Cesarean delivery rates in diabetic multifetal pregnancies

1
Cesarean delivery rates in diabetic multifetal
pregnancies

• The California Diabetes and Pregnancy Program
  2006 Database
• CDC 2009 Diabetes Translation Conference
• April 24, 2009

Joyce Sung, M.D. Department of Obstetrics/Gynecolo
gy, Stanford University
2
Overview

• Background DM in pregnancy
• Background CDAPP
• Methods
• Results
• Demographics
• Mode of delivery
• Conclusions

3
Background DM in pregnancy

• Diabetes complicates 4 of all pregnancies 1
• Type 1 DM
• Type 2 DM
• Gestational DM (GDM)
• diet controlled or insulin requiring
• Screening 1 hour Glucola test (50 g load)
• Diagnosis 3 hour test (100 g load)
• Impaired glucose tolerance (IGT)
• one abnormal value on 3 hour GTT

• CDC NVSR, Vol.56, No.6 (Births Final Data for
  2005)

4
Background DM in pregnancy

• Multiple gestation is a risk factor for GDM 1
• Singletons 3.87
• Multiples 5.68

• CDC NVSR, Vol.56, No.13 (Expanded Health Data
  from the New Birth Certificate, 2005

5
Background complications

• Pregnancy complications
• Macrosomia
• Pre-eclampsia
• Fetal demise
• Congenital anomalies (pre-existing DM)

6
Background complications

• Neonatal complications
• Neonatal ICU admission
• Hypoglycemia
• Hyperbilirubinemia
• Hypocalcemia
• Respiratory distress syndrome

7
Background complications

• Beyond pregnancy
• For mothers with GDM, increased risk developing
  overt DM
• For offspring, increased risk metabolic syndrome,
  obesity

8
Bacgkround Complications

• Twins with GDM
• N13 higher RDS, hyperbilirubinemia, NICU LOS 1
• N28 lower vaginal delivery rate, higher
  elective cesarean rate 2
• N33 no significant differences in perinatal
  outcomes 3

• Keller et al., Acta Genet Med Gemellol 1991.
• Moses et al., ANZJOG 2003
• Cho et al., J Korean Med Sci 2006

9
Background What is CDAPP?

• California Diabetes and Pregnancy Program
• Founded in 1984
• Under the California Department of Public Health
  Maternal, Child and Adolescent Health (MCAH)
  Division
• Funded by Federal Title V MCH Block Grant Funds

10
Background CDAPP Services

• Develops, updates, and disseminates Sweet
  Success Guideline for Care
• Recruits, educates, and consults with Sweet
  Success clinical providers
• Promotes awareness for preconception care
• Collaborates with Comprehensive Perinatal
  Services Program (CPSP), California Diabetes
  Program (CDP)

11
Background CDAPP regions

• 1 North Coast
• 2 North Eastern
• 3 East Bay
• 4 Mid-Coastal
• 5 Central Valley Sierra
• 6.1 Long Beach Perinatal
• 6.2 South Bay, Harbor/UCLA
• 7 Inland Counties
• 8 Orange County
• 9 San Diego Imperial

From www.cdph.ca.gov
12
Methods

• Data is prospectively collected online or on
  paper at each affiliated clinic
• 210 affiliated clinics
• 10 regions

13
Methods

• CDAPP 2006 database
• Inclusion
• Diabetes (T1 DM, T2 DM, GDM) or IGT
• Multifetal pregnancies
• Statistical analysis
• SPSS 17.0 software
• Chi-square and ANOVA

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Results

• Total of 17,117 entries
• 277 unique multifetal pregnancies
• 478 entries on multifetal newborns 1

1. Not all multifetal pregnancies listed data for
each newborn separately
15
Results Patient demographics
16
Results Patient demographics
n277
17
Results Patient demographics
n277
18
Results Patient demographics
n277
19
Results Pregnancy characteristics
n277
20
Results Pregnancy characteristics
n277
21
Results Pregnancy outcomes
In the case of the fetal death, the other twin
was recorded as a liveborn
22
Results Delivery mode of twins
Triplets excluded
23
Results Delivery mode of twins
If exclude repeat cesarean and spontaneous
abortion
(p0.066)
24
Results Delivery mode of twins

• Primary cesarean rate did not differ with
• Pre-gestational BMI (p0.36)
• DM diagnosis at first visit (p0.79)

25
Results neonatal outcomes

• Birthweight, NICU admission, and infant LOS did
  not depend on DM diagnosis at first visit

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Conclusions

• High rates of cesarean delivery in diabetic
  multifetal pregnancies
• These patients should be triaged to higher level
  of care
• BMI, type of DM were not associated with delivery
  mode
• This is in contrast with singleton diabetic
  pregnancies where BMI, T1- and T2-DM increased
  rates of macrosomia, NICU admission, and primary
  CD

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Acknowledgements

• CDAPP
• Lisa Bollman, RNC, PHN, CPHQ
• Renato Littaua, DVM, MPVM
• Mark Taslimi, MD
• Deirdre Lyell, MD
• Yasser El-Sayed, MD
• Maurice Druzin, MD
• Leona Dang-Kilduff, RN, MSN, CDE

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Appendix
29
Postpartum diabetes diagnosis
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Twins with GDM

• U.S. Keller et al, 1991
• 13 twins with GDM vs. 13 twins without GDM
• Higher RDS, hyperbili, NICU LOS
• Australia Moses et al, 2003
• 28 GDM twins vs. 29 non-GDM twins (took 10 years)
• Similar pt demographics, BW, APGARs
• Decreased VD rate (53.6 vs. 80)
• Higher elective CD rate (25.0 vs. 3.4)
• Korea Cho et al 2006
• 33 GDM twins vs. 66 non-GDM twins
• 3 IUFD / 66 4.5