Screening for Gestational Diabetes: US Preventive Services Task Force Recommendation Statement

A retrospective study to investigate the risk factors for gestational diabetes mellitus and its impact on maternal and neonatal outcomes

BACKGROUND

Currently, risk factors for gestational diabetes mellitus (GDM) and its impact on maternal and neonatal outcomes have not been fully elucidated. Therefore, we performed a retrospective epidemiologic study to explore the above research objectives.

METHODS

We collected extensive clinical data from January 2020 to June 2023 for 855 maternity cases at the Department of Obstetrics and Gynecology, Chaoyang Hospital, Capital Medical University. Vitamin D deficiency, undergoing assisted reproductive techniques, advanced maternal age (≥35), multiparas, abortion history, pre-pregnancy body mass index (≥25.0), twin pregnancy, polycystic ovary syndrome (PCOS), family history of diabetes, history of delivering a low-birth-weight infant, and weight gain during gestation of >2 kg per month (mean) as variables that may affect GDM to investigate the risk factors for GDM. In addition, a total of 15 adverse postpartum outcomes (including maternal complications and neonatal complications) were used to explore the adverse effects of maternal comorbidity with GDM. Variables that were significant in the univariate logistic regression model were included in the multivariate logistic regression model. Receiver operating characteristic (ROC) curves were conducted for the ability to predict the risk of the GDM and its impact on maternal and neonatal outcomes, using variables derived from the multivariate logistic regression models.

RESULTS

The results of multivariate logistic regression analyses shown that only multipara was not a risk factor for the development of GDM. Postpartum hemorrhage (blood loss ≥500 ml) and the neonatal Apgar score (≤9) (all P > 0.05) was excluded in the multivariate logistic regression model. According to the results of multivariate logistic regression analyses, the incidence of hypothyroid complications, hyperlipidemic complications, postpartum anemia, gestational hypertension, racket placenta, premature rupture of membranes, fetal malposition, macrosomia (≥4000 g), low-birth-weight infants (<2500 g), prematurity, neonatal infections, neonatal jaundice, and fetal distress was higher in pregnancies with combined GDM (all P < 0.05). The model demonstrated excellent diagnostic performance, with an area under the ROC curve of 0.91, indicating its efficacy in predicting adverse prognostic outcomes associated with maternal GDM.

CONCLUSIONS

It is essential for women of childbearing age to correct vitamin D deficiency as well as to maintain their body mass index within the normal range before preparing for pregnancy. Maternal weight gain needs to be managed appropriately throughout pregnancy, which may reduce the risk of GDM to some extent. Therefore, our results suggest that effective measures to reduce the risk of GDM are essential for both the mother and the newborn.

Glucose variability as a key mediator in the relationship between pre-pregnancy overweight/obesity and late-onset hypertensive disorders of pregnancy

To evaluate the role of high glucose variability (High-GV) in early pregnancy as a potential mediating factor between pre-pregnancy overweight/obesity and late-onset HDP (LoHDP), where effective preventive strategies remain limited. This multicenter retrospective study analyzed data from 802 pregnancies across 14 facilities. Pregnancies with a 75 g-OGTT performed by 20 weeks of gestation were included. Structural equation modeling (SEM) was used to evaluate direct and indirect effects of body mass index (BMI), High-GV, and covariates (e.g., age, ART, primiparity) on LoHDP. Overweight/obese women had significantly higher rates of High-GV (26.1 vs. 16.4%, p = 0.001) and LoHDP (17.6 vs. 7.9%, p < 0.001) compared to non-overweight/obese women. SEM revealed that BMI influenced LoHDP through both direct and indirect pathways. BMI had a direct effect on LoHDP (β = 0.20, p < 0.01), and an indirect effect mediated by High-GV, with BMI significantly associated with High-GV (β = 0.15, p < 0.01), and High-GV positively associated with LoHDP (β = 0.12, p < 0.01). In Non-GDM pregnancies, High-GV showed an even stronger association with LoHDP (β = 0.25, p < 0.001). This study identifies High-GV as a key mediator linking pre-pregnancy overweight/obesity to LoHDP. These findings suggest that targeting glucose variability in early pregnancy could mitigate LoHDP risk, particularly in overweight/obese women, regardless of GDM status. Future preventive strategies should integrate multifaceted approaches addressing maternal BMI and glucose regulation to improve maternal and neonatal outcomes.

Detection and treatment of early gestational diabetes mellitus: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To estimate the impact of detection and treatment of early gestational diabetes mellitus on short-term maternal, fetal, and neonatal outcomes. We defined 2 maternal (gestational diabetes prevalence and cesarean section) and 2 neonatal (preterm birth and macrosomia) primary outcomes. We also defined 5 maternal and 12 fetal-neonatal secondary outcomes.

DATA SOURCES

Ovid Medline, Cochrane CENTRAL, and Embase since inception. The search was updated in November 2024.

STUDY ELIGIBILITY CRITERIA

Inclusion criteria: randomized controlled trials addressing detection and treatment of early gestational diabetes (diagnosed before 20 completed weeks).

EXCLUSION CRITERIA

pregestational diabetes or overt diabetes in pregnancy.

STUDY APPRAISAL AND SYNTHESIS METHODS

The Cochrane Handbook was used to guide data extraction and interpretation including risk of bias assessment (Risk of Bias 2 tool). Aggregation and comparison of results were performed with Revman 5.4.1. Pooled relative risk and mean differences were calculated with 95% confidence intervals using random-effects models. The quality of the evidence for primary outcomes was summarized using Grading of Recommendations Assessment, Development and Evaluation criteria.

RESULTS

We identified 1221 unique references. Seven articles addressing early gestational diabetes met the eligibility criteria with a total of 30,791 participants. These studies used 2 strategies: (1) treatment vs usual care of women with a diagnosis of early gestational diabetes and (2) population-based approaches, either performing screening (vs not) or using different cutoffs for diagnosis. In studies comparing treatment vs usual care, differences were observed only in secondary outcomes: more drug treatment, less maternal weight gain, lower birthweight, and less respiratory distress. In studies comparing different population-based strategies, primary outcomes differed for a higher rate of early and overall gestational diabetes (relative risk, 5.50; 95% confidence interval, 3.56-8.48 and 1.83; 95% confidence interval, 1.41-2.38, respectively) and a lower rate of primary cesarean section (relative risk, 0.88; 95% confidence interval, 0.84-0.93); as to secondary outcomes, differences were observed in terms of higher total pregnancy-induced hypertension and preeclampsia. The quality of evidence for most outcomes was low/very low.

CONCLUSION

Detection and treatment of early gestational diabetes mellitus do not offer indisputable benefits either in treated women or at the population level. More studies are required to elucidate this issue.

Gestational Diabetes and Risk of Stroke Among US Black Women

BACKGROUND

There is a paucity of evidence on whether gestational diabetes (GDM) is a risk factor for cerebral vascular disease for Black women and lack of data on incident stroke as end point.

METHODS

We conducted a large prospective cohort study of Black women across the United States and assessed the association between self-reported history of GDM and incident stroke. The study began when participants became parous or enrolled in 1995. We followed up 41 143 parous Black women who were free of cerebral vascular disease or cancer and followed up until incident stroke, death, or the end of 2021. Our exposure was self-reported history of GDM, and outcome was incident stroke. Multivariable Cox proportional hazards model was used to estimate hazard ratios (HRs) and 95% CIs, adjusting for major known risk factors for stroke.

RESULTS

A total of 1495 incident stroke cases were identified among 41 143 Black women from 1995 until 2021 (881 505 person-years of follow-up). Black women with a history of GDM had a consistent 1.4-fold increased risk of stroke compared with those with a healthy pregnancy (age-adjusted HR, 1.44 [95% CI, 1.14-1.82]; multivariable HR, 1.41 [95% CI, 1.11-1.79]). Compared with healthy parous women with neither GDM nor type 2 diabetes, women with a history of both had a 2.6-fold increased stroke risk (multivariable HR, 2.59 [95% CI, 1.88-3.57]); women with only type 2 diabetes have 2-fold increased stroke risk (multivariable HR, 2.04 [95% CI, 1.79-2.32]); women with a history of GDM but no progression to type 2 diabetes do not have an increased risk of stroke (multivariable HR, 1.22 [95% CI, 0.86-1.73]).

CONCLUSIONS

In this large prospective study of Black women, a vulnerable population at high risk for stroke, a history of GDM increased stroke incidence by 41%. There was no elevated risk of stroke for Black women with a history of GDM and no progression to type 2 diabetes, while the stroke risk increased by 2.6-fold for Black women with GDM and progression to type 2 diabetes. Our results highlight the importance of consideration of history of GDM for stroke early prevention, especially Black women with progression to T2DM after GDM.

Neighbourhood Deprivation and Gestational Diabetes Mellitus in Arizona From the AzPEARS Study

BACKGROUND

The maternal population residing in rural areas, tribal lands or near the United States-Mexico border are at high risk for adverse pregnancy complications, notably gestational diabetes mellitus (GDM). Few studies have considered the socioeconomic status (SES) attributes of neighbourhoods on maternal health during gestation. Given that the national and global rate of GDM is rising, this analysis moves beyond individual-level factors and investigates the role of neighbourhood deprivation on GDM risk.

OBJECTIVE

To investigate the relationship between neighbourhood deprivation and risk of GDM using Arizona state birth records.

METHODS

This population-based study of singleton live births (N = 481,113) utilised birth certificates from 2014 to 2020 from the AzPEARS study. Using American Community Survey (5-year data) linked to 2010 US Census tracts, a composite neighbourhood deprivation index (NDI) score (continuous and quartiles) was derived from 8 socioeconomic indicators. Risk ratios (RR) and 95% confidence intervals (95% CI) were used to examine the association between NDI and GDM risk, adjusting for maternal age, maternal education, race/ethnicity, parity, rurality, and birth year.

RESULTS

The state-wide incidence of GDM was 7.8% (n = 37,636) with variation by neighbourhoods (4% to 12%). GDM risk was highest for Native Americans (17.6%), Asian/Pacific Islanders (13.7%) and Hispanic/Latinas (8.3%). Compared to mothers living in areas with the lowest quartile of NDI, mothers living in neighbourhoods with the highest deprivation had an adjusted risk ratio of 1.21 for developing GDM (95% CI 1.18, 1.26).

CONCLUSIONS

We observed that neighbourhood deprivation was positively associated with a higher risk of GDM for each increase in quartile. These results suggest that NDI, a proxy for neighbourhood socioeconomic status, may contribute to GDM risk. Identifying high-risk neighbourhoods for place-based interventions targeting the most vulnerable birthing populations may be an effective strategy in the prevention of GDM.

