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Pregnancy in the prediabetic patient
PWEGCNANCY IN THE PBEDIABETIC
(From
the
Depa.rtment
Obstetrical
of
Sercices
Obstetrics, Hermann
of
Bny@r Univfrsity Hospi,tnJ trnd
PATIENT
CoTlc~~r of .V edic*i,le, drfferson Iln~?.s Iiospitul)
cued
the
T IS well known t,hat, in diabetic pregnancies, the incidcncc of mistarriapt. prematurity, large babies, stillbirths, and neonatal deaths is much higher than normal. A number of writers ha.vc reported that, at least some ot’ these’ abnormalities are found in pregnant women who are destined to dovelop diabetes later ig life.
I
reviewing the histories oi’ known diabetics. Niller, Kuder and Hurwitql concluded that the number of overweight babies, the neonatal death rate, and the stillbirth rate were much increased for twenty years before clinical evidences of diabetes appeared. Herzstein and I)olgc~ reported a total fetal mort,aiity of only 6 per cent in 319 pregnancies occurring over a period of twenty years prior to the onset of clinical diabetes, but, 15.4 per cent in the five years immediately prior to the diagnosis. Gaspar,” (.‘ameron,* Edward Allen,5 and Palmer and Barnes6 ha.ve reported similar findings. The purpose of this paper is to show that diabetic patients in the Hermann and Jefferson Davis Hospitals exhibited a higher than average incidence OT these abnormalities years ‘before t,he disease tvas clinically evident. The st,udy comprises figures taken from the obstetrical histories oi’ 122 known diabetic patients. These histories were obtained by interviews and not -from reeords. Twenty-two cases were cxclndcd bec~ausc of sterility, inadequale history, or single status of the patient, leaving a series 0I’ 100 known diabetic* patients. Table 1 shows the ~UIII~XV O! patients of each l’ilp(1 includctl in thus series. ~~~-_-__-.--. -..--
Whit~e Negro Mexicxn -~-.Totwls
..___---
-.__ JEFFERSON DAVIS HOSPITAT,
___-----
RERMANN HOSPITAL
01 IS ::
19 28 11 58 ___~
- ~-
---
42
___ ______.~....
-..-~~~
TOTAL
4n 46 1c Ino-
The number of pregnancies in the group was 454, an everage of 4.54 pc1* patient. This would indicate no lack of fertility. liikewise, an absolute st,erilitp of ‘i.3 per cent, is not high. The averaye age at which the patients began childbearing was 19.5 years ant1 i0 ~)cr cent of thv cwtirv numbrr had their first baby by t,hc ag
PREGNANCY
IN
THE
PREDIABETIC
PATIEN’I!
559
diagnosis. On closer analysis, the decreased fertility in this t.ime period would be more correctly attributed to the diabetes and not to advanced age, since the average age of onset, of the disease, in patients who had a baby as rccent1.v as 5 vears before developing diabetes, was 33 years, 15 years less than the average ;or the series. In the entire series, there were only nine patients all of whose pregnancies were normal. In these patients, the average number of babies born was 3.6-less than the average for the series. Also, in this group, the average length of time from the birth of the youngest child to the onset of clinical symptoms was 34 years. In order to facilitate the study, the total time of child-bearing was divided into five-year periods preceding the diagnosis of the disease. Three patients gave a history of having a baby 50 to 55 years before their diabetes However, the majority of all the pregnancies became clinically evident. occur-red in the periods 16 to 40 years prior to the diagnosis. Considering miscarriage, prematurity, oversized baby, stillbirth, and neonatal death, there were surprisingly few normal pregnancies. The greatest percentage of abnormals, 78 per cent, occurred in the five years immediately prior to the onset of the disease. There were 55 per cent abnormals in the 6to lo-year period. The periods from 11 to 45 years showed percentage abnormals varying from 54 to 67 per cent. Pregnancies occurring more than 45 years before the onset of diabetes were so few in number that reliable percentages are not to be had. TABLE
II.
