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Predictors of emergency cesarean section in women with preexisting diabetes

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Highlights

  • Eighty percent of women planned a vaginal delivery with a success rate of 65 %.

  • Birth weight was similar between vaginal and emergency cesarean section deliveries.

  • Predictors of emergency cesarean section were similar to the background population.

  • Ultrasonic estimated fetal size did not predict emergency cesarean section.

Abstract

Objective

Preexisting diabetes in pregnancy is associated with a high risk of emergency cesarean section (CS), which is associated with increased risk of maternal and neonatal complications. Thus, the aim of this study was to identify possible predictors of emergency CS in women with preexisting diabetes.

Study design

This is a secondary analysis of a prospective observational study of 204 women with preexisting diabetes (118 with type 1 diabetes and 86 with type 2) with singleton pregnancies recruited at Rigshospitalet, Copenhagen, Denmark from August 2015 to February 2018. Mode of delivery (trial of labor or planned CS) was individually planned in late pregnancy based on clinical variables reflecting maternal and fetal health including glycemic control and ultrasonically estimated fetal weight. Univariate and multivariable analyses were performed to identify possible predictors of in labor emergency CS.

Results

Trial of labor was planned in 79 % (n = 162) of the women of whom 65 % (n = 105) were delivered vaginally and 35 % (n = 57) by an emergency CS, while the remaining 21 % (n = 42) were offered a planned CS. Nulliparity (adjusted odds ratio (aOR) 5.6 95 % CI 1.7–18.8), presence of a hypertensive disorder (aOR 2.8, 95 % CI 1.2–6.7) and previous CS (aOR 6.7, 95 % CI 1.5–28.9) were independently associated with an emergency CS. Maternal height was inversely associated with emergency CS (aOR 0.6 95 %, CI 0.5-0.9 per 5 cm decrease). Neither maternal HbA1c nor ultrasonically estimated fetal size in late pregnancy were associated with emergency CS. Women scheduled for a planned CS were characterized by poorer glycemic control and higher estimated fetal size than those offered a trial of labor.

Conclusion

Nulliparity, presence of a hypertensive disorder, previous CS and shorter maternal height were predictors of emergency CS in women with a planned trial of labor, whereas this not was the case for late pregnancy maternal Hba1c or fetal size estimated by ultrasound.

Introduction

Preexisting diabetes in pregnancy is associated with an increased risk of adverse outcomes such as; preterm delivery, hypertensive complications, large for gestational age infants (LGA), shoulder dystocia and perinatal mortality [[1], [2], [3]]. In many clinical settings, pregnant women with preexisting diabetes undergo induction of labor before their due date to prevent perinatal complications. However, many will end up with an emergency cesarean section (CS), in fact the rate of emergency CS in pregnancies complicated by preexisting diabetes is 3–4 fold compared with women without diabetes [1,4,5].

Emergency CS is associated with an increased risk of maternal intra- and postoperative complications compared with elective CS [6,7], thus it is a clinical challenge to strive for a high vaginal delivery rate and a good balance between elective and emergency CS [8]. The purpose of this study was to identify possible predictors of emergency CS in women with preexisting diabetes.

Section snippets

Study population

This is a secondary analysis of data collected in a prospective observational cohort study focusing on home blood pressure measurements and hypertensive disorders in women with preexisting diabetes [9]. The analysis was restricted to women followed ante- and perinatally at Center for Pregnant Women with Diabetes, Rigshospitalet, Denmark, covering a geographically area of two million inhabitants. The inclusion criteria were preexisting type 1 or type 2 diabetes, age ≥18 years and delivery ≥24

Theory

One of the goals of The St Vincent Declaration concerning diabetes care and research from 1989 states that pregnancy outcome in women with diabetes should approximate that of the background population [18]. Thus, it would be ideal with updated information on potential predictors of emergency CS to optimize our guidance and recommendations for pregnant women with preexisting diabetes concerning mode of delivery,

Most previous studies evaluating predictors of CS did not stratify for elective and

Results

Table 1 shows maternal characteristics and perinatal outcome for the 204 women stratified by diabetes type. Overall, 79 % of the women (n = 162) planned vaginal delivery resulting in 65 % (n = 105) delivering vaginally, and 35 % (n = 57) by emergency CS, while the remaining 21 % (n = 42) had planned CS (Table 2). Thus, in total 51 % gave birth vaginally, while 49 % delivered by CS. All were liveborn.

