of serum blood glucose versus sub-optimal control was associated with a significant reduction in the risk of perinatal mortality (2 studies, 5286 participants: RR = 0.40, 95% CI 0.25- 0.63), but not stillbirths (3 studies, 2469 participants: RR = 0.51, 95% CI 0.14-1.88). Preconception care of diabetes (information about need for optimization of glycemic control before pregnancy, assessment of diabetes complications, review of dietary habits, intensification of capillary blood glucose self-monitoring and optimization of insulin therapy) versus none (3 studies: 910 participants) was associated with a reduction in perinatal mortality (RR = 0.29, 95% CI 0.14 -0.60). Using the Delphi process for estimating effect size of optimal diabetes recognition and management yielded a median effect size of 10% reduction in stillbirths.
Diabetes, especially pre-gestational diabetes with its attendant vascular complications, is a significant risk factor for stillbirth and perinatal death. Our review highlights the fact that very few studies of adequate quality are available that can provide estimates of the effect of screening for aid management of diabetes in pregnancy on stillbirth risk. Using the Delphi process we recommend a conservative 10% reduction in the risk of stillbirths, as a point estimate for inclusion in the LiST.
妊娠糖尿病会显著增加母婴、胎儿和新生儿并发症的风险。我们对妊娠期间糖尿病的早期发现和控制对死产的潜在影响进行了综述，以便可能将其纳入 Lives Saved Tool (LiST)。
系统检索了截至 2010 年 7 月的所有已发表的随机对照试验和观察性研究。采用标准化的数据提取表，由两名独立作者提取数据。进行了荟萃分析，并进行了不同的亚组分析。根据 CHERG 规则进行分析，并使用经过评估的纳入荟萃分析的研究的整体质量的适应性 GRADE 标准和建议进行分级。
共选择了 70 项研究进行数据提取，包括 14 项干预研究和 56 项观察性研究。没有发现评估妊娠期间糖尿病早期检测与标准筛查（妊娠 24-28 周之间的葡萄糖挑战试验）的随机对照试验。妊娠期间强化管理（包括专门的饮食建议、增加监测和定制饮食疗法）与常规管理（饮食建议和按需胰岛素）相比，死产风险无显著降低（RR 0.20；95%CI：0.03-1.10）（“中等”质量证据）。与亚最佳控制相比，最佳控制血清血糖与围产期死亡率显著降低相关（2 项研究，5286 名参与者：RR=0.40，95%CI 0.25-0.63），但与死产无关（3 项研究，2469 名参与者：RR=0.51，95%CI 0.14-1.88）。与没有进行任何干预（3 项研究：910 名参与者）相比，糖尿病孕前保健（关于妊娠前血糖控制优化需求的信息、糖尿病并发症评估、饮食习惯回顾、毛细血管血糖自我监测强化和胰岛素治疗优化）可降低围产期死亡率（RR=0.29，95%CI 0.14-0.60）。使用德尔菲法估计最佳糖尿病识别和管理效果大小的中位数效应大小为死产风险降低 10%。
糖尿病，特别是伴有血管并发症的孕前糖尿病，是死产和围产期死亡的重要危险因素。我们的综述强调了一个事实，即很少有足够质量的研究能够提供关于妊娠糖尿病筛查和管理对死产风险的影响的估计。使用德尔菲法，我们建议将 10%的死产风险降低作为列入 Lives Saved Tool (LiST) 的一个保守的点估计值。
