- Email: [email protected]
Factors influencing the cesarean section rate among diabetics: Indications and risk factors
S178
SPO Abstracts
January 1997 A m J Obstet Gynecol
624
GLUCOMETER CORRELATION O N VENOUS GLUCOLA SAMPLES. A Dillon, K Menard, P VanDorsten, P R.usff, R Newman, Dept. Ob/Gyn, Med Univ of SC, Charleston, SC. OBJECTIVE: To explore a cost-saving measure for 1 hour glucola screening by establishing venous whole blood glucometer thresholds that reliably predict plasma results obtained by automated glucose oxidase analysis on the same sample. STUDY DESIGN: 129 consecutive pregnant women underwent the standard 50g glucose screen for gestational diabetes. A venous sample was collected by phlebotomy at one hour. A drop of whole blood was immediately renloved fi-om the sample and analyzed on the Accu-chek III. The remaining sample was submitted for routine plasma analysis. All values were obtained on the same glucolneter which was calibrated daily in our phlebotomy lab. Reasonable thresholds were chosen by inspection of the data and the binomial distribution applied to determine statistical significance (~ = .05). RESULTS: Excellent correlation (R~ 81.9%) exists between the glucometer and laboratory values. A glucometer value of < 110 m g / d l with at least 95% certainty corresponds to a lab value < 135 mg/dl. Similarly, a glucometer value > 155 m g / d l predicts a lab value > 135 mg/dl. 73% (95/129) of glucometer values were below the 110 m g / d l threshold, 2% (4/129) were above the 155 m g / d l threshold. CONCLUSION: Venous blood assayed by gluconreter using thresholds of < 110 m g / d l or > 155 rng/dl can reliably predict normal and abnormal glucola results. Patients with indeterminate glucometer results (110-155 mg/dl) would require laboratory analysis. Advantages to glucometer testing on venous blood samples include reduction in the nmnber of automated laboratory studies by 75% wifl~ substantial cost savings. Three quarters of all patients can immediately receive reassuring information, while the patients with the worst glucose intolerance can be immediately identified and diagnostic testing scheduled.
626
THE INFLUENCE OF INSULIN-DEPENDENT DIABETES AND THE DEGREE OF GLYCEMIC CONTROL O N SECOND TRIMESTER TRIPLE SCREEN MARKERS. HM Imseis, MB Lando~, KL Smith, x S Hissrich,x SG Cabbe. Departments of Obstetrics & Gynecology, mad Pathology, Ohio State University College of Medicine, Columbus, Ohio. OBJECTIVES: (1) To assess whether differences in triple screen markers exist between insulin-dependent women and the normal population. (2) To assess whether glycemic control influences this potential relationship. (3) To determine whether diabetic nephropathy can affect triple screen marker levels. STUDY DESIGN: Serum triple screen values for 176 insulin~tependent diabetic patients were matched with clinical data from patient charts. Unadjusted medians for AFP, uE3, and hCG were obtained for a control population of 39,202 Caucasian, non-diabetic patient.s. Medians were calculated for each gestational age in our diabetic population and are expressed as multiples of flm median (MOM) of control pregnancies at the same gestational age. Regression analysis was used to determine the influence of maternal weight, glycosylated hemoglobin level, mean glucose level, total daily insulin dosage, and presence of nephropathy on the levels of AFP, uE.~, and hCG. RESULTS: In diabetics, the median values for AFP were 0.84 MOM (p 0.008), uE3, 0.88 MOM (p 0.05), and hCG, 1.05 MOM (p - NS). A relationship was noted between hCG level and maternal weight (R - 0.343, p < 0.0001) and between AFP and total insulin dosage (R = 0.276, p 0.0016). Otherwise, no relationship was demonstrated between the levels of the triple screen markers and maternal weight, glycosylated hemoglobin level, mean glucose level, total daily insulin dosage. The depression in AFP and uE 3 was observed equally in diabetic patients with and without nephropathy. CONCLUSIONS: This large series of insulin-dependent diabetic pregnancies demonstrates that in addition to lower AFP levels, uE 3 is similarly depressed compared to the normal population. There does not appear to be a relationship between glycemic control and levels of triple screen markers.