ANALYSIS
OF PATIENTS ACCORDING PRIOR TO DIAGNOSIS
TO NORMALCY OF DIABETES
OF PREGNANCY
AND
YEARS
A YEARSBEFORE ONSET
NUMBEROF PREGNANCIES
ABNORMAL PREGNANCIES (PERCENT)
MISCARRIAGES (PERCENT)
o-5 6-10 11-15 16-20
27 42 46 53
78 55 67 ..
30 17 B”R .-
21-25
76
20”
15
E”6 51
54 55 60
1:
31-35 26-30 36-40
.
8
Miscarriage, which occurs in 10 per cent of normal pregnancies, and 25 to 30 per cent of diabetics, was almost three times the normal in the first fiveyear period. In the twenty-five years prior to diagnosis, the incidence was 18.4 per cent; from then to forty years, 7.5 per cent; with an average of 13.9 per cent for all cases up to 40 years. Overweight of the fetus was one of the most significant findings in the In t,he first five-year period, the percentage of babies weighing 8 study. pounds or more was 52.6. From there up to forty years before the onset of disease, the percentage was still high, yet lower than in the first period. The average for twenty years prior to the diagnosis was 39.5 per cent; from the twenty-first through the fortieth years, 35.1 per cent. In 35 cases where the patient did not know the numerical weight of the baby, even though she insisted that it was a large one, the baby was included as If these babies had been excluded entirely from the of normal weight. calculations, the final figures on oversized babies would have been even greater.
Of the 27 pregnancies occurring in the first five-year period, 19.5 per cent resulted in premature babies. The average for the first twenty years was 4.5 tw cent. ‘the average for the twenty-first through the fortieth years before the diagnosis was 4 per cent. Neonatal deaths and stillbirths were calculated on 359 children born in the forty years prior to the diagnosis. This eliminated 58 miscarriages which occurred in the same period. The rate for the first fice years was 21 per cent. The figure was high for t,hirty years prior to diagnosis, averaging 10.4 per cent for twenty years, and 8.8 per cent from the twenty-first to fortieth year prior t,o onset of disease. The length of time before the onset of the disease during which abMiscarriages normalities were noted was not the same for each condition. were noted for twenty-five years before the patient showed symptoms of diabetes; overweight of the fetus was consistently noted for forty years; the premature rate, the neonatal death rate, and the stillbirth rate for thirty years. The Rh factors were determined on 77 of the total 121 patients who were interviewed. These determinations were made because of interesting simila,ritiea noted in the findings at autopsy in babies dying of erythroblastosis and babies born to diabetic mothers7 Unfortunately the series is much too small to be conclusive. However, the following fignrcs are of int.erest, : NEGRO
Rh Rh
WHITE
r85per
cent - 15 per cent
The totals (including
Rh Rh
11 Mexican patients) Rh Rh
+ 81.8 - 18.2
t 80.7 - 19.3
per cent per cent
are :
per cent per cent
There was no greater incidence of obstetrical accidents in the Rh-negative patients than in the Rh-positive patients. Records of Wassermann tests were available in nearly all cases. In the few who had histories of positive Wassermanns, it was felt that treatment had been adequate to prevent damage to the pregnancy.
References 1. Miller, 2. Herzstein, 3. Gaepar, 4. Cameron, 5. Allen, 6. Palmer 7. Miller,
Kuder, and Hurwitz: J. A. M. A. 124: 271, 1944. Joseph, and Dolger, Henry: Aa6. J. OBST. & GYNEC. 51: John L.: West. J. Surg. 53: 21, 1945. Paul B.: J. Oklahoma M. A. 37: 443, 1944. Edward: AM. J. 0~8~. & GYNEC. 38: 982, 1939. and Barnes: West. J. Surg. 53: 95, 1945. Johnson, and Durlaoher: Am. J. Pediat. 24: 603, 1944.