Guidelines for antenatal and preoperative care in cesarean delivery: Enhanced Recovery After Surgery Society recommendations (part 1)-2025 update

BACKGROUND

Enhanced recovery after cesarean delivery protocols include evidence-based interventions designed to improve patient experience, pregnancy, and neonatal outcomes while reducing healthcare-related costs. This is the first update of the Enhanced Recovery After Surgery Society guidelines for antenatal and preoperative care before cesarean delivery after the original publication in 2018.

METHODS

Interventions were selected based on expert consensus using the Delphi method. An updated literature search was conducted in September 2024 using the Embase, PubMed, MEDLINE, EBSCO CINAHL (Cumulative Index of Nursing and Allied Health Literature), Scopus, and Web of Science databases. Targeted searches were performed by a medical librarian to identify relevant articles published since the 2018 Enhanced Recovery After Surgery Society guidelines publication, which evaluated each antenatal and preoperative enhanced recovery after cesarean delivery intervention, focusing on randomized clinical trials and large observational studies (≥800 patients) to maximize search feasibility and relevance. Following a review of the evidence, a consensus was reached regarding the quality of evidence and the strength of recommendation for each proposed intervention according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system.

RESULTS

The 6 recommended enhanced recovery after cesarean delivery interventions are (1) antenatal pathway patient education for scheduled caesarean delivery (evidence low to very low, recommendation strong); (2) multidisciplinary medical and surgical staff education regarding enhanced recovery after cesarean delivery support, intervention implementation, and measurement (evidence low, recommendation strong); (3) optimization of the medical care for pregnant patients with comorbid conditions, such as anemia, obesity, hypertension, prepregnancy and gestational diabetes, smoking (tobacco, cannabis, vaping), congenital heart disease, epilepsy, autoimmune disease, and asthma (evidence moderate, recommendation strong); (4) abdominal skin preparation with chlorhexidine gluconate impregnated cloth (evening before scheduled cesarean delivery) (evidence moderate; recommendation weak); (5) the duration of preoperative fasting based on the content intake (evidence low, recommendation weak); (6) the use of a preoperative, nonparticulate carbohydrate drink (evidence low-moderate, recommendation strong).

CONCLUSION

The first 3 recommendations are for use in the antenatal period (10-38 weeks of gestation), which allow for the optimization of patient comorbidities, whereas the remaining 3 recommendations are for preoperative interventions (skin preparation, preoperative fasting directives, and preoperative carbohydrate supplementation). Educational tools for cesarean delivery with well-designed shared decision-making focus on comorbidity management should be developed. These management tasks are viewed as routine care; however, the measurable success and impact have clinical variance. The enhanced recovery after cesarean delivery goal for patients who are undergoing a scheduled caesarean delivery is to maximize the quality of the pregnant patient's recovery and the fetal-neonatal outcome.

Timing of eating and glycemic control during pregnancy: A systematic review

AIMS

Glycemic dysregulation during pregnancy is common and increases risk of adverse birth outcomes and future chronic disease. Timing of eating is known to influence glycemic control but has not been thoroughly examined in the context of pregnancy. We systematically reviewed the literature assessing timing of eating and glycemic outcomes during pregnancy.

DATA SYNTHESIS

PubMed, CINAHL, EMBASE, and Web of Science were searched for studies published before March 2024. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and registered the review with PROSPERO (CRD42024574992). Eligible studies were interventional or observational and collected quantitative data on the association of timing of eating with glycemic outcomes in pregnant persons with or without gestational diabetes mellitus (GDM). 1804 articles were evaluated for inclusion, of which 14 articles met criteria (from 5 interventional and 8 observational studies).

CONCLUSIONS

Timing of eating was associated with glycemic outcomes independent of GDM status; later timing and a shorter overnight fasting duration were associated with poorer glycemic control. Timing considerations may be a valuable addition to recommendations for glycemia management during pregnancy.

Diabetes and pregnancy: A call for terminology standardization in clinical practice

Currently, there is no unified consensus on the terminology used to describe diabetes in the context of pregnancy, leading to confusion among clinicians and challenges in research. This review article proposes a set of terms to classify diabetes during pregnancy based on timing and diagnostic criteria, whether before or during pregnancy. A review of previous documents addressing terminology and classification was conducted, identifying four main terms: (1) pregestational diabetes mellitus, referring to diabetes diagnosed before pregnancy; (2) early gestational diabetes mellitus, diagnosed before 24 weeks of gestation; (3) late gestational diabetes mellitus, diagnosed at or after 24 weeks of gestation; and (4) diabetes in pregnancy, diagnosed at any gestational age. This proposal does not include an analysis of hyperglycemia's pathophysiological mechanisms or specific diagnostic criteria. The proposed classification could serve as a foundation for a global initiative to establish a consensus on terminology for diabetes in pregnancy. A universally accepted terminology would reduce clinical confusion, provide a framework for defining diagnostic criteria, facilitate research on maternal and fetal complications, and support studies exploring the postpartum progression of diabetes.

Identification and validation of palmitoylation-related biomarkers in gestational diabetes mellitus

Palmitoylation plays a crucial role in the pathophysiology of diabetes, and an increase in palmitoylation may inhibit the function of insulin receptors, thereby affecting the progression of gestational diabetes mellitus (GDM). However, its involvement in gestational diabetes mellitus (GDM) remains underexplored. This study analyzed GDM-related datasets and 30 palmitoylation-related genes (PRGs), identifying MNDA, FCGR3B, and AQP9 as significantly upregulated biomarkers in GDM samples. Consistent with the dataset analysis, reverse transcription-polymerase chain reaction (RT-qPCR) confirmed elevated AQP9 expression. Comprehensive analyses, including nomogram construction, enrichment analysis, immune infiltration assessment, molecular regulatory network generation, drug prediction, and molecular docking, were conducted. The biomarker-based nomogram demonstrated excellent predictive performance for GDM risk. MNDA, FCGR3B, and AQP9 were significantly enriched in pathways such as "Myc-targets-v1" and "TNFA signaling via NFkB." Additionally, eosinophil infiltration showed a strong positive correlation with these biomarkers. Regulatory networks involving SH3BP5-AS1-hsa-miR-182-5p-AQP9 and hsa-miR-182-5p-AQP9-ELF5 were identified, and stable binding energies were observed between the biomarkers and corresponding drugs. These findings provide promising avenues for early GDM screening and diagnosis.

Efficacy and safety of pharmacological treatments for gestational diabetes: a systematic review comparing metformin with glibenclamide and insulin

AIM

Gestational diabetes, characterized by impaired glucose tolerance occurring or diagnosed during pregnancy, is a significant public health concern. When lifestyle and dietary measures fail (30 % of women), insulin is the standard treatment. Oral antidiabetic agents, such as metformin (Glucophage) and glibenclamide, could provide a promising alternative. The aim here was to evaluate the effectiveness and safety of these treatments in gestational diabetes.

METHODS

This study is based on a systematic literature review. A keyword search for "metformin (Glucophage)," "glibenclamide," "pregnancy," and "gestational diabetes" was conducted in the PubMed and Google Scholar databases from 2013 to 2023.

RESULTS

A total of 45 studies were selected and analyzed. metformin (Glucophage) appears to offer a combination of effectiveness in glycemic control and maternal and neonatal safety. Compared to insulin, it reduces maternal weight gain, lowers maternal hypoglycemia rates, and shows a tendency to reduce gestational hypertension and preeclampsia. Additionally, infants born to mothers on metformin (Glucophage) are less likely to be macrosomic, experience fewer neonatal hypoglycemic episodes, and require fewer admissions to intensive care units. On the other hand, glibenclamide seems effective in glycemic control but is associated with higher rates of macrosomia and neonatal hypoglycemia.

CONCLUSION

Metformin (Glucophage) appears to be a promising alternative to insulin for treating gestational diabetes, while uncertainties remain regarding the safety of glibenclamide.

The Role of Ultra-Rapid-Acting Insulin Analogs in Diabetes: An Expert Consensus

Ultra-rapid-acting insulin analogs (URAA) are a further development and refinement of rapid-acting insulin analogs. Because of their adapted formulation, URAA provide an even faster pharmacokinetics and thus an accelerated onset of insulin action than conventional rapid-acting insulin analogs, allowing for a more physiologic delivery of exogenously applied insulin. Clinical trials have confirmed the superiority of URAA in controlling postprandial glucose excursions, with a safety profile that is comparable to the rapid-acting insulins. Consequently, many individuals with diabetes mellitus may benefit from URAA in terms of prandial glycemic control. Unfortunately, there are only few available recommendations from authoritative sources for use of URAA in clinical practice. Therefore, this expert consensus report aims to define populations of people with diabetes mellitus for whom URAA may be beneficial and to provide health care professionals with concrete, practical recommendations on how best to use URAA in this context.

Oral Glucose-Lowering Agents vs Insulin for Gestational Diabetes: A Randomized Clinical Trial

Importance

Metformin and glyburide monotherapy are used as alternatives to insulin in managing gestational diabetes. Whether a sequential strategy of these oral agents results in noninferior perinatal outcomes compared with insulin alone is unknown.

Objective

To test whether a treatment strategy of oral glucose-lowering agents is noninferior to insulin for prevention of large-for-gestational-age infants.

Design, Setting, and Participants

Randomized, open-label noninferiority trial conducted at 25 Dutch centers from June 2016 to November 2022 with follow-up completed in May 2023. The study enrolled 820 individuals with gestational diabetes and singleton pregnancies between 16 and 34 weeks of gestation who had insufficient glycemic control after 2 weeks of dietary changes (defined as fasting glucose >95 mg/dL [>5.3 mmol/L], 1-hour postprandial glucose >140 mg/dL [>7.8 mmol/L], or 2-hour postprandial glucose >120 mg/dL [>6.7 mmol/L], measured by capillary glucose self-testing).

Interventions

Participants were randomly assigned to receive metformin (initiated at a dose of 500 mg once daily and increased every 3 days to 1000 mg twice daily or highest level tolerated; n = 409) or insulin (prescribed according to local practice; n = 411). Glyburide was added to metformin, and then insulin substituted for glyburide, if needed, to achieve glucose targets.

Main Outcomes and Measures

The primary outcome was the between-group difference in the percentage of infants born large for gestational age (birth weight >90th percentile based on gestational age and sex). Secondary outcomes included maternal hypoglycemia, cesarean delivery, pregnancy-induced hypertension, preeclampsia, maternal weight gain, preterm delivery, birth injury, neonatal hypoglycemia, neonatal hyperbilirubinemia, and neonatal intensive care unit admission.

Results

Among 820 participants, the mean age was 33.2 (SD, 4.7) years). In participants randomized to oral agents, 79% (n = 320) maintained glycemic control without insulin. With oral agents, 23.9% of infants (n = 97) were large for gestational age vs 19.9% (n = 79) with insulin (absolute risk difference, 4.0%; 95% CI, -1.7% to 9.8%; P = .09 for noninferiority), with the confidence interval of the risk difference exceeding the absolute noninferiority margin of 8%. Maternal hypoglycemia was reported in 20.9% with oral glucose-lowering agents and 10.9% with insulin (absolute risk difference, 10.0%; 95% CI, 3.7%-21.2%). All other secondary outcomes did not differ between groups.

