Association of History of Gestational Diabetes With Long-term Cardiovascular Disease Risk in a Large Prospective Cohort of US Women

Postnatal Cardiometabolic Health After Metformin Use in Gestational Diabetes: A Secondary Analysis of the EMERGE Trial

AIM

Women with gestational diabetes mellitus (GDM) display adverse lifetime cardiometabolic health. We examined whether early metformin in GDM could impact cardiometabolic risk factors postpartum.

METHODS

EMERGE, a double-blind, placebo-controlled trial, randomized pregnancies 1:1 to placebo or metformin at GDM diagnosis and followed participants from randomization until 12 ± 4 weeks postpartum. In total, 478 pregnancies were available for postpartum maternal assessment, 237 and 241 assigned to metformin and placebo respectively. Weight (kg), body mass index (BMI) (kg/m2), waist circumference (cm), and blood pressure (mmHg) were measured, infant feeding method documented, and blood specimens drawn for a 75-gram oral glucose tolerance test, fasting insulin, C-peptide, and lipid analysis.

RESULTS

Despite similar weight and BMI at trial randomization, participants receiving metformin had significantly lower weight (79.5 ± 15.9 vs 82.6 ± 16.9 kg; P = .04) and BMI (29.3 [5.6] vs 30.5 [5.4]; P = .018) at the postpartum visit. However, no difference in weight change from randomization to 12 weeks postpartum was observed between metformin and placebo groups. Overall, 29% (n = 139) of the cohort met criteria for prediabetes or diabetes, with no positive impact with metformin. There were also no differences in measurements of insulin resistance, blood pressure, or lipids between groups.

CONCLUSION

Early metformin use in GDM did not impact important cardiometabolic parameters in the early postpartum period despite significant benefits in weight gain and insulin use in pregnancy.

Perspective on the nursing management for gestational diabetes mellitus: A perspective

This study provides a comprehensive examination of gestational diabetes mellitus (GDM), shedding light on the geographical and ethnic variations in its prevalence. It elucidates the diagnostic evolution, noting the transition from rudimentary glucose tests to the more sophisticated Oral Glucose Tolerance Test (OGTT), which not only facilitates early detection but also standardizes screening protocols. The study delves into the evolution of GDM diagnosis, emphasizing the standardization of the OGTT and its pivotal role in enhancing early detection rates. It meticulously discusses holistic management approaches for GDM, encompassing tailored dietary interventions, prescribed physical activity, and pharmacotherapy. The need for individualized strategies to optimize glucose control is strongly emphasized. The study underscores the significance of mental health in GDM management, advocating for integrated psychological support and stress management interventions to bolster metabolic regulation. An exploration of telemedicine and artificial intelligence highlights their potential to revolutionize GDM care by enabling real-time monitoring and personalized interventions, thus improving patient outcomes. An analysis of health policies and educational efforts underscores their impact on GDM management, advocating for proactive measures to mitigate its prevalence through public health initiatives. The study identifies key research gaps and offers a focused analysis of critical advancements in GDM management, including personalized care strategies and the role of innovative technologies such as artificial intelligence and telemedicine in improving outcomes. Finally, the study calls for further research into personalized treatment modalities and innovative diagnostic tools to address existing gaps in GDM management, particularly in diverse demographic groups.

Gestational diabetes mellitus and subsequent cardiovascular disease in a period of rising diagnoses: Cohort study

INTRODUCTION

Evidence suggests that gestational diabetes mellitus (GDM) is associated with subsequent cardiovascular disease; however, it is unclear what impact changes in screening and diagnostic criteria have had on the association of GDM with long-term outcomes such as cardiovascular disease. The purpose of this study was to determine the association between GDM and subsequent cardiovascular disease during a period of rising gestational diabetes diagnosis in England. Specifically, associations were compared before and after 2008, when national guidelines supporting risk factor-based screening were introduced.

MATERIAL AND METHODS

We conducted a cohort study using routinely collected data from the Clinical Practice Research Datalink linked to the Hospital Episode Statistics and Office for National Statistics databases. The study consisted of persons aged 15-45 years with a livebirth or stillbirth between 1998 and 2017 and without a history of cardiovascular disease or pre-pregnancy diabetes mellitus. Cox proportional hazards models, with propensity score weighting using matching weights, were used to estimate adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs) for the association of GDM diagnosis in the first recorded pregnancy with subsequent cardiovascular disease.

RESULTS

Among 232 315 individuals, the incidence of cardiovascular disease was 6.6 per 1000 person-years among those with GDM and 2.2 per 1000 person-years among those without GDM over a mean follow-up duration of 5.8 years. The overall aHR, 95% CI was 1.91 (1.41, 2.60). Diagnosis of GDM increased over the study period, from 0.7% in 1998-99 to 5.3% in 2017. The effect size was not markedly different in the years before (1998-2007: adjusted HR 2.05, 95% CI 2.05 1.35, 3.12) and after 2008 (2008-2017: adjusted HR 1.79, 95% CI 1.15, 2.80).

CONCLUSIONS

There was a strong association of GDM with cardiovascular disease after accounting for social and demographic factors and multiple comorbidities, and this association was present both before and after 2008, when national gestational diabetes screening criteria were established.

Primary and secondary cardiovascular prevention through life cycles in women. Consensus document of the SEC-GT CVD in Women, ACP-SEC, SEGO, AEEM, SEEN, semFYC, SEMERGEN, AEP, and AEM

This consensus document on cardiovascular disease in women summarizes the views of a panel of experts organized by the Working Group on Women and Cardiovascular Disease of the Spanish Society of Cardiology (SEC-GT CVD in Women), and the Association of Preventive Cardiology of the SEC (ACP-SEC). The document was developed in collaboration with experts from various Spanish societies and associations: the Spanish Society of Gynecology and Obstetrics (SEGO), the Spanish Society of Endocrinology and Nutrition (SEEN), the Spanish Association for the Study of Menopause (AEEM), the Spanish Association of Pediatrics (AEP), the Spanish Society of Primary Care Physicians (SEMERGEN), the Spanish Society of Family and Community Medicine (semFYC), and the Spanish Association of Midwives (AEM). The document received formal approval from the SEC. This consensus serves as a guide for the clinical community on the diagnostic approach and management of cardiovascular health during the stages or life cycles of women: adolescence, the menopausal transition, postpartum disorders, and other gynecologic conditions. It is based on current evidence and best available practices.

Predictors of Cardiometabolic Health a Few Months Postpartum in Women Who Had Developed Gestational Diabetes

BACKGROUND

To assess the incidence of dysglycaemia and metabolic syndrome and factors associated with them 5 months postpartum in women with gestational diabetes mellitus (GDM) in their last pregnancy.

METHODS

We conducted an observational prospective cohort study in 558 women with previous GDM who attended a 5-month postpartum follow-up clinic. Backward elimination was performed to select significant factors for the multivariable logistic regression model. Dysglycaemia (prediabetes and type 2 diabetes (T2D)) and metabolic syndrome were used as outcomes in separate models.

RESULTS

Dysglycaemia was diagnosed in 202 (36.2%) women, including 174 (31.2%) with prediabetes and 28 (5.0%) with T2D. Women with dysglycaemia, compared with those with normoglycaemia, were more likely to be of black ethnicity (33.2 vs. 20.5%) and have severe GDM (31.7 vs. 16%), a higher postpartum BMI (29.5 vs. 27.6 kg/m2), and metabolic syndrome (20 vs. 7%). Multivariable logistic regression analysis showed that significant predictors of dysglycaemia were black (OR 2.09; 95% CI: 1.27-3.46) and mixed ethnicity (OR 3.05; 95% CI: 1.26-7.42), diagnosis of GDM before 24 weeks gestation (OR 3.05, 95% CI: 1.90-4.91), and treatment of GDM with metformin (OR 1.63; 95% CI: 1.05-2.55) or insulin (OR 2.08; 95% CI: 1.14-3.79) rather than diet alone. Significant predictors of metabolic syndrome were postpartum maternal BMI (OR 5.49; 95% CI: 2.60-11.59) and absence of breastfeeding (OR 2.14; 95% CI: 1.21-3.77).