420,
1946.
(From
the
Depa.rtment
Obstetrical
of
Sercices
Obstetrics, Hermann
of
Bny@r Univfrsity Hospi,tnJ trnd
PATIENT
CoTlc~~r of .V edic*i,le, drfferson Iln~?.s Iiospitul)
cued
the
T IS well known t,hat, in diabetic pregnancies, the incidcncc of mistarriapt. prematurity, large babies, stillbirths, and neonatal deaths is much higher than normal. A number of writers ha.vc reported that, at least some ot’ these’ abnormalities are found in pregnant women who are destined to dovelop diabetes later ig life.
I
reviewing the histories oi’ known diabetics. Niller, Kuder and Hurwitql concluded that the number of overweight babies, the neonatal death rate, and the stillbirth rate were much increased for twenty years before clinical evidences of diabetes appeared. Herzstein and I)olgc~ reported a total fetal mort,aiity of only 6 per cent in 319 pregnancies occurring over a period of twenty years prior to the onset of clinical diabetes, but, 15.4 per cent in the five years immediately prior to the diagnosis. Gaspar,” (.‘ameron,* Edward Allen,5 and Palmer and Barnes6 ha.ve reported similar findings. The purpose of this paper is to show that diabetic patients in the Hermann and Jefferson Davis Hospitals exhibited a higher than average incidence OT these abnormalities years ‘before t,he disease tvas clinically evident. The st,udy comprises figures taken from the obstetrical histories oi’ 122 known diabetic patients. These histories were obtained by interviews and not -from reeords. Twenty-two cases were cxclndcd bec~ausc of sterility, inadequale history, or single status of the patient, leaving a series 0I’ 100 known diabetic* patients. Table 1 shows the ~UIII~XV O! patients of each l’ilp(1 includctl in thus series. ~~~-_-__-.--. -..--
Whit~e Negro Mexicxn -~-.Totwls
..___---
-.__ JEFFERSON DAVIS HOSPITAT,
___-----
RERMANN HOSPITAL
01 IS ::
19 28 11 58 ___~
- ~-
---
42
___ ______.~....
-..-~~~
TOTAL
4n 46 1c Ino-
The number of pregnancies in the group was 454, an everage of 4.54 pc1* patient. This would indicate no lack of fertility. liikewise, an absolute st,erilitp of ‘i.3 per cent, is not high. The averaye age at which the patients began childbearing was 19.5 years ant1 i0 ~)cr cent of thv cwtirv numbrr had their first baby by t,hc ag
PREGNANCY
IN
THE
PREDIABETIC
PATIEN’I!
559
diagnosis. On closer analysis, the decreased fertility in this t.ime period would be more correctly attributed to the diabetes and not to advanced age, since the average age of onset, of the disease, in patients who had a baby as rccent1.v as 5 vears before developing diabetes, was 33 years, 15 years less than the average ;or the series. In the entire series, there were only nine patients all of whose pregnancies were normal. In these patients, the average number of babies born was 3.6-less than the average for the series. Also, in this group, the average length of time from the birth of the youngest child to the onset of clinical symptoms was 34 years. In order to facilitate the study, the total time of child-bearing was divided into five-year periods preceding the diagnosis of the disease. Three patients gave a history of having a baby 50 to 55 years before their diabetes However, the majority of all the pregnancies became clinically evident. occur-red in the periods 16 to 40 years prior to the diagnosis. Considering miscarriage, prematurity, oversized baby, stillbirth, and neonatal death, there were surprisingly few normal pregnancies. The greatest percentage of abnormals, 78 per cent, occurred in the five years immediately prior to the onset of the disease. There were 55 per cent abnormals in the 6to lo-year period. The periods from 11 to 45 years showed percentage abnormals varying from 54 to 67 per cent. Pregnancies occurring more than 45 years before the onset of diabetes were so few in number that reliable percentages are not to be had. TABLE
II.
