RESUMEN
BACKGROUND: Gestational diabetes mellitus (GDM) is a common medical condition that complicates pregnancy and causes adverse maternal and fetal outcomes. At present, most treatment strategies focus on normalisation of maternal blood glucose values with use of diet, lifestyle modification, exercise, oral anti-hyperglycaemics and insulin. This has been shown to reduce the incidence of adverse outcomes, such as birth trauma and macrosomia. However, this involves intensive monitoring and treatment of all women with GDM. We propose that using medical imaging to identify pregnancies displaying signs of being affected by GDM could help to target management, allowing low-risk women to be spared excessive intervention, and facilitating better resource allocation. OBJECTIVES: We wanted to address the following question: in women with gestational diabetes, does the use of fetal imaging plus maternal blood glucose concentration to indicate the need for medical management compared with glucose concentration alone reduce the risk of adverse perinatal outcomes? SEARCH METHODS: We searched Cochrane Pregnancy and Childbirth's Trials Register (29 January 2019), ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (ICTRP) (both on 29 January 2019), and reference lists of retrieved studies. SELECTION CRITERIA: Randomised controlled trials, including those published in abstract form only. Studies using a cluster-randomised design and quasi-randomised controlled trials were both eligible for inclusion, but we didn't identify any. Cross-over trials were not eligible for inclusion in our review.We included women carrying singleton pregnancies who were diagnosed with GDM, as defined by the trials' authors. The intervention of interest was the use of fetal biometry on imaging methods in addition to maternal glycaemic values for indicating the use of medical therapy for GDM. The control group was the use of maternal glycaemic values alone for indicating the use of such therapy. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and assessed risk of bias. Two review authors extracted data and checked them for accuracy. MAIN RESULTS: Three randomised controlled trials met the inclusion criteria for our systematic review - the studies randomised a total of 524 women.We assessed the three included studies as being at a low to moderate risk of bias; the nature of the intervention made it difficult to achieve blinding of participants and personnel and none of the trial reports contained information about methods of allocation concealment (and were therefore assessed as being at an unclear risk of selection bias).In all studies, the intervention was the use of fetal biometry on ultrasound to identify fetuses displaying signs of fetal macrosomia, and the use of this information to indicate the use of medical anti-hyperglycaemic treatments. Those pregnancies were subject to more stringent blood glucose targets than those without signs of fetal macrosomia.Maternal outcomesThe use of fetal biometry in addition to maternal blood glucose concentration (compared with maternal blood glucose concentration alone) may make little or no difference to the incidence of caesarean delivery (risk ratio (RR) 0.81, 95% confidence interval (CI) 0.59 to 1.10; 2 trials, 428 women; low-certainty evidence). We are unclear about the results for hypertensive disorders of pregnancy (RR 0.80, 95% CI 0.34 to 1.89; 2 trials, 325 women) due to very low-certainty evidence. The included trials did not report on development of type 2 diabetes in the mother or maternal hypoglycaemia.Fetal and neonatal outcomesThe use of fetal biometry may make little or no difference to the incidence of neonatal hypoglycaemia (RR 0.90, 95% CI 0.57 to 1.42; 3 trials, 524 women; low-certainty evidence). Very low-certainty evidence means that we are unclear about the results for large-for-gestational age (RR 0.81, 95% CI 0.38 to 1.74; 3 trials, 524 women); shoulder dystocia (RR 0.33, 95% CI 0.01 to 7.98; 1 trial, 96 women); a composite measure of perinatal morbidity or mortality (RR 1.00, 95% CI 0.21 to 4.71; 1 study, 96 women); or perinatal mortality (RR 0.33, 95% CI 0.01 to 7.98; 1 trial, 96 women). AUTHORS' CONCLUSIONS: This review is based on evidence from three trials involving 524 women. The trials did not report some important outcomes of interest to this review, and the majority of our secondary outcomes were also unreported. The available evidence ranged from low- to very low-certainty, with downgrading decisions based on limitations in study design, imprecision and inconsistency.There is insufficient evidence to evaluate the use of fetal biometry (in addition to maternal blood glucose concentration values) to assist in guiding the medical management of GDM, on either maternal or perinatal health outcomes, or the associated costs.More research is required, ideally larger randomised studies which report the maternal and infant short- and long-term outcomes listed in this review, as well as those outcomes relating to financial and resource implications.
Asunto(s)
Biometría/métodos , Diabetes Gestacional/terapia , Macrosomía Fetal/prevención & control , Complicaciones del Embarazo/prevención & control , Femenino , Humanos , Insulina/uso terapéutico , Embarazo , Resultado del Embarazo , Ensayos Clínicos Controlados Aleatorios como AsuntoRESUMEN
It is estimated that everyday 7000 women worldwide have their pregnancy end with a stillbirth, however, research and data collection on stillbirth remains underfunded. This stillbirth case series audit investigates an apparent rise in stillbirths at a Sydney tertiary referral hospital in Australia. A retrospective case series of singleton stillbirths from 2005-2010 was conducted at Westmead Hospital. Stillbirth was defined as per the Perinatal Society of Australia and New Zealand classification as a death of a baby before or during birth, from the 20th week of pregnancy onwards, or a birth weight of 400 grams or more if gestational age is unknown. A total of 215 singleton stillbirths were identified in a cohort of 28 109, a rate of 7.6 per 1000 singleton births. There was a significant increase in annual stillbirth rate at our institution; the rate exceeded both Australian national and state singleton stillbirth rates. After pregnancy terminations over 20 weeks were excluded from the data, there was no statistical change in the stillbirth rate over time. Congenital anomalies (27%) and unexplained antepartum death (15%) remained as major causes; fetal growth restriction (17%) was also identified as an increasingly important cause, particularly in preterm gestations. Termination of pregnancy after 20 weeks was found to be the cause of rising stillbirth rate at our institution. Local and national data collection on stillbirth should be standardised and should include differentiation of termination of pregnancy as a separate entity so as to accurately assess stillbirth to target appropriate research and resource allocation.