CONCLUSIONS

At 5 months postpartum, a high proportion of women who developed GDM showed evidence of dysglycaemia. Future studies should investigate interventions that could reduce the risk of short- and long-term consequences of suboptimal cardiometabolic health in such women.

Pregnancy Complications and Long-Term Atherosclerotic Cardiovascular Disease Risk

PURPOSE OF REVIEW

Discuss the relationship between pregnancy complications and long-term atherosclerotic cardiovascular disease (ASCVD) risk.

RECENT FINDINGS

A large body of research confirms an association between pregnancy complications and increased short and long-term ASCVD risk and seeks to understand mechanisms for these associations. Social determinants of health continue to have a critical impact on the prevalence of adverse pregnancy outcomes (APOs) and long term ASCVD risk. Of the APOs, hypertensive disorders of pregnancy (HDP) are associated with the highest ASCVD risk. Additionally, recent research shows an association between APOs and microvascular coronary heart disease. APOs are associated with increased risk of ASCVD, however there is conflicting evidence on whether there is a causal relationship between APOs and ASCVD or if APOs are simply a marker of ASCVD risk. Current ASCVD risk models do not incorporate a history of APOs, therefore it is imperative that healthcare providers take a reproductive health history and account for pregnancy complications when counseling patients on long-term cardiovascular risk. Non-invasive modalities such as coronary artery calcium scoring can be considered as an adjunct, but further research is warranted to determine which patients would benefit most.

Sex-related differences in heart failure patients: physiological mechanisms of cardiovascular ageing and evidence-based sex-specific medical therapies

This review aims to describe the sex differences in heart failure (HF) patients, with a particular emphasis on the effect of cardiovascular ageing. Additionally, it takes into consideration the sex-related variation in cardiovascular health and physiology and the role ageing plays in HF and its implications in drug therapy. The pharmacokinetics and pharmacodynamics of the common HF medications, classified according to the established sub-types, are summarised with respect to sex-specific documented findings. Despite numerous studies confirming significant differences in HF outcomes according to sex, there are no current guidelines that consider patients' sex in medical therapy of HF. Moreover, females are significantly under-represented in research trials, as well as under-treated in clinical practice, which hinders our understanding of HF in this demographic. Most of the current knowledge on sex-specific HF therapies is driven by secondary analyses of studies not primarily undertaking sex-specific analyses. Therefore, we propose a multi-faceted approach, including increased awareness among healthcare providers and more inclusive research to create a personalised care plan accounting for sex differences in HF management. Given the highlighted knowledge gaps, it is paramount for new research efforts to account for the different sex phenotypes in HF.

Gestational diabetes and future cardiovascular diseases: associations by sex-specific genetic data

BACKGROUND AND AIMS

Observational studies have highlighted that gestational diabetes mellitus is associated with a higher risk of cardiovascular diseases, but the causality remains unclear. Herein, the causality between genetic predisposition to gestational diabetes mellitus and the risk of cardiovascular diseases was investigated using sex-specific Mendelian randomization analysis.

METHODS

Linkage disequilibrium score regression analysis and two-sample Mendelian randomization analysis were applied to infer the genetic correlation and causality, respectively. Mediation analysis was conducted using a two-step Mendelian randomization approach. Sensitivity analyses were performed to differentiate causality from pleiotropy. The genome-wide association study summary statistics for gestational diabetes mellitus were obtained from FinnGen consortium, while for cardiovascular diseases were generated based on individual-level genetic data from the UK Biobank.

RESULTS

Linkage disequilibrium score regression analyses revealed that gestational diabetes mellitus had a significant genetic correlation with coronary artery disease and myocardial infarction after Benjamini-Hochberg correction in ever-pregnant women. In Mendelian randomization analyses, odds ratios (95% confidence interval) for coronary artery disease and myocardial infarction were 1.09 (1.01-1.17) and 1.12 (.96-1.31) per unit increase in the log-odds of genetic predisposition to gestational diabetes mellitus in ever-pregnant women, respectively. Further, Type 2 diabetes and hypertension were identified as mediators for the causality of genetic predisposition to gestational diabetes mellitus on coronary artery disease. In sensitivity analyses, the direction of odds ratio for the association between instrumental variables with gestational diabetes mellitus-predominant effects and the risk of coronary artery disease was consistent with the primary results in ever-pregnant women, although not statistically significant.

CONCLUSIONS

This study demonstrated a suggestive causal relationship between genetic predisposition to gestational diabetes mellitus and the risk of coronary artery disease, which was mainly mediated by Type 2 diabetes and hypertension. These findings highlight targeting modifiable cardiometabolic risk factors may reduce the risk of coronary artery disease in women with a history of gestational diabetes mellitus.

Correlation between gestational diabetes mellitus and postpartum cardiovascular metabolic indicators and inflammatory factors: a cohort study of Chinese population

Objective

This study aimed to analyze the correlation between gestational diabetes mellitus and postpartum metabolic indicators and inflammatory factors, and explore the role of inflammatory factors, so as to provide evidence for the early prevention of postpartum CVD risk in gestational diabetes mellitus.

Methods

This prospective study was based on the pregnant women cohort study established in Peking University International Hospital from December 2017 to March 2019. A total of 120 women were enrolled sequentially, including 60 cases of gestational diabetes mellitus (GDM group) and 60 cases of non-gestational diabetes mellitus (non-GDM group) after 4-7 years. The general information, inflammatory factors and metabolic indicators of the women were collected and analyzed.

Results

(1)The TyG and siMS levels in the GDM group were higher than those in the non-GDM group (p<0.05, respectively). The interleukin-6(IL-6) levels in the GDM group were higher than those in the non-GDM group and the difference was statistically significant (p<0.05). (2) The results of linear regression analysis showed that GDM was associated with postpartum GLU0min (β=0.94, 95%CI: 0.27-1.60, p<0.05), GLU120min (β=2.76, 95%CI: 1.57-3.94, p<0.05) and HbA1c (β=0.49, 95%CI: 0.27-1.60, p<0.05). At the same time, GDM was significantly correlated with postpartum metabolic indicators triglyceride-glucose (TyG) index (β=0.31, 95%CI: 0.01-0.61, p<0.05) and siMS score (β=0.45, 95%CI: 0.03-0.88, p<0.05).The results of linear regression analysis showed that GDM was significantly correlated with IL-6 (β=0.91, 95%CI: 0.02-1.79, p<0.05). (3) Logistic regression analysis showed that GDM was an independent risk factor for postpartum abnormal metabolism (OR=10.62, 95%CI: 1.66-68.17, p<0.05), and an independent risk factor for postpartum high low-density lipoprotein cholesterolemia (OR=3.38, 95%CI: 1.01-11.56, p<0.05). (4) The IL-6 had a mediating effect in the association between GDM and postpartum TyG and siMS, with the mediating effect sizes being 20.59% and 30.77%, respectively.

Conclusion

This study revealed that GDM history can lead to abnormal glucose and lipid metabolism indexes in postpartum women, affect the levels of postpartum CVD-related metabolic indicators. Meanwhile, IL-6 shows a mediating role, providing important clinical evidence for the prevention and control of CVD in such high-risk populations and the improvement of cardiovascular health.

