diabetes in pregnancy: antepartum considerations and new perspectives amy rouse, md maternal-fetal...
TRANSCRIPT
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Diabetes in Pregnancy: Antepartum Considerations
and New Perspectives
Diabetes in Pregnancy: Antepartum Considerations
and New Perspectives
Amy Rouse, MDMaternal-Fetal Medicine
Saddleback Memorial Medical Center31 January 2009
Amy Rouse, MDMaternal-Fetal Medicine
Saddleback Memorial Medical Center31 January 2009
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ObjectivesObjectives
After completing this session, the learner should be able:
1) To identify key considerations in women with diabetes/ insulin resistance who may become pregnant
2) To recognize updated guidelines for identifying women at risk for gestational diabetes
3) To understand the impact of hyperglycemia below the threshold of a diagnosis of gestational diabetes
After completing this session, the learner should be able:
1) To identify key considerations in women with diabetes/ insulin resistance who may become pregnant
2) To recognize updated guidelines for identifying women at risk for gestational diabetes
3) To understand the impact of hyperglycemia below the threshold of a diagnosis of gestational diabetes
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Part I: PreconceptionPart I: Preconception
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Preconception IssuesPreconception Issues
Any woman of reproductive age who is not actively using reliable contraception may become pregnant
Periconception glycemic control is the single most influential factor in embryonic development
Any woman of reproductive age who is not actively using reliable contraception may become pregnant
Periconception glycemic control is the single most influential factor in embryonic development
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Pregnancy Happens . . .Pregnancy
Happens . . .
2009, The National Campaign to Prevent Teen and Unplanned Pregnancy
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… Even to Women with Diabetes
… Even to Women with Diabetes
St. James PJ et al:Prospective cohort study of 66 women with diabetes1/3 became pregnant within 5 years (n=23)
Only 26 percent of pregnancies were planned
Conclusion: Addressing pregnancy planning in women with diabetes must improve
St. James PJ et al:Prospective cohort study of 66 women with diabetes1/3 became pregnant within 5 years (n=23)
Only 26 percent of pregnancies were planned
Conclusion: Addressing pregnancy planning in women with diabetes must improve
Diabetes Care Vol 16, Issue 12 1572-1578; 1993
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Courtesy of Gabbe Obstetrics: Normal and Problem Pregnancies
White’s Classification in Pregnancy
White’s Classification in Pregnancy
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Diabetes and Early Pregnancy Loss
Diabetes and Early Pregnancy Loss
Poor glycemic control is associated with increased spontaneous abortion
Higher loss rates with long standing disease or with vasculopathyClass C, D, and F: SAB rates of 25%, 44%, and 22%, respectively
Jovanovic: Loss rate similar to general population with excellent glycemic control
Poor glycemic control is associated with increased spontaneous abortion
Higher loss rates with long standing disease or with vasculopathyClass C, D, and F: SAB rates of 25%, 44%, and 22%, respectively
Jovanovic: Loss rate similar to general population with excellent glycemic control
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Diabetes and Birth Defects
Diabetes and Birth Defects
Background rate of major congenital malformations ~2%
Infants of diabetic mothers: 6-10%, accounting for 40% of perinatal deaths in these babies (Reece EA 1996)
Background rate of major congenital malformations ~2%
Infants of diabetic mothers: 6-10%, accounting for 40% of perinatal deaths in these babies (Reece EA 1996)
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Diabetes and Birth Defects
Diabetes and Birth Defects
UK data BMJ 2006: 4.6% major congenital malformation rate in all pregestational diabetic pregnanciesNeural tube defects increased 4.2 fold
Congenital heart disease increased 3.4 fold
UK data BMJ 2006: 4.6% major congenital malformation rate in all pregestational diabetic pregnanciesNeural tube defects increased 4.2 fold
Congenital heart disease increased 3.4 fold
Only 65% of neonatal anomalies were identified antenatally
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Diabetes and Birth Defects
Diabetes and Birth Defects
Miller et al 1981: 3.4% malformation rate if periconception HbA1c <8.5%
22.4% malformation rate if periconception HbA1c >8.5%
End-organ damage not modifiable at time of pregnancy, but control is!