Conclusions and Relevance

Treatment of gestational diabetes with metformin and additional glyburide, if needed, did not meet criteria for noninferiority compared with insulin with respect to the proportion of infants born large for gestational age.

Trial Registration

Netherlands Trial Registry Identifier: NTR6134.

Challenging the American College of Obstetricians and Gynecologists' Clinical Practice Update on Screening for Pre-existing Diabetes and Early Gestational Diabetes

A recent American College of Obstetricians and Gynecologists Clinical Practice Update continues to recommend targeted (as opposed to universal) screening for pregestational diabetes, no longer recommends screening for early gestational diabetes mellitus (GDM), and provides updated guidelines for immediate postpartum testing for diabetes in patients with GDM. Here, we present data that the targeted screening paradigm, which has repeatedly been shown to fail in practice because of its complexity, no longer makes sense in the context of the high and rising prevalence of diabetes and diabetic risk factors, and we argue that the time has come for universal early pregnancy screening for pregestational diabetes. Furthermore, the recommendation against early screening for GDM is based on 2021 U.S. Preventive Services Task Force guidance, which in turn is based almost entirely on a single underpowered study that excluded individuals at highest risk and does not account for more recent research showing benefits of early diagnosis and treatment. Universal early pregnancy screening for pregestational diabetes may also help to identify patients at risk who will benefit from early GDM diagnosis and treatment and may provide rationale for prioritizing postpartum diabetes testing.

Early-life menstrual characteristics and gestational diabetes in a large US cohort

BACKGROUND

Associations between early-life menstrual cycle characteristics (MCC) and gestational diabetes (GDM) remain unclear.

OBJECTIVES

To evaluate associations between early-life MCCs and GDM in first pregnancy, across pregnancies and its recurrence.

METHODS

This analysis included participants from a US-based digital cohort enrolled between 11/2019 and 9/2023 who provided consent, completed relevant surveys, were without diabetes and aged ≥18 at first pregnancy (n = 30,473). Age at menarche [<11 (early), 11-15 (referent), ≥16 (late) years] and time from menarche to cycle regularity [<1 (referent), 1-2, 3-4, ≥5 years, not yet regular, regular after hormones] were self-recalled at enrolment. Additionally, the last three categories were considered prolonged time-to-regularity (PTTR). GDM history was recalled at enrolment for each pregnancy. We restricted to pregnancies of ≥24 weeks with a live birth. We evaluated associations of early-life MCCs with GDM at first pregnancy using modified Poisson regression, across pregnancies using cluster-weighted Poisson generalised estimating equation and GDM recurrence using multinomial logistic regression, adjusted for sociodemographic, early-life factors and age at pregnancy. Missing variables were imputed with multiple imputation by chained equations.

RESULTS

Among 30,473 participants, 20,591 had eligible first pregnancies, of which 5.9% reported GDM. In 17,512 participants with ≥2 pregnancies, 8.3% had GDM once and 3.7% had recurrent GDM. Early menarche (<11 years, vs. 11-15 years) was associated with GDM in first pregnancy (RR 1.34, 95% CI 1.15, 1.57), across pregnancies (RR 1.24, 95% CI 1.10, 1.39) and recurrence (OR 1.51, 95% CI 1.21, 1.89). PTTR was associated with GDM in the first pregnancy (RR 1.22, 95% CI 1.08, 1.38), across pregnancies (RR 1.16, 95% CI 1.05, 1.27) and recurrence (OR 1.19, 95% CI 0.99, 1.43).

CONCLUSIONS

Earlier menarche and prolonged time-to-regularity are associated with higher risk of GDM and recurrence, suggesting menstrual characteristics during childhood/adolescence as potential early-life markers for GDM.

[Preventive activities in women: PAPPS 2024 update]

In the 2024 PAPPS update, we present preventive activities specific to women's health, except those related to cancer prevention (which are included in another document) and aspects related to differential morbidity of gender, which is a cross-cutting element for all working groups. Contraception is an essential preventive activity; the right to decide both the number of children that they will have and when to have them is considered basic. We must inform about contraceptive methods, guaranteeing in follow-up their safety, efficacy, and effectiveness (tables are included on changing from one method to another to preserve contraceptive protection). We must inform about emergency contraception and propose it in in the event of unprotected intercourse. We will use opportunistic screening to do this, without needing to screen for thrombophilia or dyslipidaemia, but we will screen for hypertension. Pregnancy is a major life experience and general practitioners should not ignore it. We should be competent at both preconception consultation (recommend folic acid intake, avoiding exposure to occupational and environmental hazards, screen for certain pathologies, and assess the intake of medication not indicated during pregnancy) and during follow-up of pregnancy. Whether or not we follow-up the pregnancy, we should not fail to monitor it, taking advantage of this period to promote healthy lifestyles and manage potential intercurrent events. Menopause in general and osteoporosis in particular exemplify the strategy of medicalising life events that has been followed by different bodies and organisations. In our update we address the prevention and treatment of symptoms secondary to oestrogen deprivation. We also propose osteoporosis prevention, including bone density scanning according to the fracture risk in the next 10 years, therefore, bone density screening is not recommended in women under 60 years of age. We recommend the FRAX tool for assessing risk, or better, measuring hip fracture risk with prevalence data from the Community of Madrid. The indication for treatment is linked to the Z-score (bone mineral density compared with women of the same age), since this is a condition associated with aging, and not the T-score, which is used to compare women of 20 years of age.

The role of blood testing in prevention, diagnosis, and management of chronic diseases: A review

Blood tests are vital to prevention, diagnosis, and management of chronic diseases. Despite this, it can be challenging to construct a comprehensive view of the clinical importance of blood testing because relevant literature is typically fragmented across different disease areas and patient populations. This lack of collated evidence can also make it difficult for primary care providers to adhere to best practices for blood testing across different diseases and guidelines. Thus, this review article synthesizes the recommendations for, and importance of, blood testing across several common chronic conditions encountered in primary care and internal medicine, including cardiovascular diseases, diabetes mellitus, chronic kidney disease, vitamin D deficiency, iron deficiency, and rheumatoid arthritis. Future research is needed to continue improving chronic disease management through clearer dissemination and awareness of clinical guidelines among providers, and better access to blood testing for patients (e.g., via pre-visit laboratory testing).

The role of first-trimester systemic immune-inflammation index for the prediction of gestational diabetes mellitus

OBJECTIVE

The aim of this study was to investigate the role of systemic immune-inflammation index, neutrophil-lymphocyte ratio, lymphocyte-monocyte ratio, and platelet-lymphocyte ratios calculated in the first trimester as inflammatory markers in predicting gestational diabetes mellitus diagnosis.

METHODS

This study was conducted retrospectively at a tertiary center between January 2020 and June 2023. A total of 111 pregnant women with gestational diabetes and 378 pregnant women in the control group were included in the study. Systemic immune-inflammation index, neutrophil-lymphocyte ratio, lymphocyte-monocyte ratio, and platelet-lymphocyte ratios values were compared between the gestational diabetes mellitus group patients and the healthy group. Receiver operating characteristic analysis curve was used for predicting gestational diabetes mellitus using systemic immune-inflammation index and lymphocyte-monocyte ratio.

RESULTS

In pregnant women in the first trimester, systemic immune-inflammation index and lymphocyte-monocyte ratio values based on routine complete blood count parameters were found to be statistically significantly higher in gestational diabetes mellitus patients compared to healthy patients, while neutrophil-lymphocyte ratio and platelet-lymphocyte ratios values were found to be similar (p=0.033, p=0.005, p=0.211, and p=0.989). For predicting gestational diabetes mellitus, a cut-off value of 655.75 for systemic immune-inflammation index resulted in 80.2% sensitivity and 34.4% specificity, and a cut-off value of 3.62 for lymphocyte-monocyte ratio resulted in 56.8% sensitivity and 63.2% specificity, indicating good discriminatory ability.

CONCLUSION

We believe that systemic immune-inflammation index and lymphocyte-monocyte ratio values measured in the first-trimester complete blood count parameters are effective in predicting gestational diabetes mellitus but are not effective in determining insulin requirement.

Can System Inflammation Response Index or Systemic Immune Inflammation Index predict gestational diabetes mellitus in the first trimester? A prospective observational study

OBJECTIVE

To evaluate System Inflammation Response Index (SIRI) and Systemic Immune Inflammation Index (SII), which are the inflammatory indices, for the prediction of gestational diabetes mellitus (GDM) in the first trimester.

METHODS

This was a prospective observational study conducted in a tertiary center from April 2023 to September 2023. Ninety-four pregnant women with gestational diabetes and 107 healthy pregnant women were included. The two groups were compared according to first-trimester SIRI and SII values. A receiver operating characteristic (ROC) curve analysis was performed to determine the optimal cut-off levels of SII and SIRI in predicting GDM.

RESULTS

Significantly higher first-trimester SII and SIRI values were present in the gestational diabetes group (P < 0.001). Optimal cut-off values in the prediction of gestational diabetes were found to be 1.58 (area under the curve [AUC] 0.71, 67% sensitivity, 65% specificity, 95% confidence interval [CI] 0.64-0.78, P < 0.001) and 875 (AUC 0.70, 66% sensitivity, 65% specificity, 95% CI 0.63-0.77, P < 0.001) for SIRI and SII, respectively. Neutrophil counts, mean platelet volume (MPW), neutrophil to lymphocyte ratio (NLR), and red cell distribution width (RDW) were significantly higher in the GDM group (P < 0.001, P = 0.02, P = 0.01, P < 0.01, respectively).

CONCLUSION

Novel inflammatory indices SII and SIRI may be useful in the prediction of GDM in the first trimester, but their utility in the prediction of insulin requirement is questionable. They may be used as additional tools in routine clinical practice.

Epidemiology and management of gestational diabetes

Gestational diabetes is defined as hyperglycaemia first detected during pregnancy at glucose concentrations that are less than those of overt diabetes. Around 14% of pregnancies globally are affected by gestational diabetes; its prevalence varies with differences in risk factors and approaches to screening and diagnosis; and it is increasing in parallel with obesity and type 2 diabetes. Gestational diabetes direct costs are US$1·6 billion in the USA alone, largely due to complications including hypertensive disorders, preterm delivery, and neonatal metabolic and respiratory consequences. Between 30% and 70% of gestational diabetes is diagnosed in early pregnancy (ie, early gestational diabetes defined by hyperglycaemia before 20 weeks of gestation). Early gestational diabetes is associated with worse pregnancy outcomes compared with women diagnosed with late gestational diabetes (hyperglycaemia from 24 weeks to 28 weeks of gestation). Randomised controlled trials show benefits of treating gestational diabetes from 24 weeks to 28 weeks of gestation. The WHO 2013 recommendations for diagnosing gestational diabetes (one-step 75 gm 2-h oral glucose tolerance test at 24-28 weeks of gestation) are largely based on the Hyperglycemia and Adverse Pregnancy Outcomes Study, which confirmed the linear association between pregnancy complications and late-pregnancy maternal glycaemia: a phenomenon that has now also been shown in early pregnancy. Recently, the Treatment of Booking Gestational Diabetes Mellitus (TOBOGM) trial showed benefit in diagnosis and treatment of early gestational diabetes for women with risk factors. Given the diabesity epidemic, evidence for gestational diabetes heterogeneity by timing and subtype, and advances in technology, a life course precision medicine approach is urgently needed, using evidence-based prevention, diagnostic, and treatment strategies.

