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Preconception care for diabetic women for improving maternal and fetal outcomes: a systematic review and meta-analysis.

ABSTRACT:

Background

Preexisting diabetes mellitus is associated with increased risk for maternal and fetal adverse outcomes. Despite improvement in the access and quality of antenatal care recent population based studies demonstrating increased congenital abnormalities and perinatal mortality in diabetic mothers as compared to the background population. This systematic review was carried out to evaluate the effectiveness and safety of preconception care in improving maternal and fetal outcomes for women with preexisting diabetes mellitus.

Methods

We searched the following databases, MEDLINE, EMBASE, WEB OF SCIENCE, Cochrane Library, including the CENTRAL register of controlled trials and CINHAL up to December 2009, without language restriction, for any preconception care aiming at health promotion, glycemic control and screening and treatment of diabetes complications in women of reproductive age group with type I or type II diabetes. Study design were trials (randomized and non-randomized), cohort and case-control studies. Of the 1612 title scanned 44 full papers were retrieved of those 24 were included in this review. Twelve cohort studies at low and medium risk of bias, with 2502 women, were included in the meta-analysis.

Results

Meta-analysis suggested that preconception care is effective in reducing congenital malformation, RR 0.25 (95% CI 0.15-0.42), NNT17 (95% CI 14-24), preterm delivery, RR 0.70 (95% CI 0.55-0.90), NNT = 8 (95% CI 5-23) and perinatal mortality RR 0.35 (95% CI 0.15-0.82), NNT = 32 (95% CI 19-109). Preconception care lowers HbA1c in the first trimester of pregnancy by an average of 2.43% (95% CI 2.27-2.58). Women who received preconception care booked earlier for antenatal care by an average of 1.32 weeks (95% CI 1.23-1.40).

Conclusion

Preconception care is effective in reducing diabetes related congenital malformations, preterm delivery and maternal hyperglycemia in the first trimester of pregnancy.

SUBMITTER: Wahabi HA

PROVIDER: S-EPMC2972233 | biostudies-literature | 2010 Oct

REPOSITORIES: biostudies-literature

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Preconception care for diabetic women for improving maternal and fetal outcomes: a systematic review and meta-analysis.

Wahabi Hayfaa A HA Alzeidan Rasmeia A RA Bawazeer Ghada A GA Alansari Lubna A LA Esmaeil Samia A SA

BMC pregnancy and childbirth 20101014

<h4>Background</h4>Preexisting diabetes mellitus is associated with increased risk for maternal and fetal adverse outcomes. Despite improvement in the access and quality of antenatal care recent population based studies demonstrating increased congenital abnormalities and perinatal mortality in diabetic mothers as compared to the background population. This systematic review was carried out to evaluate the effectiveness and safety of preconception care in improving maternal and fetal outcomes fo ...[more]

PMID: 20946676

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Project description:BackgroundInfants born to mothers with pre-existing type 1 or type 2 diabetes mellitus are at greater risk of congenital anomalies, perinatal mortality and significant morbidity in the short and long term. Pregnant women with pre-existing diabetes are at greater risk of perinatal morbidity and diabetic complications. The relationship between glycaemic control and health outcomes for both mothers and infants indicates the potential for preconception care for these women to be of benefit. This is an update of the original review, which was first published in 2010.ObjectivesTo assess the effects of preconception care in women with diabetes on health outcomes for mothers and their infants.Search methodsWe searched Cochrane Pregnancy and Childbirth's Trials Register (31 January 2017) and reference lists of retrieved articles.Selection criteriaRandomised controlled trials (RCTs) assessing the effects of preconception care for diabetic women. Cluster-RCTs and quasi-RCTs were eligible for inclusion but none were identified.Data collection and analysisTwo reviewers independently assessed study eligibility, extracted data and assessed the risk of bias of the included studies. We checked data for accuracy and assessed the quality of the evidence using the GRADE approach.Main resultsWe included three trials involving 254 adolescent girls with type 1 or type 2 diabetes, with an overall unclear to high risk of bias. The three trials were conducted at diabetes clinics in the USA, and assessed the READY-Girls (Reproductive-health Education and Awareness of Diabetes in Youth for Girls) programme versus standard care.Considering primary outcomes, one trial reported no pregnancies in the trial period (12 months) (very low-quality evidence, with downgrading based on study limitations (risk of bias) and imprecision); in the other two trials, pregnancy was an exclusion criterion, or was not clearly reported on. None of the trials reported on the other primary maternal outcomes, hypertensive disorders of pregnancy and caesarean section; or primary infant outcomes, large-for-gestational age, perinatal mortality, death or morbidity composite, or congenital malformations. Similarly, none of the trials reported on the secondary outcomes, for which we had planned to assess the quality of the evidence using the GRADE approach (maternal: induction of labour; perineal trauma; gestational weight gain; long-term cardiovascular health; infant: adiposity; type 1 or 2 diabetes; neurosensory disability).The majority of secondary maternal and infant outcomes, and outcomes relating to the use and costs of health services were not reported by the three included trials. Regarding behaviour changes associated with the intervention, in one trial, participants in the preconception care group had a slightly higher score for the actual initiation of discussion regarding preconception care with healthcare providers at follow-up (nine months), compared with those in the standard care group (mean difference 0.40, 95% confidence interval -0.02 to 0.82 (on a scale of 0 to 4 points); participants = 87) (a summation of four dichotomous items; possible range 0 to 4, with 0 being no discussion).Authors' conclusionsThere are insufficient RCT data available to assess the effects of preconception care for diabetic women on health outcomes for mothers and their infants.More high-quality evidence is needed to determine the effects of different protocols of preconception care for diabetic women. Future trials should be powered to evaluate effects on short- and long-term maternal and infant outcomes, and outcomes relating to the use and costs of health services. We have identified three ongoing studies that we will consider in the next review update.