ANALYSIS
OF PATIENTS ACCORDING PRIOR TO DIAGNOSIS
TO NORMALCY OF DIABETES
OF PREGNANCY
AND
YEARS
A YEARSBEFORE ONSET
NUMBEROF PREGNANCIES
ABNORMAL PREGNANCIES (PERCENT)
MISCARRIAGES (PERCENT)
o-5 6-10 11-15 16-20
27 42 46 53
78 55 67 ..
30 17 B”R .-
21-25
76
20”
15
E”6 51
54 55 60
1:
31-35 26-30 36-40
.
8
Miscarriage, which occurs in 10 per cent of normal pregnancies, and 25 to 30 per cent of diabetics, was almost three times the normal in the first fiveyear period. In the twenty-five years prior to diagnosis, the incidence was 18.4 per cent; from then to forty years, 7.5 per cent; with an average of 13.9 per cent for all cases up to 40 years. Overweight of the fetus was one of the most significant findings in the In t,he first five-year period, the percentage of babies weighing 8 study. pounds or more was 52.6. From there up to forty years before the onset of disease, the percentage was still high, yet lower than in the first period. The average for twenty years prior to the diagnosis was 39.5 per cent; from the twenty-first through the fortieth years, 35.1 per cent. In 35 cases where the patient did not know the numerical weight of the baby, even though she insisted that it was a large one, the baby was included as If these babies had been excluded entirely from the of normal weight. calculations, the final figures on oversized babies would have been even greater.
Of the 27 pregnancies occurring in the first five-year period, 19.5 per cent resulted in premature babies. The average for the first twenty years was 4.5 tw cent. ‘the average for the twenty-first through the fortieth years before the diagnosis was 4 per cent. Neonatal deaths and stillbirths were calculated on 359 children born in the forty years prior to the diagnosis. This eliminated 58 miscarriages which occurred in the same period. The rate for the first fice years was 21 per cent. The figure was high for t,hirty years prior to diagnosis, averaging 10.4 per cent for twenty years, and 8.8 per cent from the twenty-first to fortieth year prior t,o onset of disease. The length of time before the onset of the disease during which abMiscarriages normalities were noted was not the same for each condition. were noted for twenty-five years before the patient showed symptoms of diabetes; overweight of the fetus was consistently noted for forty years; the premature rate, the neonatal death rate, and the stillbirth rate for thirty years. The Rh factors were determined on 77 of the total 121 patients who were interviewed. These determinations were made because of interesting simila,ritiea noted in the findings at autopsy in babies dying of erythroblastosis and babies born to diabetic mothers7 Unfortunately the series is much too small to be conclusive. However, the following fignrcs are of int.erest, : NEGRO
Rh Rh
WHITE
r85per
cent - 15 per cent
The totals (including
Rh Rh
11 Mexican patients) Rh Rh
+ 81.8 - 18.2
t 80.7 - 19.3
per cent per cent
are :
per cent per cent
There was no greater incidence of obstetrical accidents in the Rh-negative patients than in the Rh-positive patients. Records of Wassermann tests were available in nearly all cases. In the few who had histories of positive Wassermanns, it was felt that treatment had been adequate to prevent damage to the pregnancy.
References 1. Miller, 2. Herzstein, 3. Gaepar, 4. Cameron, 5. Allen, 6. Palmer 7. Miller,
Kuder, and Hurwitz: J. A. M. A. 124: 271, 1944. Joseph, and Dolger, Henry: Aa6. J. OBST. & GYNEC. 51: John L.: West. J. Surg. 53: 21, 1945. Paul B.: J. Oklahoma M. A. 37: 443, 1944. Edward: AM. J. 0~8~. & GYNEC. 38: 982, 1939. and Barnes: West. J. Surg. 53: 95, 1945. Johnson, and Durlaoher: Am. J. Pediat. 24: 603, 1944.
420,
1946.