No difference was seen in mode of delivery, rate of induction of labor, instrumental deliveries

Comments

In this prospectively collected cohort of pregnant women with preexisting diabetes nearly 80 % planned a vaginal delivery with a successful result in 65 %, while 35 % was delivered by emergency CS. We found that emergency CS was associated to shorter maternal height, nulliparity, previous CS and presence of hypertensive disorders, but not to type of diabetes, glycemic control or ultrasonic estimates of fetal size in late pregnancy.

The rate of emergency CS in this study was approximately 3 times

Conclusion

In this prospectively collected cohort of women with preexisting diabetes the majority planned vaginal delivery and one third of these women were delivered by emergency CS.

Predictors of emergency CS were shorter maternal height, nulliparity, previous CS and presence of hypertensive disorders, but not diabetes type, glycemic control or ultrasonic estimated fetal size in late pregnancy.

Funding

The original study [9] was funded by Rigshospitalet’s Research Foundation and the Novo Nordisk foundation (grant no. NNF14OC0009275).

Transparency document

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Declaration of Competing Interest

The authors have no conflicts to declare.

Margit Bistrup Fischer graduated from medical school in 2013. Since 2014 Margit Bistrup Fischer has been working in the field of gynecology and obstetrics and pediatrics. Margit Bistrup Fischer has previously published in a national peer-reviewed journal and is currently in a one-year research fellowship at Rigshospitalet, University of Copenhagen. Margit Bistrup Fischer aims to specialize in gynecology and obstetrics.

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  • Margit Bistrup Fischer graduated from medical school in 2013. Since 2014 Margit Bistrup Fischer has been working in the field of gynecology and obstetrics and pediatrics. Margit Bistrup Fischer has previously published in a national peer-reviewed journal and is currently in a one-year research fellowship at Rigshospitalet, University of Copenhagen. Margit Bistrup Fischer aims to specialize in gynecology and obstetrics.

    Marianne Vestgaard is a medical doctor from 2011. Since 2007 Marianne has been researching in the field of Diabetes and Pregnancy with main focus on hypertensive disorders. Marianne is currently finishing up a PhD at the University of Copenhagen, Denmark, within the field. Marianne has published in international peer-reviewed journals and presented her work at international conferences. Further Marianne is at the first year in residency training in gynecology and obstetrics.

    Björg Ásbjörnsdóttir graduated from medical school in 2013. Since 2011 Björg Ásbjörnsdóttir has done research in the field of diabetes and pregnancy with main focus on gestational weight gain and adverse pregnancy outcomes. Currently, Björg Ásbjörnsdóttir is a PhD student at the University of Copenhagen. Björg has published in international peer-reviewed journals and presented her work at international conferences. Björg Ásbjörnsdóttir aims to specialize in endocrinology.

    Prof. Elisabeth R Mathiesen, MD, DMSc, is a Specialist in Endocrinology and leader of the endocrine function in Center for Pregnant Women with Diabetes at Rigshospitalet, Copenhagen. She has been working clinically and scientifically in the field diabetes and pregnancy for nearly 30 years, since 2010 as professor at the University of Copenhagen. Elisabeth Mathiesen has published more than 300 scientific papers or reviews and her H-factor is 40. Elisabeth Mathiesen has received two awards within the field Diabetes and Pregnancy namely The Jørgen Pedersen Lecture by the DPSG and The Norbert Freinkel Award by the American Diabetes Association.

    Prof. Peter Damm, MD, DMSc, is a Specialist in Obstetrics and Head of the Center for Pregnant Women with Diabetes at Rigshospitalet. He has been working clinically and scientifically in the field diabetes and pregnancy for nearly 30 years, since 2008 as professor at the University of Copenhagen. Peter Damm has published more than 275 peer-reviewed original scientific papers or reviews and his H-factor is 47. Peter Damm has received two awards within the field Diabetes and Pregnancy namely The Jørgen Pedersen Lecture by the DPSG and The Norbert Freinkel Award by the American Diabetes Association.

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