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Hyperglycemia in pregnancy: diagnostics and duration of labor
Linköping University, Department of Biomedical and Clinical Sciences, Division of Children's and Women's Health. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center of Paediatrics and Gynaecology and Obstetrics, Department of Gynaecology and Obstetrics in Norrköping.ORCID iD: 0000-0002-6249-4259
2023 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Objectives: The overall aim of this thesis was to evaluate the impact of maternal hyperglycemia in pregnancy on the duration of active labor, to evaluate indications for cesarean section and further, to examine cut-offs for gestational diabetes mellitus diagnosis based on capillary sampling.

Material and methods: Study I was a cross-sectional study on diagnostic accuracy performed at an antenatal care clinic at the University Hospital in Linköping, Sweden. The study included 175 women undergoing an oral glucose tolerance test (OGTT) and aimed to compare capillary and venous sampling in the diagnosis of gestational diabetes mellitus (GDM) using Accu-Chek Inform II.

Studies II and III were population-based, nationwide, Swedish register studies using data from the Swedish Pregnancy Register (SPR). In these, 247 524 primiparous women who delivered a singleton fetus, ≥34+0 (completed gestational weeks + additional days) with a cephalic presentation between 1 January 2014 and 30 May 2020 and had their data available in the SPR were included. Time in active labor was compared between women with GDM and women without diabetes (study II) and between women with type 1 diabetes and women without diabetes (study III) using Kaplan- Meier survival analysis and Cox regression analysis.

In study III, we also evaluated indications for elective and emergency cesarean section (CS) in women with type 1 diabetes and women without diabetes.

Results: In study I, the cut-offs for a GDM diagnosis using capillary samples were corrected from 5.1 to 5.3 mmol/L for the fasting sample, from 10.0 to 11.1 mmol/L for the 1 h sample and from 8.5 to 9.4 mmol/L for the 2 h sample using half of the dataset. Applying these cut-offs to the remaining dataset resulted in a sensitivity, specificity and accuracy of 85.0%, 95.0% and 90.3% respectively, with a positive predictive value (PPV) of 83%, a negative predictive value (NPV) of 96% and a positive likelihood ratio (LHR) of 16.4 using capillary sampling for the GDM diagnosis at fasting and 2-h.

In study II, women with GDM had a significantly longer time in active labor, both with a spontaneous onset and induction of labor compared to women without diabetes. Women with GDM also had a decreased chance of vaginal delivery at a certain time-point compared to women without diabetes, with an adjusted hazard ratio (aHR) of 0.92 (0.88- 0.96) and 0.83 (0.76-0.90) for those with spontaneous onset and induction of labor respectively. Women with GDM had an increased risk for time in active labor ≥12 h both in spontaneous labor onset (adjusted odds ratio (aOR) 1.14 (1.04-1.25)) and in induction of labor (aOR 1.55 (1.28-1.87)).

Women with type 1 diabetes had a significantly longer time in active labor, both in spontaneous onset and induced labor compared to women without diabetes. They also had a decreased chance of vaginal delivery at a certain time-point compared to women without diabetes with an aHR of 0.65 (0.60-0.70). The total rate of CS was 34.6% in the group of women with type 1 diabetes and 9.5% in the group of women without diabetes (both elective and emergency CS). The most common indication for elective CS among women with type 1 diabetes was suspected macrosomia (50.4%) whereas the corresponding number was 8.7% among women without diabetes. For emergency CS, the most common indication was fetal distress in women with type 1 diabetes (31.9%) and the corresponding number in women without diabetes was 35.9%.

Conclusions: Regarding the diagnosis of GDM, we propose that capillary fasting and 2-hour post-prandial glucose samples, analyzed using the Accu-Chek Inform II system, could be used for the diagnosis of GDM during pregnancy. This approach would involve the use of adjusted cut-off values and demonstrates an acceptable level of accuracy within an antenatal care setting. It is imperative to obtain duplicate samples in order to maintain adequate precision. Furthermore, it is advisable to continue with the OGTT when the fasting samples fall within the normal range, as this leads to a greater number of women receiving a GDM diagnosis.

Regarding time in active labor, both women with GDM and type 1 diabetes seemed to spend a longer time in active labor and were less likely to have a vaginal delivery at any given time compared to their non-diabetic counterparts. In order to customize and individualize intrapartum care, it is imperative to conduct further investigations that illustrate the influence of hyperglycemia in pregnancy on the duration of active labor and on the outcomes during childbirth. In subsequent studies, it will be determined whether the observed difference in the duration of active labor, as indicated in the current studies, remains consistent when employing new definitions of active labor and labor progression.

