Niu Brenda, Lee Vanessa R, Cheng Yvonne W, Frias Antonio E, Nicholson James M, Caughey Aaron B
Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR.
Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR.
Am J Obstet Gynecol. 2014 Oct;211(4):418.e1-6. doi: 10.1016/j.ajog.2014.06.015. Epub 2014 Jun 6.
Type A1 gestational diabetes mellitus (A1GDM), also known as diet-controlled gestational diabetes, is associated with an increase in adverse perinatal outcomes such as macrosomia and Erb palsy. However, it remains unclear when to deliver these women because optimal timing of delivery requires balancing neonatal morbidities from early term delivery against the risk of intrauterine fetal demise (IUFD). We sought to determine the optimal gestational age (GA) for women with A1GDM to deliver.
A decision-analytic model was built to compare the outcomes of delivery at 37-41 weeks in a theoretical cohort of 100,000 women with A1GDM. Strategies involving expectant management until a later GA accounted for probabilities of spontaneous delivery, indicated delivery, and IUFD during each week. GA-associated risks of neonatal complications included cerebral palsy, infant death, and Erb palsy. Probabilities were derived from the literature, and total quality-adjusted life years were calculated. Sensitivity analyses were used to investigate the robustness of the baseline assumptions.
Our model showed that induction at 38 weeks maximized quality-adjusted life years. Within our cohort, delivery at 38 weeks would prevent 48 stillbirths but lead to 12 more infant deaths compared to 39 weeks. Sensitivity analysis revealed that 38 weeks remains the optimal timing of delivery until IUFD rates fall <0.3-fold of our baseline assumption, at which point expectant management until 39 weeks is optimal.
By weighing the risks of IUFD against infant deaths and neonatal morbidities from early term delivery, we determined that the ideal GA for women with A1GDM to deliver is 38 weeks.
A1型妊娠期糖尿病（A1GDM），也称为饮食控制型妊娠期糖尿病，与巨大儿和臂丛神经麻痹等不良围产期结局增加有关。然而，何时分娩这些女性仍不清楚，因为最佳分娩时机需要在早产导致的新生儿发病率与宫内胎儿死亡（IUFD）风险之间进行权衡。我们试图确定A1GDM女性的最佳孕周（GA）。
构建了一个决策分析模型，以比较100,000名A1GDM女性理论队列在37 - 41周分娩的结局。涉及期待管理直至更晚孕周的策略考虑了每周自然分娩、指征性分娩和IUFD的概率。与孕周相关的新生儿并发症风险包括脑瘫、婴儿死亡和臂丛神经麻痹。概率来自文献，并计算了总质量调整生命年。进行敏感性分析以研究基线假设的稳健性。
我们的模型表明，38周引产可使质量调整生命年最大化。在我们的队列中，与39周相比，38周分娩可预防48例死产，但会导致多12例婴儿死亡。敏感性分析显示，在IUFD发生率降至我们基线假设的<0.3倍之前，38周仍是最佳分娩时机，此时期待管理至39周是最佳的。
通过权衡IUFD风险与早产导致的婴儿死亡和新生儿发病率，我们确定A1GDM女性的理想分娩孕周为38周。
