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 Table of Contents  
ORIGINAL ARTICLES
Year : 2021  |  Volume : 12  |  Issue : 5  |  Page : 86-91

Pregnancy outcome in women with type 1 and type 2 diabetes mellitus in Dubai hospital: A retrospective observational study


Department of Obstetrics and Gynecology, Dubai Hospital, Dubai, UAE

Date of Submission07-Mar-2021
Date of Decision03-May-2021
Date of Acceptance18-May-2021
Date of Web Publication20-Jul-2021

Correspondence Address:
Dr. Shabnam Saquib
Department of Obstetrics and Gynecology, Dubai Hospital, Dubai.
UAE
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jod.jod_29_21

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  Abstract 

Aim and Objectives: Pregestational diabetes mellitus (PGDM) affects less than 1% of the obstetric population. It has a significant impact on maternal and fetal morbidity and mortality. This study aimed at evaluating antenatal care and pregnancy outcomes in women with PGDM who delivered in Dubai Hospital during 2017–2019. Materials and Methods: A retrospective analysis of all women with diabetes mellitus who delivered in a tertiary care hospital at Dubai from January 1, 2017, to December 31, 2019, was conducted. Maternal characteristics, type of diabetes mellitus, prepregnancy and antenatal glycemic control, mode of delivery, birth weight, and perinatal outcomes were evaluated during the study period. We also compared glycated hemoglobin (HbA1c) levels prepregnancy and during the antenatal period in type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM), with its impact on maternal and fetal outcomes. Results: There were 7284 women who delivered during the study period at our hospital, out of whom 28 women (18.8%) had T1DM and 121 women (81.2%) had T2DM. A total of 144 (96.6%) patients were booked in the antenatal-diabetes mellitus combined clinic. Seventy-nine (53%) women had measured HbA1c within six months before pregnancy. Only 53% women preconceptionally had HbA1c levels <6.5%; however, by the third trimester, 74% of women achieved HbA1c <6.5%. Antenatally, 26 women were associated with essential hypertension, 10 with nephropathy, and eight with retinopathy and 12 women developed preeclampsia. Forty-six (30%) women had preterm delivery at less than 37 weeks. This was significantly higher in T1DM versus T2DM (50% vs. 27%, P value = 0.01). The cesarean section rate was 62%, and 50% of them were due to repeat elective cesarean section. Twelve babies born were more than 4kg, and one of them weighed more than 5kg (5.270kg). There were five cases with stillbirth, no neonatal death was recorded within seven days, and the perinatal mortality rate was 30/1000. Conclusion: The interval prevalence of PGDM in our cohort was 2%. Achieving HbA1c levels <6.5% in two-third of the women with diabetes mellitus by the third trimester resulted in a prevalence of macrosomia (8%) similar to the general population.

Keywords: Glycated hemoglobin (HbA1c), maternal morbidity, perinatal mortality, pregestational diabetes mellitus (PGDM)


How to cite this article:
Saquib S, Tambawala ZY, Waheed S, Hubaishi NM. Pregnancy outcome in women with type 1 and type 2 diabetes mellitus in Dubai hospital: A retrospective observational study. J Diabetol 2021;12, Suppl S1:86-91

How to cite this URL:
Saquib S, Tambawala ZY, Waheed S, Hubaishi NM. Pregnancy outcome in women with type 1 and type 2 diabetes mellitus in Dubai hospital: A retrospective observational study. J Diabetol [serial online] 2021 [cited 2021 Oct 16];12, Suppl S1:86-91. Available from: https://www.journalofdiabetology.org/text.asp?2021/12/5/86/321819




  Introduction Top


The United Arab Emirates (UAE) is among the top 20 countries in the world with a high prevalence of diabetes mellitus: 19% of the country’s population suffers from the “silent pandemic.” According to the International Diabetes Federation (IDF) data, there will be a rise in diabetes mellitus cases from 425 million in 2017 to 629 million in 2045. In the Middle East and North Africa (MENA) region, cases will rise from 39 million to 67 million by 2045.1 Globally, type 1 diabetes mellitus (T1DM) accounts for 5%–10% of the population and type 2 diabetes mellitus (T2DM) for 90%–95%.[1],[2]

