Programmable Births in Gestational Diabetes Mellitus: Minimizing Risks — Improving Maternal and Perinatal Outcomes

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Abstract

Background. Modernity is characterized by an avalanche-like increase in the frequency of gestational diabetes mellitus (in 4–5 times over the past 20 years). The main tasks of the work in the risk strategy of gestational diabetes mellitus are: prediction of pregnancy complications and the searchingh for new technologies for their delivery. To date, there are still very controversial questions about the timing and methods of delivery of patients with gestational diabetes mellitus. Due to the high incidence of unfavourable perinatal outcomes in gestational diabetes mellitus, the percentage of cesarean sections in some countries reaches 60%, which leads to maternal morbidity and a decrease in the reproductive health of the population. Aims — is to improve of maternal and neonatal outcomes based of the rational choice of delivery technology in gestational diabetes mellitus. Methods. A retrospective analysis of delivery methods was performed in 9769 patients with gestational diabetes mellitus at full-term gestation. Results. The developed and implemented programmed delivery technique was an alternative to cesarean sections, it allowed to reduce the frequency of abdominal delivery, while improving maternal and neonatal outcomes. The frequency of cesarean sections in programmed delivery was 2 times lower than in the presented facilities and significantly lower than in the population (10.0–10.7%). In the programmed delivery group there was a significant reducing morbidity of hypoglycemia in newborns compared to planned caesarean section — by 2 times and respiratory distress syndrome — by 2.5 times (p < 0.05). The indices of cerebral status impairment, birth traumatism corresponded to physiological childbirth and did not exceed the average population. Conclusions. The method of programmed delivery presented in this paper was one of the reserves for reducing the frequency of cesarean sections and allowed to personalize delivery in respiratory distress syndrome.

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Justification
Gestational diabetes mellitus (GDM) is the most frequent violation of carbohydrate metabolism in pregnant women and one of the main causes of maternal and perinatal complications. Modernity is characterized by an avalanche-like increase in the frequency of GDM (over the past 20 years by 4-5 times), which is associated with both the obesity epidemic and an increase in the importance of other diabetogenic factors: an increase in the reproductive age of patients, the active introduction of assisted reproductive technologies, etc. [ 1-7]. GDM is a disease in which hyperglycemia is established or detected for the first time during pregnancy, but its indicators do not meet the criteria for overt diabetes mellitus [8, 9]. In obstetric institutions in Moscow, specializing in the provision of medical care to pregnant women with diabetes (GBUZ "GKB No. 1 named after N.I. Pirogov DZM" branch "Maternity hospital No. 25" and GBUZ "GKB No. 29 named after N.E.Bauman DZM "), the detection rate of GDM in 2019 was 19.7%, which is significantly higher than in the Russian Federation (7.2%) [10]. Improvement in the diagnosis of GDM is due to the precise implementation of the algorithms adopted in the Russian Federation in 2012 [8]. In recent years, in the hospitals presented, the number of births in these patients has approached 25% of all puerperas.
GDM significantly increases the risk of obstetric complications. Hypertensive complications occur 3 times more often than in the physiological course of the gestational process. Preeclampsia, which from year to year ranks first among the causes of maternal mortality, complicates pregnancy in more than 30% of patients with GDM. The frequency of premature delivery, including according to indications from the mother and the fetus, reaches 15-20% [1, 11, 12].
The negative effect of GDM on the fetus leads to placental insufficiency and the formation of a symptom complex of diabetic fetopathy (DF), which in case of irrational delivery worsens perinatal outcomes, up to severe trauma and fetal death [13, 14, 15]. Considering the above, the frequency of caesarean section (CS) in GDM exceeds the average population indicators [16-22] and reaches 57.4% in some countries [16-22]. Many researchers, even recognizing the priority for induction of labor in GDM, insist on a significant expansion of the indications for caesarean section. The frequency of abdominal delivery in pregnant women with GDM is significantly influenced by concomitant complications of gestation, the presence of a large fetus, the severity of DF, aggravated obstetric history (OAA), especially the scar on the uterus. At the same time, one cannot but take into account that abdominal delivery compared to vaginal delivery increases the risks of bleeding, amniotic fluid embolism, purulent-septic diseases and maternal mortality in general - 5 times [23, 24, 25].