625
INSULIN, C-PEPTIDE AND IGF-1 LEVELS IN DIABETIC AND NONDIABETIC PREGNANCIES: RELATIONSHIP T O FETAL GROWTH. MB Landon, SG Gabbe, P Samuels, P Zimmerman x, D Knits x, T O'Dorisio~, The Ohio State College of Medicine, Columbus, Ohio OBJECTIVE: To determine the relationship between hormonal regulation of fetal growth, maternal glycenfia and birth weight in pregestational diabetic women. STUDY DESIGN: We measured cord serum insulin, C-peptide, and IGF-1 in 21 women with IDDM at term and in 10 normal controls. Maternal glycemia was assessed by memory-based glucose reflectance meter data during the second and third trimesters. Newborns were classified as AGA and LGA which was further categorized as asymmetric and symmetrically large. RESULTS: Mean birth weight (3687 9 vs. 3286 9, p < .001), insulin (74.0 u U / m l vs. 23.2 u U / m l , p < .002), C-peptide (2.5 • 3.0 n g / m l vs. 1.0 -+ 5 rig/nil, p < .04) were greater in DM vs. controls. IGF-I levels were similar among these groups. In DM pregnancies, mean maternal glucose, insulin, C-peptide, and IGF-1 were all elevated in pregnancies resulting in LGA infants. Insulin and C-peptide were higher in LGA DM vs. LGA controls (102.9 + 72.12 vs. 24.9 • 22.3 u U / m l p < .005) and 3.7 • 3.8 vs. 0.9 ~ 0.6 n g / m l , p < .04). Maternal glucose was higher in asymmetric LGA DM vs. symmetric LGA DM, yet insulin and C-peptide were sintilarly elevated compared to LGA non-DM. Significant correlations existed between maternal glucose, C-peptide, insulin and birth weight in DM. CONCLUSIONS: Birth weight is clearly influenced by maternal glycemic status and fetal insulin production in DM pregnancies. IGF-1 levels are similar in DM and controls, but may be augnmnted by excess insulin production in LGA DM. Hyperinsulinism is a feature of both anthropometric subtypes of large-for-gestational age infants of diabetic mothers.
627
FACTORS INFLUENCING THE CESAREAN SECTION RATE AMONG DIABETICS: INDICATIONS AND RISK FACTORS. Kathleen M. Berkowitz M.D., Siri L. Kjos, M.D. and Kevin Dahmer~, B.S. Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA OBJECTIVE: To determine risk factors for cesarean section among women with Class A1-R diabetes and to identify possible areas of intervention to decrease the high rate of cesarean delivery. METHODS: Rates of cesarean delivery, labor induction or augmentation, concomitant maternal and fetal complications, prior cesarean delivery and history of vaginal birth after cesarean were evaluated for the cohort of 5,923 diabetic women delivering at Women's Hospital from 1986-1994. Maternal age, parity, weight, diabetes class, glucose control in the third trimester, qnality of dating criteria, indication for induction of labor, indication for cesarean section and gestational age at delivery were recorded as well as birthweight, Apgar scores and rates of admission to the neonatal ICU. Data were analyzed by multiple regression analysis to determine the relative influence of each factor. RESULTS: The cesarean delivery rate increased progressively" with increasing severity of diabetes class (23.3% Class AI to 73.7% for Class A2) despite the lack of significant differences in gestational age at delivery" (3.5 days), birthweight (• 150 grams) and quality of dating criteria. Antepartum use of insulin increased the risk of cesarean delivery (OR 1.65), regardless of the level of third trimester glycemic control. While relative rates of various indications for induction did not vary by diabetes class, induction of labor and the presence of PIH were associated with increased risk for cesarean delivery (OR 6.5 and 1.7). As severity- of diabetes class increased, so did the rates of cesarean section for failed induction, repeat cesarean without trial of labor and maternal indications. CONCLUSIONS: The rate of cesarean delivery among diabetic women is influenced most by the antepartum use of insulin, the presence of PIH and induction of labor. Strategies aimed at decreasing the high rate of cesarean delivery among women with gestational or pre-gestational diabetes should focus on improved methods for the induction of labor, the effect of labor management protocols and the prevention of maternal complications.