Diabetes mellitus in pregnancy is associated with an increased risk for both maternal and fetal morbidity and mortality. Recently, many young women are embarking on their pregnancy with diabetes mellitus and have very poor control of their blood glucose before conception. If prepregnancy blood glucose is not well controlled, it would lead to a deterioration of diabetes mellitus, and it increases the risk of miscarriage, preeclampsia, preterm delivery, and cesarean section. There is also a two- to five-fold increased risk of macrosomia, congenital anomalies, stillbirth, and neonatal death compared with a nondiabetic pregnancy.[3]

In 1989, St. Vincent Declaration goals were to approximate the outcome of pregnancies in women with diabetes mellitus to be the same as those of nondiabetic women.[4] Since then, many international guidelines and protocols were established to achieve these goals. In 2005, Confidential Enquiry into Maternal and Child Health (CEMACH) suggested that interventions such as preconception care, periconceptional folic acid, adequate pre- and antenatal glycemic control, and management of gestational weight gain can reduce the complications associated with diabetes mellitus in pregnancy.[5]

It is difficult to provide the earlier mentioned interventions in routine antenatal clinics since it requires a dedicated multidisciplinary team for its accomplishment. We at Dubai hospital have started an antenatal-diabetes mellitus combined clinic since 2015 to provide these interventions and specialized care for our patients. The objective of our study is to find the interval prevalence of pregestational diabetes mellitus (PGDM), its prepregnancy and antenatal glycemic control, and maternal and fetal outcome in the pregnancy of our obstetric population.


  Materials and Methods Top


A retrospective case descriptive study was conducted at Dubai Hospital, Dubai, UAE; it analyzed the pregnancy outcomes in diabetic pregnancies from January 1, 2017, to December 31, 2019. All women with T1DM, T2DM and those recently diagnosed with diabetes mellitus during pregnancy with high fasting (126 mg/dL) blood glucose or 2h postprandial (200 mg/dL) blood glucose were included in the study. All women with gestational diabetes mellitus and those cases with missing records were excluded from the study.

The data were retrieved from the maternity register, patient files, and computerized hospital database. Patients’ records were reviewed for maternal age, gravidity, parity, BMI, ethnicity, prepregnancy, and antenatal glycemic control. Antenatal and postpartum outcomes such as preeclampsia, preterm delivery less than 37 weeks, nephropathy, retinopathy, mode of delivery, and postpartum hemorrhage were evaluated.

Perinatal outcome was assessed by macrosomia, that is, weight more than 4kg, 5-min Apgar score less than seven, admission to the neonatal intensive care unit (NICU), fetal congenital anomalies, stillbirth, and early neonatal death. Perinatal mortality was defined as stillbirth after 24 weeks and neonatal death within seven days after birth. Neonatal complications such as respiratory distress syndrome (RDS), hypoglycemia, and jaundice were also reviewed.

Dubai hospital follows the IDF and the National Institute for Health and Care Excellence (NICE) guidelines for the management of diabetes mellitus in pregnancy. All T1DM and T2DM women were managed in antenatal and diabetes mellitus multidisciplinary service, which included diabetologist, obstetrician with special interest in diabetes mellitus, dietician, and diabetic nurse. Folic acid (5 mg) was advised from beginning of the pregnancy and if possible, at least eight weeks before conception. During antenatal care, the target glycemic control with fasting blood glucose was between 65 and 95 mg/dL, blood glucose at 1h was less than 140 mg/dL and at 2h less than 120 mg/dL, to maintain glycated hemoglobin (HbA1c) level less than 6.5% during pregnancy. As per protocol, HbA1c level was checked in each trimester; a detailed anomaly scan between 18 and 20 weeks of gestation and fetal electrocardiography between 24 and 26 weeks of gestation were done to rule out any congenital anomalies. Regular outpatient follow-ups depending on glycemic control, growth scan every two weeks, and fetal surveillance with a nonstress test from 35 weeks of gestation were conducted. Delivery was planned between 37 and 38 weeks of gestation for those on insulin and between 38 and 39 weeks of gestation for those on Metformin. During the intrapartum period, glycemic control was maintained between 70 and 125 mg/dL by insulin infusion, as per protocol.