Project description:BACKGROUND:Pre-gestational diabetes mellitus is associated with increased risk of maternal and perinatal adverse outcomes. This systematic review was conducted to evaluate the effectiveness and safety of pre-conception care (PCC) in improving maternal and perinatal outcomes. METHODS:Databases from MEDLINE, EMBASE, WEB OF SCIENCE, and Cochrane Library were searched, including the CENTRAL register of controlled trials, and CINHAL up until March 2019, without any language restrictions, for any pre-pregnancy care aiming at health promotion, glycemic control, and screening and treatment of diabetes complications in women with type I or type II pre-gestational diabetes. Trials and observational studies were included in the review. Newcastle-Ottawa scale and the Cochrane collaboration methodology for data synthesis and analysis were used, along with the GRADE tool to evaluate the body of evidence. RESULTS:The search identified 8500 potentially relevant citations of which 40 reports of 36 studies were included. The meta-analysis results show that PCC reduced congenital malformations risk by 71%, (Risk ratio (RR) 0.29; 95% CI: 0.21-0.40, 25 studies; 5903 women; high-certainty evidence). The results also show that PCC may lower HbA1c in the first trimester of pregnancy by an average of 1.27% (Mean difference (MD) 1.27; 95% CI: 1.33-1.22; 4927 women; 24 studies, moderate-certainty evidence). Furthermore, the results suggest that PCC may lead to a slight reduction in the risk of preterm delivery of 15%, (RR 0.85; 95% CI: 0.73-0.99; nine studies, 2414 women; moderate-certainty evidence). Moreover, PCC may result in risk reduction of perinatal mortality by 54%, (RR 0.46; 95% CI: 0.30-0.73; ten studies; 3071 women; moderate-certainty evidence). There is uncertainty about the effects of PCC on the early booking for antenatal care (MD 1.31; 95% CI: 1.40-1.23; five studies, 1081 women; very low-certainty evidence) and maternal hypoglycemia in the first trimester, (RR 1.38; 95% CI: 1.07-1.79; three studies; 686 women; very low- certainty evidence). In addition, results of the meta-analysis indicate that PCC may lead to 48% reduction in the risk of small for gestational age (SGA) (RR 0.52; 95% CI: 0.37-0.75; six studies, 2261 women; moderate-certainty evidence). PCC may reduce the risk of neonatal admission to intensive care unit (NICU) by 25% (RR 0.75; 95% CI: 0.67-0.84; four studies; 1322 women; moderate-certainty evidence). However, PCC may have little or no effect in reducing the cesarean section rate (RR 1.02; 95% CI: 0.96-1.07; 14 studies; 3641 women; low-certainty evidence); miscarriage rate (RR 0.86; 95% CI: 0.70-1.06; 11 studies; 2698 women; low-certainty evidence); macrosomia rate (RR 1.06; 95% CI: 0.97-1.15; nine studies; 2787 women, low-certainty evidence); neonatal hypoglycemia (RR 0.93; 95% CI: 0.74-1.18; five studies; 880 women; low-certainty evidence); respiratory distress syndrome (RR 0.78; 95% CI: 0.47-1.29; four studies; 466 women; very low-certainty evidence); or shoulder dystocia (RR 0.28; 95% CI: 0.07-1.12; 2 studies; 530 women; very low-certainty evidence). CONCLUSION:PCC for women with pre-gestational type 1 or type 2 diabetes mellitus is effective in improving rates of congenital malformations. In addition, it may improve the risk of preterm delivery and admission to NICU. PCC probably reduces maternal HbA1C in the first trimester of pregnancy, perinatal mortality and SGA. There is uncertainty regarding the effects of PCC on early booking for antenatal care or maternal hypoglycemia during the first trimester of pregnancy. PCC has little or no effect on other maternal and perinatal outcomes.