SPO Abstracts
January 1997 A m J Obstet Gynecol
624
GLUCOMETER CORRELATION O N VENOUS GLUCOLA SAMPLES. A Dillon, K Menard, P VanDorsten, P R.usff, R Newman, Dept. Ob/Gyn, Med Univ of SC, Charleston, SC. OBJECTIVE: To explore a cost-saving measure for 1 hour glucola screening by establishing venous whole blood glucometer thresholds that reliably predict plasma results obtained by automated glucose oxidase analysis on the same sample. STUDY DESIGN: 129 consecutive pregnant women underwent the standard 50g glucose screen for gestational diabetes. A venous sample was collected by phlebotomy at one hour. A drop of whole blood was immediately renloved fi-om the sample and analyzed on the Accu-chek III. The remaining sample was submitted for routine plasma analysis. All values were obtained on the same glucolneter which was calibrated daily in our phlebotomy lab. Reasonable thresholds were chosen by inspection of the data and the binomial distribution applied to determine statistical significance (~ = .05). RESULTS: Excellent correlation (R~ 81.9%) exists between the glucometer and laboratory values. A glucometer value of < 110 m g / d l with at least 95% certainty corresponds to a lab value < 135 mg/dl. Similarly, a glucometer value > 155 m g / d l predicts a lab value > 135 mg/dl. 73% (95/129) of glucometer values were below the 110 m g / d l threshold, 2% (4/129) were above the 155 m g / d l threshold. CONCLUSION: Venous blood assayed by gluconreter using thresholds of < 110 m g / d l or > 155 rng/dl can reliably predict normal and abnormal glucola results. Patients with indeterminate glucometer results (110-155 mg/dl) would require laboratory analysis. Advantages to glucometer testing on venous blood samples include reduction in the nmnber of automated laboratory studies by 75% wifl~ substantial cost savings. Three quarters of all patients can immediately receive reassuring information, while the patients with the worst glucose intolerance can be immediately identified and diagnostic testing scheduled.
626
THE INFLUENCE OF INSULIN-DEPENDENT DIABETES AND THE DEGREE OF GLYCEMIC CONTROL O N SECOND TRIMESTER TRIPLE SCREEN MARKERS. HM Imseis, MB Lando~, KL Smith, x S Hissrich,x SG Cabbe. Departments of Obstetrics & Gynecology, mad Pathology, Ohio State University College of Medicine, Columbus, Ohio. OBJECTIVES: (1) To assess whether differences in triple screen markers exist between insulin-dependent women and the normal population. (2) To assess whether glycemic control influences this potential relationship. (3) To determine whether diabetic nephropathy can affect triple screen marker levels. STUDY DESIGN: Serum triple screen values for 176 insulin~tependent diabetic patients were matched with clinical data from patient charts. Unadjusted medians for AFP, uE3, and hCG were obtained for a control population of 39,202 Caucasian, non-diabetic patient.s. Medians were calculated for each gestational age in our diabetic population and are expressed as multiples of flm median (MOM) of control pregnancies at the same gestational age. Regression analysis was used to determine the influence of maternal weight, glycosylated hemoglobin level, mean glucose level, total daily insulin dosage, and presence of nephropathy on the levels of AFP, uE.~, and hCG. RESULTS: In diabetics, the median values for AFP were 0.84 MOM (p 0.008), uE3, 0.88 MOM (p 0.05), and hCG, 1.05 MOM (p - NS). A relationship was noted between hCG level and maternal weight (R - 0.343, p < 0.0001) and between AFP and total insulin dosage (R = 0.276, p 0.0016). Otherwise, no relationship was demonstrated between the levels of the triple screen markers and maternal weight, glycosylated hemoglobin level, mean glucose level, total daily insulin dosage. The depression in AFP and uE 3 was observed equally in diabetic patients with and without nephropathy. CONCLUSIONS: This large series of insulin-dependent diabetic pregnancies demonstrates that in addition to lower AFP levels, uE 3 is similarly depressed compared to the normal population. There does not appear to be a relationship between glycemic control and levels of triple screen markers.