Gestational Diabetes Mellitus: Unveiling Maternal Health Dynamics from Pregnancy Through Postpartum Perspectives

Gestational Diabetes Mellitus (GDM) is the most frequent pregnancy-related medical issue and presents significant risks to both maternal and foetal health, requiring monitoring and management during pregnancy. The prevalence of GDM has surged globally in recent years, mirroring the rise in diabetes and obesity rates. Estimated to affect from 5% to 25% of pregnancies, GDM impacts approximately 21 million live births annually, according to the International Diabetes Federation (IDF). However, consensus on diagnostic approaches remains elusive, with varying recommendations from international organizations, which makes the comparison between research complicated. Compounding concerns are the short-term and long-term complications stemming from GDM for mothers and offspring. Maternal outcomes include heightened cardiovascular risks and a notable 70% risk of developing Type 2 Diabetes Mellitus (T2DM) within a decade postpartum. Despite this, research into the metabolic profiles associated with a previous GDM predisposing women to T2D remains limited. While genetic biomarkers have been identified, indicating the multifaceted nature of GDM involving hormonal changes, insulin resistance, and impaired insulin secretion, there remains a dearth of exploration into the enduring health implications for both mothers and their children. Furthermore, offspring born to mothers with GDM have been shown to face an increased risk of obesity and metabolic syndrome during childhood and adolescence, with studies indicating a heightened risk ranging from 20% to 50%. This comprehensive review aims to critically assess the current landscape of Gestational Diabetes Mellitus (GDM) research, focusing on its prevalence, diagnostic challenges, and health impacts on mothers and offspring. By examining state-of-the-art knowledge and identifying key knowledge gaps in the scientific literature, this review aims to highlight the multifaceted factors that have hindered a deeper understanding of GDM and its long-term consequences. Ultimately, this scholarly exploration seeks to promote further investigation into this critical area, improving health outcomes for mothers and their children.

Gestational diabetes mellitus, body mass index, and cardiometabolic multimorbidity: A prospective cohort study

PURPOSE

Gestational diabetes mellitus (GDM) could increase the risks of type 2 diabetes mellitus (T2DM) and cardiovascular disease. However, evidence on its association with cardiometabolic multimorbidity (CMM) was limited. This study aimed to evaluate the association between GDM and the prevalence, incidence, patterns, and progression of CMM; and the role of body mass index (BMI) in such association.

METHODS

This study included 203,372 women who have given birth in UK Biobank. The diagnoses of GDM and cardiometabolic diseases (including stroke, coronary heart disease [CHD], and T2DM) were reported by participants or obtained through linkage to inpatient hospital data until 31st December 2020. BMI was assessed at the baseline assessment. CMM was defined as having two or more of included cardiometabolic diseases. Logistic regression models and Cox proportional hazard models were used to assess the association between GDM and CMM, and the modifications on both additive and multiplicative scales were assessed to evaluate the effect of BMI on such association.

RESULTS

A total of 1217 women had a history of GDM, 2351 participants had CMM at the end of follow-up and 1601 was newly diagnosed during follow-up. GDM was associated with higher prevalence (odds ratio [OR]=4.64, 95 % confidence interval [95 % CI]=3.54-6.08) and incidence (hazard ratio [HR]=3.62, 95 % CI=2.62-5.00) of CMM. In particular, GDM was associated with higher odds of T2DM, coexisting T2DM and vascular disease, and T2DM followed by vascular disease. Formal testing for effect modification suggested multiplicative modification by BMI for the association between GDM and incident CMM.

CONCLUSIONS

GDM was associated with CMM in women's late life, with multiplicative modification effects of BMI. Our results suggest that maternal and lifestyle interventions (e.g., weight management) are warranted for the primary and secondary prevention of CMM, particularly in women with a history of GDM.

Association of ideal cardiovascular health and history of gestational diabetes mellitus in NHANES 2007-2018

BACKGROUND

Population-based studies of ideal cardiovascular health (CVH) and gestational diabetes mellitus (GDM) are scarce.

METHODS

We conducted a cross-sectional analysis of 2007-2018 National Health Examination and Nutrition Survey women aged ≥ 20 years, who had data on Life's Simple 7 (LS7) metrics and self-reported GDM history. Each LS7 metric was assigned a score of 0 (non-ideal) and 1(ideal) and summed to obtain total ideal CVH scores (0-7). We used logistic regression models to assess associations between LS7 ideal CVH scores (0-7) and GDM history, accounting for socio-demographic factors.

RESULTS

Among 9199 women (mean age: 46 years, 8 % with a GDM history), there was a progressive decrease in the odds of past GDM history across increasing ideal CVH scores. Compared to females with 0-1 ideal CVH scores, females with ideal CVH scores of 3, 4 and 5-7 had an associated 39 % lower [odds ratio: 0.61 (95 % CI: 0.41-0.90)], 50 % lower [0.50 (0.33-0.76)] and 66 % lower [0.34 (0.20-0.56)] odds of past GDM history, respectively. There were notable racial/ethnic and citizenship/nativity differences in these associations.

CONCLUSIONS

Women with higher ideal CVH scores had lower odds of GDM history. Our findings underscore the importance of optimizing cardiometabolic health among women with GDM history.

Global research trends and hotspots in gestational diabetes and long-term cardiovascular health: A bibliometric analysis

AIMS

To identify emerging trends and hotspots in research regarding cardiovascular disease (CVD) risk linked to gestational diabetes mellitus (GDM).

METHODS

A systematic bibliometric review of the literature on the risk of long-term CVD in patients with GDM between 1990 and 2022 from the Web of Science Core Collection (WoSCC) was performed by using Citespace and VOSviewer.

RESULTS

This analysis gathered a total of 1185 articles, with 77 publications in 2019 and 119 in 2022, demonstrating a steady growth in the amount of research on the relationship between GDM and CVD in recent years. The United States of America (USA) led in national publications, followed by the United Kingdom (UK) and Canada. Key institutions included Harvard University, the University of Toronto, and the University of Oslo, with Prof. Ravi Retnakaran and Prof. Jane W. Rich-Edwards being prominent figures. The most productive journal was the Journal of Clinical Endocrinology &Metabolism, while Diabetes Care was the most influential and most co-cited journal. Common terms over the last 20 years included "risk," "type 2 diabetes," "cardiovascular disease," and "gestational diabetes," with recent focus shifting towards "prevention," "gene expression," and "DNA methylation".

CONCLUSION

This is the first bibliometric analysis linking CVD and GDM. Future research should investigate pathways between GDM and CVD, emphasizing gene expression and inflammation, while advocating for collaborative prevention strategies.

Diagnosis and Treatment of Hyperglycemia in Pregnancy: Type 2 Diabetes Mellitus and Gestational Diabetes

Hyperglycemia in pregnancy due to pre-existing Type 2 diabetes mellitus (T2DM) and gestational diabetes mellitus (GDM) is rising globally with increasing rates of risk factors for metabolic disease. This review summarizes current evidence and recommendations from national and international guidelines for diagnosis and management of T2DM and GDM to optimize maternal and neonatal outcomes.

Risk of cardiovascular events after gestational diabetes: a retrospective population study

AIMS

To investigate whether the risk for post-partum cardiovascular diseases (CVD) is driven by gestational diabetes (GDM), by GDM-related risk factors and/or by pre-gestational (Pre-GD) or post-gestational diabetes (Post-GD).

METHODS

Women delivering in Tuscany, Italy in years 2010-2012 (n = 74,720), were identified from certificates of care at delivery and further identified as affected with GDM, Pre-GD or Post-GD through regional administrative databases. Women with GDM, Pre-GD or Post-GD were retrospectively evaluated for risk of post-partum hospitalizations for CVD (myocardial infarction or stroke; n = 728) across years 2013-2021, comparing women with different forms of diabetes to those without diabetes. Risk of CVD was assessed as odds ratio (OR 95% CI), after logistic multivariate models, considering all recorded pre-gestational characteristics as covariates.

RESULTS

The adjusted OR (aOR) for post-partum CVD hospitalizations was not significantly related to GDM itself (aOR: 0.85; 0.64-1.12; p = ns), but increased in women with Pre-GD (aOR: 2.02; 1.09-3.71; p = 0.024) and Post-GD, associated or not to prior GDM (aOR; 4.21; 2.45-7.23 and respectively aOR: 3.80; 2.38-6.05; p < 0.0001 for both). In presence of pre-pregnancy maternal obesity (BMI ≥ 30 kg/m2) the aOR of CVD approximatively doubled (aOR: 1.90; 1.51-2.40); p < 0.0001, independently of GDM and of Post-GD. The adjusted risk of CVD was lower among employed women (aOR: 0.83; 0.70-0.99); p = 0.04 and significantly higher in presence of poorer education levels (aOR: 1.32; 1.11-1.57); p < 0.0001.

CONCLUSION

In this population the risk of post-partum CVD was driven by Pre- and Post-GD, not by GDM alone. Pre-gestational obesity represented a major independent risk factor for post-partum CVD.

