Gestational diabetes mellitus: relationship of adverse outcomes with severity of disease.

AIMS: To derive accurate estimates of risk of maternal and neonatal complications in women with gestational diabetes mellitus (GDM) and to investigate the association of the effect size of these risks on subgroups of GDM managed with dietary modification, metformin and insulin therapy. METHODS: This was a large retrospective cohort study undertaken at a large maternity unit in the United Kingdom between January 2010 and June 2022. We included singleton pregnancies that booked at our unit at 11-13 weeks' gestation. The rates of maternal and neonatal complications in pregnancies with GDM that were managed by a multidisciplinary team (MDT) in the specialist high-risk clinic were compared to those in non-diabetic pregnancies. We stratified pregnancies with GDM into those that were managed with diet, metformin and insulin to pregnancies without diabetes. Logistic regression analysis was carried out to determine risks of pregnancy complications in pregnancies with GDM and its treatment subgroups. Risks were expressed as absolute risks (AR) and odds ratio (OR) (95% confidence intervals [CI]). Forest plots were used to graphically demonstrate risks. RESULTS: The study population included 51,211 singleton pregnancies including 2089 (4.1%) with GDM and 49,122 (95.9%) controls without diabetes. In pregnancies with GDM, there were 1247 (59.7%) pregnancies managed with diet, 451 (21.6%) with metformin and 391 (18.7%) who required insulin for maintaining euglycaemia. Pregnancies with GDM had higher maternal age, body mass index (BMI), higher rates of Afro-Caribbean and South Asian racial origin and higher rates of chronic hypertension. In pregnancies with GDM compared to non-diabetic controls, there was an increased rate of preterm delivery, delivery of LGA neonate, polyhydramnios, preeclampsia, need for IOL, elective and emergency CS and PPH whereas the rate of delivery of SGA neonates and likelihood of an unassisted vaginal delivery were lower. In pregnancies with GDM, there is significantly increased risk of maternal and neonatal complications in those that require insulin compared to those that are managed on dietary modification alone. CONCLUSIONS: There is a linear association between the risk of adverse outcomes and the severity of GDM with those on insulin treatment demonstrating an increased association with complications compared to those that have milder disease requiring only dietary modification.

Maternal and neonatal complications in pregnancies with and without pre-gestational diabetes mellitus.

OBJECTIVES: To compare pregnancy complications in pregnancies with and without pre-gestational diabetes mellitus (DM) managed in a multidisciplinary high-risk diabetes antenatal clinic. METHODS: This screening cohort study was undertaken at a large maternity unit in the United Kingdom between January 2010 and December 2022. We included singleton pregnancies that booked at our unit at 11-13 weeks' gestation. Univariate and multivariate logistic regression analysis was carried out to determine risks of complications in pregnancies with type 1 and type 2 DM after adjusting for maternal and pregnancy characteristics. Effect sizes were expressed as absolute risks (AR) and odds ratio (OR) (95 % confidence intervals [CI]). RESULTS: The study population included 53,649 singleton pregnancies, including 509 (1.0 %) with pre-existing DM and 49,122 (99.0 %) without diabetes. Multivariate logistic regression analysis demonstrated that there was a significant contribution from pre-existing DM in prediction of adverse outcomes, including antenatal complications such as fetal defects, stillbirth, preterm delivery, polyhydramnios, preeclampsia and delivery of large for gestational age (LGA) neonates; intrapartum complications such as caesarean delivery (CS) and post-partum haemorrhage; and neonatal complications including admission to neonatal intensive care unit, hypoglycaemia, jaundice and hypoxic ischaemic encephalopathy (HIE). In particular, there was a 5-fold increased risk of stillbirth and HIE. CONCLUSIONS: The maternal and neonatal complications in pregnancies with pre-existing DM are significantly increased compared to those without DM despite a decade of intensive multidisciplinary antenatal care. Further research is required to investigate strategies and interventions to prevent morbidity and mortality in pregnancies with pre-gestational DM.

Gestational Diabetes Mellitus: Association with Maternal and Neonatal Complications.

Background and objectives: Gestational diabetes mellitus (GDM) is known to be associated with pregnancy complications but there is limited evidence about the strength of these associations in recent clinical practice, especially after the introduction of strict guidelines for the management of pregnancies with GDM in a multidisciplinary team setting. The objectives of our study were to first compare the rates of complications in pregnancies with GDM with those that had pre-existing diabetes mellitus and those without diabetes; and second, to derive measures of effect size expressed as odds ratios after adjustment for confounding factors to assess the independent association of GDM in prediction of these pregnancy complications. Materials and Methods: This was a prospective cohort study undertaken at a large maternity unit in the United Kingdom between January 2010 and June 2022. We included singleton pregnancies that were booked at our unit at 11-13 weeks' gestation. Multivariate regression analysis was carried out to determine the risks of complications in pregnancies with GDM after adjusting for pregnancy characteristics. Risks were expressed as odds ratio (OR) (95% confidence intervals [CI]) and expressed graphically in forest plots. Results: The study population included 53,649 singleton pregnancies including 509 (1%) with pre-existing DM, 2089 (4%) with GDM and 49,122 (95%) pregnancies without diabetes. Multivariate regression analysis demonstrated that there was a significant independent contribution from GDM in the prediction of adverse outcomes, including maternal complications such as preterm delivery, polyhydramnios, preeclampsia and delivery of large for gestational age neonates and elective caesarean section (CS); and neonatal complications including admission to neonatal intensive care unit, hypoglycaemia, jaundice and respiratory distress syndrome. Conclusions: GDM is associated with an increased rate of pregnancy complications compared to those without diabetes, even after adjustment for maternal and pregnancy characteristics. GDM does not increase the risk of stillbirth, hypoxic ischaemic encephalopathy or neonatal death.