625
INSULIN, C-PEPTIDE AND IGF-1 LEVELS IN DIABETIC AND NONDIABETIC PREGNANCIES: RELATIONSHIP T O FETAL GROWTH. MB Landon, SG Gabbe, P Samuels, P Zimmerman x, D Knits x, T O'Dorisio~, The Ohio State College of Medicine, Columbus, Ohio OBJECTIVE: To determine the relationship between hormonal regulation of fetal growth, maternal glycenfia and birth weight in pregestational diabetic women. STUDY DESIGN: We measured cord serum insulin, C-peptide, and IGF-1 in 21 women with IDDM at term and in 10 normal controls. Maternal glycemia was assessed by memory-based glucose reflectance meter data during the second and third trimesters. Newborns were classified as AGA and LGA which was further categorized as asymmetric and symmetrically large. RESULTS: Mean birth weight (3687 9 vs. 3286 9, p < .001), insulin (74.0 u U / m l vs. 23.2 u U / m l , p < .002), C-peptide (2.5 • 3.0 n g / m l vs. 1.0 -+ 5 rig/nil, p < .04) were greater in DM vs. controls. IGF-I levels were similar among these groups. In DM pregnancies, mean maternal glucose, insulin, C-peptide, and IGF-1 were all elevated in pregnancies resulting in LGA infants. Insulin and C-peptide were higher in LGA DM vs. LGA controls (102.9 + 72.12 vs. 24.9 • 22.3 u U / m l p < .005) and 3.7 • 3.8 vs. 0.9 ~ 0.6 n g / m l , p < .04). Maternal glucose was higher in asymmetric LGA DM vs. symmetric LGA DM, yet insulin and C-peptide were sintilarly elevated compared to LGA non-DM. Significant correlations existed between maternal glucose, C-peptide, insulin and birth weight in DM. CONCLUSIONS: Birth weight is clearly influenced by maternal glycemic status and fetal insulin production in DM pregnancies. IGF-1 levels are similar in DM and controls, but may be augnmnted by excess insulin production in LGA DM. Hyperinsulinism is a feature of both anthropometric subtypes of large-for-gestational age infants of diabetic mothers.
627
FACTORS INFLUENCING THE CESAREAN SECTION RATE AMONG DIABETICS: INDICATIONS AND RISK FACTORS. Kathleen M. Berkowitz M.D., Siri L. Kjos, M.D. and Kevin Dahmer~, B.S. Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA OBJECTIVE: To determine risk factors for cesarean section among women with Class A1-R diabetes and to identify possible areas of intervention to decrease the high rate of cesarean delivery. METHODS: Rates of cesarean delivery, labor induction or augmentation, concomitant maternal and fetal complications, prior cesarean delivery and history of vaginal birth after cesarean were evaluated for the cohort of 5,923 diabetic women delivering at Women's Hospital from 1986-1994. Maternal age, parity, weight, diabetes class, glucose control in the third trimester, qnality of dating criteria, indication for induction of labor, indication for cesarean section and gestational age at delivery were recorded as well as birthweight, Apgar scores and rates of admission to the neonatal ICU. Data were analyzed by multiple regression analysis to determine the relative influence of each factor. RESULTS: The cesarean delivery rate increased progressively" with increasing severity of diabetes class (23.3% Class AI to 73.7% for Class A2) despite the lack of significant differences in gestational age at delivery" (3.5 days), birthweight (• 150 grams) and quality of dating criteria. Antepartum use of insulin increased the risk of cesarean delivery (OR 1.65), regardless of the level of third trimester glycemic control. While relative rates of various indications for induction did not vary by diabetes class, induction of labor and the presence of PIH were associated with increased risk for cesarean delivery (OR 6.5 and 1.7). As severity- of diabetes class increased, so did the rates of cesarean section for failed induction, repeat cesarean without trial of labor and maternal indications. CONCLUSIONS: The rate of cesarean delivery among diabetic women is influenced most by the antepartum use of insulin, the presence of PIH and induction of labor. Strategies aimed at decreasing the high rate of cesarean delivery among women with gestational or pre-gestational diabetes should focus on improved methods for the induction of labor, the effect of labor management protocols and the prevention of maternal complications.