Changing diagnostic criteria for gestational diabetes (CDC4G) in Sweden: A stepped wedge cluster randomised trial

BACKGROUND

The World Health Organisation (WHO) 2013 diagnostic criteria for gestational diabetes mellitus (GDM) has been criticised due to the limited evidence of benefits on pregnancy outcomes in different populations when switching from previously higher glycemic thresholds to the lower WHO-2013 diagnostic criteria. The aim of this study was to determine whether the switch from previous Swedish (SWE-GDM) to the WHO-2013 GDM criteria in Sweden following risk factor-based screening improves pregnancy outcomes.

METHODS AND FINDINGS

A stepped wedge cluster randomised trial was performed between January 1 and December 31, 2018 in 11 clusters (17 delivery units) across Sweden, including all pregnancies under care and excluding preexisting diabetes, gastric bypass surgery, or multifetal pregnancies from the analysis. After implementation of uniform clinical and laboratory guidelines, a number of clusters were randomised to intervention (switch to WHO-2013 GDM criteria) each month from February to November 2018. The primary outcome was large for gestational age (LGA, defined as birth weight >90th percentile). Other secondary and prespecified outcomes included maternal and neonatal birth complications. Primary analysis was by modified intention to treat (mITT), excluding 3 clusters that were randomised before study start but were unable to implement the intervention. Prespecified subgroup analysis was undertaken among those discordant for the definition of GDM. Multilevel mixed regression models were used to compare outcome LGA between WHO-2013 and SWE-GDM groups adjusted for clusters, time periods, and potential confounders. Multiple imputation was used for missing potential confounding variables. In the mITT analysis, 47 080 pregnancies were included with 6 882 (14.6%) oral glucose tolerance tests (OGTTs) performed. The GDM prevalence increased from 595/22 797 (2.6%) to 1 591/24 283 (6.6%) after the intervention. In the mITT population, the switch was associated with no change in primary outcome LGA (2 790/24 209 (11.5%) versus 2 584/22 707 (11.4%)) producing an adjusted risk ratio (aRR) of 0.97 (95% confidence interval 0.91 to 1.02, p = 0.26). In the subgroup, the prevalence of LGA was 273/956 (28.8%) before and 278/1 239 (22.5%) after the switch, aRR 0.87 (95% CI 0.75 to 1.01, p = 0.076). No serious events were reported. Potential limitations of this trial are mainly due to the trial design, including failure to adhere to guidelines within and between the clusters and influences of unidentified temporal variations.

CONCLUSIONS

In this study, implementing the WHO-2013 criteria in Sweden with risk factor-based screening did not significantly reduce LGA prevalence defined as birth weight >90th percentile, in the total population, or in the subgroup discordant for the definition of GDM. Future studies are needed to evaluate the effects of treating different glucose thresholds during pregnancy in different populations, with different screening strategies and clinical management guidelines, to optimise women's and children's health in the short and long term.

TRIAL REGISTRATION

The trial is registered with ISRCTN (41918550).

Nanomaterial-related hemoglobin-based oxygen carriers, with emphasis on liposome and nano-capsules, for biomedical applications: current status and future perspectives

Oxygen is necessary for life and plays a key pivotal in maintaining normal physiological functions and treat of diseases. Hemoglobin-based oxygen carriers (HBOCs) have been studied and developed as a replacement for red blood cells (RBCs) in oxygen transport due to their similar oxygen-carrying capacities. However, applications of HBOCs are hindered by vasoactivity, oxidative toxicity, and a relatively short circulatory half-life. With advancements in nanotechnology, Hb encapsulation, absorption, bioconjugation, entrapment, and attachment to nanomaterials have been used to prepare nanomaterial-related HBOCs to address these challenges and pend their application in several biomedical and therapeutic contexts. This review focuses on the progress of this class of nanomaterial-related HBOCs in the fields of hemorrhagic shock, ischemic stroke, cancer, and wound healing, and speculates on future research directions. The advancements in nanomaterial-related HBOCs are expected to lead significant breakthroughs in blood substitutes, enabling their widespread use in the treatment of clinical diseases.

Prediction model of preeclampsia using machine learning based methods: a population based cohort study in China

Introduction

Preeclampsia is a disease with an unknown pathogenesis and is one of the leading causes of maternal and perinatal morbidity. At present, early identification of high-risk groups for preeclampsia and timely intervention with aspirin is an effective preventive method against preeclampsia. This study aims to develop a robust and effective preeclampsia prediction model with good performance by machine learning algorithms based on maternal characteristics, biophysical and biochemical markers at 11-13 + 6 weeks' gestation, providing an effective tool for early screening and prediction of preeclampsia.

Methods

This study included 5116 singleton pregnant women who underwent PE screening and fetal aneuploidy from a prospective cohort longitudinal study in China. Maternal characteristics (such as maternal age, height, pre-pregnancy weight), past medical history, mean arterial pressure, uterine artery pulsatility index, pregnancy-associated plasma protein A, and placental growth factor were collected as the covariates for the preeclampsia prediction model. Five classification algorithms including Logistic Regression, Extra Trees Classifier, Voting Classifier, Gaussian Process Classifier and Stacking Classifier were applied for the prediction model development. Five-fold cross-validation with an 8:2 train-test split was applied for model validation.

Results

We ultimately included 49 cases of preterm preeclampsia and 161 cases of term preeclampsia from the 4644 pregnant women data in the final analysis. Compared with other prediction algorithms, the AUC and detection rate at 10% FPR of the Voting Classifier algorithm showed better performance in the prediction of preterm preeclampsia (AUC=0.884, DR at 10%FPR=0.625) under all covariates included. However, its performance was similar to that of other model algorithms in all PE and term PE prediction. In the prediction of all preeclampsia, the contribution of PLGF was higher than PAPP-A (11.9% VS 8.7%), while the situation was opposite in the prediction of preterm preeclampsia (7.2% VS 16.5%). The performance for preeclampsia or preterm preeclampsia using machine learning algorithms was similar to that achieved by the fetal medicine foundation competing risk model under the same predictive factors (AUCs of 0.797 and 0.856 for PE and preterm PE, respectively).

Conclusions

Our models provide an accessible tool for large-scale population screening and prediction of preeclampsia, which helps reduce the disease burden and improve maternal and fetal outcomes.

Design, rationale and protocol for Glycemic Observation and Metabolic Outcomes in Mothers and Offspring (GO MOMs): an observational cohort study

INTRODUCTION

Given the increasing prevalence of both obesity and pre-diabetes in pregnant adults, there is growing interest in identifying hyperglycaemia in early pregnancy to optimise maternal and perinatal outcomes. Multiple organisations recommend first-trimester diabetes screening for individuals with risk factors; however, the benefits and drawbacks of detecting glucose abnormalities more mild than overt diabetes in early gestation and the best screening method to detect such abnormalities remain unclear.

METHODS AND ANALYSIS

The goal of the Glycemic Observation and Metabolic Outcomes in Mothers and Offspring study (GO MOMs) is to evaluate how early pregnancy glycaemia, measured using continuous glucose monitoring and oral glucose tolerance testing, relates to the diagnosis of gestational diabetes (GDM) at 24-28 weeks' gestation (maternal primary outcome) and large-for-gestational-age birth weight (newborn primary outcome). Secondary objectives include relating early pregnancy glycaemia to other adverse pregnancy outcomes and comprehensively detailing longitudinal changes in glucose over the course of pregnancy. GO MOMs enrolment began in April 2021 and will continue for 3.5 years with a target sample size of 2150 participants.

ETHICS AND DISSEMINATION

GO MOMs is centrally overseen by Vanderbilt University's Institutional Review Board and an Observational Study Monitoring Board appointed by National Institute of Diabetes and Digestive and Kidney Diseases. GO MOMs has potential to yield data that will improve understanding of hyperglycaemia in pregnancy, elucidate better approaches for early pregnancy GDM screening, and inform future clinical trials of early GDM treatment.

TRIAL REGISTRATION NUMBER

NCT04860336.

Development and validation of a Non-INvaSive Pregnancy RIsk ScoRE (INSPIRE) for the screening of high-risk pregnant women for gestational diabetes mellitus in Pakistan

Introduction

The prevalence of gestational diabetes mellitus (GDM) is on the rise in low-income and middle-income countries, such as Pakistan. Therefore, the development of a risk score that is simple, affordable and easy to administer is needed. Our study aimed to develop a Non-INvaSive Pregnancy RIsk ScoRE (INSPIRE) for GDM screening in Pakistani pregnant women based on risk factors reported in the literature.

Methods

Using a cross-sectional study design, we enrolled 500 pregnant women who attended antenatal clinics at one tertiary and two secondary care hospitals in Karachi between the 28th and 32nd weeks of gestation. We randomly divided data into derivation (n=404; 80%) and validation datasets (n=96; 20%). We conducted interviews to collect information on sociodemographic factors and family history of diabetes, measured mid-upper arm circumference (MUAC) and reviewed the medical records of women for obstetric history and oral glucose tolerance test (OGTT) results. We performed a multivariable logistic regression analysis to obtain coefficients of selected predictors for GDM in the derivation dataset. Calibration was estimated using Pearson's χ2 goodness of fit test while discrimination was checked using the area under the curve (AUC) in the validation dataset.

Results

Overall, the GDM prevalence was 26% (n=130). INSPIRE was based on six predictors: maternal age, MUAC, family history of diabetes, a history of GDM, previous bad obstetrical outcome and a history of macrosomia. INSPIRE achieved a good calibration (Pearson's χ2=29.55, p=0.08) and acceptable discrimination with an AUC of 0.721 (95% CI 0.61 to 0.83) with a sensitivity of 74.1% and specificity of 59.4% in the validation dataset.

Conclusion

We developed and validated an INSPIRE that efficiently differentiates Pakistani pregnant women at high risk of GDM from those at low risk, thus reducing the unnecessary burden of the OGTT test.