Suspected fetal macrosomia is the main reason for elective CS among women with type I diabetes and needs to be addressed further.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2023. , p. 97
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1870
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
URN: urn:nbn:se:liu:diva-199003DOI: 10.3384/9789180753302ISBN: 9789180753296 (print)ISBN: 9789180753302 (electronic)OAI: oai:DiVA.org:liu-199003DiVA, id: diva2:1809906
Public defence
2023-12-08, Belladonna, Building 511, Campus US, Linköping, 09:00
Opponent
Supervisors
Available from: 2023-11-06 Created: 2023-11-06 Last updated: 2024-01-29Bibliographically approved
List of papers
1. Comparison of Venous and Capillary Sampling in Oral Glucose Testing for the Diagnosis of Gestational Diabetes Mellitus: A Diagnostic Accuracy Cross-Sectional Study Using Accu-Chek Inform II
Open this publication in new window or tab >>Comparison of Venous and Capillary Sampling in Oral Glucose Testing for the Diagnosis of Gestational Diabetes Mellitus: A Diagnostic Accuracy Cross-Sectional Study Using Accu-Chek Inform II
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2020 (English)In: Diagnostics (Basel), ISSN 2075-4418, Vol. 10, no 12, article id 1011Article in journal (Refereed) Published
Abstract [en]

Gestational diabetes mellitus (GDM) is a common complication with negative impacts on mother and child. The primary aim of this study was to examine whether plasma glucose cutoffs for GDM diagnosis based on venous sampling can be replaced by cutoffs based on capillary sampling. A prospective cross-sectional study was performed at an antenatal care clinic including 175 pregnant women undergoing an oral glucose tolerance test (OGTT). Duplicate samples were collected by capillary and venous puncture while fasting and 1 h and 2 h after an OGTT. Both samples were analyzed on Accu-Chek Inform II. The cutoffs for a GDM diagnosis using capillary samples were corrected from 5.1 to 5.3 mmol/L for the fasting sample, from 10.0 to 11.1 mmol/L for the 1 h sample, and from 8.5 to 9.4 mmol/L for the 2-h sample using half of the dataset. Applying these cutoffs to the remaining dataset resulted in a sensitivity, specificity, and accuracy of 85.0%, 95.0%, and 90.3%, respectively, with a positive predictive value (PPV) of 83%, an negative predictive value (NPV) of 96%, and a positive negative likelihood ratio (LHR) of 16.4 using capillary sampling for the GDM diagnosis at fasting and 2-h after. Corrected cutoffs and capillary samples can be used for the diagnosis of GDM with maintained diagnostic accuracy using Accu-Chek Inform II.

Place, publisher, year, edition, pages
MDPI, 2020
Keywords
antenatal care; gestational diabetes mellitus; pregnancy; OGTT; fasting glucose; capillary sampling
National Category
Radiology, Nuclear Medicine and Medical Imaging
Identifiers
urn:nbn:se:liu:diva-172625 (URN)10.3390/diagnostics10121011 (DOI)000602040100001 ()33255868 (PubMedID)
Note

Funding Agencies|ALF grants Region Ostergotland, Sweden [LIO-531111]

Available from: 2021-01-24 Created: 2021-01-24 Last updated: 2024-01-10
2. Gestational diabetes mellitus and time in active labor: A population-based cohort study
Open this publication in new window or tab >>Gestational diabetes mellitus and time in active labor: A population-based cohort study
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2023 (English)In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 102, no 7, p. 873-882Article in journal (Refereed) Published
Abstract [en]

IntroductionWomen with gestational diabetes mellitus (GDM) have higher rates of adverse perinatal outcomes compared with women without GDM, including an increased risk for having labor induced and for cesarean section. The findings from previous studies analyzing duration of labor in women with GDM are contradictory.The aim of the study was to evaluate the impact of GDM on time in spontaneous and induced active labor. Material and methodsThis was a population-based cohort study including 247 524 primiparous women who gave birth to a singleton fetus with cephalic presentation, >= 34(+0) (completed gestational weeks + additional days) between January 2014 and May 2020 in Sweden. Data was obtained from the Swedish Pregnancy Register. Time in active labor was compared between women with GDM and without GDM with a spontaneous labor onset or induction of labor using Kaplan Meier survival analysis and Cox regression analysis. ResultsWomen with GDM had significantly longer time in active labor, both with a spontaneous onset and induction of labor compared to women without GDM. Women with GDM had a decreased chance of vaginal delivery at a certain time-point compared to women without GDM, with adjusted hazard ratio of 0.92 (0.88-0.96) and 0.83 (0.76-0.90) for those with spontaneous onset and induction of labor, respectively. Women with GDM had increased risk for time in active labor >= 12 h both in spontaneous labor onset (adjusted odds ratio 1.14 [1.04-1.25]) and in induction of labor (adjusted odds ratio 1.55 [1.28-1.87]). ConclusionsWomen with GDM seem to spend a longer time in active labor, both in spontaneous and induced active labor compared to women without GDM. To be able to individualize care intrapartum, there is a need for more studies demonstrating the impact of hyperglycemia during pregnancy on outcomes during childbirth.

Place, publisher, year, edition, pages
WILEY, 2023
Keywords
active labor; cesarean section; duration of labor; gestational diabetes mellitus; induction of labor; trial of labor; vaginal delivery
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:liu:diva-194464 (URN)10.1111/aogs.14592 (DOI)000985316100001 ()37170849 (PubMedID)
Available from: 2023-06-09 Created: 2023-06-09 Last updated: 2024-01-10

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