Prevalence of Hypertensive Disorders of Pregnancy and Gestational Diabetes Mellitus by Race and Ethnicity in Illinois, 2018 to 2020

PURPOSE

Use administrative discharge data from 2018 to 2020 to determine if there are differences in the prevalence of hypertensive disorders of pregnancy (HDP) and gestational diabetes mellitus (GDM) by race and ethnicity in Illinois.

STUDY DESIGN AND METHODS

This retrospective cross-sectional study used administrative discharge records from all patients who had live births in Illinois over a 3-year period; 2018, 2019, 2020. Multivariate analyses were performed to control for covariates and determine if associations vary by race and ethnicity for HDP and GDM.

RESULTS

A total of 287,250 discharge records were included. Multivariate analyses showed that after adjusting for covariates, non-Hispanic Black women had 1.60 increased odds of HDP compared to non-Hispanic White women (OR, 1.60; 95% CI, 1.55-1.65). Hispanic women (OR, 1.45; 95% CI, 1.40-1.50), Asian/Pacific Islander women (OR, 2.07; 95% CI, 1.97-2.17), and American Indian/Alaska Native women (OR, 1.43; 95% CI, 1.17-1.74) had an increased odds of GDM compared to non-Hispanic White women.

CLINICAL IMPLICATIONS

Women of color were at increased odds for HDP and GDM in Illinois. To eliminate poor maternal outcomes in women of color at risk for HDP and GDM, more culturally congruent health equity practices, policies, and comprehensive care interventions must be adopted.

Gestational diabetes mellitus and development of intergenerational overall and subtypes of cardiovascular diseases: a systematic review and meta-analysis

OBJECTIVE

We aimed to summarize the association between gestational diabetes mellitus (GDM) and its intergenerational cardiovascular diseases (CVDs) impacts in both mothers and offspring post-delivery in existing literature.

METHODS

PubMed, Embase, Web of Science, and Scopus were utilized for searching publications between January 1980 and June 2024, with data extraction and meta-analysis continuing until 31 July 2024. Based on a predefined PROSPERO protocol, studies published as full-length, English-language journal articles that reported the presence of GDM during pregnancy and its association with any CVD development post-delivery were selected. All studies were evaluated using the Newcastle-Ottawa Scale. Maximally adjusted risk estimates were pooled using random-effects meta-analysis to assess the risk ratio (RR) of GDM, and overall and subtypes of CVDs in both mothers and offspring post-delivery.

RESULTS

The meta-analysis was based on 38 studies with a total of 77,678,684 participants. The results showed a 46% increased risk (RR 1.46, 95% CI 1.34-1.59) for mothers and a 23% increased risk (1.23, 1.05-1.45) for offspring of developing overall CVDs after delivery, following a GDM-complicated pregnancy. Our subgroup analysis revealed that mothers with a history of GDM faced various risks (20% to 2-fold) of developing different subtypes of CVDs, including cerebrovascular disease, coronary artery disease, heart failure, and venous thromboembolism.

CONCLUSIONS

These findings underscore the heightened risk of developing various CVDs for mothers and offspring affected by GDM, emphasizing the importance of preventive measures even right after birth to mitigate the burden of CVDs in these populations.

Implementing care for women with gestational diabetes after delivery-the challenges ahead

Gestational diabetes (GDM), defined as glucose intolerance during pregnancy, affects one in six pregnancies globally and significantly increases a woman's lifetime risk of type 2 diabetes mellitus (T2DM). Being a relatively young group, women with GDM are also at higher risk of developing diabetes related complications (e.g., cardiovascular disease, non-alcoholic fatty liver disease) later in life. Children of women with GDM are also likely to develop GDM and this perpetuates a cycle of diabetes, escalating our current pandemic of metabolic disease. The global prevalence of GDM has now risen by more than 30% over the last two decades, making it an emerging public health concern. Antepartum management of maternal glucose is unable to fully mitigate the associated lifetime cardiometabolic risk. Thus, efforts may need to focus on improving care for women with GDM during the postpartum period where prevention or therapeutic strategies could be implemented to attenuate progression of GDM to DM and its associated vascular complications. However, strategies to provide care for women in the postpartum period often showed disappointing results. This has led to a missed opportunity to halt the progression of impaired glucose tolerance/impaired fasting glucose to DM in women with GDM. In this review, we examined the challenges in the management of women with GDM after delivery and considered how each of these challenges are defined and could present as a gap in translating evidence to clinical care. We highlighted challenges related to postpartum surveillance, postpartum glucose testing strategies, postpartum risk factor modification, and problems encountered in engagement of patients/providers to implement interventions strategies in women with GDM after delivery. We reasoned that a multisystem approach is needed to address these challenges and to retard progression to DM and cardiovascular disease (CVD) in women with GDM pregnancies. This is very much needed to pave way for an improved, precise, culturally sensitive and wholistic care for women with GDM.

Associations between menopausal symptoms and cardiovascular disease in middle-aged Chinese women

OBJECTIVE

This study aimed to examine the association between severity of menopausal symptoms and cardiovascular disease (CVD) risk among middle-aged Chinese women.

METHODS

A cross-sectional study recruited 9679 women aged 40-70 years from three socioeconomic regions of China in 2018. Menopausal symptoms were assessed by the modified Kupperman Menopausal Index (KMI). The severity of individual symptoms was classified as none (0 points), mild (1 points) and moderate-to-severe symptoms (2-3 points), and overall menopausal symptoms were classified as none (<15 points), mild (15-24 points) or moderate-to-severe (≥25 points) according to the sum score of the KMI. Logistic regression models were used to examine associations of the severity of menopausal symptoms with CVD risk.

RESULTS

A total of 5.6% of participants reported being diagnosed with CVD. Overall menopausal symptoms were more common in women aged 60-70 years than in women aged 40-59 years. After multiple adjustment, mild (odds ratio [OR] = 2.07, 95% confidence interval [CI]: 1.64-2.61) and moderate-to-severe (OR = 2.64, 95% CI: 1.92-3.63) overall menopausal symptoms were associated with increased risk of CVD compared with no symptoms. Significant positive associations between the severity of individual menopausal symptoms and CVD risk were observed for all 13 items.

CONCLUSION

The severity of menopausal symptoms was positively associated with CVD risk in middle-aged Chinese women.

Effect of prior gestational diabetes on the risk of cardiovascular disease and death in women with type 2 diabetes: The Fremantle Diabetes Study Phase II

BACKGROUND

To examine whether prior gestational diabetes mellitus (GDM) is associated with prevalent coronary heart disease (CHD), cerebrovascular disease (CeVD) and peripheral arterial disease (PAD), and all-cause mortality, in community-based women with type 2 diabetes.

METHODS

Baseline prevalences of CHD/CeVD/PAD/prior GDM were determined in 718 females (mean ± SD age 65.5 ± 11.9 years) from the Fremantle Diabetes Study Phase II. Deaths between baseline (2008-2011) and end-2016 were ascertained. Cox regression identified predictors of mortality with GDM as a candidate variable.

RESULTS

Compared to the 673 women without GDM, the 39 (5.4 %) with prior GDM were younger, more likely Aboriginal, smokers and obese, had longer diabetes duration and higher HbA1c levels, and were more dyslipidemic (P ≤ 0.046). Prevalences of CHD (24.6 versus 23.1 %), CeVD (7.5 % versus 2.6 %) and PAD (27.5 % versus 23.7 %) were not significantly different in those without versus with prior GDM (P ≥ 0.35). There were 116 deaths (16.2 %) during 6.8 ± 1.6 years of follow-up. Age, Aboriginal ethnicity, marital status, current smoking, heart rate, estimated glomerular filtration rate, CHD and PAD were independently associated with all-cause mortality (P ≤ 0.023); GDM status did not add to the most parsimonious model (P = 0.62).

CONCLUSIONS

Prior GDM does not increase CVD risk or all-cause mortality in women with type 2 diabetes.

