Perinatal Outcomes in Pregnancies Achieved After Fertility Treatments with and without Diet-Controlled GDM

doi:10.21203/rs.3.rs-5027274/v1

Objective:To evaluate the rates of adverse perinatal outcomes among women who conceived after fertility treatments with and without diet-controlled GDM.

Methods: In this retrospective population-based cohort study, all pregnancies of non-diabetic and diet-controlled GDM women who conceived after fertility treatments (in-vitro fertilization - IVF and ovulation induction - OI) and delivered between the years 1996-2016 in a tertiary medical center, were included. Pregnancies of women with pre-gestational diabetes mellitus, and those complicated with gestational diabetes mellitus A2, multiple pregnancies, congenital malformations and those lacking prenatal care, were excluded. Demographical, clinical, and obstetrical characteristics were recorded, and pregnancy complications and adverse perinatal outcomes were compared between the groups. Multivariate logistic regression models were used to control for confounders. Statistical analyses were performed using logistic regression to control for potential confounders. A p-value of < 0.05 was considered statistically significant.

Results: During the study period, 6,254 deliveries met the inclusion criteria, 10.23% of them (n=640) had diet-controlled GDM. Pregnancies with diet-controlled GDM were found to be associated with significantly higher rates of hypertensive disorders of pregnancy (15.6% vs. 9.8%, p<0.001), polyhydramnios (5.9% vs. 2.7%, p<0.001), and cesarean deliveries (40.8% vs. 31.9%, p<0.001). Diet-controlled GDM was also found to be an independent protective factor against perinatal mortality (aOR=0.22, 95%Cl 0.05-0.92, P=0.04) possibly due to the more intensive monitoring and management typically provided to women undergoing fertility treatments. This close care may mitigate some of the risks associated with ART, leading to improved perinatal outcomes.

Conclusion: Among pregnancies achieved after fertility treatments, diet-controlled GDM was associated with reduced perinatal mortality and higher rates of certain pregnancy complications. These findings highlight the importance of close monitoring and careful management of women with diet-controlled GDM, as it may help mitigate risks associated with ART pregnancies. Further research is needed to understand the mechanisms behind these outcomes and to optimize management strategies for this specific population.

Gestational Diabetes Mellitus (Gdm)

Fertility Treatment

Ovulation Induction (Oi)

In Vitro Fertilization (Ivf)

Pregnancy Complications

Birth Defects

Management of subfertility in couples has many different approaches for intervention, depending on the cause of subfertility [1]. Ovulation induction (OI) and Assisted Reproductive Technology (ART) are the common methods of managing infertility[ 2]. In general, pregnancies achieved after ARTare at elevated risk of adverse obstetric outcomes, such as gestational diabetes mellitus (GDM), severe preeclampsia and perinatal mortality [3]. Compared with those conceived through OI, the risk of adverse obstetric outcomes is higher among pregnancies conceived after In-Vitro Fertilization (IVF) [3]. Women who conceive after ART also have a statistically significant risk of placental anomalies [4], gestational hypertension[5] and CD [2,5], preterm deliveries [2,6], low birth weight [2] and small for gestational age [6].

GDM is a form of diabetes first recognized during pregnancy without evidence of pre-existing type 1 or type 2 diabetes [7]. It is classified into two subtypes: diet-controlled GDM and insulin or oral hypoglycemic agents requiring GDM (GDMA2) [8]. GDM affects 5-7% of pregnancies [9] in the USA and is associated with a high risk of adverse perinatal outcomes, including stillbirth, macrosomia, shoulder dystocia and hypoglycemia [9,10]. Maternal morbidity associated with GDM includes preeclampsia, urinary tract infections, and CD [10]. Both mother and infant exposed to GDM are more likely to develop type 2 diabetes later in life [7]. Risk factors associated with GDM include advanced maternal age, ethnicity, overweight or obesity during pregnancy, and GDM in previous pregnancies [10]. Lifestyle modification program composed of dietary counseling, increased physical activity and self-monitoring of blood glucose can effectively control most GDM women, thus reducing the risk of complications [11].

Why This Study is Needed: While ART is known to increase the risk of adverse obstetric outcomes[12], the specific outcomes in women with diet-controlled GDM who conceive via ART remain understudied. Although previous research highlights the elevated risk of GDM following ART-conceived pregnancies [13], data on whether complications associated with diet-controlled GDM are elevated in this population are sparse. For example, studies have demonstrated that IVF and OI treatments independently increase the risk of GDM [3].

