Pregnancy performance and outcomes associated with diabetic nephropathy

The purpose of the current study is to report the effect of diabetic nephropathy on pregnancy outcomes based on a review of the world's literature from 1981 to 1996. In addition, the effects of pregnancy on renal function in a select subpopulation of patients is also presented. The Medline Computer System was used to survey the English language literature on diabetic nephropathy complicating pregnancy between 1981 and 1996, which yielded a total patient population of 315. The database was analyzed according to patient population, clinical management, maternal complications and outcomes, and fetal complications and outcomes. The frequency of chronic hypertension was 42% with 60% of women manifesting hypertension by the third trimester. Pre-eclampsia developed in 41% of patients; proliferative retinopathy was observed in 63% of patients prior to pregnancy, and cesarean section delivery was performed in 74% of the patients. Among the fetal outcomes, intrauterine growth restriction (IUGR) was observed in 15%, preterm delivery in 22%, and major congenital malformations in 8% of the patients included in the database. The observed overall perinatal morality rate was 5%. Gestational age at delivery was significantly correlated with first-trimester Cr/Cl (p < 0.01), third-trimester Cr/Cl (p < 0.05), third trimester proteinuria (p < 0.01), and third-trimester blood pressure (p < 0.001). Birth weight was significantly correlated with first-trimester Cr/Cl (p < 0.01), third-trimester Cr/Cl (p < 0.001), third-trimester proteinuria (p < 0.01), and third-trimester blood pressure (p < 0.001). Of the 185 patients available for long-term follow-up (mean 35 months), 17% developed end-stage renal disease, and 5% died as a result of renal insufficiency. Among the renovascular parameters, proteinuria and mean arterial pressure significantly increased from the first to the third trimester (p < 0.05). When these parameters were evaluated at follow-up, blood pressure did not show a significant increase from first trimester values, however, proteinuria did show a weak, but significant, increase postpartum. These data suggest that with contemporary methods of perinatal care, fetal survival rates of 95% are achievable in diabetic women with nephropathy. Furthermore, although many women experienced a temporary decline in renal function during gestation, pregnancy per se, does not appear to worsen the natural progression to end-stage renal disease for most women with renal insufficiency.