| Background:Gestational diabetes mellitus(GDM)is a metabolic disease that occurs in women of childbearing age with normal glucose metabolism or potential abnormal glucose tolerance before pregnancy.According to the latest data from the international diabetes federation(IDF)in 2015,the global prevalence of high blood glucose in pregnancy is 16.2%,among which GDM accounts for 85%and other types only 15%.The prevalence of GDM is expected to increase in the coming years as the average age of pregnant women increases,the number of obese women increases and urban populations wait for lifestyle changes.GDM is potentially harmful to both mother and offspring,including increased amniotic fluid,preeclampsia,premature birth,ketoacidosis and the development of type 2 diabetes mellitus(T2DM)for mother,and abnormalities in intrauterine development,neonatal malformations,macrosomia,neonatal respiratory distress syndrome and neonatal hypoglycemia for offspring.After health education,medical nutrition,blood glucose monitoring,proper exercise and insulin treatment when necessary,most pregnant women with GDM can control blood glucose at normal levels.At present,there are few studies on the choice of delivery timing of GDM pregnant women with satisfactory blood glucose control at home and abroad,and the optimal delivery timing is still controversial.There are still great differences in clinical management of such pregnant women.In this study,perinatal outcomes of GDM pregnant women with satisfactory blood glucose control were statistically analyzed in order to determine the best time for vaginal delivery,which is of great significance for improving perinatal outcomes of GDM pregnant women.Methods:We included 7072 GDM pregnant women from November 1st,2015 to April 30th,2018,who underwent regular prenatal examination and in-hospital delivery at Women's Hospital School of Medicine Zhejiang University.We selected 2005 nulliparous(28.4%,2005/7072)with complete data and satisfactory blood glucose control.According to the time of vaginal delivery,it was divided into five groups:37+0-37+6 weeks group(n=116),38+0-38+6 weeks group(n=356),39+0-39+6 weeks group(n=682),40+0-40+6 weeks group(n=691),41+0-41+6 weeks group(n=160).According to the type of labor initiation,the pregnant women were divided into induced labor group(n=1381)and natural labor group(n=624).The outcome measures included age,gestational times,body mass index(BMI),blood glucose control method,type of labor initiation,mode of labor induction,indication of labor induction,cesarean section,indication of cesarean section,postpartum hemorrhage,shoulder dystocia,anal sphincter injury,time of labor,birth weight,hypoglycemia,jaundice requiring phototherapy,admission to Neonatal Intensive Care Unit(NICU).Results:1.Comparison of general data:there was no significant difference between 37+0-37+6 weeks group,38+0-38+6 weeks group,39+0-39+6 weeks group,40+0-40+6 weeks group and 41+0-41+6 weeks group in age,gestational times,BMI before pregnancy and blood glucose control methods(P?0.05).There were 93 cases(80.2%),292 cases(82.0%),550 cases(80.6%)at 37+0-37+6 weeks,38+0-38+6 weeks and 39+0-39+6 weeks respectively,which were higher than 398 cases(57.6%)at 40+0-40+6 weeks and 48 cases(30.0%)at 41+0-41+6weeks.There were some differences among the five groups.Misoprostol induced labor was common in 49 cases(43.8%)of 41+0-41+6 weeks group,while oxytocin induced labor was common in 36 cases(56.2%)of 38+0-38+6 weeks group and 72 cases(54.5%)of 39+0-39+6 weeks group.In 37+0-37+6 weeks group and 38+0-38+6 weeks group,the main indications of induced labor were obstetric complications and placental dysfunction.In the 39+0-39+6 week group,40+0-40+6 week group and 41+0-41+6 week group,the main indications of induced labor were obstetric complications,placental dysfunction and non delivery near/beyond the expected delivery period.2.Comparison of perinatal outcome:(1)cesarean section rate:37+0-37+6 weeks,38+0-38+6 weeks and 39+0-39+6 weeks were lower than that of 40+0-40+6 weeks and 41+0-41+6 weeks respectively(P?0.01).(2)Indications of cesarean section:fetal distress,failure of induction and relative cephalopelvic disproportion were the most common causes of obstructive delivery,and there was no significant correlation between indications of cesarean section and gestational age(P?0.05).