However, there is a lack of information whether achieving a pregnancy following fertility treatments increases the risk of adverse perinatal outcomes in patients complicated with GDM. This study aims to fill the gap by evaluating the incidence of adverse pregnancy and delivery outcomes associated with diet-controlled GDM in women who conceived after fertility treatments, specifically in the population of the Negev in Israel. Understanding these outcomes is critical for improving the management and counseling of women undergoing ART, particularly in mitigating perinatal risks in diet-controlled GDM pregnancies.

In this retrospective population-based cohort study, all pregnancies of non-diabetic and diet-controlled GDM women who conceived after fertility treatments (IVF and OI) and delivered between the years 1996-2016 at the Soroka University Medical Center (SUMC), were included. We excluded pregnancies with preterm deliveries to focus on full-term pregnancies, as preterm birth introduces a wide range of confounding factors, including neonatal morbidity and distinct perinatal care protocols, which could influence the outcomes. This approach allows for a more homogeneous study population and strengthens the internal validity of our findings.Other exclusion criteria included pregnancies complicated with pre-gestational diabetes mellitus, gestational diabetes mellitus A2 (GDMA2),multiple pregnancies, pregnancies with known intrauterine fetal anomalies (structural and chromosomal)and those lacking prenatal care.

SUMC is the only tertiary medical center and the largest birth center in the region serving a population of over 1,000,000 people in the Negev the Southern region of Israel. SUMC has over1100 beds. Thus, the study represents non-selective population-based data.

The institutional ethics committee approved the study (SUMC IRB Committee #0458-20-SOR, 18 October 2020). Since the study was retrospective, informed consent was not required. The study group included all pregnancies of women who conceived after fertility treatments and met the inclusion criteria. A comparison was performed between women with diet-controlled GDM to non-diabetic women. Demographical, clinical, and obstetrical characteristics were recorded, and pregnancy complications and adverse perinatal outcomes were compared between the groups.

Data were collected from the computerized perinatal database and the SUMC computerized charts of the obstetrics and gynecology department. To minimize potential selection bias, the perinatal database was routinely updated by attending obstetricians immediately following delivery. Medical secretaries cross-checked and reviewed the data to ensure accuracy before entering it into the database. Additionally, missing or incomplete records were cross-referenced with prenatal care records and routine hospital documentation to ensure the completeness and reliability of the data, particularly given the long study period (1996-2016).

Statistical analysis

The initial analysis was performed by using descriptive statistics, followed by advanced analytical statistics using various parametric tests. Background characteristics and outcomes were compared across study and control groups using t-test or Mann–Whitney U tests, based on variable type and distribution, or the chi square or Fisher Exact test. Odds ratios (ORs) and their 95% confidence intervals (CIs) were computed. Multivariate regression models were used to control for confounders such as maternal age, parity, previous cesarean delivery, neonatal weight, and induction of labor, as these are known factors influencing perinatal outcomes. We chose these specific variables based on their clinical relevance and their significant effects observed in the univariate analysis. We also tested for interactions between key variables to ensure that no significant interactions were missed that could influence the outcomes. A p-value of < 0.05 was considered statistically significant. Statistical analysis was performed using the SPSS 23.0 (SPSS, Chicago, IL).

During the study period, 6,254 deliveries met the inclusion criteria, 10.23% of them (n=640) had diet-controlled GDM. Baseline and delivery characteristics of the study population are presented in Table 1. Most of the variables were not different between the groups, however, mothers in the study group were significantly older as compared to controls (33.34±5.70 vs. 31.10±5.60 years, p < 0.001).

Pregnancy complications as well as delivery and neonatal outcomes are summarized in Table 2 and Table 3, respectively. Mean gestational age at delivery was slightly higher among women in the study group as compared to controls (38.19±1.75 vs. 38.38±2.31 weeks, p=0.01). Women in the study group exhibited higher rates of perinatal complications, including hypertensive disorders of pregnancy, polyhydramnios and labor induction. Women in the study group also demonstrated significantly higher rates of CD (40.8% vs. 31.9%, p<0.001). However, significantly lower rates of instrumental births and decreased rates of perinatal mortality were demonstrated among women in the study group (0.3% vs. 1.2%, p=0.04).