Project description:Abstract Objectives Determine if maternal characteristics modified newborn anthropometric outcomes in the WF trial (ClinicalTrials.gov NCT01883193). Methods Secondary analysis included combined data for all 1465 maternal infant dyads in WF sites in Guatemala, India, and Pakistan who had 1st trimester ultrasounds and newborn anthropometry with the three WF arms maintained: Arm 1 commenced a comprehensive nutrition supplement ≥3 months prior to conception; Arm 2 commenced the same supplement in the 1st trimester, and Arm 3 received no trial supplements. Maternal characteristics included were: baseline, BMI, hemoglobin, age, education, SES, and parity plus newborn sex. Newborn outcomes were Z-scores for length (LAZ), weight (WAZ), and weight-to-length ratio (WLRZ). Mixed effect regression models were fit for each outcome, including treatment arm, effect modifier, and treatment arm x effect modifier interaction as predictors and controlling for study site, maternal characteristics, and newborn sex. Results Parity, anemia and newborn sex were significant effect modifiers favoring para 0 vs para ≥1, anemia vs non anemia, and newborn male vs female. Effect of Arm 1 vs 3 was significantly larger for para 0 vs ≥1 women on length and weight (Table). Arm 2 vs 3 was not associated with improvements for para 0 in weight (P = 0.273) or WLRZ (P = 0.710). Arms 1 and 2 (vs 3) were associated with significantly higher length, weight, and WLRZ for anemic women. For parity and anemia, effect sizes for Arm 1 were greater than for Arm 2 for WAZ and WLZ (P < 0.05), but not LAZ. Arm 1 and 2 were associated with significantly higher weight and WLRZ for male vs female newborn. Conclusions In diverse low resource populations, impaired fetal growth (weight and length) is substantially improved in nulliparous and in anemic women but minimally or not at all in parous and in non-anemic women. Correction of weight decrements is most pronounced with improvement in maternal nutrition commencing prior to conception. Funding Sources Bill & Melinda Gates Foundation; NIH, NICHD and ODS. Supporting Tables, Images and/or Graphs