Cost-effectiveness of diagnosis and treatment of early gestational diabetes mellitus: economic evaluation of the TOBOGM study, an international multicenter randomized controlled trial

Background

A recently undertaken multicenter randomized controlled trial (RCT) "Treatment Of BOoking Gestational diabetes Mellitus" (TOBOGM: 2017-2022) found that the diagnosis and treatment of pregnant women with early gestational diabetes mellitus (GDM) improved pregnancy outcomes. Based on data from the trial, this study aimed to assess the cost-effectiveness of diagnosis and treatment of early GDM (from <20 weeks') among women with risk factors for hyperglycemia in pregnancy compared with usual care (no treatment until 24-28 weeks') from a healthcare perspective.

Methods

Participants' healthcare resource utilization data were collected from their self-reported questionnaires and hospital records, and valued using the unit costs obtained from standard Australian national sources. Costs were reported in US dollars ($) using the purchasing power parity (PPP) estimates to facilitate comparison of costs across countries. Intention-to-treat (ITT) principle was followed. Missing cost data were replaced using multiple imputations. Bootstrapping method was used to estimate the uncertainty around mean cost difference and cost-effectiveness results. Bootstrapped cost-effect pairs were used to plot the cost-effectiveness (CE) plane and cost-effectiveness acceptability curve (CEAC).

Findings

Diagnosis and treatment of early GDM was more effective and tended to be less costly, i.e., dominant (cost-saving) [-5.6% composite adverse pregnancy outcome (95% CI: -10.1%, -1.2%), -$1373 (95% CI: -$3,749, $642)] compared with usual care. Our findings were confirmed by both the CE plane (88% of the bootstrapped cost-effect pairs fall in the south-west quadrant), and CEAC (the probability of the intervention being cost-effective ranged from 84% at a willingness-to-pay (WTP) threshold value of $10,000-99% at a WTP threshold value of $100,000 per composite adverse pregnancy outcome prevented). Sub-group analyses demonstrated that diagnosis and treatment of early GDM among women in the higher glycemic range (fasting blood glucose 95-109 mg/dl [5.3-6.0 mmol/L], 1-h blood glucose ≥191 mg/dl [10.6 mmol/L] and/or 2-h blood glucose 162-199 mg/dl [9.0-11.0 mmol/L]) was more effective and less costly (dominant) [-7.8% composite adverse pregnancy outcome (95% CI: -14.6%, -0.9%), -$2795 (95% CI: -$6,638, -$533)]; the intervention was more effective and tended to be less costly [-8.9% composite adverse pregnancy outcome (95% CI: -15.1%, -2.6%), -$5548 (95% CI: -$16,740, $1547)] among women diagnosed before 14 weeks' gestation as well.

Interpretation

Our findings highlight the potential health and economic benefits from the diagnosis and treatment of early GDM among women with risk factors for hyperglycemia in pregnancy and supports its implementation. Long-term follow-up studies are recommended as a key future area of research to assess the potential long-term health benefits and economic consequences of the intervention.

Funding

National Health and Medical Research Council (grants 1104231 and 2009326), Region O¨rebro Research Committee (grants Dnr OLL-970566 and OLL-942177), Medical Scientific Fund of the Mayor of Vienna (project 15,205 and project 23,026), South Western Sydney Local Health District Academic Unit (grant 2016), and Western Sydney University Ainsworth Trust Grant (2019).

Predictors and Trends in First-Trimester Hemoglobin A1c Screening in New York City, 2009 to 2017

Glycated hemoglobin is an adjunct tool in early pregnancy to assess glycemic control. We examined trends and maternal predictors for those who had A1c screening in early pregnancy using hospital discharge and vital registry data between 2009 and 2017 linked with the New York City A1C Registry (N = 798,312). First-trimester A1c screening increased from 2.3% in 2009 to 7.7% in 2017. The likelihood of screening became less targeted to high-risk patients over time, with a decrease in mean A1c values from 5.8% (95% confidence interval [CI]: 5.8, 5.9) to 5.3 (95% CI: 5.3, 5.4). The prevalence of gestational diabetes mellitus increased while testing became less discriminate for those with high-risk factors, including pregestational type 2 diabetes, chronic hypertension, obesity, age over 40 years, as well as Asian or Black non-Hispanic race/ethnicity. KEY POINTS: · First-trimester A1c screening increased from 2.3% in 2009 to 7.7% in 2017 in New York City.. · The likelihood of screening became less targeted to high-risk patients over time.. · The prevalence of gestational diabetes mellitus increased, while testing became less discriminate..

Value of Non-Coding RNA Expression in Biofluids to Identify Patients at Low Risk of Pathologies Associated with Pregnancy

Pregnancy-related complications (PRC) impact maternal and fetal morbidity and mortality and place a huge burden on healthcare systems. Thus, effective diagnostic screening strategies are crucial. Currently, national and international guidelines define patients at low risk of PRC exclusively based on their history, thus excluding the possibility of identifying patients with de novo risk (patients without a history of disease), which represents most women. In this setting, previous studies have underlined the potential contribution of non-coding RNAs (ncRNAs) to detect patients at risk of PRC. However, placenta biopsies or cord blood samples are required, which are not simple procedures. Our review explores the potential of ncRNAs in biofluids (fluids that are excreted, secreted, or developed because of a physiological or pathological process) as biomarkers for identifying patients with low-risk pregnancies. Beyond the regulatory roles of ncRNAs in placental development and vascular remodeling, we investigated their specific expressions in biofluids to determine favorable pregnancy outcomes as well as the most frequent pathologies of pregnant women. We report distinct ncRNA panels associated with PRC based on omics technologies and subsequently define patients at low risk. We present a comprehensive analysis of ncRNA expression in biofluids, including those using next-generation sequencing, shedding light on their predictive value in clinical practice. In conclusion, this paper underscores the emerging significance of ncRNAs in biofluids as promising biomarkers for risk stratification in PRC. The investigation of ncRNA expression patterns and their potential clinical applications is of diagnostic, prognostic, and theragnostic value and paves the way for innovative approaches to improve prenatal care and maternal and fetal outcomes.

Efficacy and safety of metformin during pregnancy: an update

During the last decades, gestational diabetes mellitus (GDM) prevalence has been on the rise. While insulin remains the gold standard treatment for GDM, metformin use during pregnancy is controversial. This review aimed to comprehensively assess the available data on the efficacy and safety of metformin during pregnancy, both for the mother and the offspring. Metformin has been validated for maternal efficacy and safety, achieving comparable glycemic control with insulin. Additionally, it reduces maternal weight gain and possibly the occurrence of hypertensive disorders. During the early neonatal period, metformin administration does not increase the risk of congenital anomalies or other major adverse effects, including lower APGAR score at 5 min, neonatal intensive care unit admissions, and respiratory distress syndrome. Several studies have demonstrated a reduction in neonatal hypoglycemia. Metformin has been associated with an increase in preterm births and lower birth weight, although this effect is controversial and depends on the indication for which it was administered. Evidence indicates possible altered fetal programming and predisposition to childhood obesity and metabolic syndrome during adulthood after use of metformin in pregnancy. With critical questions still requiring a final verdict, ongoing research on the field must be conducted.

Gestational diabetes: One size does not fit all-an observational study of maternal and neonatal outcomes by maternal glucose profile

OBJECTIVES

To examine obstetrical and neonatal outcomes across maternal glucose profiles at the population level and to explore insulin sensitivity and beta-cell function across profiles in an independent, well-phenotyped cohort for potential pathophysiologic explanation.

RESEARCH DESIGN AND METHODS

Observational cohort study of all pregnancies with gestational diabetes screening between October 2008 and December 2018 resulting in live singleton birth in Alberta, Canada (n = 436,773) were categorized into seven maternal glucose profiles: (1) normal 50 g-glucose challenge test (nGCT), (2) normal 75-g OGTT (nOGTT), (3) isolated elevated 1 h post-load glucose (ePLPG1), (4) isolated elevated 2 h post-load glucose (ePLPG2), (5) elevated 1 and 2 h post-load glucose (ePLPG12), (6) isolated elevated FPG (eFPG), and (7) elevated FPG + elevated 1-h and/or 2-h PLG (Combined). Primary outcomes were large for gestational age (LGA) and neonatal intensive care unit (NICU) admission rates. An independent observational cohort of 1451 women was examined for measures of beta-cell function (ISSI-2, insulinogenic index/HOMA-IR) and insulin sensitivity/resistance (Matsuda index, HOMA-IR) by similar maternal glucose profiles.

RESULTS

Pregnancies with elevated FPG, either isolated or combined, had higher adverse events and lower insulin sensitivity. The combination of elevated FPG + elevated 1-h and/or 2-h PLG had the highest rates of LGA(20.9%), NICU admissions (14.7%), and lowest insulin sensitivity as measured by Matsuda index and HOMA-IR, and beta-cell function as measured by ISSI-2 and Insulinogenic index/HOMA-IR.

CONCLUSIONS

Elevated fasting plasma glucose, either alone or combined with post-load glucose elevation is associated with worse outcomes than isolated post-load glucose elevation, possibly due to higher degrees of insulin resistance. Future work is needed to better understand these differences, and explore whether tailored treatment of GDM can improve neonatal outcomes.

Various screening and diagnosis approaches for gestational diabetes mellitus and adverse pregnancy outcomes: a secondary analysis of a randomized non-inferiority field trial

INTRODUCTION

We evaluate which screening and diagnostic approach resulted in the greatest reduction in adverse pregnancy outcomes due to increased treatment.

RESEARCH DESIGN AND METHODS

This study presents a secondary analysis of a randomized community non-inferiority trial conducted among pregnant women participating in the GULF Study in Iran. A total of 35 430 pregnant women were randomly assigned to one of the five prespecified gestational diabetes mellitus (GDM) screening protocols. The screening methods included fasting plasma glucose (FPG) in the first trimester and either a one-step or a two-step screening method in the second trimester of pregnancy. According to the results, participants were classified into 6 groups (1) First-trimester FPG: 100-126 mg/dL, GDM diagnosed at first trimester; (2) First trimester FPG: 92-99.9 mg/dL, GDM diagnosed at first trimester; (3) First trimester FPG: 92-99.9 mg/dL, GDM diagnosed at second trimester; (4) First trimester FPG: 92-99.9 mg/dL, healthy at second trimester; (5) First trimester FPG<92 mg/dL, GDM diagnosed at second trimester; (6) First trimester FPG<92 mg/dL, healthy at second trimester. For our analysis, we initially used group 6, as the reference and repeated the analysis using group 2, as the reference group. The main outcome of the study was major adverse maternal and neonatal outcomes.

RESULTS

Macrosomia and primary caesarean section occurred in 9.8% and 21.0% in group 1, 7.8% and 19.8% in group 2, 5.4% and 18.6% in group 3, 6.6% and 21.5% in group 4, 8.3% and 24.0% in group 5, and 5.4% and 20.0% in group 6, respectively. Compared with group 6 as the reference, there was a significant increase in the adjusted risk of neonatal intensive care unit (NICU) admission in groups 1, 3, and 5 and an increased risk of macrosomia in groups 1, 2, and 5. Compared with group 2 as the reference, there was a significant decrease in the adjusted risk of macrosomia in group 3, a decreased risk of NICU admission in group 6, and an increased risk of hyperglycemia in group 3.