Early- to mid-gestational testosterone excess leads to adverse cardiac outcomes in postpartum sheep

Cardiovascular dysfunctions complicate 10-20% of pregnancies, increasing the risk for postpartum mortality. Various gestational insults, including preeclampsia are reported to be associated with adverse maternal cardiovascular outcomes. One such insult, gestational hyperandrogenism increases the risk for preeclampsia and other gestational morbidities but its impact on postpartum maternal health is not well known. We hypothesize that gestational hyperandrogenism such as testosterone (T) excess will adversely impact the maternal heart in the postpartum period. Pregnant ewes were injected with T propionate from day 30 to day 90 of gestation (term 147 days). Three months postpartum, echocardiograms, plasma cytokine profiles, cardiac morphometric, and molecular analysis were conducted [control (C) n = 6, T-treated (T) n = 7 number of animals]. Data were analyzed by two-tailed Student's t test and Cohen's effect size (d) analysis. There was a nonsignificant large magnitude decrease in cardiac output (7.64 ± 1.27 L/min vs. 10.19 ± 1.40, P = 0.22, d = 0.81) and fractional shortening in the T ewes compared with C (35.83 ± 2.33% vs. 41.50 ± 2.84, P = 0.15, d = 0.89). T treatment significantly increased 1) left ventricle (LV) weight-to-body weight ratio (2.82 ± 0.14 g/kg vs. 2.46 ± 0.08) and LV thickness (14.56 ± 0.52 mm vs. 12.50 ± 0.75), 2) proinflammatory marker [tumor necrosis factor-alpha (TNF-α)] in LV (1.66 ± 0.35 vs. 1.06 ± 0.18), 3) LV collagen (Masson's Trichrome stain: 3.38 ± 0.35 vs. 1.49 ± 0.15 and Picrosirius red stain: 5.50 ± 0.32 vs. 3.01 ± 0.23), 4) markers of LV apoptosis, including TUNEL (8.3 ± 1.1 vs. 0.9 ± 0.18), bcl-2-associated X protein (Bax)+-to-b-cell lymphoma 2 (Bcl2)+ ratio (0.68 ± 0.30 vs. 0.13 ± 0.02), and cleaved caspase 3 (15.4 ± 1.7 vs. 4.4 ± 0.38). These findings suggest that gestational testosterone excess adversely programs the maternal LV, leading to adverse structural and functional consequences in the postpartum period.NEW & NOTEWORTHY Using a sheep model of human translational relevance, this study provides evidence that excess gestational testosterone exposure such as that seen in hyperandrogenic disorders adversely impacts postpartum maternal hearts.

Accuracy of Maternal Self-Report of Recent Preeclampsia Among Healthy Women

Background: Preeclampsia history signals a higher risk for cardiovascular disease, but its value as a risk marker relies primarily on self-report. To identify the accuracy of maternal self-reports of recent preeclampsia, we conducted a validation study among women recruited to a web-based trial. Methods: Women with preeclampsia in the past 5 years were recruited to Heart Health 4 Moms. Preeclampsia was self-reported through an online recruitment questionnaire and affirmed via phone screen. Accuracy of maternal self-report was quantified using positive predictive value (PPV) versus medical record evidence of preeclampsia using three definitions: (1) documentation of clinician diagnosis, (2) American College of Obstetricians and Gynecologists (ACOG) 2002 diagnostic criteria (gestational hypertension and proteinuria), and (3) ACOG 2013 diagnostic criteria (gestational hypertension and proteinuria or systemic symptoms). Results: Complete medical records were received for 290 women who delivered from 2011 to 2016 and were predominantly non-Hispanic White (81.7%) with a mean age of 31.2 ± 4.8 years. Mean length of recall was 13.6 ± 14.7 months. The majority of women (92.1%) had medical record evidence of preeclampsia using ≥1 of the definitions. Maternal self-report of preeclampsia was validated for 88.3% based on clinician diagnosis, 59.0% with ACOG 2002, and 65.2% with ACOG 2013. Conclusions: In this validation study of U.S. women, the majority accurately self-reported their preeclampsia diagnosis based on medical record review. A higher proportion of self-reports validated by clinician diagnosis than ACOG criteria, suggesting women remember the diagnosis given by their provider and providers may not always follow or document criteria when making a diagnosis.

Women with a history of gestational diabetes mellitus present an accumulation of cardiovascular risk factors at age 46-A birth cohort study

INTRODUCTION

The incidence of gestational diabetes mellitus (GDM) is globally increasing, and it has been associated with later type 2 diabetes, metabolic syndrome (MetS), and cardiovascular disease (CVD). However, long-term population-based studies investigating common CVD risk factors years after pregnancy are lacking. To evaluate the future mortality and morbidity in cardiovascular and metabolic diseases, we conducted a thorough investigation of midlife risk factors in women with and without previous GDM.

MATERIAL AND METHODS

A prospective population-based cohort study was conducted of 3173 parous women from the Northern Finland Birth Cohort, 1966. Study participants were obtained from the national register or patient records. Those with a GDM diagnosis formed the GDM cohort (n = 271), and those without a previous GDM diagnosis formed the control cohort (n = 2902). Clinical examinations were performed on participants at the age of 46 and included anthropometric measurements, oral glucose tolerance test (OGTT), biochemical measurements, and cardiovascular assessment.

RESULTS

At the age of 46, women in the GDM cohort had a higher body mass index (BMI, 29.0 kg/m2 vs 26.3 kg/m2, p < 0.001) and greater waist circumference (94.1 cm vs 86.5 cm, p < 0.001) than the control cohort. In the GDM cohort, a higher incidence of impaired glucose tolerance (12.6% vs 7.3%, p = 0.002), more previously diagnosed and OGTT-detected type 2 diabetes (23.3% vs 3.9%, p < 0.001), lower high-density lipoprotein (1.53 mmol/L vs 1.67 mmol/L, p = 0.011), higher triglycerides (1.26 mmol/L vs 1.05 mmol/L, p = 0.002) and a higher fatty liver index (6.82 vs 2.47, p < 0.001), were observed even after adjusting for BMI, polycystic ovary syndrome, parity, level of education, physical activity, smoking, and alcohol consumption. The women in the GDM cohort also had more MetS (42.6% vs 21.9%, p < 0.001) and higher risk scores for CVD and fatal events (Framingham 4.95 vs 3.60, p < 0.001; FINRISK 1.71 vs 1.08, p < 0.001).

CONCLUSIONS

Women with a previous diagnosis of GDM exhibit more risk factors for CVD in midlife and are at a higher risk for cardiovascular events later in life.

Association of gestational diabetes with long-term risk of premature mortality, and cardiovascular outcomes and risk factors: A retrospective cohort analysis in the UK Biobank

AIM

To investigate the association of gestational diabetes mellitus (GDM) with premature mortality and cardiovascular (CVD) outcomes and risk factors.

MATERIALS AND METHODS

Parous women recruited to the UK Biobank cohort during 2006-2010 were followed up from their first delivery until 31 October 2021. The data were linked to Hospital Episode Statistics and mortality registries. Multivariate Cox proportional hazard models investigated associations of GDM with all-cause mortality, CVD, diabetes, hypertension and dyslipidaemia.

RESULTS

The maximum total analysis time at risk and under observation was 9 694 090 person-years. Among 220 726 women, 1225 self-reported or had a recorded diagnosis of GDM. After adjusting for confounders and behavioural factors, GDM was associated with increased risk for premature mortality [hazard ratio (HR): 1.44, 95% confidence interval (CI): 1.12-1.86], particularly CVD-related death (HR: 2.38, 95% CI: 1.63-3.48), as well as incident total CVD (HR: 1.50, 95% CI: 1.30-1.74), non-fatal CVD (HR: 1.41, 95% CI: 1.20-1.65), diabetes (HR: 14.37, 95% CI: 13.51-15.27), hypertension (HR: 1.49, 95% CI: 1.38-1.60), and dyslipidaemia (HR: 1.30, 95% CI: 1.22-1.39). The total CVD risk was greater in women with GDM who did not later develop diabetes than in those with GDM and diabetes.

CONCLUSIONS

Women with GDM are at increased risk of premature death and have increased CV risk, emphasizing the importance of interventions to prevent GDM. If GDM develops, the diagnosis represents an opportunity for future surveillance and intervention to reduce CVD risk factors, prevent CVD and improve long-term health.

