اسم المؤلف:
رياض وحيد العيساوي
اسم المشرف:
عقيل عبد المنعم حسن زوين
المستخلص:
يعتبر داء السكري المصاحب للحمل هو احد مضاعفات الحمل الاكثر شيوعا والتي ترتبط بمعدلات هامة من الاعتلال والوفاة ما حول الولادة , ان العلاج الفعال لداء السكري ما قبل الحمل ولداء السكر المصاحب للحمل قد تبين تحسين النتائج والحد من وفيات ما حول الولادة بالمقارن | Diabetes mellitus complicating pregnancy is one of the most common antenatal complications that are associated with significant perinatal mortality and morbidity(Magee et al., 1993, Schmidt et al., 2001and Platt et al., 2002). Effective treatment of pre - existing as well as gestational diabetes mellitus was shown to improve outcome and reduce perinatal mortality, as compared to untreated patients (Lao TT, et al., 2001and Langer , et al., 2005). Doppler studies have conventionally been utilized for fetal surveillance. The use maternal uterine artery Doppler as a screening tool to predict subsequent development of pre - eclampsia and fetal growth restriction in later gestation have gained acceptance in recent years. Umbilical artery Doppler, middle cerebral artery Doppler have been widely used for the assessment of growth restricted fetuses. The role of Doppler study in diabetic pregnancies has not been unequivocally evaluated. An atherogenic factor, that promotes vascular endothelial growth, insulin - like growth factor - 1 has been implicated with micro vascular complication during pregnancy (Kathryn 2000). Presently, short - term beneficial metabolic effects of recombinant human insulin - like growth nfactor - 1 (rhIGF) - 1 therapy have been demonstrated in numerous diabetic conditions, including type 1 diabetes mellitus, type 2 diabetes mellitus. Until recently, insulin - like growth factor - 1, based upon its endothelial growth promotion, was considered a mediator of vascular disease( Bayes - genis et al., 2001a; 2001b). Conversely, increasing evidence indicate the protective mechanism of insulin - like growth factor - 1 against vascular derangements, relating to its ability of nitric oxide production (Okura et al., 2001). We sought to investigate the impact of insulin - like growth factor - 1 levels on maternal/fetal blood flow in diabetic non - hypertensive pregnant women; an avenue of research that has yet to be fully explored. Taken together, this information will materialize the intervention needed to prevent or at least ameliorate diabetes maternal and fetal outcomes. OBJECTIVES1 - To evaluate effect of diabetes mellitus on utero - and cerebro - placental Doppler velocimetry in pregnant women, such as resistive index (RI), pulsatility index (PI), Systolic/diastolic ratio (S/D)2 - To find whether a meaningful correlation exists between the above mentioned parameters and the levels of HBA1c and maternal IGF - 1.3 - To predict the most sensitive parameter detecting complications of diabetes mellitus on fetal outcomes. MATERIAL AND METHOD In this prospective cohort study a total of 190 pregnant women with single viable fetus, cephalic presentation, were enrolled after having their verbal and written consent and approval of the ethical committee at Faculty of Medicine. They were divided into two Groups : group (Ia) women with gestational diabetes mellitus (n=70), group ( Ib ) women with pre - gestational diabetes mellitus (n=64) and the remaining (n=56) participants (group II) were free from diabetes and hypertension and served as a control group. The study performed at Al Ameer Diagnostic Center in Al Najaf, between March, 2013 and August, 2014.Examination of the participants done twice, in the second and third trimesters. In each time, history and clinical examinations performed with Doppler ultrasonography of the pregnant women including interrogations of bilateral maternal uterine arteries, fetal umbilical and middle cerebral arteries in addition to measurement of IGF - 1 and HbA1c concentrations. RESULTS AND CONCLUSIONS 1 - IGF - 1 mean± SD in second trimester was 582.61± 183.7 ng/ml in group Ia, 429.5± 231.3 ng/ml in group 1b and 278.6 ± 60.8 ng/ml in the group II with significant difference among the groups (P=0.0001) In the third trimester the mean± SD was 653.69 ±197.6 ng/ml in group Ia, 487.5± 242.4 ng/ml in group Ib and 316.6 ± 60.9 ng/ml in group II with significant difference among the groups (P=0.0001).2 - HbA1c mean± SD in second trimester was 6.59± 0.89 % in group Ia, 6.42 ± 0.9% in group Ib and 5.35 ± 0.56 % in group II with significant difference between group Ia and group II, as well as between Ib and group II, but no significant difference between Ia and Ib groups.Third trimester HbA1c mean value was 6.29 ± 0.78 % in group Ia , in group Ib 6.27 ± 0.87 % and 5.08 ± 0.57% in group II.There was no significant difference between group Ia and Ib (P=0.843) , while there was a significant difference between group Ia and group II as well as between group Ib and group II(P=0.0001).3 - Uterine artery Doppler velocimetry was considered more sensitive predictor than other arteries in evaluation of fetal outcomes and its sensitivity in the total studied population (190) was 44.3%, in gestational diabetic pregnancy group was 58.3%, in pregestational diabetic pregnancy 34.3% and in control was 29.4%.4 - Multiple maternal and fetal arterial Doppler studies at same time yield high predictive values in evaluation of fetal outcomes with general sensitivity in the total studied population was 63.6%, specificity 79.4%79, PPV 72.2% and NPV 71.7%. In gestational diabetic pregnancy the sensitivity was 94.4%, specificity was 61.8%, PPV was 72.3%, NPV was 91.3%. In pregestational diabetic pregnancy sensitivity was 88.6%, specificity was 86.2 %, PPV was 88.6 %, NPV was 86.2%. In control healthy pregnancies the sensitivity was 70.6 %, specificity was 71.8%, PPV was 52.2%, NPV was 84.8 %.