In addition to methods of delivery, there are still controversial questions about the timing of delivery of such patients, allowing the maximum balance between fetal maturity, macrosomia and the severity of DF [19, 26].
In recent years, there has been an increase in the quality of GDM diagnostics and the efficiency of glycemic control, which made it possible to deliver pregnant women with GDM at a time close to physiological [15, 20, 27].
Optimization of delivery in GDM implies the choice of technology in accordance with the risk strategy. In this regard, the method of programmed delivery (PR) allows for a personalized approach to delivery of patients with GDM and is one of the most important reserves for reducing the frequency of abdominal delivery in pregnant women with GDM and improving maternal and perinatal outcomes.
Objective: to improve maternal and neonatal outcomes based on rational choice of delivery technology in GDM.
To achieve the chosen goal, the following tasks were set:
1. Conduct a retrospective analysis of obstetric and perinatal complications after various methods of delivery in patients with GDM
2. Specify the criteria for selecting pregnant women with GDM for PR.
3. To improve the PR technique, taking into account the perinatal risk factors.

Methods
Study design
A retrospective analysis of delivery methods and their outcomes in patients with GDM at full-term gestation was carried out based on the reported indicators of medical institutions. A total of 9769 pregnant women with GDM were examined, at the age from 25 to 42 years of whom 2709 were delivered by PR (I-main group), 6159 - after spontaneous development of labor activity (SR - II group) and 901 - by abdominal route in a planned manner (ACL - III group). (Table 1).
Table 1. Methods of delivery in patients with gestational diabetes mellitus
Compliance criteria
All patients had a spontaneous singleton pregnancy, cephalic presentation of the fetus, were comparable in social status, age and parity of childbirth.
Conditions of conducting
Creation of a joint endocrinological center as part of multidisciplinary institutions (GBUZ "City Clinical Hospital No. 29 named after N. E. Bauman DZM" and GBUZ "City Clinical Hospital No. 1 named after N. I. Pirogov DZM", branch "Maternity Hospital No. 25" , Moscow) allowed:
• to concentrate practically all pregnant women with GDM in the Moscow metropolis;
• carry out continuous monitoring and treatment of patients at the outpatient and inpatient stages;
• timely hospitalize pregnant women in accordance with the degree of risk;
• improve the methods of delivery of these patients.
Study duration
The analysis of the histories of childbirth and the histories of newborns for 2017-2019 was carried out.

Description
The examination was carried out in accordance with the requirements of the Order of the Ministry of Healthcare of the Russian Federation No. 572n dated January 12, 2016 and the provisions of the National Guidelines for Obstetrics (2018). The diagnosis of GDM was made in accordance with the algorithms specified in the regulatory documents approved by the Ministry of Health of the Russian Federation [8, 9].
The PR method used in the work is a timely delivery in the daytime, subject to the biological readiness of the pregnant woman's body for childbirth ("maturity" of the cervix), with mandatory monitoring of the state of the fetus and uterine contractile activity, carried out in patients with a high degree of maternal and perinatal risk [26.29].
In the case of insufficiently "mature" birth canal (<8 points on the Bishop scale), pre-induction was performed. With an immature cervix (<5 points on the Bishop scale), satisfactory fetal condition, and no signs of DF, mifepristone was used as the first stage of preparation according to the usual scheme with an assessment of effectiveness within 48 hours. As the second stage, intracervical introduction of a dilated balloon catheter was used. In the presence of DF, only intracervical introduction of a dilated balloon catheter.
PR was performed according to the standard technique with labor induction by amniotomy in the morning and was carried out in accordance with the protocol of normal labor [30].
Instrumental methods used in the study: ultrasound with fetometry, assessment of the state of the placenta and amniotic fluid, dopplerometry of uteroplacental blood flow using an expert class device Voluson-E 8. For antenatal diagnosis of DF severity, a point scale was used to assess the main ultrasound markers (Table 2) ...
Table 2. Scale of antenatal assessment of the severity of DF

