Effect of ambulatory versus hospital treatment for gestational diabetes or hyperglycemia on infant mortality rates
a systematic review
Keywords:
Diabetes, gestational, Ambulatory care, Hospitalization, Review [publication type], Clinical trials as topicAbstract
CONTEXT AND OBJECTIVE: Pregnancies complicated by diabetes are associated with increased neonatal and maternal complications. The most serious maternal complication is the risk of developing type 2 diabetes, 10-12 years after the delivery. For rigorous control over blood glucose, pregnant women are treated through ambulatory management or hospitalization. The aim of this study was to evaluate the effectiveness of ambulatory management versus hospitalization in pregnancies complicated by diabetes or hyperglycemia. DESIGN AND SETTING: Systematic review conducted in a public university hospital. METHODS: A systematic review of the literature was performed and the main electronic databases were searched. The date of the most recent search was September 4, 2011. Two authors independently selected relevant clinical trials, assessed their methodological quality and extracted data. RESULTS: Only three studies were selected, with small sample sizes. There was no statistically significance different between ambulatory management and hospitalization, regarding mortality in any of the subcategories analyzed: perinatal and neonatal deaths (relative risk [RR] 0.65; 95% confidential interval [CI]: 0.11 to 3.84; P = 0.63); neonatal deaths (RR 0.29; 95% CI: 0.01 to 6.07; P = 0.43); and infant deaths (RR 0.29; 95% CI: 0.01 to 6.07; P = 0.43). CONCLUSIONS: This review, based on studies with high or moderate risk of bias, showed that there was no statistically significant difference between ambulatory management and hospital care, regarding reduction of mortality rates in pregnancies complicated by diabetes or hyperglycemia. It also suggested that there is a need for further randomized controlled trials on this issue.
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References
American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2011;34 Suppl 1:S62-9.
HAPO Study Cooperative Research Group, Metzger BE, Lowe LP, et al. Hyperglycemia and adverse pregnancy outcomes. N Engl J Med. 2008;358(19):1991-2002.
Rudge MV, Peraçoli JC, Berezowski AT, Calderon IM, Brasil MA. The oral glucose tolerance test is a poor predictor of hyperglycemia during pregnancy. Braz J Med Biol Res. 1990;23(11):1079-89.
Rudge MVC, Calderon IMP, Ramos MD, et al. Hiperglicemia materna diária diagnosticada pelo perfil glicêmico: um problema de saúde pública materno e perinatal [Maternal daily hyperglycemia diagnosed by glycemic profile: a maternal and perinatal public health problem]. Rev Bras Ginecol Obstet. 2005;27(11):691-7.
Crowther CA, Hiller JE, Moss JR, et al. Effect of treatment of gestational diabetes mellitus on pregnancy outcomes. N Engl J Med. 2005;352(24):2477-86.
Landon MB, Spong CY, Thom E, et al. A multicenter, randomized trial of treatment for mild gestational diabetes. N Engl J Med. 2009;361(14):1339-48.
Cunningham FG, MacDonald PC, Gant NF, et al. Diabetes. In: Cunningham FG, MacDonald PC, Gant NF, et al. editors. Williams Obstetrics. 20th ed. Norwalk, CT: Appleton & Lange; 1997. p. 1203-21.
Essex NL, Pyke DA, Watkins PJ, Brudenell JM, Gamsu HR. Diabetic pregnancy. Br Med J. 1973;4(5884):89-93.
Roversi GD, Canussio V, Gargiulo M, Candiani GB. The intensive care of perinatal risk in pregnant diabetics (136 cases): A new therapeutic scheme for the best control of maternal disease. J Perinat Med. 1973;1(2):114-24.
Cousins L. 10 The California Diabetes and Pregnancy Program: a statewide collaborative programme for the pre-conception and prenatal care of diabetic women. Baillière’s Clinical Obstetrics and Gynaecology. 1991;5(2):443-59. Available from: http://www. sciencedirect.com/science/article/pii/S0950355205801063. Accessed in 2013 (Jun 12).
Langer O. Management of gestational diabetes. Clin Obstet Gynecol. 2000;43(1):106-15.
Schneider JM, Curet LB, Olson RW, Shay G. Ambulatory care of the pregnant diabetic. Obstet Gynecol. 1980;56(2):144-9.
Cavassini AC, Lima SA, Calderon IM, Rudge MV. Cost-benefit of hospitalization compared with outpatient care for pregnant women with pregestational and gestational diabetes or with mild hyperglycemia, in Brazil. Sao Paulo Med J. 2012;130(1):17-26.
Cavassini ACM, Lima SAM, Calderon IMP, Rudge MVC. Custo da assistência de gestantes e parturientes diabéticas e com hiperglicemia leve [Care cost for pregnant and parturient women with diabetes and mild hyperglycemia]. Rev Saude Publica. 2012;46(2):334-43.
Lefebvre C, Manheimer E, Glanville J. Chapter 6: Searching for studies. In: Higgins JPT, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.0. The Cochrane Collaboration; 2008. Available from: http://hiv.cochrane.org/sites/hiv.cochrane.org/ files/uploads/Ch06_Searching.pdf. Accessed in 2013 (Jun 12).
Schünemann HJ, Oxman AD, Vist GE, et al. Chapter 12: Interpreting results and drawing conclusions. In: Higgins JPT, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.0. The Cochrane Collaboration; 2008. Available from: http://hiv.cochrane.org/sites/hiv.cochrane.org/files/uploads/Ch12_ Interpreting.pdf. Accessed in 2013 (Jun 11).
Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. Plos Medicine. 2009;6(7):e1000097. Available from: http:// www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal. pmed.1000097 . Accessed in 2013 (Jun 27).
Brooten D, Youngblut JM, Brown L, et al. A randomized trial of nurse specialist home care for women with high-risk pregnancies: outcomes and costs. Am J Manag Care. 2001;7(8):793-803.
Stubbs SM, Brudenell JM, Pyke DA, et al Management of the pregnant diabetic: home or hospital, with or without glucose meters? Lancet. 1980;1(8178):1122-4.
Nachum Z, Ben-Shlomo I, Weiner E, Ben-Ami M, Shalev E. Diabetes in pregnancy: efficacy and cost of hospitalization as compared with ambulatory management--a prospective controlled study. Isr Med Assoc J. 2001;3(12):915-9.
Seelbach-Göbel B, Bussen S, Rehn M. Surveillance of pregnant diabetics--comparison between outpatient and inpatient management. Arch Gynecol Obstet. 1995;256(2):89-97.
Smits MW, Paulk TH, Kee CC. Assessing the impact of an outpatient education program for patients with gestational diabetes. Diabetes Educ. 1995;21(2):129-34.