Health impacts of new-onset diabetes in women post-gestational diabetes mellitus: Insights from Hong Kong's territory-wide data

AIMS/INTRODUCTION

To determine the population health burden attributable to the development of diabetes among women with a history of gestational diabetes mellitus (GDM).

MATERIALS AND METHODS

We conducted a retrospective analysis of women with a history of GDM attending the Hong Kong Hospital Authority between 2000 and 2019. The time-varying population attributable fraction was calculated.

RESULTS

A total of 76,181 women with a history of gestational diabetes mellitus were included, 6,606 of them developed diabetes during a median follow-up of 8.6 years. The respective hazard ratios (95% confidence interval) among women with GDM who developed diabetes vs those with GDM only were 2.8 (2.2, 3.7) for cardiovascular disease (CVD), 4.8 (3.0, 7.7) for end-stage kidney disease (ESKD), 2.2 (1.9, 2.6) for infection-related hospitalization, and 1.8 (1.3, 2.4) for all-cause mortality. The development of diabetes was associated with 1.3 (0.8, 1.7), 0.6 (0.3, 0.8), 3.2 (2.4, 4.0), and 0.5 (0.2, 0.9) additional incident cases per 1,000 person-years, accounting for 24.0% (13.2%, 35.9%), 42.0% (22.5%, 58.8%), 10.8% (7.1%, 14.9%), and 6.0% (-3.1%, 16.1%) of absolute number of CVD, ESKD, infection-related hospitalization, and all-cause mortality over 20 years after GDM, respectively.

CONCLUSIONS

Diabetes is a significant contributor to the population health burden of some clinical outcomes in women with a history of gestational diabetes mellitus, but other risk factors need to be considered.

Association between gestational diabetes and cardiovascular disease within 24 months postpartum

BACKGROUND

Cardiovascular disease is the leading cause of death among women in the United States. It is well established that gestational diabetes mellitus is associated with an overall lifetime increased risk of cardiometabolic disease, even among those without intercurrent type 2 diabetes. However, the association between gestational diabetes mellitus and short-term risk of cardiovascular disease is unclear. Establishing short-term risks of cardiovascular disease for patients with gestational diabetes mellitus has significant potential to inform early screening and targeted intervention strategies to reduce premature cardiovascular morbidity among women.

OBJECTIVE

This study aimed to compare the risk of cardiovascular disease diagnosis in the first 24 months postpartum between patients with and without gestational diabetes mellitus.

STUDY DESIGN

Our longitudinal population-based study included pregnant individuals with deliveries from 2007 to 2019 in the Maine Health Data Organization's All Payer Claims Database. We excluded records with gestational age <20 weeks, non-Maine residence, multifetal gestation, no insurance in the month of delivery or the 3 months before pregnancy, an implausibly short interval until next pregnancy (<60 days), pregestational diabetes mellitus, and any prepregnancy diagnosis of the cardiovascular conditions being examined postpartum. Gestational diabetes mellitus and cardiovascular disease (heart failure, ischemic heart disease, arrhythmia/cardiac arrest, cardiomyopathy, cerebrovascular disease/stroke, and new chronic hypertension) were identified by International Classification of Diseases 9/10 diagnosis codes. Cox proportional hazards models were used to estimate hazard ratios, adjusting for potential confounding factors. We assessed whether the association between gestational diabetes mellitus and chronic hypertension was mediated by intercurrent diabetes mellitus.

RESULTS

Among the 84,746 pregnancies examined, the cumulative risk of cardiovascular disease within 24 months postpartum for those with vs without gestational diabetes mellitus was 0.13% vs 0.20% for heart failure, 0.16% vs 0.14% for ischemic heart disease, 0.60% vs 0.44% for cerebrovascular disease/stroke, 0.22% vs 0.16% for arrhythmia/cardiac arrest, 0.20% vs 0.20% for cardiomyopathy, and 4.19% vs 1.83% for new chronic hypertension. After adjusting for potential confounders, those with gestational diabetes had an increased risk of new chronic hypertension (adjusted hazard ratio, 1.56; 95% confidence interval, 1.32-1.86) within the first 24 months postpartum compared with those without gestational diabetes. There was no association between gestational diabetes and ischemic heart disease (adjusted hazard ratio, 0.75; 95% confidence interval, 0.34-1.65), cerebrovascular disease/stroke (adjusted hazard ratio, 1.13; 95% confidence interval, 0.78-1.66), arrhythmia/cardiac arrest (adjusted hazard ratio, 1.16; 95% confidence interval, 0.59-2.29), or cardiomyopathy (adjusted hazard ratio, 0.75; 95% confidence interval, 0.40-1.41) within the first 24 months postpartum. Those with gestational diabetes appeared to have a decreased risk of heart failure within 24 months postpartum (adjusted hazard ratio, 0.45; 95% confidence interval, 0.21-0.98). Our mediation analyses estimated that 28% of the effect of gestational diabetes on new chronic hypertension was mediated through intercurrent diabetes mellitus.

CONCLUSION

Patients with gestational diabetes mellitus have a significantly increased risk of new chronic hypertension as early as 24 months postpartum. Most of this effect was not due to the development of diabetes mellitus. Our findings suggest that all women with gestational diabetes need careful monitoring and screening for new chronic hypertension in the first 2 years postpartum.

No role of the third-trimester inflammatory factors in the association of gestational diabetes mellitus with postpartum cardiometabolic indicators

BACKGROUND

The influence of gestational diabetes mellitus (GDM) on postpartum cardiometabolic indicators is primarily restricted to glucose and lipid metabolism, however the indicators for liver and kidney function have been rarely explored, and the role of the third-trimester inflammatory factors in these associations has never been investigated.

METHODS

Based on the Ma'anshan birth cohort (MABC), women with or without GDM history were selected and invited to participate in a 6-year postpartum follow-up. The fasting blood samples were collected to measure 16 comprehensive metabolic indicators during a 6-year postpartum follow-up: fasting plasma glucose (FPG), glycosylated hemoglobin (HbA1c), triglycerides (TG), total cholesterol (TC), uric acid (UA), blood urea nitrogen (BUN), serum creatinine (SCR), etc. Seven inflammatory factors, including TNF-α, IFN-γ, IL-1β, IL-6, IL-10, IL-12p70, and IL-17 A, were measured with serum samples collected during the third trimester of pregnancy. Linear regression models were used to analyze the associations between GDM and 6-year postpartum metabolic indicators, GDM and third-trimester inflammatory factors, and the third-trimester inflammatory factors and 6-year postpartum metabolic indicators. Mediating and moderating effect analyses were further performed to explore if the third-trimester inflammatory factors mediate or modify the association between GDM and postpartum cardiometabolic indicators.

RESULTS

From July 2021 to August 2022, 307 participants have been followed up, with 99 women with a prior GDM history. Compared with those without GDM, individuals with a prior history of GDM had significantly elevated levels of FPG (β = 0.40, 95% CI: 0.18 to 0.62, PFDR < 0.001), HbA1c (β = 0.22, 95% CI: 0.09 to 0.34, PFDR = 0.009), TyG (β = 0.22, 95% CI: 0.07 to 0.37, PFDR = 0.024) at 6 years postpartum, and the association between GDM and SCR (β = 2.43, 95% CI: 0.02 to 4.85, PFDR = 0.144) reached nominal significance level. GDM history was associated with a decreased level of third-trimester IL-17 A (β = -0.58, 95% CI: -0.99 to -0.18, PFDR = 0.035). No significant association between third-trimester inflammatory factors and 6-year postpartum metabolic indicators was observed. And no mediating or moderating effect of third-trimester inflammatory factors was observed in those associations.

CONCLUSION

A prior history of GDM was significantly associated with elevated FPG, HbA1c, and TyG in women at 6 years postpartum, whereas third-trimester inflammatory factors had no role in mediating or moderating these associations.