The functional state of the fetus was determined using cardiotocography (CTG) on a Corometrics apparatus (General Electric Company) according to the Fisher scale in the Krebs modification. The health of newborns in the early neonatal period was assessed in conjunction with neonatologists.
The data were statistically processed using the Statisticav program. 10.0. (StatSoft © Inc., USA). When comparing quantitative traits, the Mann-Whitney test was used (significance level p <0.05), for binary - the Fisher criterion.
Results and discussion
The comparative analysis of maternal and perinatal outcomes made it possible to formulate the main approaches to delivery of patients with GDM, including the use of the PR method, which made it possible to reduce the frequency of abdominal delivery (Fig. 1).
Figure 1 Dynamics of the number of deliveries with and the frequency of cesarean section of the knee joint in patients with gestational diabetes mellitus in 2009-2019.

ACL was performed in groups of high and ultra-high perinatal risk in terms of the sum of relative indications, the main of which were: scar on the uterus (65.5%), large fetus (44.1%), DF more than 4 points (32.4%), obesity (74.9%), a high degree of perinatal risk (37%). (Table 3).
Table 3. Risk factors for caesarean section in pregnant women with gestational diabetes mellitus

The strategic focus of PR is to reduce the number of CS in patients with predictable high risks, due to a personalized approach to the management of childbirth.
Criteria for selecting pregnant women for PR:
• informed consent of the patient;
• compensation for GDM during pregnancy;
• perinatal risk of 25 or more points;
• gestational age> 39 weeks;
• head presentation of the fetus;
• satisfactory condition of the fetus according to CTG and Doppler measurements;
• antenatally diagnosed DF <4 points (Table 1);
• "mature" cervix (> 8 points on the Bishop scale).
Delivery was performed at full-term pregnancy over 39 weeks, which is consistent with the data published by the American Society of Obstetricians and Gynecologists on more successful induction of labor in patients with GDM, if it is performed at a time close to physiological (27, 28). on diet therapy was found to be optimal - expectant tactics up to 41.0 weeks, and in those receiving insulin - up to 40 weeks [27].
PR tactics for GDM:
• cancellation of prolonged-release insulin on the day of induction, prescribing a bolus regimen;
• glycemic control once every 2 hours (target values ​​- 4.0-7.0 mmol / l);
• optimal anesthetic management (epidural anesthesia);
• dynamic monitoring of the condition of the mother and fetus;
• compliance with the normal delivery protocol;
• keeping partograms;
• admissible correction of labor anomalies within 2 hours;
• Intranatal recalculation of risk factors;
• presence of a neonatologist during childbirth;
• vertical management of the persistent period.

Our study showed that despite the presence of the same risk factors in pregnant women as in PCD (Table 3), PR in 2017-2019. successfully completed through the vaginal birth canal with favorable maternal and perinatal outcomes. The frequency of cesarean section (CS) in PR was 2 times lower than in maternity hospitals and significantly lower in population (Fig. 2,3).

Fig. 2 Dynamics of the number of births and the frequency of caesarean sections in general for 2 maternity hospitals for 2014-2019.

Fig. 3 Dynamics of the number of programmed births in patients with gestational diabetes mellitus and the frequency of caesarean section for 2014-2019.
The results obtained confirm the fact that, with similar indications, PRs are an alternative to PMS and thereby - a reserve for reducing the frequency of KS.
About the fact that PR is the optimal method of delivery in patients with GDM. also evidenced by a higher frequency of CS (in 2018 and 2019 - 16.5 and 16.1%) in the group with SR (Table 4).
Table 4. Comparative frequency of caesarean section in gestational diabetes mellitus

The main indications for emergency abdominal delivery in PR and SR were: abnormalities of labor, fetal distress syndrome, and clinically narrow pelvis (Table 5).
Table 5. Indications for emergency caesarean section in patients with gestational diabetes mellitus