CONCLUSIONS

We conclude that screening approaches for GDM reduced the risk of adverse pregnancy outcomes to the same or near the same risk level of healthy pregnant women, except for the risk of NICU admission that increased significantly in groups diagnosed with GDM compared with healthy pregnant women. Individuals with slight increase in FPG (92-100 mg/dL) at first trimester, who were diagnosed as GDM, had an even increased risk of macrosomia in comparison to those group of women with FPG 92-100 mg/dL in the first trimester, who were not diagnosed with GDM, and developed GDM in second trimester TRIAL REGISTRATION: IRCT138707081281N1 (registered: February 15, 2017).

Causal relationship association of cheese intake with gestational hypertension and diabetes result from a Mendelian randomization study

BACKGROUND

The evidence from observational studies has been inconclusive on the causal relationship between cheese intake and gestational hypertension or diabetes.

AIM

To determine whether cheese consumption was causally related to hypertension and diabetes during pregnancy.

METHODS

This was a two-sample Mendelian randomized (MR) study. Summary-level genetic data for cheese intake was exposure and corresponding outcome data for gestational hypertension and gestational diabetes were extracted from the IEU OpenGWAS database. MR analysis was conducted using inverse variance weighting. For sensitivity analyses, MR-Egger regression, weighted median, weighted mode, and leave-one-out methods were conducted. A fixed-effect model was used to meta-analyze two sample MR estimates. The traits of gestational hypertension were pregnancy hypertension (123579 individuals) and oedema, proteinuria and hypertensive disorders in pregnancy, childbirth and the puerperium (123579 individuals), and traits of gestational diabetes were gestational diabetes (123579 individuals) and diabetes mellitus in pregnancy (116363 individuals), respectively.

RESULTS

Cheese intake per standard deviation increase has causally reduced the risks of gestational hypertension [odds ratio (OR) = 0.60, 95% confidence interval (CI): 0.47-0.76, P < 0.001] and gestational diabetes (OR = 0.41, 95%CI: 0.30-0.55, P < 0.001) in inverse variance weighted analysis. Sensitivity analysis showed no heterogeneity (all P > 0.05) nor horizontal pleiotropy (all P > 0.05) in the relationship between cheese intake and gestational hypertension, but heterogeneity presented (all P < 0.05) in relation to gestational diabetes in the two-sample MR analysis.

CONCLUSION

Cheese intake was inversely associated with gestational hypertension and gestational diabetes in MR analysis, suggesting that cheese consumption may be beneficial in preventing hypertension and diabetes during pregnancy.

Association between plant-based or animal-based dietary pattern and plasma glucose during oral glucose tolerance test among Chinese women with gestational diabetes mellitus: a prospective cohort study

OBJECTIVE

This study explored whether plant-based and animal-based dietary patterns are associated with plasma glucose levels during oral glucose tolerance test in women with gestational diabetes mellitus (GDM).

DESIGN

A prospective cohort study was conducted using a Food Frequency Questionnaire to collect dietary data. Dietary patterns were derived using principal component analysis. Multivariate logistic regression analysis was performed to explore the association between dietary patterns and plasma glucose levels. Stratified analyses were conducted according to maternal age, prepregnancy body mass index (BMI) and other confounders.

SETTING AND PARTICIPANTS

The study, conducted in January 2022 in two hospitals in Fujian, China, involved 424 women diagnosed with GDM using a 75 g 2-hour oral glucose tolerance test at 24-28 gestational weeks.

RESULTS

Six maternal dietary patterns (plant based and animal based) were identified. Participants with plant-based pattern had lower 2-hour plasma glucose levels than those with animal-based pattern (β=-0.314; 95% CI (-0.596 to -0.032)). After adjusting the regression model covariates, this significant association remained (β=-0.288; 95% CI (-0.568 to -0.008)) and appeared more pronounced in women aged 30 years or above and those with prepregnancy BMI<24 kg/m2.

CONCLUSIONS

Plant-based pattern is associated with lower plasma glucose levels in women with GDM, which is valuable information for dietary counselling and intervention.

Effects of dietary intervention combined with insulin aspart on serum nesfatin-1 and CTRP12 levels and pregnancy outcomes in pregnant women with gestational diabetes mellitus

To analyze the effects of dietary intervention combined with insulin aspart on the serum levels of nesfatin-1, C1q/TNF related protein-12 (CTRP12), and pregnancy outcomes in pregnant women with gestational diabetes mellitus (GDM). In this retrospective cohort study, 513 women with GDM admitted to Tangshan Central Hospital (Tangshan, China) between January 2019 and December 2022 were selected and divided into an observation group (dietary intervention combined with insulin aspart therapy; n = 284) and a control group (insulin aspart therapy, n = 229). The general characteristics, clinical outcomes, serum nesfatin-1 and CTRP12 levels, 2-hour postprandial blood glucose levels, pregnancy outcomes, and perinatal outcomes of the 2 groups were compared. After treatment, the total effective rate in the observation group was significantly higher than that of the control group (97.54% vs 86.03%, respectively; P < .001). Compared with the pretreatment levels, nesfatin-1 and CTRP12 levels were decreased in both groups; nesfatin-1 and CTRP12 levels in the observation group were significantly higher than those in the control group. After treatment, the preprandial and 2-hour postprandial blood glucose levels in the observation group were significantly lower than those in the control group. Compared with the control group, the observation group had significantly fewer cesarean sections, and a significantly lower incidence of postpartum hemorrhage, premature rupture of membranes, and other adverse pregnancy outcomes. After treatment, the risks of preterm birth, macrosomia, fetal distress, neonatal asphyxia, neonatal hypoglycemia, and other adverse perinatal outcomes were significantly lower in the observation group than in the control group. In pregnant women with GDM, dietary intervention combined with insulin aspart can improve clinical outcomes; reduce nesfatin-1, CTRP12, and blood glucose levels; and reduce the incidence of adverse pregnancy outcomes.

Continuous glucose monitoring in individuals undergoing gestational diabetes screening

BACKGROUND

Among guidelines on gestational diabetes mellitus, there is an incongruity about the threshold of maternal hyperglycemia to diagnose gestational diabetes mellitus.

OBJECTIVE

This study aimed to ascertain the association between continuous glucose monitoring metrics and adverse outcomes among individuals undergoing gestational diabetes mellitus screening.

STUDY DESIGN

This was a prospective study (from June 2020 to January 2022) of individuals who underwent 2-step gestational diabetes mellitus screening at ≤30 weeks of gestation. The participants wore a blinded continuous glucose monitoring device (Dexcom G6 Pro; Dexcom, Inc, San Diego, CA) for 10 days starting when they took the 50-g glucose challenge test. The primary outcome was a composite of adverse neonatal outcomes (large for gestational age, shoulder dystocia or neonatal injury, respiratory distress, need for intravenous glucose treatment for hypoglycemia, or fetal or neonatal death). The secondary neonatal outcomes included preterm birth, neonatal intensive care unit admission, hypoglycemia, mechanical ventilation or continuous positive airway pressure, hyperbilirubinemia, and hospital length of stay. The secondary maternal outcomes included weight gain during pregnancy, hypertensive disorders of pregnancy, induction of labor, cesarean delivery, and postpartum complications. Time within the target range (63-140 mg/dL), time above the target range (>140 mg/dL) expressed as a percentage of all continuous glucose monitoring readings, and mean glucose level were analyzed. The Youden index was used to choose the threshold of ≥10% for the time above the target range and association with adverse outcomes.

RESULTS

Of 136 participants recruited, data were available from 92 individuals (67.6%). The 2-step method diagnosed gestational diabetes mellitus in 2 individuals (2.2%). Continuous glucose monitoring indicated that 17 individuals (18.5%) had time above the target range of ≥10%. Individuals with time above the target range of ≥10% had a significantly higher likelihood of composite adverse neonatal outcomes than individuals with time above the target range of <10% (63% vs 18%; P=.001). Furthermore, compared with neonates born to individuals with time above the target range of <10%, neonates born to individuals with time above the target range of ≥10% had an increased likelihood for hypoglycemia (14.5% vs 47%; P=.009) and had a longer length of stay (2 vs 4 days; P=.03). No difference in maternal outcomes was noted between the groups.

CONCLUSION

In this prospective study of individuals undergoing gestational diabetes mellitus screening, a cutoff of the time above the target range of ≥10% using continuous glucose monitoring was associated with a higher rate of neonatal adverse outcomes. A randomized trial of continuous glucose monitoring vs 2-step screening for gestational diabetes mellitus to lower the rate of adverse outcomes is underway (identification number: NCT05430204).

Gestational Glucose Intolerance and Birth Weight-Related Complications

OBJECTIVE

To evaluate the risks of large-for-gestational-age birth weight (LGA) and birth weight-related complications in pregnant individuals with gestational glucose intolerance, an abnormal screening glucose loading test result without meeting gestational diabetes mellitus (GDM) criteria.

METHODS

In a retrospective cohort study of 46,989 individuals with singleton pregnancies who delivered after 28 weeks of gestation, those with glucose loading test results less than 140 mg/dL were classified as having normal glucose tolerance. Those with glucose loading test results of 140 mg/dL or higher and fewer than two abnormal values on a 3-hour 100-g oral glucose tolerance test (OGTT) were classified as having gestational glucose intolerance. Those with two or more abnormal OGTT values were classified as having GDM. We hypothesized that gestational glucose intolerance would be associated with higher odds of LGA (birth weight greater than the 90th percentile for gestational age and sex). We used generalized estimating equations to examine the odds of LGA in pregnant individuals with gestational glucose intolerance compared with those with normal glucose tolerance, after adjustment for age, body mass index, parity, health insurance, race and ethnicity, and marital status. In addition, we investigated differences in birth weight-related adverse pregnancy outcomes.

RESULTS

Large for gestational age was present in 7.8% of 39,685 pregnant individuals with normal glucose tolerance, 9.5% of 4,155 pregnant individuals with gestational glucose intolerance and normal OGTT, 14.5% of 1,438 pregnant individuals with gestational glucose intolerance and one abnormal OGTT value, and 16.0% of 1,711 pregnant individuals with GDM. The adjusted odds of LGA were higher in pregnant individuals with gestational glucose intolerance than in those with normal glucose tolerance overall (adjusted odds ratio [aOR] 1.35, 95% CI 1.23-1.49, P <.001). When compared separately with pregnant individuals with normal glucose tolerance, those with either gestational glucose intolerance subtype had higher adjusted LGA odds (gestational glucose intolerance with normal OGTT aOR 1.21, 95% CI 1.08-1.35, P <.001; gestational glucose intolerance with one abnormal OGTT value aOR 1.77, 95% CI 1.52-2.08, P <.001). The odds of birth weight-related adverse outcomes (including cesarean delivery, severe perineal lacerations, and shoulder dystocia or clavicular fracture) were higher in pregnant individuals with gestational glucose intolerance with one abnormal OGTT value than in those with normal glucose tolerance.