Project description:STUDY QUESTION:How is endometriosis associated with adverse maternal, fetal and neonatal outcomes of pregnancy? SUMMARY ANSWER:Women with endometriosis are at elevated risk for serious and important adverse maternal (pre-eclampsia, gestational diabetes, placenta praevia and Cesarean section) and fetal or neonatal outcomes (preterm birth, PPROM, small for gestational age, stillbirth and neonatal death). WHAT IS KNOWN ALREADY:A number of studies have shown an association between endometriosis and certain adverse maternal and fetal outcomes, but the results have been conflicting with potential for confounding by the use of assisted reproductive technology. STUDY DESIGN, SIZE, DURATION:A systematic review and meta-analysis of observational studies (1 January 1990-31 December 2017) that evaluated the effect of endometriosis on maternal, fetal and neonatal outcomes was conducted. PARTICIPANTS/MATERIALS, SETTING, METHODS:Studies were considered for inclusion if they were prospective or retrospective cohort or case-control studies; included women greater than 20 weeks gestational age with endometriosis; included a control group of gravid women without endometriosis; and, reported at least one of the outcomes of interest. Each study was reviewed for inclusion, data were extracted and risk of bias was assessed by two independent reviewers. MAIN RESULTS AND THE ROLE OF CHANCE:The search strategy identified 33 studies (sample size, n = 3 280 488) for inclusion. Compared with women without endometriosis, women with endometriosis had higher odds of pre-eclampsia (odds ratio [OR] = 1.18 [1.01-1.39]), gestational hypertension and/or pre-eclampsia (OR = 1.21 [1.05-1.39]), gestational diabetes (OR = 1.26 [1.03-1.55]), gestational cholestasis (OR = 4.87 [1.85-12.83]), placenta praevia (OR = 3.31 [2.37, 4.63]), antepartum hemorrhage (OR = 1.69 [1.38-2.07]), antepartum hospital admissions (OR = 3.18 [2.60-3.87]), malpresentation (OR = 1.71 [1.34, 2.18]), labor dystocia (OR = 1.45 [1.04-2.01]) and cesarean section (OR = 1.86 [1.51-2.29]). Fetuses and neonates of women with endometriosis were also more likely to have preterm premature rupture of membranes (OR = 2.33 [1.39-3.90]), preterm birth (OR = 1.70 [1.40-2.06]), small for gestational age <10th% (OR = 1.28 [1.11-1.49]), NICU admission (OR = 1.39 [1.08-1.78]), stillbirth (OR = 1.29 [1.10, 1.52]) and neonatal death (MOR = 1.78 [1.46-2.16]). Among the subgroup of women who conceived spontaneously, endometriosis was found to be associated with placenta praevia, cesarean section, preterm birth and low birth weight. Among the subgroup of women who conceived with the use of assisted reproductive technology, endometriosis was found to be associated with placenta praevia and preterm birth. LIMITATIONS, REASONS FOR CAUTION:As with any systematic review, the review is limited by the quality of the included studies. The diagnosis for endometriosis and the selection of comparison groups were not uniform across studies. However, the effect of potential misclassification would be bias towards the null hypothesis. WIDER IMPLICATIONS OF THE FINDINGS:The association between endometriosis with the important and serious pregnancy outcomes observed in our meta-analysis, in particular stillbirth and neonatal death, is concerning and warrants further studies to elucidate the mechanisms for the observed findings. STUDY FUNDING/COMPETING INTEREST(S):Dr Shifana Lalani is supported by a Physicians' Services Incorporated Foundation Research Grant, and Dr Innie Chen is supported by a University of Ottawa Clinical Research Chair in Reproductive Population Health and Health Services. Dr Singh declares conflicts of interests with Bayer, Abvie, Allergan and Cooper Surgical. All other authors have no conflicts of interests to declare. REGISTRATION NUMBER:PROSPERO CRD42015013911.

Project description:BackgroundBiologic medications, specifically tumour necrosis factor-α (TNF-α) inhibitors, have become increasingly prevalent in the treatment of chronic inflammatory disease (CID) in pregnancy.ObjectiveTo determine pregnancy outcomes in women with CID exposed to biologics during pregnancy.Search strategyPubMed and EMBASE databases were searched through January 1998-July 2021.Selection criteriaPeer-reviewed, English-language cohort, case-control, cross-sectional studies, and case series that contained original data.Data collection and analysisTwo authors independently conducted data extraction. A meta-analysis of proportions using a random-effects model was used to pool outcomes. Linear regression analysis was used to compare the mean of proportions of outcomes across exposure groups using the 'treated' group as the reference category. All studies were evaluated using an appropriate quality assessment tool. The GRADE approach was used to assess the overall certainty of evidence.Main resultsThirty-five studies, describing 11 172 pregnancies, were eligible for inclusion. Analysis showed pooled proportions for congenital malformations as follows: treated 0.04 (95% CI 0.03-0.04; I2 = 77) versus disease-matched 0.04 (95% CI 0.03-0.05. I2 = 86; p = 0.238); preterm delivery treated 0.04 (95% CI 0.10-0.14; I2 = 88) versus disease-matched 0.10 (95% CI 0.09-0.12; I2 = 87; p = 0.250); severe neonatal infection: treated 0.05 (95% CI 0.03-0.07; I2 = 88) versus disease-matched 0.05 (95% CI 0.02-0.07; I2 = 94; p = 0.970); low birthweight: treated 0.10 (95% CI 0.07-0.12; I2 = 93) versus disease-matched 0.08 (95% CI 0.07-0.09; I2 = 0; p = 0.241); pooled miscarriage: treated 0.13 (95% CI 0.10-0.15; I2 = 77) versus disease-matched 0.08 (95% CI 0.04-0.11; I2 = 5; p = 0.078); pre-eclampsia; treated 0.01 (95% CI 0.01-0.02; I2 = 0) versus disease-matched 0.01 (95% CI 0.00-0.01; I2 = 0; p = 0.193). No statistical differences in proportions were observed. GRADE certainty of findings was low to very low.ConclusionWe demonstrated comparable pregnancy outcomes in pregnancies exposed to biologics, disease-matched controls and CID-free pregnancies using the GRADE approach.