Women with diet-controlled GDM were more likely to have PPH (Postpartum Hemorrhage) but the difference was not statistically significant. No differences were observed regarding rates of LGA (Large for Gestational Age), shoulder dystocia, episiotomy, placental abruption and Low Apgar scores (of less than 7) at 1 and 5 minutes between the groups.

In a multivariate analysis diet-controlled GDM was independently associated with lower rates of perinatal mortality after controlling for maternal age and hypertensive disorders (aOR=0.22, 95%Cl 0.05-0.92, P=0.04) Table 4a.

An additional multivariate analysis, presented in Table 4b, demonstrated that diet-controlled GDM was independently associated with greater rates of CD after controlling for possible confounders including nulliparity, neonatal weight, maternal age, previous CD and induction of labor. (aOR=1.24, 95%Cl 1.02-1.50, P=0.03)

In this large retrospective cohort study, we aimed to investigate whether diet-controlled GDM among pregnancies achieved after fertility treatments carries a substantial risk for maternal obstetrical complications and adverse perinatal outcomes. Diet-controlled GDM pregnancies conceived after fertility treatments were found to be associated with higher rates of pregnancy and delivery complications, including hypertensive disorders of pregnancy, polyhydramnios, labor induction and CD. However, diet-controlled GDM does not appear to increase the rates of complications that are specifically associated with GDM such as shoulder dystocia and LGA. While our findings suggest associations between diet-controlled GDM and certain perinatal outcomes, we acknowledge the limitations of observational data. The results should not be directly translated into broad clinical recommendations without further validation through randomized controlled trials. These findings primarily serve as a basis for future research to investigate the mechanisms and outcomes in more detail.

Our study also found a significantly lower gestational age at birth and higher rates of labor induction in the diet-controlled GDM group. These findings may reflect the closer monitoring and active management strategies commonly applied in diet-controlled GDM pregnancies, where early interventions, including induction of labor, are sometimes preferred to avoid potential complications. However, this practice may also increase the risk of preterm birth. Future studies are needed to explore whether these early interventions offer significant benefits over a more conservative approach, particularly in well diet-controlled GDM pregnancies.

Several studies have investigated the association between subfertility and pregnancy/perinatal complications. While in the general population the incidence of GDM is around 5-7% of pregnancies [9], Zhai et. Al [14] found that pregnancies conceived by ART were associated with a significantly increased rates of GDM (OR 1.88, 95% CI 1.56–2.27). They compared the incidence of pregnancy complications in relation to different types of ART, including IVF and intracytoplasmic sperm injection (ICSI). They have found that women who conceived following IVF were more likely to develop GDM (8.2% vs. 4.6%, p<0.01) compared with pregnancies that were conceived spontaneously. Furthermore, women who underwent ICSI showed a higher incidence of GDM (8.6% vs. 4.6%, p<0.0) than the control group.

Likewise, Holst et al. [15] found that women with fertility problems had a 41% higher statistically significant increase in the risk of GDM (OR 1.41, 95% CI 1.33-1.50) [15]. Our results demonstrated that 10.23% of women who conceived after fertility treatments had diet-controlled GDM. These findings emphasize that women who conceive following fertility treatments should be strongly advised to have close medical supervision for the early detection of GDM in order to ensure optimal diabetes control and favorable pregnancy and delivery outcomes.

Several studies have investigated the association between GDM and preeclampsia and CD [16-17]. However, those studies compared between women with and without fertility treatment regarding GDM. Cosson et al. [16] showed that GDM among women conceived after fertility treatments was associated with higher rates of preeclampsia and CD than those with GDM who conceived without fertility treatments. Recently, a retrospective cohort study of Ganer Herman et al. [17] also reported that in singleton deliveries with a diagnosis of GDM among IVF pregnancies, a significant higher incidence of preeclampsia was demonstrated in the IVF group (17.3%) compared to the non-IVF group. This data is consistent with our findings showing higher rates of preeclampsia among the diet-controlled GDM group, reaching a rate of 10.8% in women following both OI and IVF treatments.