Does gestational diabetes mellitus increase the risk of cardiovascular disease? A Mendelian randomization study

PURPOSE

In recent years, epidemiological studies have revealed the relationship between gestational diabetes mellitus (GDM) and cardiovascular disease (CVD). In this study, we utilized Mendelian randomization (MR) to investigate the potential causal impact of GDM on cardiovascular disease for the first time.

METHODS

 We retrieved summary statistics from published genome-wide association studies. MR was first performed using significant SNPs extracted from the eighth data release of the FinnGen study. Next, a replication analysis for coronary artery disease (CAD) was conducted in another European ancestry population to validate our findings. Finally, mediation analysis was carried out to assess potential mediation effects.

RESULTS

Our data analysis revealed that genetically predicted GDM was significantly associated with increased CAD risk (OR 1.10, 95% CI 1.02-1.18, p 0.006). Replication analysis confirmed a significant genetic association between GDM and CAD (OR 1.07, 95% CI 1.02-1.12, p 0.003) in another European ancestry population. Mediation analysis indicated no significant mediation effect by type 2 diabetes mellitus (T2DM) on the GDM-CAD relationship (mediation effect β [95% CI]: 0.005 [-0.003, -0.017]).

CONCLUSION

Women with a prior history of GDM face an elevated risk of future CAD. This increased risk of CAD cannot be solely attributed to the subsequent onset of diabetes. Regular CAD risk assessment and primary prevention strategies are of paramount importance for women with a history of GDM.

Predicting Progression from Gestational Diabetes to Impaired Glucose Tolerance Using Peridelivery Data: An Observational Study

OBJECTIVE

This article aimed to develop a predictive model to identify persons with recent gestational diabetes mellitus (GDM) most likely to progress to impaired glucose tolerance postpartum.

STUDY DESIGN

We conducted an observational study among persons with GDM in their most recent pregnancy, defined by Carpenter-Coustan criteria. Participants were followed up from delivery through 1-year postpartum. We used lasso regression with k-fold cross validation to develop a multivariable model to predict progression to impaired glucose tolerance, defined as HbA1c≥5.7%, at 1-year postpartum. Predictive ability was assessed by the area under the curve (AUC), sensitivity, specificity, and positive and negative predictive values (PPV and NPV).

RESULTS

Of 203 participants, 71 (35%) had impaired glucose tolerance at 1-year postpartum. The final model had an AUC of 0.79 (95% confidence interval [CI]: 0.72, 0.85) and included eight indicators of weight, body mass index, family history of type 2 diabetes, GDM in a prior pregnancy, GDM diagnosis<24 weeks' gestation, and fasting and 2-hour plasma glucose at 2 days postpartum. A cutoff point of ≥ 0.25 predicted probability had sensitivity of 80% (95% CI: 69, 89), specificity of 58% (95% CI: 49, 67), PPV of 51% (95% CI: 41, 61), and NPV of 85% (95% CI: 76, 91) to identify women with impaired glucose tolerance at 1-year postpartum.

CONCLUSION

Our predictive model had reasonable ability to predict impaired glucose tolerance around delivery for persons with recent GDM.

KEY POINTS

· We developed a predictive model to identify persons with GDM most likely to develop IGT postpartum.. · The final model had an AUC of 0.79 (95% CI: 0.72, 0.85) and included eight clinical indicators.. · If validated, our model could help prioritize diabetes prevention efforts among persons with GDM..

Genetic and inflammatory factors underlying gestational diabetes mellitus: a review

Gestational diabetes mellitus (GDM) poses a significant global health concern, impacting both maternal and fetal well-being. Early detection and treatment are imperative to mitigate adverse outcomes during pregnancy. This review delves into the pivotal role of insulin function and the influence of genetic variants, including SLC30A8, CDKAL1, TCF7L2, IRS1, and GCK, in GDM development. These genetic variations affect beta-cell function and insulin activity in crucial tissues, such as muscle, disrupting glucose regulation during pregnancy. We propose a hypothesis that this variation may disrupt zinc transport, consequently impairing insulin production and secretion, thereby contributing to GDM onset. Furthermore, we discussed the involvement of inflammatory pathways, such as TNF-alpha and IL-6, in predisposing individuals to GDM. Genetic modulation of these pathways may exacerbate glucose metabolism dysregulation observed in GDM patients. We also discussed how GDM affects cardiovascular disease (CVD) through a direct correlation between pregnancy and cardiometabolic function, increasing atherosclerosis, decreased vascular function, dyslipidemia, and hypertension in women with GDM history. However, further research is imperative to unravel the intricate interplay between inflammatory pathways, genetics, and GDM. This understanding is pivotal for devising targeted gene therapies and pharmacological interventions to rectify genetic variations in SLC30A8, CDKAL1, TCF7L2, IRS1, GCK, and other pertinent genes. Ultimately, this review offers insights into the pathophysiological mechanisms of GDM, providing a foundation for developing strategies to mitigate its impact.

Increased risk of cardiovascular and renal disease, and diabetes for all women diagnosed with gestational diabetes mellitus in New Zealand-A national retrospective cohort study

BACKGROUND

Gestational diabetes mellitus increases the risk of developing type 2 diabetes. The aim of this study is to compare cardiometabolic and renal outcomes for all women in New Zealand with gestational diabetes (2001-2010) with women without diabetes, 10-20 years following delivery.

METHODS

A retrospective cohort study, utilizing a national dataset providing information for all women who gave birth between 1 January 2001 and 31 December 2010 (n = 604 398). Adolescent girls <15 years, women ≥50 years and women with prepregnancy diabetes were excluded. In total 11 459 women were diagnosed with gestational diabetes and 11 447 were matched (for age and year of delivery) with 57 235 unexposed (control) women. A national hospital dataset was used to compare primary outcomes until 31 May 2021.

RESULTS

After controlling for ethnicity, women with gestational diabetes were significantly more likely than control women to develop diabetes-adjusted hazard ratio (HR) 20.06 and 95% confidence interval (CI) 18.46-21.79; a first cardiovascular event 2.19 (1.86-2.58); renal disease 6.34 (5.35-7.51) and all-cause mortality 1.55 (1.31-1.83), all p values <.0001. The HR and 95% CI remained similar after controlling for significant covariates: diabetes 18.89 (17.36-20.56), cardiovascular events 1.79 (1.52-2.12), renal disease 5.42 (4.55-6.45), and all-cause mortality 1.44 (1.21-1.70). When time-dependent diabetes was added to the model, significance remained for cardiovascular events 1.33 (1.10-1.61), p = .003 and renal disease 2.33 (1.88-2.88), p < .0001 but not all-cause mortality.

CONCLUSIONS

Women diagnosed with gestational diabetes have an increased risk of adverse cardiometabolic and renal outcomes. Findings highlight the importance of follow-up screening for diabetes, cardiovascular risk factors, and renal disease.

Understanding the role of childhood nurture, abuse, and stability on gestational diabetes in the Coronary Artery Risk Development in Young Adults study (CARDIA)

BACKGROUND

To estimate associations between facets of the maternal childhood family environment with gestational diabetes (GDM) and to test mediation by pre-pregnancy waist circumference.

METHODS

We used data from CARDIA, a cohort of individuals aged 18-30 years at baseline (1985-86), followed over 30 years (2016). We included participants with one or more pregnancies ≥ 20 weeks after baseline, without pre-pregnancy diabetes. The primary exposure was the Childhood Family Environment Scale (assessed year 15), including the total score and abuse, nurture, and stability subscales as continuous, separate exposures. The outcome was GDM (self-reported at each visit for each pregnancy). We fit log binomial models with generalized estimating equations to calculate risk ratios (RR) and 95% confidence intervals (CI), adjusting for age at delivery, parity, race (Black or White), and parental education. We used regression models with bootstrapped CIs to test mediation and effect modification by excess abdominal adiposity at the last preconception CARDIA visit (waist circumference ≥ 88 cm).

RESULTS

We included 1033 individuals (46% Black) with 1836 pregnancies. 130 pregnancies (7.1%) were complicated by GDM. For each 1 point increase on the abuse subscale (e.g., from "rarely or never" to "some or little of the time") there was a 30% increased risk of GDM (RR: 1.3, 95% CI: 1.0, 1.7). There was evidence of effect modification but not mediation by preconception abdominal adiposity.