Miller et al 1981: 3.4% malformation rate if periconception HbA1c <8.5%
22.4% malformation rate if periconception HbA1c >8.5%
End-organ damage not modifiable at time of pregnancy, but control is!
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Diabetes and Birth Defects
Diabetes and Birth Defects
Lucas et al 1989, n=105:Overall malformation rate 13.3%
Lucas et al 1989, n=105:Overall malformation rate 13.3%
HbA1c range Rate of Malformation
>11.2% 25%
9.2-11.1% 23%
7.2-9.1% 14%
<7.2% 0
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Why do Birth Defects Happen?
Why do Birth Defects Happen?
MultifactorialClear direct association with hyperglycemia 3-6 weeks after conception
Teratogenic potential ofInositolProstaglandinsReactive oxygen species
MultifactorialClear direct association with hyperglycemia 3-6 weeks after conception
Teratogenic potential ofInositolProstaglandinsReactive oxygen species
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Why do Birth Defects Happen?
Why do Birth Defects Happen?
Hyperglycemia in embryo increases oxygen radical production -> inhibits prostacyclin -> increased thromboxanes/ prostaglandins -> abnormal vascularization of developing tissueMouse model demonstrates decreased defects if prostaglandin inhibitors or antioxidants given (vitamins C and E)
Hyperglycemia in embryo increases oxygen radical production -> inhibits prostacyclin -> increased thromboxanes/ prostaglandins -> abnormal vascularization of developing tissueMouse model demonstrates decreased defects if prostaglandin inhibitors or antioxidants given (vitamins C and E)
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Preventing Birth Defects
Preventing Birth Defects
Planned pregnancy/ recognize potential for pregnancy
Preconception consultationAchieve glycemic control (more to follow)
Multivitamins or prenatal vitamins
Folic acid supplementation
Planned pregnancy/ recognize potential for pregnancy
Preconception consultationAchieve glycemic control (more to follow)
Multivitamins or prenatal vitamins
Folic acid supplementation
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“I don’t have diabetes.”
“I don’t have diabetes.”
Increasing concerns in group of women with Prediabetes, Impaired Glucose Tolerance
Polycystic Ovarian Syndrome (PCOS)
ObesityWe need your help! Screen and treat!
Increasing concerns in group of women with Prediabetes, Impaired Glucose Tolerance
Polycystic Ovarian Syndrome (PCOS)
ObesityWe need your help! Screen and treat!
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PCOS and Pregnancy Outcome
PCOS and Pregnancy Outcome
Thatcher SS 2006:Retrospective analysis in suburban REI practice, n=237 pregnancies
Pts used metformin +/- clomid, gonadotropins, or ART
Increased GDM and prematurityDid not observe change in rate of malformation
Thatcher SS 2006:Retrospective analysis in suburban REI practice, n=237 pregnancies
Pts used metformin +/- clomid, gonadotropins, or ART
Increased GDM and prematurityDid not observe change in rate of malformation
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Part II: Early Identification of
Gestational Diabetes
Part II: Early Identification of
Gestational Diabetes
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Gestational DiabetesGestational Diabetes
Maternal RisksExcessive weight gain
PreeclampsiaCesarean sectionFuture gestational diabetes
Subsequent type 2 diabetes and heart disease
Maternal RisksExcessive weight gain
PreeclampsiaCesarean sectionFuture gestational diabetes
Subsequent type 2 diabetes and heart disease
Risks to OffspringMacrosomiaBirth traumaHypoglycemiaDelayed lung maturationHypocalcemiaPolycythemiaStillbirthChildhood disease
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Neonatal Morbidity - Delayed Lung Maturation
Neonatal Morbidity - Delayed Lung Maturation
Moore TM et al AJOG 2003Moore TM et al AJOG 2003
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Neonatal Morbidity - Shoulder Dystocia
Neonatal Morbidity - Shoulder Dystocia
Nesbitt TS et al AJOG 1998Nesbitt TS et al AJOG 1998
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Neonatal Morbidity - Birth Trauma
Neonatal Morbidity - Birth Trauma
Brachial plexus injuryFacial nerve injuryFractures of humerus or clavicleCephalohematomaBrain injuryDeath
Brachial plexus injuryFacial nerve injuryFractures of humerus or clavicleCephalohematomaBrain injuryDeath
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Neonatal Morbidity - Birth Trauma
Neonatal Morbidity - Birth Trauma