(3)The probability of postpartum hemorrhage was higher in 39+0-39+6 weeks group,40+0-40+6 weeks group and 41+0-41+6 weeks group than in 37+0-37+6 weeks group and 38+0-38+6 weeks group(P?0.01).(4)Shoulder dystocia:the incidence of shoulder dystocia was similar in the five groups(P?0.05).(5)Anal sphincter injury:there was no significant difference between the five groups(P?0.05).(6)The duration of labor:the longest(634.79±341.63min)in the 41+0-41+6 week group,the shortest(432.82±278.83min)in the 37+0-37+6 week group,and no significant difference(P?0.01)in the 38+0-40+6 week group.3.Comparison of perinatal outcomes:(1)the incidence of low birth weight infants in 37+0-37+6 weeks group and 38+0-38+6 weeks group was higher than that in 39+0-39+6 weeks group,40+0-40+6 weeks group and 41+0-41+6 weeks group(P?0.01).The birth rate of macrosomia in 39+0-39+6 weeks group was significantly lower than that in 40+0-40+6 weeks group and 41+0-41+6 weeks group(P?0.01).(2)Neonatal hypoglycemia:there was no significant difference among the five groups(P?0.05).(3)The incidence of phototherapy for neonatal jaundice:37+0-37+6 weeks group and 38+0-38+6 weeks group were higher than the other three groups(P?0.01).The phototherapy rates of 39+0-39+6 weeks group and 40+0-40+6 weeks group were similar(P?0.01).In 41+0-41+6 weeks group,the lowest phototherapy rate was 25(15.6%).(4)NICU occupancy rate:37+0-37+6 weeks group was higher than the other four groups(P?0.01).The NICU occupancy rate of 39+0-39+6 weeks group was similar to that of 40+0-40+6 weeks group(P?0.01).In 41+0-41+6 weeks group,the lowest NICU occupancy rate was 47(29.4%).4.Correlation analysis between gestational weeks and cesarean section rate:after adjusting the age of pregnant women,BMI before pregnancy,gestational times,type of labor initiation,blood glucose control methods and other confounding factors,the cesarean section rate of 39+0-39+6 weeks group was taken as a reference,and there was no significant risk of cesarean section in 37+0-37+6 weeks group(AOR:0.528;95%CI:0.242-1.151;P:0.108),38+0-38+6 weeks group(AOR:0.881;95%CI:0.570-1.362;P:0.569)The risk of cesarean section increased significantly in 40+0-40+6 weeks(AOR:1.531;95%CI:1.108-2.116;P:0.010),41+0-41+6 weeks(AOR:1.692;95%CI:1.036-2.763;P:0.036).5.Comparison of cesarean section rate between induced labor group and natural labor group:(1)the cesarean section rate in induced labor group was similar in different gestational weeks(37+0-41+6 weeks),and the difference was not statistically significant(P?0.05).The cesarean section rate in different gestational weeks(37+0-41+6 weeks)was significantly different(P?0.05),but there was no difference between the two groups(P?0.01).(2)After adjusting the age of pregnant women,BMI before pregnancy,pregnancy times,blood glucose control methods and other confounding factors,it was found that the cesarean section rate of 37+0-37+6 weeks group,38+0-38+6 weeks group,39+0-39+6 weeks group,40+0-40+6 weeks group,41+0-41+6 weeks group was higher than that of natural labor group(P?0.05).Conclusion:1.Compared with 39+0-39+6 weeks delivery,the cesarean section rate of pregnant women after 40+0 weeks delivery increased by 1 times.37+0-37+6 weeks was the shortest,41+0-41+6 weeks was the longest,38+0-40+6 weeks was similar.For the nulliparous with gestational diabetes mellitus,even if the blood glucose control is satisfactory,the pregnancy should be terminated before 40+0 weeks,which is beneficial to shorten the labor process and reduce the cesarean section rate2.When the gestational age of delivery is less than 39+0 weeks,the jaundice rate and NICU occupancy rate of neonates who need phototherapy are significantly increased;when the gestational age of delivery is more than 40+0 weeks,the incidence of macrosomia is significantly increased.Blind prolongation or shortening of the gestational period has adverse effects on the birth weight,jaundice of newborn requiring phototherapy and NICU occupancy rate.Termination of pregnancy at 39+0-39+6 weeks was beneficial to reducing neonatal complications.3.Compared with natural labor,induced abortion and termination of pregnancy increased the risk of cesarean section,and it's unconcerned with the gestational age. |
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