In the JournalsPerspective

Induced labor tied to neonatal complications among women with diabetes before pregnancy

Howard Berger, MD

Routine induction of labor among women with diabetes before pregnancy is not associated with an increase in the rate of cesarean delivery, but is associated with certain neonatal complications, according to findings published in BMJ Open Diabetes Research and Care.

“Based on this population-based, retrospective data, delivery of women with preexisting diabetes before 39 weeks’ gestation is associated with a higher rate of neonatal complications and does not reduce the cesarean section rate,” Howard Berger, MD, head of maternal fetal medicine at St. Michael’s Hospital, Toronto, and associate professor at the University of Toronto, told Healio. “Clinicians are often faced with the dilemma of when to deliver pregnant women with preexisting type 1 and type 2 diabetes. On one hand, it is known that pregnancies in women with preexisting diabetes are at increased risk for certain complications, including stillbirth and the development of preeclampsia. This has led to many clinicians electively choosing to deliver these women before 39 weeks’ gestation, but the price that is paid is an increase in early-term deliveries, which carry with them an increase in certain neonatal complications.”

Berger and colleagues analyzed data from women with diabetes before pregnancy who had a singleton birth at 38 weeks’ gestation or later, using data from the Better Outcomes Registry and Network, a province-wide registry of all hospital and home births in Toronto. Deliveries occurred between April 2012 and March 2017, with researchers excluding women with placenta previa, previous cesarean section, and women diagnosed with gestational hypertension of preeclampsia before 38 weeks.

Pregnant women in hospital 
Routine induction of labor among women with diabetes before pregnancy is not associated with an increase in the rate of cesarean delivery, but is associated with certain neonatal complications.
Source: Adobe Stock

“The cohort was divided into two exposure groups to mimic the real-life dilemma faced by a health care provider: whether to induce at 38 weeks’ gestation or expectantly manage until at least 390/7 weeks,” the researchers wrote. “Women who underwent induction of labor between 380/7 and 386/7 weeks [n = 937] were compared with those expectantly managed and who remained undelivered by 390/7 weeks [n = 1,276]. ... Primary outcome was all-cause cesarean delivery.”

Researchers used modified Poisson regression analyses to generate relative risks adjusted for parity, maternal age, prepregnancy BMI and diabetes type.

Within the cohort, cesarean delivery occurred among 269 women in the induced labor group and among 333 women in the expectantly managed group (28.7% vs. 26.1%), for an RR of 1.07 (95% CI, 0.94-1.22). Rates of instrumental delivery were 11.2% and 10.2% for the induced labor group and the expectantly managed group, respectively (adjusted RR = 1.25; 95% CI, 0.98-1.61).

Other neonatal complications were more common among infants in the induced labor group, compared with the expectantly managed group, including neonatal ICU admission (aRR = 1.61; 95% CI, 1.36-1.9), jaundice requiring phototherapy (aRR = 1.93; 95% CI, 1.46-2.57) and newborn hypoglycemia (aRR = 1.74; 95% CI 1.46-2.07).

Researchers noted that there were no cases of stillbirth in the expectantly managed group; however, hypertensive disorders developed among 5.7% of women. Researchers also cautioned that the study was underpowered to detect very rare adverse outcomes, such as neonatal death.

“Our study provides support to the notion that among ‘lower-risk’ women with preexisting diabetes, allowing pregnancies to continue with close surveillance to 39 completed weeks is an option that is better for the neonate and not worse for the mother,” Berger said. “One of course must remember that anytime we postpone delivery — even among women without preexisting diabetes — we will be exposing pregnancies to the small, increased absolute risk of experiencing preeclampsia or stillbirth.” – by Regina Schaffer

For more information:

Howard Berger, MD, can be reached at the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Unity Health Toronto, 30 Bond St., Toronto, Ontario, Canada, M5B 1W8; email: howard.berger@unityhealth.to.

Disclosures: The authors report no relevant financial disclosures.

Howard Berger, MD

Routine induction of labor among women with diabetes before pregnancy is not associated with an increase in the rate of cesarean delivery, but is associated with certain neonatal complications, according to findings published in BMJ Open Diabetes Research and Care.