Athukorala et al: positive relationship between maternal fasting hyperglycemia and incidence of shoulder dystociaRisk doubled with each 1 mmol increase in fasting glucose value on OGTT
Athukorala et al: positive relationship between maternal fasting hyperglycemia and incidence of shoulder dystociaRisk doubled with each 1 mmol increase in fasting glucose value on OGTT
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Screening for GDMScreening for GDM
First step: Early identification of risk factors
Second step: One hour 50 g glucose screen
Third step: Three hour 100 g OGTT for diagnosis
First step: Early identification of risk factors
Second step: One hour 50 g glucose screen
Third step: Three hour 100 g OGTT for diagnosis
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Risk Factors for GDM: Assess at First Prenatal Visit
Risk Factors for GDM: Assess at First Prenatal Visit Overweight before
pregnancy (BMI > 25)
1st degree relative with diabetes
Previous glucose intolerance/ GDM
Previous macrosomia or large for gestational age baby
Overweight before pregnancy (BMI > 25)
1st degree relative with diabetes
Previous glucose intolerance/ GDM
Previous macrosomia or large for gestational age baby
PCOSAge > 25 yrsMembers of certain ethnic groups
Multiparous women (13%)
Left column are HIGH RISK factors
PCOSAge > 25 yrsMembers of certain ethnic groups
Multiparous women (13%)
Left column are HIGH RISK factors
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Universal Screening v. Selective Screening
for GDM
Universal Screening v. Selective Screening
for GDMCosson et al compared universal to selective screeningUniversal group had more favorable fetal outcomes
Williams et al studied following ADA guidelines (not screening low risk)10 to 11% would not have been screenedMissed 4% who would have been diagnosed with GDM
Cosson et al compared universal to selective screeningUniversal group had more favorable fetal outcomes
Williams et al studied following ADA guidelines (not screening low risk)10 to 11% would not have been screenedMissed 4% who would have been diagnosed with GDM
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Screening for GDMScreening for GDM
High risk patient requires screening earlier in pregnancy, before 24-28 weeks, ideally at first prenatal visit
First trimester glucose intolerance triggers suspicious pre-existing overt diabetes (type 1 or type 2) or insulin resistance
High risk patient requires screening earlier in pregnancy, before 24-28 weeks, ideally at first prenatal visit
First trimester glucose intolerance triggers suspicious pre-existing overt diabetes (type 1 or type 2) or insulin resistance*First OB appt*
Risk Factors Assessed
High risk-do 50 g screen Low risk-screen at 24-28 wks
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ADA Position Statement50–G oral glucose tolerance
screen for GDM
ADA Position Statement50–G oral glucose tolerance
screen for GDM
140mg cutoff -- 80% sensitivity
130mg cutoff -- 90% sensitivity
Alternatively, patients with high risk factors
can go directly to diagnostic testing instead of initial
screening
140mg cutoff -- 80% sensitivity
130mg cutoff -- 90% sensitivity
Alternatively, patients with high risk factors
can go directly to diagnostic testing instead of initial
screening
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Screening for GDM50-g oral glucose
challenge
Screening for GDM50-g oral glucose
challenge
Serum glucose cut-off point
Proportion with positive test
Sensitivity for GDM
> 140 mg/dl 14-18% 80%> 130 mg/dl
Recommendations as proposed by Metzger et al
20-25 % 90%
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Diagnosis of GDM Using 3-hour 100 g
OGTT
Diagnosis of GDM Using 3-hour 100 g
OGTT KEEP IN MIND PATIENT MAY BE:
undiagnosed type 2mild abnormal glucose tolerance prior to pregnancy that worsens with gestation
normal glucose tolerance before pregnancy that becomes abnormal with advancing gestation
undiagnosed type 1 (symptoms but no diagnosis)
KEEP IN MIND PATIENT MAY BE:undiagnosed type 2mild abnormal glucose tolerance prior to pregnancy that worsens with gestation
normal glucose tolerance before pregnancy that becomes abnormal with advancing gestation
undiagnosed type 1 (symptoms but no diagnosis)
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ADA and WHO Criteria for the Diagnosis of Gestational Diabetes Mellitus
ADA and WHO Criteria for the Diagnosis of Gestational Diabetes Mellitus
ADA 100-g ADA 75-g WHO 75-g