Fifteen-minute consultation: Is this umbilical venous catheter safe to use?

Umbilical venous catheters are widely used in neonatal practice, therefore promoting safe use of such catheters to reduce complications remains a healthcare priority. This report will equip the reader with essential knowledge for successful catheter insertion and maintenance, which is key to better outcomes. Recent advances in safe localisation of catheter tip and the development of a red flag system will enhance the clinician's ability to predict potential complications related to these catheters as they remain in situ.

Simple steps to prevent hospital-acquired pneumonia in non-intubated patients: a quality improvement project.

BACKGROUND: Hospital-acquired pneumonia (HAP) affects approximately 1.5% of UK inpatients. As well as leading to significant morbidity and mortality, HAP increases burden on hospitals by lengthening hospital stay. At a district general hospital in Kent, a quality improvement project (QIP) was designed that introduced simple preventive measures that could be implemented by ward nurses and allied health professionals. METHODS: Three audit cycles studying a total of 222 inpatients on elderly care wards were undertaken over a 6-month period to assess staff compliance at various stages of the project, with interventions between each cycle. Actions included raising bedheads to 30°, sitting patients out of bed for meals, discouraging use of drinking straws, and regular mouth care. RESULTS: Overall, improvements were seen in three of the measures. Considering the percentage of patients, there was a 23% increase in patients with bedheads >30°, 21% increase in use of adult feeding cups rather than straws, and 26% rise in patients sitting out of bed for meals. CONCLUSION: The main objective of this QIP was to show that these simple yet potentially life-saving interventions are easy to implement on a busy ward, and the results have shown this to be true.

Outcome of ventilated infants born at term without major congenital abnormalities.

UNLABELLED: The longer-term outcome of term-born infants without congenital anomalies requiring ventilation in the first 24 h after birth has rarely been reported. Our aims were to determine the mortality and long-term morbidity of such infants and identify risk factors for adverse outcome. The outcomes of 43 of 45 infants born at term consecutively requiring mechanical ventilation were reviewed. The infants had: meconium aspiration syndrome (n = 11), hypoxic ischaemic encephalopathy (HIE) (n = 11), respiratory depression (n = 12), sepsis (n = 5), persistent pulmonary hypertension of the newborn (n = 3) and middle cerebral artery infarction (n = 1). Eleven infants developed seizures (26%), 13 (30%) had abnormal electroencephalograms and 11 (26%) had abnormal MRI scans; 26% had an adverse outcome: six died, and five had severe neurodisability at 2 years. The infants with congenital toxoplasmosis and a middle cerebral artery infarction were excluded from the prediction analysis. In the remaining 41 patients, requirement for anticonvulsants (relative risk, RR = 4.44, 95% CI = 1.48 to 12.70; p = 0.014) and prolonged ventilation (longer than 3 days) (RR 4.83, 95% CI 1.51 to 15.64) predicted adverse outcome. Infants with HIE had an increased risk of adverse outcome (relative risk 5.45, 95% CI 1.01 to 33.85), but an adverse outcome occurred in infants with other diagnoses. CONCLUSION: Mortality and neurodisability at follow-up were common in infants born at term without major congenital anomalies who required mechanical ventilation in the first 24 h after birth, particularly in those who developed seizures requiring treatment and prolonged ventilation.

Rosai-Dorfman disease: a previously unreported association with sickle cell disease.

BACKGROUND: Rosai-Dorfman Disease is an uncommon benign systemic histio-proliferative disease. This is the first time the disease, although more common in people of African descent, is described in association with Sickle cell disease. CASE PRESENTATION: A Nigerian boy born started a complex medical history with post-natal anemia of unknown origin. Subsequently he was diagnosed with Sickle Cell Anemia (Hb SS). At age 3 during a routine review, he was noted to have generalised massive lymphadenopathy. He had further reoccurrences of this lymphadenopathy, but investigations did not reveal the cause until age five. At this point, because of the progressive lymph node enlargement, a biopsy was performed, and he was diagnosed with Rosai-Dorfman Disease. Since that time, the child has had further episodes of intermittent massive lymphadenopathy, particularly associated with Sickle Crisis. His medical history has been further complicated by development of complications from Sickle Cell Disease, cardiomyopathy and an autoimmune hemolytic anemia with multiple alloantibodies. CONCLUSION: This case for the first time presents the co-existence of two diseases, of increased prevalence in those of African descent, but to date not described in the literature to occur concurrently.