“Based on this population-based, retrospective data, delivery of women with preexisting diabetes before 39 weeks’ gestation is associated with a higher rate of neonatal complications and does not reduce the cesarean section rate,” Howard Berger, MD, head of maternal fetal medicine at St. Michael’s Hospital, Toronto, and associate professor at the University of Toronto, told Healio. “Clinicians are often faced with the dilemma of when to deliver pregnant women with preexisting type 1 and type 2 diabetes. On one hand, it is known that pregnancies in women with preexisting diabetes are at increased risk for certain complications, including stillbirth and the development of preeclampsia. This has led to many clinicians electively choosing to deliver these women before 39 weeks’ gestation, but the price that is paid is an increase in early-term deliveries, which carry with them an increase in certain neonatal complications.”

Berger and colleagues analyzed data from women with diabetes before pregnancy who had a singleton birth at 38 weeks’ gestation or later, using data from the Better Outcomes Registry and Network, a province-wide registry of all hospital and home births in Toronto. Deliveries occurred between April 2012 and March 2017, with researchers excluding women with placenta previa, previous cesarean section, and women diagnosed with gestational hypertension of preeclampsia before 38 weeks.

Pregnant women in hospital 
Routine induction of labor among women with diabetes before pregnancy is not associated with an increase in the rate of cesarean delivery, but is associated with certain neonatal complications.
Source: Adobe Stock

“The cohort was divided into two exposure groups to mimic the real-life dilemma faced by a health care provider: whether to induce at 38 weeks’ gestation or expectantly manage until at least 390/7 weeks,” the researchers wrote. “Women who underwent induction of labor between 380/7 and 386/7 weeks [n = 937] were compared with those expectantly managed and who remained undelivered by 390/7 weeks [n = 1,276]. ... Primary outcome was all-cause cesarean delivery.”

Researchers used modified Poisson regression analyses to generate relative risks adjusted for parity, maternal age, prepregnancy BMI and diabetes type.

Within the cohort, cesarean delivery occurred among 269 women in the induced labor group and among 333 women in the expectantly managed group (28.7% vs. 26.1%), for an RR of 1.07 (95% CI, 0.94-1.22). Rates of instrumental delivery were 11.2% and 10.2% for the induced labor group and the expectantly managed group, respectively (adjusted RR = 1.25; 95% CI, 0.98-1.61).

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Other neonatal complications were more common among infants in the induced labor group, compared with the expectantly managed group, including neonatal ICU admission (aRR = 1.61; 95% CI, 1.36-1.9), jaundice requiring phototherapy (aRR = 1.93; 95% CI, 1.46-2.57) and newborn hypoglycemia (aRR = 1.74; 95% CI 1.46-2.07).

Researchers noted that there were no cases of stillbirth in the expectantly managed group; however, hypertensive disorders developed among 5.7% of women. Researchers also cautioned that the study was underpowered to detect very rare adverse outcomes, such as neonatal death.

“Our study provides support to the notion that among ‘lower-risk’ women with preexisting diabetes, allowing pregnancies to continue with close surveillance to 39 completed weeks is an option that is better for the neonate and not worse for the mother,” Berger said. “One of course must remember that anytime we postpone delivery — even among women without preexisting diabetes — we will be exposing pregnancies to the small, increased absolute risk of experiencing preeclampsia or stillbirth.” – by Regina Schaffer

For more information:

Howard Berger, MD, can be reached at the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Unity Health Toronto, 30 Bond St., Toronto, Ontario, Canada, M5B 1W8; email: howard.berger@unityhealth.to.

Disclosures: The authors report no relevant financial disclosures.

    Perspective
    Grenye O

    Grenye O'Malley

    The authors did a good job of taking retrospective data and trying to answer the question of whether or not to induce as specifically as possible, excluding women with conditions like gestational hypertension and preeclampsia. With pregnancy, it is difficult to conduct randomized controlled studies, which is why we don’t have much data to answer these questions. Here, it is not always perfect, but the authors did a good job of thinking through the clinical reasoning. The authors also address cesarean delivery rates, which were not different between groups. One of the biggest things still lacking is we do not have a large enough study to address the rate of stillbirth among these women. That continues to be an underlying stressor for the patient and the provider making suggestions. The good thing is that outcome is declining, though we’re not sure what we are doing that is causing that decline. The more information we can get as endocrinologists for how controlled blood glucose is affecting all of these outcomes, the better.

    • Grenye O'Malley, MD
    • Endocrinologist, Mount Sinai Diabetes Center
      Assistant Professor of Medicine, Endocrinology, Diabetes and Bone Disease
      Icahn School of Medicine at Mount Sinai, New York

    Disclosures: O’Malley reports no relevant financial disclosures.