Project description:BackgroundTo assess whether elevated thyroid-stimulating hormone (TSH) levels before conception can predict poor outcomes of assisted reproductive technology (ART).MethodsPrior to July 2018, we searched the PubMed, EMBASE, COCHRANE, Google Scholar, and CNKI databases for studies. Retrospective or prospective reports that compared ART results in patients with subclinical hypothyroidism (SCH) with normal thyroid function were selected. Two reviewers separately reviewed each potential article for qualification, analyzed the quality of the studies according to the Newcastle-Ottawa scale, and extracted the data. The PRISMA guidelines were adopted.ResultsWe selected a total of 18 publications that included 14,846 participants for this meta-analysis. When the TSH cut-off value for SCH was set at 2.5 mIU/L, no significant differences were observed in ART-related outcomes between SCH patients and normal women. The evaluated outcomes included the live birth rate (LBR) (OR: 0.93; 95% CI (0.77,1.12), P =?0.43), clinical pregnancy rate (CPR) (OR:1.02; 95% CI (0.90,1.17); P =?0.74), pregnancy rate (PR) (OR: 1.00; 95% CI (0.89,1.12); P =?0.99), and miscarriage rate (MR) (OR:1.24; 95% CI (0.85, 1.80); P =?0.26). Furthermore, when a higher TSH level was used as the cut-off value to diagnose SCH (i.e., 3.5-5 mIU/L), a significant difference was found in the MR (OR: 1.91; 95% CI (1.09, 3.35); P =?0.02) between the two groups of ART-treated women. However, when a broader cut-off value was used to define SCH, no significant differences were observed in the LBR (OR: 0.72; 95% CI (0.47,1.11); P =?0.14), CPR (OR: 0.82; 95% CI (0.66,1.00); P =?0.052), or PR (OR: 1.07; 95% CI (0.72,1.60); P =?0.74) between the two groups of ART-treated women.ConclusionNo difference was observed in ART outcomes when a TSH cut-off value of 2.5 mIU/L was used. However, when a broader TSH cut-off value was used, preconception SCH resulted in a higher miscarriage rate than in normal women.

Project description:BackgroundPreconception care is the provision of biomedical, behavioural, and social health interventions provided to women and couples before conception. However, in Ethiopia, little is known and practised to support preconception care. Therefore, this study aimed to assess women's knowledge and utilisation of preconception care and its associated factors in Ethiopia using systematic review and meta-analysis.MethodIn the current meta-analysis, variables were searched from different electronic database systems, which included PubMed, Google Scholar, EMBASE, HINAR, Scopus, Web of Sciences, and Grey literature. Data were extracted using a standardised data collection measurement tool. The data were analysed by using STATA 14 statistical software. I2 tests assessed heterogeneity between the studies. A random-effect model was used to forecast the pooled knowledge and utilisation of preconception care.ResultsThirteen full-text studies were included. The pooled prevalence of knowledge and utilisation of preconception care among women in Ethiopia was 30.95% and 16.27% respectivelly. Secondary education (OR = 2.78, 95% CI,2.01-3.85), college and above (OR = 5.05, 95% CI,2.70-9.44), and antenatal care (OR = 3.89, 95% CI, 1.69-8.98) were significantly associated with knowledge level whereas; age (OR = 2.43, 95% CI, 1.30-4.53) and knowledge on preconception care (OR = 3.95, 95% CI,2.35-6.62) were positively associated with utilisation of preconception.ConclusionsWomen's level of knowledge and utilisation of preconception care was significantly low. Educational status and antenatal care follow-up were factors shown to affect knowledge of preconception care. Age and having a sound knowledge of preconception care indicated a significant association towards utilisation of preconception care. Thus, integrating preconception care strategies and policies that can address all the components of preconception care services with other maternal and child health services will be essential when designing effective implementation strategies to improve preconception care uptake. Besides this, advocating for better education for women, awareness creation, and increasing antenatal care services are essential. Prospero registration: CRD42020218062.

Dataset Information

Preconception care for diabetic women for improving maternal and fetal outcomes: a systematic review and meta-analysis.

Background

Methods

Results

Conclusion

Publications

Preconception care for diabetic women for improving maternal and fetal outcomes: a systematic review and meta-analysis.

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