CONCLUSION

Gestational glucose intolerance in pregnancy is associated with birth weight-related adverse pregnancy outcomes. Glucose lowering should be investigated as a strategy for lowering the risk of these outcomes in this group.

Prenatal Care for the Obese and Severely Obese Pregnant Patient

Modifications of prenatal care will be needed in expected weight gain, nutritional recommendations, screening tests, thromboprophylaxis, ultrasound, antenatal testing, and timing and mode of delivery.

Gestational diabetes mellitus and COVID-19: The epidemic during the pandemic

During the global coronavirus disease 2019 (COVID-19) pandemic, people worldwide have experienced an unprecedented rise in psychological distress and anxiety. In addition to this challenging situation, the prevalence of diabetes mellitus (DM), a hidden epidemic, has been steadily increasing in recent years. Lower-middle-income countries have faced significant barriers in providing accessible prenatal care and promoting a healthy diet for pregnant women, and the pandemic has made these challenges even more difficult to overcome. Pregnant women are at a higher risk of developing complications such as hyper-tension, preeclampsia, and gestational diabetes, all of which can have adverse implications for both maternal and fetal health. The occurrence of gestational diabetes has been on the rise, and it is possible that the pandemic has worsened its prevalence. Although data is limited, studies conducted in Italy and Canada suggest that the pandemic has had an impact on gestational diabetes rates, especially among women in their first trimester of pregnancy. The significant disruptions to daily routines caused by the pandemic, such as limited exercise options, indicate a possible link between COVID-19 and an increased likelihood of experiencing higher levels of weight gain during pregnancy. Notably, individuals in the United States with singleton pregnancies are at a significantly higher risk of excessive gestational weight gain, making this association particularly important to consider. Although comprehensive data is currently lacking, it is important for clinical researchers to explore the possibility of establishing correlations between the stress experienced during the pandemic, its consequences such as gestational gain weight, and the increasing incidence of gestational DM. This knowledge would contribute to better preventive measures and support for pregnant individuals during challenging times.

Stillbirth: prevention and supportive bereavement care

Around half of the two million stillbirths occurring worldwide each year are preventable. This review compiles the most up-to-date evidence to inform stillbirth prevention. Many general maternal health interventions also reduce the risk of stillbirth, for example, antenatal care attendance. This review focuses on specific aspects of care: glucose metabolism, targeted aspirin prophylaxis, clotting and immune disorders, sleep positions, fetal movement monitoring, and preconception and interconception health. In the past few years, covid-19 infection during pregnancy has emerged as a risk factor for stillbirth, particularly among women who were not vaccinated. Alongside prevention, efforts to address stillbirth must include provision of high quality, supportive, and compassionate bereavement care to improve parents' wellbeing. A growing body of evidence suggests beneficial effects for parents who received supportive care and were offered choices such as mode of birth and the option to see and hold their baby. Staff need support to be able to care for parents effectively, yet, studies consistently highlight the scarcity of specific bereavement care training for healthcare providers. Action is urgently needed and is possible. Action must be taken with the evidence available now, in healthcare settings with high or low resources, to reduce stillbirths and improve training and care.

Evaluating glucose variability through OGTT in early pregnancy and its association with hypertensive disorders of pregnancy in non-diabetic pregnancies: a large-scale multi-center retrospective study

BACKGROUND

Recent evidence suggests increased glucose variability (GV) causes endothelial dysfunction, a central pathology of hypertensive disorders of pregnancy (HDP). We aimed to investigate the association between GV in early pregnancy and subsequent HDP development among non-diabetes mellitus (DM) pregnancies.

METHODS

This multicenter retrospective study used data from singleton pregnancies between 2009 and 2019. Among individuals who had 75 g-OGTT before 20 weeks of gestation, we evaluated GV by 75 g-OGTT parameters and examined its relationship with HDP development, defining an initial-increase from fasting-plasma glucose (PG) to 1-h-PG and subsequent-decrease from 1-h-PG to 2-h-PG.

RESULTS

Approximately 3.0% pregnancies (802/26,995) had 75 g-OGTT before 20 weeks of gestation, and they had a higher prevalence of HDP (14.3% vs. 7.5%). The initial-increase was significantly associated with overall HDP (aOR 1.20, 95% CI 1.02-1.42), and the subsequent-decrease was associated with decreased and increased development of early-onset (EoHDP: aOR 0.56, 95% CI 0.38-0.82) and late-onset HDP (LoHDP: aOR 1.38, 95% CI 1.11-1.73), respectively.

CONCLUSIONS

A pattern of marked initial-increase and minor subsequent-decrease (i.e., sustained hyperglycemia) was associated with EoHDP. Contrarily, the pattern of marked initial-increase and subsequent-decrease (i.e., increased GV) was associated with LoHDP. This provides a new perspective for future study strategies.

Pregnancy as an Early Cardiovascular Moment: Peripartum Cardiovascular Health

Pregnancy is commonly referred to as a window into future CVH (cardiovascular health). During pregnancy, physiological adaptations occur to promote the optimal growth and development of the fetus. However, in approximately 20% of pregnant individuals, these perturbations result in cardiovascular and metabolic complications, which include hypertensive disorders of pregnancy, gestational diabetes, preterm birth, and small-for-gestational age infant. The biological processes that lead to adverse pregnancy outcomes begin before pregnancy with higher risk of adverse pregnancy outcomes observed among those with poor prepregnancy CVH. Individuals who experience adverse pregnancy outcomes are also at higher risk of subsequent development of cardiovascular disease, which is largely explained by the interim development of traditional risk factors, such as hypertension and diabetes. Therefore, the peripartum period, which includes the period before (prepregnancy), during, and after pregnancy (postpartum), represents an early cardiovascular moment or window of opportunity when CVH should be measured, monitored, and modified (if needed). However, it remains unclear whether adverse pregnancy outcomes reflect latent risk for cardiovascular disease that is unmasked in pregnancy or if adverse pregnancy outcomes are themselves an independent and causal risk factor for future cardiovascular disease. Understanding the pathophysiologic mechanisms and pathways linking prepregnancy CVH, adverse pregnancy outcomes, and cardiovascular disease are necessary to develop strategies tailored for each stage in the peripartum period. Emerging evidence suggests the utility of subclinical cardiovascular disease screening with biomarkers (eg, natriuretic peptides) or imaging (eg, computed tomography for coronary artery calcium or echocardiography for adverse cardiac remodeling) to identify risk-enriched postpartum populations and target for more intensive strategies with health behavior interventions or pharmacological treatments. However, evidence-based guidelines focused on adults with a history of adverse pregnancy outcomes are needed to prioritize the prevention of cardiovascular disease during the reproductive years and beyond.

Treatment of Gestational Diabetes Mellitus Diagnosed Early in Pregnancy

BACKGROUND

Whether treatment of gestational diabetes before 20 weeks' gestation improves maternal and infant health is unclear.

METHODS

We randomly assigned, in a 1:1 ratio, women between 4 weeks' and 19 weeks 6 days' gestation who had a risk factor for hyperglycemia and a diagnosis of gestational diabetes (World Health Organization 2013 criteria) to receive immediate treatment for gestational diabetes or deferred or no treatment, depending on the results of a repeat oral glucose-tolerance test [OGTT] at 24 to 28 weeks' gestation (control). The trial included three primary outcomes: a composite of adverse neonatal outcomes (birth at <37 weeks' gestation, birth trauma, birth weight of ≥4500 g, respiratory distress, phototherapy, stillbirth or neonatal death, or shoulder dystocia), pregnancy-related hypertension (preeclampsia, eclampsia, or gestational hypertension), and neonatal lean body mass.

RESULTS

A total of 802 women underwent randomization; 406 were assigned to the immediate-treatment group and 396 to the control group; follow-up data were available for 793 women (98.9%). An initial OGTT was performed at a mean (±SD) gestation of 15.6±2.5 weeks. An adverse neonatal outcome event occurred in 94 of 378 women (24.9%) in the immediate-treatment group and in 113 of 370 women (30.5%) in the control group (adjusted risk difference, -5.6 percentage points; 95% confidence interval [CI], -10.1 to -1.2). Pregnancy-related hypertension occurred in 40 of 378 women (10.6%) in the immediate-treatment group and in 37 of 372 women (9.9%) in the control group (adjusted risk difference, 0.7 percentage points; 95% CI, -1.6 to 2.9). The mean neonatal lean body mass was 2.86 kg in the immediate-treatment group and 2.91 kg in the control group (adjusted mean difference, -0.04 kg; 95% CI, -0.09 to 0.02). No between-group differences were observed with respect to serious adverse events associated with screening and treatment.

CONCLUSIONS

Immediate treatment of gestational diabetes before 20 weeks' gestation led to a modestly lower incidence of a composite of adverse neonatal outcomes than no immediate treatment; no material differences were observed for pregnancy-related hypertension or neonatal lean body mass. (Funded by the National Health and Medical Research Council and others; TOBOGM Australian New Zealand Clinical Trials Registry number, ACTRN12616000924459.).

Intermediate hyperglycemia in early pregnancy: A South Asian perspective

"Intermediate hyperglycemia in early pregnancy (IHEP)" refers to mild hyperglycemia detected before 24 gestational weeks (GW), satisfying the criteria for the diagnosis of gestational diabetes mellitus. Many professional bodies recommend routine screening for "overt diabetes" in early pregnancy, which identifies a significant number of women with mild hyperglycemia of undetermined significance. A literature search revealed that one-third of GDM women in South Asian countries are diagnosed before the conventional screening period of 24 GW to 28 GW; hence, they belong in the IHEP category. Most hospitals in this region diagnose IHEP by oral glucose tolerance test (OGTT) using the same criteria used for GDM diagnosis after 24 GW. There is some evidence to suggest that South Asian women with IHEP are more prone to adverse pregnancy events than women with a diagnosis of GDM after 24 GW, but this observation needs to be proven by randomized control trials. Fasting plasma glucose is a reliable screening test for GDM that can obviate the need for OGTT for GDM diagnosis among 50% of South Asian pregnant women. HbA1c in the first trimester predicts GDM in later pregnancy, but it is not a reliable test for IHEP diagnosis. There is evidence to suggest that HbA1c in the first trimester is an independent risk factor for several adverse pregnancy events. Further research to identify the patho-genetic mechanisms behind the fetal and maternal effects of IHEP is strongly recommended.