Fasting (mg/dl) 95 95 126
1-hour (mg/dl) 180 180 ----
2-hour (mg/dl) 155 155 140
3-hour (mg/dl) 140 ---- ----
Two or more values must be met or exceeded for dx of GDM with 100 g OGTT
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Part III: Hyperglycemia, Not
Diabetes, in Pregnancy
Part III: Hyperglycemia, Not
Diabetes, in Pregnancy
Whattoexpect.com
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HAPO Study – PurposeHAPO Study – Purpose
NEJM May 8, 2008Hyperglycemia and Adverse Pregnancy Outcomes
To clarify risks of adverse outcomes associated with degrees of maternal glucose intolerance not meeting criteria for gestational diabetes mellitus
NEJM May 8, 2008Hyperglycemia and Adverse Pregnancy Outcomes
To clarify risks of adverse outcomes associated with degrees of maternal glucose intolerance not meeting criteria for gestational diabetes mellitus
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Background – Pedersen Hypothesis
Background – Pedersen Hypothesis
1952: Maternal hyperglycemia causes fetal hyperglycemia, which leads to exaggerated fetal response to insulin
1952: Maternal hyperglycemia causes fetal hyperglycemia, which leads to exaggerated fetal response to insulin
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HAPO Study Cooperative Research Group
HAPO Study Cooperative Research Group
Cohort studyFifteen centers in nine countries25,505 pregnant women underwent 75 g oral GTT at 24-32 weeks gestation
Patients and providers blinded to results unless unsafe:Fasting >105 mg/ dL2 hour glucose > 200 mg/ dLAny glucose < 45 mg/ dL or > 160 mg/ dL
Cohort studyFifteen centers in nine countries25,505 pregnant women underwent 75 g oral GTT at 24-32 weeks gestation
Patients and providers blinded to results unless unsafe:Fasting >105 mg/ dL2 hour glucose > 200 mg/ dLAny glucose < 45 mg/ dL or > 160 mg/ dL
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HAPO Study – Exclusions
HAPO Study – Exclusions
< 18 y/oDelivering outside of study facilityUnknown dating/ poor datingMultiple gestationConception by IVF or gonadotropin use
Prior dx of GDM or DMPrior glucose testing this pregnancyInfection with HIV, Hep B, Hep C
< 18 y/oDelivering outside of study facilityUnknown dating/ poor datingMultiple gestationConception by IVF or gonadotropin use
Prior dx of GDM or DMPrior glucose testing this pregnancyInfection with HIV, Hep B, Hep C
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HAPO Study – Primary Outcomes
HAPO Study – Primary Outcomes
Birth weight > 90th percentile for gestational age
Primary cesarean deliveryClinical neonatal hypoglycemia
Cord-blood serum C-peptide level above 90th percentile
Birth weight > 90th percentile for gestational age
Primary cesarean deliveryClinical neonatal hypoglycemia
Cord-blood serum C-peptide level above 90th percentile
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HAPO Study – Secondary Outcomes
HAPO Study – Secondary Outcomes
Delivery < 37 weeks gestationShoulder dystocia or birth injury
Need for admission to NICUHyperbilirubinemiaPreeclampsia
Delivery < 37 weeks gestationShoulder dystocia or birth injury
Need for admission to NICUHyperbilirubinemiaPreeclampsia
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HAPO – StatisticsHAPO – Statistics
Continuous variables – mean and standard deviation
Categorial data – number and percentage
Glucose measurements evaluated as both continuous and categorical for primary outcomes
For secondary outcomes, only continuous
Continuous variables – mean and standard deviation
Categorial data – number and percentage
Glucose measurements evaluated as both continuous and categorical for primary outcomes
For secondary outcomes, only continuous
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HAPO – Data Analysis, Categorical
HAPO – Data Analysis, Categorical
Glycemic values categorized into seven levels for fasting, 1- and 2-hour valuesEx] fasting subsets included:
100-104 (105 unblinded) – 99th percentile95-99 – 97th percentile90-9485-8980-8475-79<75
Glycemic values categorized into seven levels for fasting, 1- and 2-hour valuesEx] fasting subsets included:
100-104 (105 unblinded) – 99th percentile95-99 – 97th percentile90-9485-8980-8475-79<75
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HAPO – Data Analysis, Continuous
HAPO – Data Analysis, Continuous
Odds ratios calculated for a 1 standard deviation increaseFasting1-hour2-hour
Logistic regression modelsAdjusted for confounders
BMIAgeSmokingHypertensionFamily history of DM, etc.
