Adverse pregnancy outcomes in women with diabetes-related microvascular disease and risks of disease progression in pregnancy: A systematic review and meta-analysis.
Journal
PLoS medicine
ISSN: 1549-1676
Titre abrégé: PLoS Med
Pays: United States
ID NLM: 101231360
Informations de publication
Date de publication:
11 2021
11 2021
Historique:
received:
24
05
2021
accepted:
26
10
2021
revised:
08
12
2021
pubmed:
23
11
2021
medline:
22
12
2021
entrez:
22
11
2021
Statut:
epublish
Résumé
The rise in the global prevalence of diabetes, particularly among younger people, has led to an increase in the number of pregnant women with preexisting diabetes, many of whom have diabetes-related microvascular complications. We aimed to estimate the magnitude of the risks of adverse pregnancy outcomes or disease progression in this population. We undertook a systematic review and meta-analysis on maternal and perinatal complications in women with type 1 or 2 diabetic microvascular disease and the risk factors for worsening of microvascular disease in pregnancy using a prospective protocol (PROSPERO CRD42017076647). We searched major databases (January 1990 to July 2021) for relevant cohort studies. Study quality was assessed using the Newcastle-Ottawa Scale. We summarized the findings as odds ratios (ORs) with 95% confidence intervals (CIs) using random effects meta-analysis. We included 56 cohort studies involving 12,819 pregnant women with diabetes; including 40 from Europe and 9 from North America. Pregnant women with diabetic nephropathy were at greater risk of preeclampsia (OR 10.76, CI 6.43 to 17.99, p < 0.001), early (<34 weeks) (OR 6.90, 95% CI 3.38 to 14.06, p < 0.001) and any preterm birth (OR 4.48, CI 3.40 to 5.92, p < 0.001), and cesarean section (OR 3.04, CI 1.24 to 7.47, p = 0.015); their babies were at higher risk of perinatal death (OR 2.26, CI 1.07 to 4.75, p = 0.032), congenital abnormality (OR 2.71, CI 1.58 to 4.66, p < 0.001), small for gestational age (OR 16.89, CI 7.07 to 40.37, p < 0.001), and admission to neonatal unit (OR 2.59, CI 1.72 to 3.90, p < 0.001) compared to those without nephropathy. Diabetic retinopathy was associated with any preterm birth (OR 1.67, CI 1.27 to 2.20, p < 0.001) and preeclampsia (OR 2.20, CI 1.57 to 3.10, p < 0.001) but not other complications. The risks of onset or worsening of retinopathy were increased in women who were nulliparous (OR 1.75, 95% CI 1.28 to 2.40, p < 0.001), smokers (OR 2.31, 95% CI 1.25 to 4.27, p = 0.008), with existing proliferative disease (OR 2.12, 95% CI 1.11 to 4.04, p = 0.022), and longer duration of diabetes (weighted mean difference: 4.51 years, 95% CI 2.26 to 6.76, p < 0.001) compared to those without the risk factors. The main limitations of this analysis are the heterogeneity of definition of retinopathy and nephropathy and the inclusion of women both with type 1 and type 2 diabetes. In pregnant women with diabetes, presence of nephropathy and/or retinopathy appear to further increase the risks of maternal complications.
Sections du résumé
BACKGROUND
The rise in the global prevalence of diabetes, particularly among younger people, has led to an increase in the number of pregnant women with preexisting diabetes, many of whom have diabetes-related microvascular complications. We aimed to estimate the magnitude of the risks of adverse pregnancy outcomes or disease progression in this population.