Understanding clinical outcome measures reported in HIV pregnancy studies involving antiretroviral-naive and antiretroviral-experienced women

HIV infection is a clinically significant public health disease and contributes to increased risk of maternal and fetal morbidity and mortality. HIV pregnancy studies use outcome measures as metrics to show how people with HIV feel, function, or survive. These endpoints are crucial for tracking the evolution of HIV illness over time, assessing the effectiveness of antiretroviral therapy (ART), and comparing outcomes across studies. Although the need for ideal outcome measures is widely acknowledged, selecting acceptable outcome measures for these HIV pregnancy studies can be challenging. We discuss the many outcome measures that have been implemented over time to assess HIV in pregnancy studies, their benefits, and drawbacks. Finally, we offer suggestions for improving the reporting of outcome measures in HIV in pregnancy studies. Medical professionals can best care for pregnant women living with HIV receiving ART by having a thorough understanding of these outcome metrics.

Screening and management of major endocrinopathies during pregnancy: an update

Endocrinopathies during pregnancy constitute a challenging issue, being prevalent and requiring appropriate management to avoid maternal and fetal complications. This review aims to summarize and present major endocrine problems during pregnancy, the appropriate screening, maternal monitoring and management, fetal monitoring, and follow-up. Glucose metabolism, thyroid function, as well as calcium and vitamin D metabolism are the main endocrine domains that should be screened and monitored during pregnancy. Gestational diabetes mellitus (GDM) is the most prevalent endocrine disease during pregnancy, followed by thyroid disorders. Specific recommendations are provided for the optimal clinical care of pregnant women and their offspring for GDM, thyroid disorders, and calcium and vitamin D disorders.

Prepregnancy body mass index and gestational diabetes mellitus across Asian and Pacific Islander subgroups in California

BACKGROUND

The American College of Obstetricians and Gynecologists recommends early screening for gestational diabetes mellitus among pregnant Asian people with a prepregnancy body mass index ≥23.0 kg/m2, in contrast with the recommended screening at a body mass index ≥25 kg/m2 for other races and ethnicities. However, there is significant heterogeneity within Asian and Pacific Islander populations, and gestational diabetes mellitus and its association with body mass index among Asian and Pacific Islander subgroups may not be uniform across all groups.

OBJECTIVE

This study aimed to analyze the association between body mass index and gestational diabetes mellitus among Asian and Pacific Islander subgroups in California, specifically gestational diabetes mellitus rates among those with a body mass index above vs below 23 kg/m2, which is the cutoff point for the designation of being overweight among Asians populations.

STUDY DESIGN

Using a linked delivery hospitalization discharge and vital records database, we identified patients who gave birth in California between 2007 and 2017 and who self-reported to be 1 of 13 Asian and Pacific Islander subgroups, which was collected from birth and fetal death certificates. In each subgroup, we evaluated the association between body mass index and gestational diabetes mellitus using multivariable logistic regression models adjusted for age, education, parity, payment method, the trimester in which prenatal care was initiated, and nativity. We fit body mass index nonlinearly with splines and categorized body mass index as being above or below 23 kg/m2. Predicted probabilities of gestational diabetes mellitus with 95% confidence intervals were calculated across body mass index values using the nonlinear regression models.

RESULTS

The overall prevalence of gestational diabetes mellitus was 14.3% (83,400/584,032), ranging between 8.4% and 17.1% across subgroups. The highest prevalence was among Indian (17.1%), Filipino (16.7%), and Vietnamese (15.5%) subgroups. In these subgroups, gestational diabetes mellitus was diagnosed in 10% to 13% of those with a body mass index <23.0 kg/m2 and in 22% of those with a body mass index ≥23 kg/m2. Gestational diabetes mellitus was least common among Korean (8.4%), Japanese (9.0%), and Samoan (9.8%) subgroups with a gestational diabetes mellitus rate of 5% to 7% among those with a body mass index <23.0 kg/m2 and in 10% to 15% among those with a body mass index ≥23 kg/m2. Although Samoan patients had the highest rate of obesity, defined as body mass index ≥30 kg/m2 (57.4%), they had the third lowest prevalence of gestational diabetes mellitus. Conversely, Vietnamese patients had the second lowest rate of obesity (2.4%) but the highest rate of gestational diabetes mellitus at a body mass index of ≥23 kg/m2 (22.3%).

CONCLUSION

Gestational diabetes mellitus and its association with body mass index varied among Asian subgroups but increased as body mass index increased. Subgroups with the lowest prevalence of obesity trended toward a higher prevalence of gestational diabetes mellitus and those with a higher prevalence of obesity trended toward a lower prevalence of gestational diabetes mellitus.

Gestational Glucose Intolerance and Risk of Future Diabetes

OBJECTIVE

Pregnant individuals are universally screened for gestational diabetes mellitus (GDM). Gestational glucose intolerance (GGI) (an abnormal initial GDM screening test without a GDM diagnosis) is not a recognized diabetes risk factor. We tested for an association between GGI and diabetes after pregnancy.

RESEARCH DESIGN AND METHODS

We conducted a retrospective cohort study of individuals followed for prenatal and primary care. We defined GGI as an abnormal screening glucose-loading test result at ≥24 weeks' gestation with an oral glucose tolerance test (OGTT) that did not meet GDM criteria. The primary outcome was incident diabetes. We used Cox proportional hazards models with time-varying exposures and covariates to compare incident diabetes risk in individuals with GGI and normal glucose tolerance.

RESULTS

Among 16,836 individuals, there were 20,359 pregnancies with normal glucose tolerance, 2,943 with GGI, and 909 with GDM. Over a median of 8.4 years of follow-up, 428 individuals developed diabetes. Individuals with GGI had increased diabetes risk compared to those with normal glucose tolerance in pregnancy (adjusted hazard ratio [aHR] 2.01 [95% CI 1.54-2.62], P < 0.001). Diabetes risk increased with the number of abnormal OGTT values (zero, aHR 1.54 [1.09-2.16], P = 0.01; one, aHR 2.97 [2.07-4.27], P < 0.001; GDM, aHR 8.26 [6.49-10.51], P < 0.001 for each compared with normal glucose tolerance). The fraction of cases of diabetes 10 years after delivery attributable to GGI and GDM was 8.5% and 28.1%, respectively.

CONCLUSIONS

GGI confers an increased risk of future diabetes. Routinely available clinical data identify an unrecognized group who may benefit from enhanced diabetes screening and prevention.

Pregnancies complicated by gestational diabetes and fetal growth restriction: an analysis of maternal and fetal body composition using magnetic resonance imaging

INTRODUCTION

Maternal body composition may influence fetal body composition.

OBJECTIVE

The objective of this pilot study was to investigate the relationship between maternal and fetal body composition.

METHODS

Three pregnant women cohorts were studied: healthy, gestational diabetes (GDM), and fetal growth restriction (FGR). Maternal body composition (visceral adipose tissue volume (VAT), subcutaneous adipose tissue volume (SAT), pancreatic and hepatic proton-density fat fraction (PDFF) and fetal body composition (abdominal SAT and hepatic PDFF) were measured using MRI between 30 to 36 weeks gestation.

RESULTS

Compared to healthy and FGR fetuses, GDM fetuses had greater hepatic PDFF (5.2 [4.2, 5.5]% vs. 3.2 [3, 3.3]% vs. 1.9 [1.4, 3.7]%, p = 0.004). Fetal hepatic PDFF was associated with maternal SAT (r = 0.47, p = 0.02), VAT (r = 0.62, p = 0.002), and pancreatic PDFF (r = 0.54, p = 0.008). When controlling for maternal SAT, GDM increased fetal hepatic PDFF by 0.9 ([0.51, 1.3], p = 0.001).

CONCLUSION

In this study, maternal SAT, VAT, and GDM status were positively associated with fetal hepatic PDFF.

An Innovative Teaching Approach for Diabetes Mellitus in Laboratory Medicine Uses the Clinical Laboratory Diagnostic Pathway

Objectives

The routine teaching mode of diabetes mellitus (DM) is divided into various sub-majors of medical laboratory, which is not conducive to clinical laboratory physicians quickly mastering relevant knowledge. A novel DM laboratory testing pathway is established to improve teaching efficiency and enhance the effects of talent cultivation in laboratory medicine.

Methods

The guidelines and expert consensuses of DM were gathered from professional websites and databases. The clinical laboratory diagnostic pathway was formulated, and the questionnaire and mutual evaluation were used to evaluate the teaching effectiveness of 8-year undergraduate students enrolled in 2018 and enrolled in 2019, respectively.

Results

Clinical laboratory physicians developed and approved the DM clinical laboratory diagnostic pathway, which included the entire process of DM diagnosis and differential diagnosis, drug selection, treatment impact monitoring, prognosis evaluation, etc. The results of the questionnaires showed that, in comparison to the teaching mode used with the students enrolled in 2018 and enrolled in 2019, the percentages of more improvement and significant improvement were significantly increased (P < 0.01) and the percentages of no improvement and slight improvement were significantly decreased (P < 0.01). Following the instruction of the DM clinical laboratory diagnostic route, the results were greatly improved, including points emphasized and the accuracy of responding to questions, among other things, according to the teachers' and students' mutual evaluation (P < 0.05).

Conclusions

To enhance the teaching quality in laboratory medicine, it is required to build the disease clinical laboratory diagnostic pathway for a novel teaching method. This may boost teachers' and students' confidence and broaden their knowledge.

Gestational diabetes mellitus in early pregnancy amongst Asian Indian women: Evidence for poor pregnancy outcomes despite treatment

AIM

To compare the pregnancy outcomes in women with gestational diabetes (GDM) based on the timing of diagnosis.

METHODS

This retrospective cohort study was conducted between January 2011 and September 2017 amongst 2638 Asian Indian pregnant women. The inclusion criteria included; singleton pregnancies having HbA1c <48 mmols/mol (6.5%) in the first trimester, GDM screening by 75 g OGTT using IADPSG criteria and delivery at our centre. The cohort was divided into 3 groups: Early GDM (E-GDM)-diagnosis <24 gestational weeks (Gw), Standard GDM (S-GDM)-diagnosis ≥24Gw, Non-GDM- No GDM ≥24 Gw. Multivariable logistic regression models compared the pregnancy outcomes between Non-GDM, S-GDM and E-GDM groups. A sub-group multivariable analysis was done amongst GDM women using gestational age at diagnosis both as a categorical and continuous variable.

RESULTS

Compared to Non-GDM women, the odds were higher for premature birth, large for gestational age (LGA) babies, macrosomia, Neonatal ICU(NICU) admission and lower for normal vaginal delivery in the E-GDM group, but for the S-GDM group, the risk was higher for premature birth, LGA babies, NICU admission and induction of labour. Compared to GDM women in the 24-28 Gw category significantly higher odds for premature birth and LGA babies were observed in the <14 Gw category. A continuous increase of 19% odds for premature birth with every 4 weeks decrease in gestational age at GDM diagnosis was observed.

CONCLUSIONS

Asian Indian women having a GDM diagnosis before 24Gw are at higher risk for adverse pregnancy events than those having diagnosis ≥24Gw or not having GDM.