However, in the same study by Ganer Herman et al. [17] no difference was noted in the rate of CD between the study groups, while in our study there was a higher rate of CD in the diet-controlled GDM group. The CD rates in our study (40.8% in the study group vs. 31.9% in the control group) were lower than those reported in similar studies (e.g., Ganer Herman et al. reported CD rates exceeding 70%) [17]. This difference may be attributed to variations in clinical management practices. In Israel, where our study was conducted, guidelines for the management of GDM pregnancies may be more conservative, with a higher threshold for recommending CD, especially in diet-controlled GDM cases where diabetes is well-controlled. Additionally, regional practices regarding labor management and physician decision-making may differ from other countries where more liberal use of CD is observed. For example, our institution tends to prioritize vaginal delivery unless there are clear indications for CD, which could account for the lower rates in our study population. Nevertheless, in the current study and in the study of Ganer Herman et al. [17], no differences in placental abruption, birth weight, or low Apgar score were detected between the groups. Furthermore, no differences in the need for blood transfusion, episiotomy and shoulder dystocia have been noticed between groups in our study.

Although previous studies considered GDM as a major public health problem associated with increased perinatal morbidity and mortality [18-19], recent studies demonstrated that there is no elevated risk for perinatal mortality among pregnancies with diet-controlled GDM [20-21]. However, time of GDM presentation may have influence on perinatal outcomes. A systematic review and meta-analysis of 13 cohort studies compared clinical characteristics and pregnancy outcomes of early diagnosed and treated GDM women (< 24 weeks of gestation) with women who were diagnosed and treated late in pregnancy (24–28 weeks of gestation). The review has shown that early-onset GDM women had a significantly higher likelihood of perinatal mortality (RR 3.58 [1.91, 6.71]) [22].

As far as we know, no previous research investigated the perinatal mortality rate in diet-controlled GDM women who conceived after fertility treatment. Interestingly, our study found that diet-controlled GDM pregnancies were associated with lower perinatal mortality compared to the control group (0.3% vs. 1.2%, p=0.04), which persisted even after controlling for potentially relevant clinical confounders. This finding may be explained by the intensive monitoring and close management typically provided to women undergoing ART. Women with diet-controlled GDM who conceived via ART are likely to receive more frequent prenatal visits, tighter glucose control, and early intervention when complications arise, which could result in better outcomes. Furthermore, the nature of diet-controlled GDM may inherently pose a lower risk compared to GDMA2, where insulin is required. In this context, the comprehensive care provided to these women may mitigate the risks typically associated with ART, leading to improved perinatal outcomes. In our study, diet-controlled GDM pregnancies demonstrated a lower risk of perinatal mortality, likely due to the intensive monitoring and management that women undergoing fertility treatments typically receive. This includes more frequent prenatal visits, closer glucose monitoring, and early interventions when complications arise. However, it is essential to consider that over-intervention, such as increased rates of labor induction, may not always lead to better outcomes. Further investigation is required to determine the optimal balance between monitoring and intervention in diet-controlled GDM pregnancies, ensuring that care is both proactive and judicious. Another potential explanation is that women undergoing ART may have heightened awareness and motivation to adhere to medical advice and lifestyle changes, given the difficulty they faced in achieving pregnancy. This increased engagement with healthcare professionals could play a role in reducing complications, including perinatal mortality.

In this study, we used multivariate regression models to control for known confounders, including maternal age, parity, hypertensive disorders, previous cesarean deliveries, and neonatal birth weight. However, we recognize that the relatively small sample size may limit the ability to fully exclude the influence of confounding factors. While our findings are robust within the scope of the data analyzed, further research with larger sample sizes is necessary to confirm these results and better understand potential interactions between these confounders.

In recent decades, the rising rate of CD has been a major source of concern worldwide. CD can reduce maternal/neonatal mortality, but high rate of CD may be associated with an increased risk of severe maternal outcomes such as, Intensive Care Unit admission, blood transfusion, hysterectomy and even maternal mortality [23]. Previous studies reported an increased CD rate among GDM women compared with that of euglycemic women, especially with non-elective indications [24-26]. Higher CD rates may be due to macrosomia or changes in the obstetrical management due to the knowledge that the mother has GDM [24-25]. Several characteristics have been identified as risk factors for CD in women with GDM, including advanced maternal age, nulliparity, obesity and insulin use[27]. In addition, induction of labor is known to be associated with an increased risk of CD[26]. According to our findings, diet-controlled GDM women had greater rates of CD (aOR=1.24, 95%Cl 1.02-1.50, P=0.03), which persisted after controlling for potentially confounders including nulliparity, neonatal weight, maternal age, previous CD and induction of labor. Our hypothesis is that the presence of GDM in pregnant women, especially those who conceived after fertility treatments, may influence obstetrical practice and reduce the threshold for surgical delivery. Thus, patterns of physician decision making contributed to the higher rated of CDs among our study population. Further assessment of the mode of delivery is needed to determine the optimal obstetrical care for this specific patient population.