METHODS AND FINDINGS
We undertook a systematic review and meta-analysis on maternal and perinatal complications in women with type 1 or 2 diabetic microvascular disease and the risk factors for worsening of microvascular disease in pregnancy using a prospective protocol (PROSPERO CRD42017076647). We searched major databases (January 1990 to July 2021) for relevant cohort studies. Study quality was assessed using the Newcastle-Ottawa Scale. We summarized the findings as odds ratios (ORs) with 95% confidence intervals (CIs) using random effects meta-analysis. We included 56 cohort studies involving 12,819 pregnant women with diabetes; including 40 from Europe and 9 from North America. Pregnant women with diabetic nephropathy were at greater risk of preeclampsia (OR 10.76, CI 6.43 to 17.99, p < 0.001), early (<34 weeks) (OR 6.90, 95% CI 3.38 to 14.06, p < 0.001) and any preterm birth (OR 4.48, CI 3.40 to 5.92, p < 0.001), and cesarean section (OR 3.04, CI 1.24 to 7.47, p = 0.015); their babies were at higher risk of perinatal death (OR 2.26, CI 1.07 to 4.75, p = 0.032), congenital abnormality (OR 2.71, CI 1.58 to 4.66, p < 0.001), small for gestational age (OR 16.89, CI 7.07 to 40.37, p < 0.001), and admission to neonatal unit (OR 2.59, CI 1.72 to 3.90, p < 0.001) compared to those without nephropathy. Diabetic retinopathy was associated with any preterm birth (OR 1.67, CI 1.27 to 2.20, p < 0.001) and preeclampsia (OR 2.20, CI 1.57 to 3.10, p < 0.001) but not other complications. The risks of onset or worsening of retinopathy were increased in women who were nulliparous (OR 1.75, 95% CI 1.28 to 2.40, p < 0.001), smokers (OR 2.31, 95% CI 1.25 to 4.27, p = 0.008), with existing proliferative disease (OR 2.12, 95% CI 1.11 to 4.04, p = 0.022), and longer duration of diabetes (weighted mean difference: 4.51 years, 95% CI 2.26 to 6.76, p < 0.001) compared to those without the risk factors. The main limitations of this analysis are the heterogeneity of definition of retinopathy and nephropathy and the inclusion of women both with type 1 and type 2 diabetes.
CONCLUSIONS
In pregnant women with diabetes, presence of nephropathy and/or retinopathy appear to further increase the risks of maternal complications.
Identifiants
pubmed: 34807920
doi: 10.1371/journal.pmed.1003856
pii: PMEDICINE-D-21-02305
pmc: PMC8654151
doi:
Types de publication
Journal Article
Meta-Analysis
Systematic Review
Langues
eng
Sous-ensembles de citation
IM
Pagination
e1003856Déclaration de conflit d'intérêts
The authors have declared that no competing interests exist.
Références
Acta Diabetol. 2017 Dec;54(12):1115-1121
pubmed: 28975446
Diabetes Care. 2021 Jan;44(1):181-187
pubmed: 33177172
Diabetes Care. 1996 Oct;19(10):1067-74
pubmed: 8886551
Diabet Med. 2007 Nov;24(11):1229-34
pubmed: 17725628
Diabetes Care. 2009 Jan;32(1):38-44
pubmed: 18945922
Growth Horm IGF Res. 2011 Feb;21(1):25-30
pubmed: 21212010
Acta Obstet Gynecol Scand. 1998 Jul;77(6):620-4
pubmed: 9688239
Arch Gynecol Obstet. 2008 Aug;278(2):129-34
pubmed: 18193440
Acta Obstet Gynecol Scand. 2001 Dec;80(12):1096-103
pubmed: 11846705
J Diabetes Res. 2015;2015:310239
pubmed: 25945354
