Department of Obstetrics and Gynecology, University of Calgary, Calgary, Alberta, Canada.
Department of Medicine, University of Calgary, Calgary, Alberta, Canada.
Acta Obstet Gynecol Scand. 2020 Mar;99(3):341-349. doi: 10.1111/aogs.13761. Epub 2019 Dec 8.
Women with diabetes, and their infants, have an increased risk of adverse events due to excess fetal growth. Earlier delivery, when fetuses are smaller, may reduce these risks. This study aimed to evaluate the week-specific risks of maternal and neonatal morbidity/mortality to assist with obstetrical decision making.
In this population-based cohort study, women with type 1 diabetes (n = 5889), type 2 diabetes (n = 9422) and gestational diabetes (n = 138 917) and a comparison group without diabetes (n = 2 553 243) who delivered a singleton infant at ≥36 completed weeks of gestation between 2004 and 2014 were identified from the Canadian Institute of Health Information Discharge Abstract Database. Multivariate logistic regression was used to determine the week-specific rates of severe maternal and neonatal morbidity/mortality among women delivered iatrogenically vs those undergoing expectant management.
For all women, the absolute risk of severe maternal morbidity/mortality was low, typically impacting less than 1% of women, and there was no significant difference in gestational age-specific severe maternal morbidity/mortality between iatrogenic delivery and expectant management among women with any form of diabetes. Among women with gestational diabetes, iatrogenic delivery was associated with an increased risk of neonatal morbidity/mortality compared with expectant management at 36 and 37 weeks' gestation (76.7 and 27.8 excess cases per 1000 deliveries, respectively) and a lower risk of neonatal morbidity/mortality at 38, 39 and 40 weeks' gestation (7.9, 27.3 and 15.9 fewer cases per 1000 deliveries, respectively). Increased risks of severe neonatal morbidity following iatrogenic delivery compared with expectant management were also observed for women with type 1 diabetes at 36 (98.3 excess cases per 1000 deliveries) and 37 weeks' gestation (44.5 excess cases per 1000 deliveries) and for women with type 2 diabetes at 36 weeks' gestation (77.9 excess cases per 1000 deliveries) weeks.
The clinical decision regarding timing of delivery is complex and contingent on maternal-fetal wellbeing, including adequate glycemic control. This study suggests that delivery at 38, 39 or 40 weeks' gestation may optimize neonatal outcomes among women with diabetes.
由于胎儿过度生长，糖尿病女性及其婴儿发生不良事件的风险增加。当胎儿较小时，提前分娩可能会降低这些风险。本研究旨在评估母婴发病率/死亡率的周特异性风险，以协助产科决策。
本队列研究基于人群，纳入了 2004 年至 2014 年期间在加拿大健康信息研究所出院摘要数据库中，在≥36 周妊娠时分娩单胎且患有 1 型糖尿病（n=5889）、2 型糖尿病（n=9422）和妊娠期糖尿病（n=138917）的女性，以及无糖尿病的对照组女性（n=2553243）。采用多变量逻辑回归分析比较了医源性分娩与期待管理的孕妇周特异性严重母婴发病率/死亡率。
所有女性的严重产妇发病率/死亡率的绝对风险均较低，通常影响不到 1%的女性，并且在患有任何形式糖尿病的女性中，医源性分娩和期待管理之间在特定孕周的严重产妇发病率/死亡率没有显著差异。与期待管理相比，在 36 周和 37 周妊娠时，医源性分娩与妊娠期糖尿病女性的新生儿发病率/死亡率升高相关（分别为每 1000 例分娩增加 76.7 和 27.8 例病例），而在 38 周、39 周和 40 周妊娠时则风险降低（分别为每 1000 例分娩减少 7.9、27.3 和 15.9 例病例）。与期待管理相比，1 型糖尿病女性在 36 周（每 1000 例分娩增加 98.3 例病例）和 37 周妊娠时（每 1000 例分娩增加 44.5 例病例）以及 2 型糖尿病女性在 36 周妊娠时（每 1000 例分娩增加 77.9 例病例）的医源性分娩后新生儿严重发病率的风险更高。
分娩时机的临床决策较为复杂，取决于母婴健康状况，包括血糖控制情况。本研究表明，对于糖尿病女性，在 38 周、39 周或 40 周分娩可能会优化新生儿结局。