Odds ratios calculated for a 1 standard deviation increaseFasting1-hour2-hour
Logistic regression modelsAdjusted for confounders
BMIAgeSmokingHypertensionFamily history of DM, etc.
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Mean values were recorded as fasting 81, 1 hr 134, 2 hr 111
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Summary of HAPO Findings
Summary of HAPO Findings
Associations between increasing fasting, 1-hour, and 2-hour glucose values andBirthweight > 90th percentileCord blood serum C-peptidePrimary cesarean (weaker)Neonatal hypoglycemia (weaker)Premature deliveryShoulder dystocia/ birth injuryNICU admissionHyperbilirubinemiaPreeclampsia
All in patients who are below criteria for GDM
Associations between increasing fasting, 1-hour, and 2-hour glucose values andBirthweight > 90th percentileCord blood serum C-peptidePrimary cesarean (weaker)Neonatal hypoglycemia (weaker)Premature deliveryShoulder dystocia/ birth injuryNICU admissionHyperbilirubinemiaPreeclampsia
All in patients who are below criteria for GDM
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Future StudyFuture StudyInstead of screening for glucose intolerance, screening for hypoglycemia? (Everyone at risk goes on the diet)
Screening and treating for macrosomia? For “diabetogenic pregnancies”?
Establishment of new thresholds for diagnosing gestational diabetes or gestational glucose intolerance? (Ex] One abnormal value on 3 hr GTT? One SD above the mean?)
Stronger evidence that treatment improves (clinically relevant) outcomes?
Instead of screening for glucose intolerance, screening for hypoglycemia? (Everyone at risk goes on the diet)
Screening and treating for macrosomia? For “diabetogenic pregnancies”?
Establishment of new thresholds for diagnosing gestational diabetes or gestational glucose intolerance? (Ex] One abnormal value on 3 hr GTT? One SD above the mean?)
Stronger evidence that treatment improves (clinically relevant) outcomes?
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Will More Treatment Mean Better Outcomes?
Will More Treatment Mean Better Outcomes?
ACHOIS Trial: Evaluated neonatal outcomes in women with gestational diabetesNNT to avoid one adverse outcome: 43
HAPO demonstrated fewer IUGR/ SGA babiesProblems if aggressively treat mild hyperglycemia?
Associations not tested, may not be causally mediated
ACHOIS Trial: Evaluated neonatal outcomes in women with gestational diabetesNNT to avoid one adverse outcome: 43
HAPO demonstrated fewer IUGR/ SGA babiesProblems if aggressively treat mild hyperglycemia?
Associations not tested, may not be causally mediated
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What to do Today: Don’t Forget Postpartum TestingWhat to do Today: Don’t Forget Postpartum TestingAll women with diagnosis of gestational diabetes should be offered screening in the nonpregnant stateFasting glucose2-hour 75 g OGTT
Cohort study demonstrated 58% risk of overt DM within 8 years (previously quoted 15 yrs) Weight loss and lifestyle changes can reduce risk by 50%
All women with diagnosis of gestational diabetes should be offered screening in the nonpregnant stateFasting glucose2-hour 75 g OGTT
Cohort study demonstrated 58% risk of overt DM within 8 years (previously quoted 15 yrs) Weight loss and lifestyle changes can reduce risk by 50%
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SummarySummaryThe optimal time to positively influence pregnancy outcome is before the patient gets pregnantRole of primary care physicians and educators is critical (this means you!)
Gestational diabetes can be identified in the first trimester in a cohort of high risk patients
Small differences in blood glucose translate to significant differences in pregnancy outcomes
The optimal time to positively influence pregnancy outcome is before the patient gets pregnantRole of primary care physicians and educators is critical (this means you!)
Gestational diabetes can be identified in the first trimester in a cohort of high risk patients
Small differences in blood glucose translate to significant differences in pregnancy outcomes