This study was approved by the Dubai scientific research ethics committee (DSREC-08/2019_19), and confidentiality of data was maintained. The Statistical Package for the Social Sciences, version 25.0 (IBM Corp, Armonk, NY, USA), was used to analyze the data. Continuous variables were reported as means and SD for bell-shaped data. For skewed data, median and range were reported. Categorical variables are reported as frequency and percentages. P value <0.05 is considered a significant value.


  Results Top


A total of 7284 deliveries occurred during the study period, out of which 149 (2.04%) were known women with T1DM and T2DM. Twenty-eight women (18.8%) were with T1DM, and 121 women (81.2%) were with T2DM.

Maternal characteristics

The overall average age of the women was 35 years: The youngest was 19 years, and the oldest was 45 years. As expected, women with T2DM were older and more than 35 years of age compared with women with T1DM (P value = 0.0001). A significant number of women were obese in both groups; however, in comparison, women with T2DM were more obese, and two women had BMI more than 50. Multiparity of five and above was higher in T2DM, and three cases were para 8 and above. T1DM is more common in the Middle East population compared with the Asian and African population. [Table 1] and [Figure 1] describe maternal demographic data.
Table 1: Maternal characteristics

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Figure 1: Ethnicity

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Standard of care

Of our women with diabetes mellitus, 96.6% were booked in the antenatal-diabetes mellitus combined clinic. Only five T2DM cases were of unbooked women. All women with T1DM were booked during either the first or second trimester of pregnancy. Overall, 53% (79/149) of women had a prepregnancy clinic visit and checked their HbA1c within six months before pregnancy. Overall, 68% of women with T1DM were following in diabetic clinics than women with T2DM (50%); however, prepregnancy means that HbA1c levels were higher for women with T1DM (7.6 ± 1.6) compared with women with T2DM (6.8 ± 1.5). Only 31.5% (6/19) of women with T1DM and 60% (36/60) of women with T2DM had HbA1c levels below 6.5% prepregnancy as recommended by the NICE guidelines. Eight women with T1DM had HbA1c more than 8 mg%, and the highest value was 10.7 mg%. In T2DM, 10 patients had HbA1c more than 8 mg%, with the highest value being 12.2 mg%. There was no proper documentation about the prepregnancy intake of folic acid in all these women. Antepartum glycemic control was checked in each trimester, with mean HbA1c levels as charted in [Table 2].
Table 2: Comparison of antepartum glycemic control

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Obstetric outcome

Women with T2DM had less preterm delivery compared with women with T1DM (27% vs. 50%, P value = 0.01), with a mean gestational age of delivery in T1DM being 35.8 ± 2.2 and in T2DM being 36.9 ± 1.9. Four women with T1DM and six women with T2DM delivered in less than 34 weeks. Women with T1DM and T2DM had no significant difference in mode of delivery. Overall, 38% had vaginal delivery and 62% had cesarean section. Of these, 50% were elective cesarean section and only 12% were primary cesarean section. Fifty-three women (36%) had induction of labor, out of whom 39 (73%) had successful vaginal delivery, which revealed very good standard of care during the intrapartum period.

Neonatal outcome

There were two sets of twins in women with T1DM (30) and one in women with T2DM (122), thus totaling 152 infants. Only 12 (8%) infants had a weight more than 4kg, more so in women with T1DM (10%) than women with T2DM (7%). The HbA1c of these women ranged from around 8% to 9% at booking in women with T1DM and from 7% to 8% in the third trimester. Though the HbA1C was 6%–7% at booking in women with T2DM, there was no proper compliance by these women, leading to a rise in HbA1C to 7%–8% in the third trimester.

There was only one unbooked woman with uncontrolled glucose in the T2DM group with a neonatal birth weight of 5.2kg. Forty-three (28%) babies were admitted in the NICU mostly with T1DM mothers. Twenty (13%) developed RDS, mainly in the case of preterm delivered babies. Overall, 42% and 44% of babies in women with diabetes mellitus were born with hypoglycemia and jaundice.