Our study has several limitations. At first, its retrospective design allows us only to establish proof of association, but not causation. In addition, while we took steps to ensure the completeness and accuracy of the data, the reliance on a single-center study over a long study period (1996–2016) may introduce potential biases, including regional-specific practices and changes in clinical management over time. The data were collected retrospectively, and although we implemented thorough cross-checking and review processes, there remains the possibility of missing or incomplete data that could affect our findings.

Additionally, since our study was conducted at a single tertiary medical center, the findings may not be generalizable to other populations, particularly those outside of Israel or in different healthcare settings. Multi-center studies would provide a broader perspective and help verify whether the associations observed in our study are consistent across diverse populations.

Another limitation is the long duration of years that were included in the database. Possible changes in diagnosis and treatment may have occurred during a follow-up period of 20 years. This may include changes in diet-controlled GDM screening and diagnosis and changes in treatments and blood glucose targets. However, since we focused only on the subcategory of diet-controlled GDM and there has been no change in its classification as diet-only controlled GDM over the years, it is less probable that patients were misclassified.

Our study has several notable strengths. Our results are based on a computerized database, which included a large cohort of patients, from a single tertiary medical center, thereby decreasing the likelihood of incorrect outcome data. Moreover, our dataset combines maternal and neonatal data, thus enabling us to control for many pregnancy and delivery variables.

In conclusion, While our findings highlight the increased risk of CD, hypertensive disorders, and polyhydramnios in diet-controlled GDM pregnancies achieved via fertility treatments, they also suggest that with appropriate monitoring, perinatal mortality can be minimized. Clinicians should consider more intensive glucose monitoring and earlier interventions for hypertensive disorders in this population. However, our results also indicate that with well diet-controlled GDM, the risk of perinatal mortality can be reduced, suggesting that overly aggressive interventions may not always be necessary. Targeted prenatal care protocols that focus on early detection of hypertensive disorders, vigilant fetal monitoring, and optimizing maternal glucose control could improve outcomes. Clinicians should remain vigilant but avoid unnecessary cesarean deliveries unless medically indicated, as the risk of adverse perinatal outcomes like perinatal mortality appears lower in well diet-controlled GDM pregnancies. Further studies are needed to determine whether the threshold for recommending cesarean delivery in diet-controlled GDM pregnancies should be adjusted, particularly in ART-conceived pregnancies.

Statements and Declarations:

The authors report no conflict of financial or non-financial interests to disclose. Baraah Abu Karen wrote the first draft of the manuscript. No honorarium, grant, funds or other form of payment was given to anyone to produce the manuscript. This is a database study and as such has no clinical trial registration number.

Author contributions:

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Reut Rotem, Yael Baumfeld and Baraah Abu Karen. The first draft of the manuscript was written by Baraah Abu Karen and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Ethics approval:

This study was performed in line with the principles of the Declaration of Helsinki (SUMC IRB Committee #0458-20-SOR, 18 October 2020).

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Table 1 – Baseline and delivery characteristics of pregnant women who conceived following fertility treatments with and without Diet-controlled GDM.

Variables		Study Group (Diet-Controlled GDM) N=640	Control Group (Non-GDM) n=5614	P-value
Patients characteristics
Maternal Age (year, mean ±SD)		33.34±5.70	31.10±5.60	< 0.001
Ethnicity	Jewish n (%)	540 (84.4)	4478 (79.8)
Ethnicity	Bedouin n (%)	100 (15.6)	1136 (20.2)	0.01
Nulliparous n(%)		369 (57.7)	3052 (54.4)	0.11
Gravidity (mean ±SD)		2.33±1.69	2.22±1.55	0.10
Parity (mean +-SD)		1.63±0.90	1.70±1.00	0.10
Sp CS (Previous cesarean delivery)		90 (14.1)	763 (13.6)	0.74
Fertility tx type	IVF	386 (60.3)	3371 (60.0)
Fertility tx type	OI	254 (39.7)	2243 (40.0)	0.90
Smoking		2 (0.3)	26 (0.5)	1.00

*S/P – status post *CS- caesarean section *tx- treatment.

Table 2 – Pregnancy complications of pregnant women who conceived following fertility treatments with and without Diet-Controlled GDM.

