Pregnancies in women with diabetic nephropathy: long-term outcome for mother and child

Abstract

SummaryIn order to improve the basis upon which to advise women with diabetic nephropathy about pregnancy, we studied the effect of diabetic nephropathy on the course of pregnancy, perinatal outcome, infant development and long-term outcome of the mothers. All pregnancies of women with diabetic nephropathy (defined as proteinuria > 400 mg/day (n = 26), creatinine clearance < 80 ml/min and hypertension in the first trimester (n = 10)) followed at our centre from 1982 to 1992 were identified (34 White class F and 2 White class T) and the women and their children re-examined in the spring 1993. From the first to the third trimester the percentage of women with proteinuria over 3 g/day increased from 14 to 53 % and those treated with antihypertensive medication from 53 to 97 %. There were no intrauterine or perinatal deaths, but one child died suddenly 4 weeks postpartum. Of 36 newborns (gestational week at birth 36(3), birth weight 2384(834) g)), 11 were born before week 34 and 8 had respiratory distress syndrome. Renal function in the first trimester, diastolic blood pressure in the third trimester and an HbAlc above normal were predictive of gestational age at delivery and low birth weight (stepwise regression analysis). At follow-up of the children (n = 35, age 4.5 (0.4-10) years) the majority (n = 27) were normally developed but seven had psychomotor retardation (four of them major). One child had a severe motor retardation due to a congenital anomaly. At follow up, 21 of the 29 mothers had preserved renal function (creatinine 1.3 (0.8-4.3) mg/dl and 8 had developed end stage renal disease and required dialysis (2 of whom were White class T) within 3 (1-9) years postpartum. Of those, 4 women (3 White F and i White T) had died. Pregnancy did not seem to specifically accelerate the rate of decline of renal function. In women with diabetic nephropathy perinatal mortality can be prevented but perinatal and long-term infant morbidity remains elevated. Women with severely impaired renal function before pregnancy are at risk for serious morbidity when their children are still young. Improvement might be made if all women were to receive specialized care and counselling before, throughout and after pregnancy. [Diabetologia (1995) Today the perinatal outcome of pregnancies of diabetic women without advanced diabetic complications is similar to that in non-diabetic women, if there is normoglycaemic control throughout pregnancy. Therefore, in women with well-controlled diabetes who do not have nephropathy or other advanced vascular complications their decision about whether or not to have children will largely be influenced by factors not associated with diabetes itself. In contrast, for women with diabetic nephropathy (who in most cases also have proliferative retinopa-

Pregnancy outcomes in mothers with pregestational diabetes: a population-based study in North Rhine (Germany) from 1988 to 1993

“…The perinatal mortality in North Rhine during 1988±1993 was slightly lower than the population based ®gures reported from Sweden for 1983±1985 (3.1%) [2]. However, reports from two German centres indicate that in cohorts of type I diabetic women below 1% perinatal deaths are possible [9,18]. In diabetic mothers a reduction of the perinatal death rate to the standards of the nondiabetic mothers (0.6% during the study period) therefore appears possible and is one of the WHO targets [23].…”

“…Of the children of the diabetic mothers, 25% were premature, a rate considerably higher than that reported from specialized centres in Germany in children of diabetic mothers (15%) [9,18]. Prematurity is a major cause for neonatal morbidity in children of diabetic mothers.…”

“…Most of the reports on near-normal pregnancy outcomes in mothers with pregestational diabetes mellitus are derived from single specialized centres [5,9,16,18] and therefore might not be representative of the whole population. They rather re¯ect the excellence of these centres and/or the selection of the population who attend these centres.…”

Hypertension and the pregnancy complicated by diabetes

“…Pregestational Insulin-dependent DM and Incidence of PIH Most studies addressing the association between PGDM and hypertensive complications in pregnancy agree that the incidence of preeclampsia and PIH is increased in this population [6][7][8][9][10][11][12][13][14]. In fact, the 3% to 7% incidence observed among healthy women is increased to 9% to 66% among diabetic patients [15•].…”

Diabetes in der Schwangerschaft

“…Dies betrifft die Frühgeburtenrate, Wachstumsretardierungen, intrauterinen Fruchttod und die perinatale/neonatale Mortalität. In einer Nachbeobachtungsstudie aus dem Krankengut des Universitätsklinikums Düsseldorf wiesen zudem über 22% der Lebendgeborenen von Müttern mit manifester diabetischer Nephropathie psychomotorische Retardierungen auf, die in 11% als schwer eingestuft wurden [12].…”