Congenital anomalies were noted in two cases of T1DM: One had hypertrophy of the heart, and another neonate had bilateral hydrocele. Among T2DM, five showed cardiac anomalies such as left ventricular dilatation, atrial septal defect, septal hypertrophy, severe pulmonary stenosis, and nonobstructive hypertrophic cardiomyopathy. Six neonates with T2DM had congenital talipes equinous varus, occipital encephalocele, hydrocephalous, single kidney, and penoscrotal webbing.

One stillbirth in women with T1DM (30/1000) had a high HbA1c of 8.8%, ventricular septal defect with nephropathy, and essential hypertension. In the four cases of women with T2DM (30/1000), two of them were unbooked and two women with high HbA1c did not follow-up in the third trimester. We had no neonatal death with seven days after birth in our cohort.

[Table 3] gives the details about obstetric and perinatal outcomes:
Table 3: Comparison of obstetric and perinatal outcomes in T1DM and T2DM in pregnancy

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  Discussion Top


The interval prevalence of PGDM in our cohort during the study period was 2% in comparison to 0.38% in the United Kingdom and 0.9% in the United States.[6] This high prevalence could be due to Dubai Hospital being a tertiary referral center for all women with diabetes mellitus in pregnancy and also the population having a higher prevalence of diabetes mellitus. In comparison to T1DM (18%), T2DM (81%) was more common in our study. The women with T2DM were older, obese, and multiparous, as shown in a similar study by Murphy et al.[7],[8] T1DM is more prevalent in the MENA region compared with the East Asian countries. This could be related to genetic factors due to the increased prevalence of consanguineous marriages in our region.[9]

Several studies and guidelines have stated that adequate prepregnancy care and HbA1c <6.5% before pregnancy in women with diabetes mellitus could result in better maternal and neonatal outcomes. In our study, we observed that half (50%) of the women with diabetes mellitus were following up in a diabetic clinic before pregnancy. This is significantly greater than one-third (34.5%) of the women in the CEMACH study.[5] Though a lesser number of women with T2DM (50%) attended the prepregnancy diabetic clinic than women with T1DM (68%), the prepregnancy HbA1c levels of T2DM (6.7 ± 1.5) were better controlled compared with T1DM (7.6 ± 1.6). Almost 96% of women with diabetes mellitus were booked and followed up in a specialized antenatal and diabetes mellitus clinic. Dedicated antenatal care resulted in good glycemic control in the women. In comparison with the study by Murphy et al. (40% and 76%), our study showed better control in HbA1c <6.5% in T1DM and T2DM (62% and 80%) till the second trimester.[7] The mean HbA1c level also significantly improved from 7.6% to 5.9% in T1DM and from 6.7% to 6.1% in T2DM.

Due to vascular pathology, women with T1DM have a higher percentage of essential hypertension, diabetic nephropathy, and diabetic retinopathy and they are more likely to develop diabetic ketoacidosis during pregnancy compared with women with T2DM. Preeclampsia was more common in women with T2DM (9%) compared with women with T1DM (3%); this is similar to the study done by Stogianni et al.[10] However, our overall prevalence of preeclampsia is less compared with studies conducted in Sweden and Oman (8% vs. 21%, 17.2%).[10],[11]

In our study, 30% of women had preterm delivery, which is comparable to CEMACH,[5] Sweden,[10] Oman,[11] and Dublin[12] data (35.8%, 38%, 25.9%, and 22%) but higher than the general maternity population rate of 7.4%. Most of the preterm deliveries were associated with chronic diabetes mellitus and obstetric issues such as essential hypertension, diabetic ketoacidosis, preeclampsia, intrauterine growth restriction, twins, and previous multiple surgeries. Though there was adequate glycemic control during pregnancy, more incidence of preterm delivery was seen in T1DM with high prepregnancy HbA1c levels and in patients with metabolic changes existing before pregnancy.

There was no significant difference in the mode of delivery in both types of diabetes mellitus. Overall, 38% had vaginal delivery and 62% had cesarean section, which is a better outcome than the CEMACH study (24% vs. 76%). Mainly, 50% of cesarean sections were elective, due to repeat cesarean sections for multiple uterine scars and due to diabetic consequences such as malpresentation, preeclampsia, intrauterine growth restriction, and vascular pathology. Primary emergency cesarean section accounted for only 12% of the deliveries, which is well under the WHO cutoff of 15%.[13] Two-third of the women who were induced had successful vaginal delivery; this reveals a very good standard of care during the intrapartum period.