Variables		Study Group (Diet-Controlled GDM) N=640	Control Group (Non-GDM) n=5614	P-value
Pregnancy complications
HTN	All (Including all types of hypertension: chronic hypertension, gestational hypertension and pre-eclampsia)	100 (15.6)	550 (9.8)	< 0.001
PET	All	69 (10.8)	425 (7.6)	0.01
	Eclampsia	0 (0.0)	0 (0.0)
	Mild	52 (8.1)	309 (5.5)	0.01
	Severe	17 (2.7)	116 (2.1)	0.33
Polyhydramnios n(%)		38 (5.9)	153 (2.7)	< 0.001
Labor Induction		275 (43.0)	2026 (36.1)	0.001
Placental Abruption n(%)		6 (0.9)	49 (0.9)	0.87
Previa	Placenta	13 (2.0)	77 (1.4)	0.18
Previa	Vasa	1 (0.2)	10 (0.2)	1.00
Preterm	<37 weeks, n (%)	76 (11.9)	654 (11.7)	0.87
Preterm	<34 weeks, n (%)	15 (2.3)	175 (3.1)	0.28

*HTN- hypertension *PET- pre-eclampsia.

Table 3 – Delivery and neonatal outcomes of pregnant women who conceived following fertility treatments with and without Diet-Controlled GDM.

Variables		Study Group (Diet-Controlled GDM) N=640	Control Group (Non-GDM) n=5614	P-value
Delivery and Neonatal outcomes
Gestational age (weeks+days, mean ±SD)		38.19±1.75	38.38±2.31	0.01
Mode of delivery	Spontaneous vaginal delivery n(%)	359 (56.1)	3574 (63.7)	< 0.001
	Vaccum extraction n(%)	20 (3.1)	250 (4.5)	< 0.001
	Caesarean deliveries (CD) n(%)	261 (40.8)	1790 (31.9)	< 0.001
PPH		9 (1.4)	41 (0.7)	0.07
Shoulder dystocia n(%)		0 (0.0)	7 (0.1)	1.00
Episiotomy % (n)		125 (19.5)	1097 (19.5)	1.00
Low APGAR 1 minute (<7) % (n)		42 (6.6)	346 (6.2)	0.71
Low APGAR 5 minutes (<7) % (n)		6 (0.9)	43 (0.8)	0.65
Birth weight (kg, mean ±SD)		3101.75±513.80	3063.49±573.01	0.11
AGA		581 (90.8)	5074 (90.4)	0.70
LGA		27 (4.2)	218 (3.9)	0.96
SGA		32 (5.0)	322 (5.7)
Perinatal mortality	All	2 (0.3)	68 (1.2)	0.04
	APD	2 (0.3)	38 (0.7)	0.43
	IPD	0 (0.0)	5 (0.1)	1.00
	PPD	0 (0.0)	26 (0.5)	0.10
Gender	Male n(%)	325 (50.8)	2764 (49.2)
Gender	Female n(%)	315 (49.2)	2850 (50.8)	0.46

*PPH- postpartum hemorrhage *AGA\ LGA\ SGA- appropriate/ large/ small for gestational age *APD\IPD\PPD – antepartum\intrapartum\postpartum death.

Table 4a - Multivariate analysis for the prediction of perinatal mortality associated with Diet-Controlled GDM among pregnancies achieved after fertility treatments.

Variables	OR	95% CI	P value
Age	1.03	0.99-1.07	0.15
HTN	2.23	1.23-4.03	0.01
Diet-Controlled GDM	0.22	0.05-0.92	0.04

*Controlled for maternal age and HTN.

*HTN- hypertension.

Table 4b - Multivariate analysis for the prediction of cesarean delivery associated with Diet-Controlled GDM among pregnancies achieved after fertility treatments.

Variables	OR	95% CI	P value
Nulliparity	4.27	3.65-5.00	< 0.001
Neonatal weight	1.00	1.00-1.00	< 0.001
Maternal age	1.13	1.12-1.14	< 0.001
Sp CS (Previous cesarean delivery)	14.00	11.42-17.17	< 0.001
Induction	0.52	0.45-0.59	< 0.001
Diet-Controlled GDM	1.24	1.02-1,50	0.03

*Controlled for nulliparity, neonatal weight, maternal age, Sp CS and induction.

Perinatal Outcomes in Pregnancies Achieved After Fertility Treatments with and without Diet-Controlled GDM

Status:

Journal Publication

Version 1

Abstract

Introduction

Materials And Methods

Results

Discussion

Declarations

References

Tables

Status:

Journal Publication

Version 1