The analysis did not reveal statistically significant differences in the health status of newborns in the groups with spontaneous onset of labor and programmed labor, with the exception of SDR (2.5% in the "PR" group versus 3.1% in the "SR" group, p <0, 05). (Table 6).
Table 6. Neonatal complications in newborns from mothers with gestational diabetes mellitus

Moreover, in the PR group, there was a significant decrease in the incidence of hypoglycemia in newborns compared with planned caesarean section - 2 times (2.9 and 6%, respectively, p <0.05) and SDR - 2.5 times (2.5 and 6.5%, respectively, p <0.05), which confirms the opinion of the medical community about the preference for planned induction of labor in pregnant women with GDM [27.28]. Despite the frequency of macrosomia in the PR group with GDM (26%), the indices of impairment of cerebral status, birth traumatism corresponded to physiological childbirth and did not exceed the average population. Also, there were no statistically significant differences in the frequency of transferring newborns to stage II of nursing in all three groups.

Conclusion
1. In-depth diagnostics of the condition of the mother and the fetus in patients with GDM allows for delivery at a time close to physiological.
2. The results obtained indicate the validity of the criteria for the selection of pregnant women for PR.
3. PRs minimize the risks of maternal and neonatal complications in patients with GDM.
4. The developed and implemented PR technique is an alternative to CS, thereby reducing the frequency of abdominal delivery.

×

About the authors

Nadezhda M. Startseva

RUDN University

Email: n.startseva@yahoo.com
ORCID iD: 0000-0001-5795-2393
SPIN-code: 3415-3773

MD, PhD, Professor

Russian Federation, 6, Miklukho-Maklaya str., 117198, Moscow

Viktor E. Radzinsky

RUDN University

Email: radzinsky@mail.ru
ORCID iD: 0000-0003-4956-0466
SPIN-code: 4507-7510

MD, PhD, Professor

Russian Federation, 6, Miklukho-Maklaya str., 117198, Moscow

Olga V. Papysheva

S.S. Udin City Clinical Hospital

Email: viulen@mail.ru
ORCID iD: 0000-0002-1143-669X

MD, PhD

Russian Federation, Moscow

Larisa N. Esipova

N.E. Bauman City Clinical Hospital No. 29

Email: larisaesipova1@mail.ru
ORCID iD: 0000-0002-1190-238X
Russian Federation, Moscow

Marina A. Oleneva

N.I. Pirogov City Clinical Hospital No. 1, “Maternity house No. 25”

Email: 9161650729@mail.ru
ORCID iD: 0000-0003-2083-7476

MD, PhD

Russian Federation, Moscow

Olga B. Lukanovskaya

N.E. Bauman City Clinical Hospital No. 29

Email: lukanovskaya@gmail.com
ORCID iD: 0000-0003-3865-1290
Russian Federation

Olgа N. Cheporeva

N.I. Pirogov City Clinical Hospital No. 1, “Maternity house No. 25”

Email: tcolga@yandex.ru

MD, PhD

Russian Federation, Moscow

Еvgenij K. Tazhetdinov

N.I. Pirogov City Clinical Hospital No. 1, “Maternity house No. 25”

Author for correspondence.
Email: e_tazhetdinov@mail.ru
ORCID iD: 0000-0002-1918-6031

MD, PhD

Russian Federation, Moscow

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2. Fig. 1. Dynamics of the number of births and the frequency of cesarean sections in patients with gestational diabetes mellitus, 2009–2019. GDM - gestational diabetes mellitus, CS - caesarean section

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3. Fig. 2. Dynamics of the number of births and the frequency of cesarean sections in general for 2 maternity hospitals, 2014–2019 KS - caesarean section

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4. Fig. 3. Dynamics of the number of programmed births in patients with gestational diabetes mellitus and the frequency of caesarean section, 2014–2019. GDM - gestational diabetes mellitus, CS - caesarean section, PR - programmed labor

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