In the current study, the interval prevalence of macrosomia (8%) was comparable to the general population (6%–10%) and much lesser than CEMACH (21%) and other studies.[5],[7],[10] Murphy et al. noted more infants having large for gestational age (LGA) in T1DM compared with T2DM (46% vs. 23%), and this was also observed in our study (10% vs. 7%). In both groups, even when women had initial suboptimal glucose control, the birth weight of infants was less than 4kg as their HbA1c levels were well controlled below 6.5% in the third trimester. This indicates the importance of optimal control of blood glucose in the third trimester of pregnancy. There was a very low incidence of shoulder dystocia (1.3%) compared with the CEMACH and Dublin study (5.4% vs. 7.9%).[5],[12]

The NICU admission was 28%, which was mainly seen in infants with T1DM. Almost half of the babies born to mothers with diabetes mellitus developed hypoglycemia and jaundice in the cohort but most of them were observed in the postnatal ward, so NICU admissions were far lesser than in the CEMACH, Oman, and Dublin study (56%, 42%, and 31%).[5],[11],[12] In our cohort, there was a case of stillbirth in T1DM (30/1000) and four cases of stillbirth in T2DM (30/1000). Our stillbirth rate was higher than that of the 2015 National Statistic in England and Wales (10.7/1000 for T1DM and 10.5/1000 for T2DM),[14] but all of these women were either unbooked or had no follow-up in the third trimester. Stillbirths in PGDM occur later in pregnancy after 32 weeks of gestation and are associated with hypertensive disorders of pregnancy, maternal medical complications, and LGA.[14],[15],[16] Our hospital protocol recommends fetal surveillance from 35 weeks of gestation to prevent stillbirth in the booked antenatal patients. Women with PGDM have a two- to nine-fold higher risk of babies having congenital anomalies, given a prevalence of 2.7%–18.6%, compared with the healthy population having a prevalence of 2%–3%.[17],[18],[19] In our cohort, we had 11% of babies with major and minor congenital anomalies.

Limitations

Being a retrospective data collection, our study could have recall bias and missing information. Though Dubai hospital is a tertiary care center for women with diabetes mellitus in pregnancy, still our data may not represent the entire UAE population. Nevertheless, this is one of the few studies done in the UAE comparing maternal and neonatal outcomes in women with diabetes mellitus.


  Conclusion Top


The interval prevalence of diabetes mellitus in pregnancy in our study (2%) is comparatively higher than the western population. Significance of a prepregnancy clinic and HbA1c levels <6.5% before pregnancy need to be emphasized in our population. Strict glycemic control during the second and third trimester resulted in better intrapartum and perinatal outcomes. There was a low incidence of macrosomia and primary cesarean sections in the current study, which was almost similar to the general population due to the dedicated multidisciplinary clinical care and strict glycemic control. However, it has not reduced the incidence of preterm delivery rate, which needs further studies to evaluate its factors.

Ethical approval

This study was approved by the Dubai Scientific Research Ethics Committee (DSREC-08/2019_19), and confidentiality of data was maintained.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
International Diabetes Federation. IDF Diabetes Atlas. 9th ed. Brussels: International Diabetes Federation;2020. p. 7-44. http//www.diabetesatlas.org/. [Last accessed on 2018 Aug 07].  Back to cited text no. 1
    
2.
Alawadi F, Hassanein M, Suliman E, Hussain HY, Mamdouh H, Ibrahim G, et al. The prevalence of diabetes and pre-diabetes among the Dubai population: Finding from Dubai Household Health Surveys, 2014 and 2017. Dubai Diabetes Endocrinol J2020;26:78-84.  Back to cited text no. 2
    
3.
Macintosh MC, Fleming KM, Bailey JA, Doyle P, Modder J, Acolet D, et al. Perinatal mortality and congenital anomalies in babies of women with type 1 or type 2 diabetes in England, Wales, and Northern Ireland: Population based study. BMJ 2006;333:177.  Back to cited text no. 3
    