Am J Med. 1949 Nov;7(5):609-16
pubmed: 15396063
Clin Exp Ophthalmol. 2007 Apr;35(3):231-6
pubmed: 17430509
Am J Obstet Gynecol. 1992 Apr;166(4):1214-8
pubmed: 1566772
N Engl J Med. 2017 Aug 17;377(7):613-622
pubmed: 28657417
Acta Paediatr Jpn. 1991 Apr;33(2):159-65
pubmed: 1957639
Obstet Gynecol. 2001 Apr;97(4):587-92
pubmed: 11275032
Rev Diabet Stud. 2013 Spring;10(1):68-78
pubmed: 24172700
Diabetes Care. 2013 Nov;36(11):3489-94
pubmed: 24009298
BJOG. 2006 Nov;113(11):1329-32
pubmed: 17004981
Obstet Gynecol. 1993 Nov;82(5):802-7
pubmed: 8414328
Acta Med Austriaca. 1997;24(5):170-4
pubmed: 9480617
J Coll Physicians Surg Pak. 2004 Feb;14(2):75-8
pubmed: 15228867
Invest Ophthalmol Vis Sci. 2005 Feb;46(2):709-13
pubmed: 15671303
Am J Obstet Gynecol. 1990 Aug;163(2):505-8
pubmed: 2386136
Diabetologia. 2012 Feb 8;:
pubmed: 22314812
J Fr Ophtalmol. 1992;15(8-9):474-7
pubmed: 1294611
Diabet Med. 1997 Dec;14(12):1059-65
pubmed: 9455934
Diabetologia. 1995 Feb;38(2):227-35
pubmed: 7713319
Bratisl Lek Listy. 2017;118(1):56-60
pubmed: 28127984
Am J Obstet Gynecol. 1996 Apr;174(4):1180-9; discussion 1189-91
pubmed: 8623845
Aust N Z J Obstet Gynaecol. 2020 Dec;60(6):E18-E52
pubmed: 33200400
Z Geburtshilfe Perinatol. 1990 Mar-Apr;194(2):58-64
pubmed: 2343609
Diabet Med. 2001 Jul;18(7):573-7
pubmed: 11553188
Geburtshilfe Frauenheilkd. 1995 May;55(5):275-9
pubmed: 7607385
Diabetologia. 2008 Jun;51(6):1041-5
pubmed: 18392803
J Fr Ophtalmol. 2010 Sep;33(7):481-6
pubmed: 20674081
Invest Ophthalmol Vis Sci. 1994 Jul;35(8):3199-208
pubmed: 8045714
J Obstet Gynaecol Res. 1997 Dec;23(6):555-63
pubmed: 9433048
Diabetologia. 2000 Dec;43(12):1534-9
pubmed: 11151763
BMJ. 1997 Sep 13;315(7109):629-34
pubmed: 9310563
J Matern Fetal Neonatal Med. 2010 Sep;23(9):999-1003
pubmed: 20059444
Jpn J Ophthalmol. 2016 Nov;60(6):454-458
pubmed: 27456842
Lancet. 2014 Aug 30;384(9945):766-81
pubmed: 24880830
Ren Fail. 2000;22(5):573-80
pubmed: 11041289
Diabetes Res Clin Pract. 2018 Apr;138:229-237
pubmed: 29475019
Am J Hypertens. 2006 May;19(5):513-9
pubmed: 16647626
Diabetes Care. 2000 Aug;23(8):1084-91
pubmed: 10937502
BMJ. 2009 Jul 21;339:b2535
pubmed: 19622551
Diabet Med. 2019 Feb;36(2):237-242
pubmed: 30499197
Diabetes Care. 2001 Oct;24(10):1739-44
pubmed: 11574435
Diabetes Care. 1995 May;18(5):631-7
pubmed: 8586000
Diabetes Care. 1990 Jan;13(1):34-40
pubmed: 2404715
Am J Perinatol. 1998 Jul;15(7):413-21
pubmed: 9759908
J Nephrol. 1999 Jan-Feb;12(1):41-6
pubmed: 10203003
Clin Exp Ophthalmol. 2016 May;44(4):321-34
pubmed: 27062093
Diabetes Metab Syndr. 2011 Jul-Sep;5(3):137-42
pubmed: 22813566
Obstet Gynecol. 1996 Mar;87(3):401-9
pubmed: 8598963
BJOG. 2021 Apr;128(5):880-889
pubmed: 32992408
Am J Obstet Gynecol. 2008 Sep;199(3):278.e1-5
pubmed: 18771982
Pregnancy Hypertens. 2014 Jan;4(1):34-40
pubmed: 26104252
Obstet Gynecol. 2010 May;115(5):1014-1020
pubmed: 20410777
Diabetes. 2003 Mar;52(3):852-6
pubmed: 12606530
Ophthalmology. 1996 Nov;103(11):1815-9
pubmed: 8942876
Curr Diab Rep. 2015 Apr;15(4):22
pubmed: 25732848
QJM. 1999 Aug;92(8):451-4
pubmed: 10627861
Diabetologia. 2016 Jan;59(1):92-100
pubmed: 26474777
Diabetologia. 2010 Jun;53(6):1076-83
pubmed: 20225131