4.
Diabetes care and research in Europe: The Saint Vincent declaration. Diabet Med1990;7:360.  Back to cited text no. 4
    
5.
Confidential Enquiry into Maternal and Child Health. Pregnancy in Women with Type 1 and Type 2 Diabetes in 2002–03, England, Wales and Northern Ireland. London: CEMACH;2005.  Back to cited text no. 5
    
6.
Deputy NP, Kim SY, Conrey EJ, Bullard KM. Prevalence and changes in preexisting diabetes and gestational diabetes among women who had a live birth - United States, 2012-2016. MMWR Morb Mortal Wkly Rep 2018;67:1201-7.  Back to cited text no. 6
    
7.
Murphy HR, Bell R, Cartwright C, Curnow P, Maresh M, Morgan M, et al. Improved pregnancy outcomes in women with type 1 and type 2 diabetes but substantial clinic-to-clinic variations: A prospective nationwide study. Diabetologia 2017;60:1668-77.  Back to cited text no. 7
    
8.
Owens LA, Sedar J, Carmody L, Dunne F . Comparing type 1 and type 2 diabetes in pregnancy- similar conditions or is a separate approach required? BMC Pregnancy and Childbirth2015;15:69.   Back to cited text no. 8
    
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Majeed A, El-Sayed AA, Khoja T, Alshamsan R, Millett C, Rawaf S. Diabetes in the Middle-East and North Africa: An update. Diabetes in the Middle-East and North Africa: An update. Diabetes Res Clin Pract 2014;103:218-22.  Back to cited text no. 9
    
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Stogianni A, Lendahls L, Landin-Olsson M, Thunander M.Obstetric and perinatal outcomes in pregnancies complicated by diabetes, and control pregnancies, in Kronoberg, Sweden. BMC Pregnancy Childbirth 2019;19:159.  Back to cited text no. 10
    
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Abu-Heija AT, Al-Bash M, Mathew M. Gestational and pregestational diabetes mellitus in Omani women: Comparison of obstetric and perinatal outcomes. Sultan Qaboos Univ Med J2015;15(4):e496-500.  Back to cited text no. 11
    
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Higgins M, Galvin D, McAuliffe F, Coffey M, Firth R, Daly S, et al. Pregnancy in women with type-1 and type-2 diabetes in Dublin. Ir J Med Sci 2011;180:469-73.  Back to cited text no. 12
    
13.
World Health Organization Human Reproduction Programme. WHO statement on caesarean section rates. Reprod Health Matters 2015;23:149-50.  Back to cited text no. 13
    
14.
Office for National Statistics. Births in England and Wales : 2014. Office for National Statistics. https://www.ons.gov.uk › bulletins › 2015-07-15  Back to cited text no. 14
    
15.
Holman N, Bell R, Murphy H, Maresh M. Women with pre-gestational diabetes have a higher risk of stillbirth at all gestations after 32 weeks. Diabet Med 2014;31:1129-32.  Back to cited text no. 15
    
16.
Page JM, Allshouse AA, Cassimatis I, Smid MC, Arslan E, Thorsten V, et al. Characteristics of stillbirths associated with diabetes in a diverse U.S. Cohort. Obstet Gynecol 2020;136:1095-102.  Back to cited text no. 16
    
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Temple R, Aldridge V, Greenwood R, Heyburn P, Sampson M, Stanley K. Association between outcome of pregnancy and glycaemic control in early pregnancy in type 1 diabetes: Population based study. BMJ 2002;325:1275-6.  Back to cited text no. 17
    
18.
Macintosh MCM, Fleming KM, Bailey JA, Doyle P, Modder J, Acolet D, et al. Perinatal mortality and congenital anomalies in babies of women with type 1 or type 2 diabetes in England, Wales, and Northern Ireland: Population-based study. BMJ 2006;333:177.  Back to cited text no. 18
    
19.
Gabbay-Benziv R, Reece EA, Wang F, Yang P. Birth defects in pregestational diabetes: Defect range, glycemic threshold and pathogenesis. World J Diabetes 2015;6:481-8.  Back to cited text no. 19
    


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