CONCLUSIONS

A more adverse childhood family environment was associated with increased risk of GDM, with a stronger association among individuals with preconception waist circumference ≥ 88 cm.

Knowledge and care regarding long-term cardiovascular risk after hypertensive disorders of pregnancy and gestational diabetes

BACKGROUND

Adverse pregnancy outcomes (APO), such as preeclampsia (PE) and gestational diabetes (GDM) are substantial risk factors for cardiovascular disease (CVD) later in life. Identifying these high-risk female individuals during pregnancy offers the possibility of preventing long-term CVD and chronic kidney disease via a structured therapeutic and surveillance plan. We aimed to evaluate the current practice of postpartum care in women after APO and the impact on the women's awareness about their future risk for CVD.

METHODS

Women diagnosed with PE and GDM at the University Hospital of St. Poelten/Lilienfeld between 2015-2020 were identified and participated in a structured telephone interview about postpartum medical care and knowledge about the impact of APOs on long-term cardiovascular health.

RESULTS

Of 161 out of the 750 women contacted, 29% (n = 46) were diagnosed with PE and 71% (n = 115) with GDM. One third of all women and up to 44% of women diagnosed with PE, were unaware that APOs are related to CVD. Women diagnosed with PE were less likely to receive postpartum care information than those with GDM (30.4% vs. 49.6%, p = 0.027), and only one third of all women after APOs were counselled by a physician or healthcare professional. Of the women 50% received recommendations regarding lifestyle changes after delivery; significantly more women with GDM than women with PE (54% vs. 37%, p = 0.05). Only 14% had at least one long-term follow-up.

CONCLUSION

This study identified a significant deficit of structured postpartum care and a lack of awareness among women after APO and their healthcare providers about the increased risk of long-term CVD.

Parental genetically predicted liability for coronary heart disease and risk of adverse pregnancy outcomes: a cohort study

BACKGROUND

Adverse pregnancy outcomes (APO) may unmask or exacerbate a woman's underlying risk for coronary heart disease (CHD). We estimated associations of maternal and paternal genetically predicted liability for CHD with lifelong risk of APOs. We hypothesized that associations would be found for women, but not their male partners (negative controls).

METHODS

We studied up to 83,969‬ women (and up to 55,568‬ male partners) from the Norwegian Mother, Father and Child Cohort Study or the Trøndelag Health Study with genotyping data and lifetime history of any APO in their pregnancies (1967-2019) in the Medical Birth Registry of Norway (miscarriage, stillbirth, hypertensive disorders of pregnancy, gestational diabetes, small for gestational age, large for gestational age, and spontaneous preterm birth). Maternal and paternal genetic risk scores (GRS) for CHD were generated using 148 gene variants (p-value < 5 × 10-8, not in linkage disequilibrium). Associations between GRS for CHD and each APO were determined using logistic regression, adjusting for genomic principal components, in each cohort separately, and combined using fixed effects meta-analysis.

RESULTS

One standard deviation higher GRS for CHD in women was related to increased risk of any hypertensive disorders of pregnancy (odds ratio [OR] 1.08, 95% confidence interval [CI] 1.05-1.10), pre-eclampsia (OR 1.08, 95% CI 1.05-1.11), and small for gestational age (OR 1.04, 95% CI 1.01-1.06). Imprecise associations with lower odds of large for gestational age (OR 0.98, 95% CI 0.96-1.00) and higher odds of stillbirth (OR 1.04, 95% CI 0.98-1.11) were suggested. These findings remained consistent after adjusting for number of total pregnancies and the male partners' GRS and restricting analyses to stable couples. Associations for other APOs were close to the null. There was weak evidence of an association of paternal genetically predicted liability for CHD with spontaneous preterm birth in female partners (OR 1.02, 95% CI 0.99-1.05), but not with other APOs.

CONCLUSIONS

Hypertensive disorders of pregnancy, small for gestational age, and stillbirth may unmask women with a genetically predicted propensity for CHD. The association of paternal genetically predicted CHD risk with spontaneous preterm birth in female partners needs further exploration.

Precision stratification of prognostic risk factors associated with outcomes in gestational diabetes mellitus: a systematic review

BACKGROUND

The objective of this systematic review is to identify prognostic factors among women and their offspring affected by gestational diabetes mellitus (GDM), focusing on endpoints of cardiovascular disease (CVD) and type 2 diabetes (T2D) for women, and cardiometabolic profile for offspring.

METHODS

This review included studies published in English language from January 1st, 1990, through September 30th, 2021, that focused on the above outcomes of interest with respect to sociodemographic factors, lifestyle and behavioral characteristics, traditional clinical traits, and 'omics biomarkers in the mothers and offspring during the perinatal/postpartum periods and across the lifecourse. Studies that did not report associations of prognostic factors with outcomes of interest among GDM-exposed women or children were excluded.

RESULTS

Here, we identified 109 publications comprising 98 observational studies and 11 randomized-controlled trials. Findings indicate that GDM severity, maternal obesity, race/ethnicity, and unhealthy diet and physical activity levels predict T2D and CVD in women, and greater cardiometabolic risk in offspring. However, using the Diabetes Canada 2018 Clinical Practice Guidelines for studies, the level of evidence was low due to potential for confounding, reverse causation, and selection biases.

CONCLUSIONS

GDM pregnancies with greater severity, as well as those accompanied by maternal obesity, unhealthy diet, and low physical activity, as well as cases that occur among women who identify as racial/ethnic minorities are associated with worse cardiometabolic prognosis in mothers and offspring. However, given the low quality of evidence, prospective studies with detailed covariate data collection and high fidelity of follow-up are warranted.

Rural-urban disparities in pregestational and gestational diabetes in pregnancy: Serial, cross-sectional analysis of over 12 million pregnancies

OBJECTIVE

To compare trends in pregestational (DM) and gestational diabetes (GDM) in pregnancy in rural and urban areas in the USA, because pregnant women living in rural areas face unique challenges that contribute to rural-urban disparities in adverse pregnancy outcomes.

DESIGN

Serial, cross-sectional analysis.

SETTING

US National Center for Health Statistics (NCHS) Natality Files from 2011 to 2019.

POPULATION

A total of 12 401 888 singleton live births to nulliparous women aged 15-44 years.

METHODS

We calculated the frequency (95% confidence interval [CI]) per 1000 live births, the mean annual percentage change (APC), and unadjusted and age-adjusted rate ratios (aRR) of DM and GDM in rural compared with urban maternal residence (reference) per the NCHS Urban-Rural Classification Scheme overall, and by delivery year, reported race and ethnicity, and US region (effect measure modification).

MAIN OUTCOME MEASURES

The outcomes (modelled separately) were diagnoses of DM and GDM.

RESULTS

From 2011 to 2019, there were increases in both the frequency (per 1000 live births; mean APC, 95% CI per year) of DM and GDM in rural areas (DM: 7.6 to 10.4 per 1000 live births; APC 2.8%, 95% CI 2.2%-3.4%; and GDM: 41.4 to 58.7 per 1000 live births; APC 3.1%, 95% CI 2.6%-3.6%) and urban areas (DM: 6.1 to 8.4 per 1000 live births; APC 3.3%, 95% CI 2.2%-4.4%; and GDM: 40.8 to 61.2 per 1000 live births; APC 3.9%, 95% CI 3.3%-4.6%). Individuals living in rural areas were at higher risk of DM (aRR 1.48, 95% CI 1.45%-1.51%) and GDM versus those in urban areas (aRR 1.17, 95% CI 1.16%-1.18%). The increased risk was similar each year for DM (interaction p = 0.8), but widened over time for GDM (interaction p < 0.01). The rural-urban disparity for DM was wider for individuals who identified as Hispanic race/ethnicity and in the South and West (interaction p < 0.01 for all); and for GDM the rural-urban disparity was generally wider for similar factors (i.e. Hispanic race/ethnicity, and in the South; interaction p < 0.05 for all).

CONCLUSIONS

The frequency of DM and GDM increased in both rural and urban areas of the USA from 2011 to 2019 among nulliparous pregnant women. Significant rural-urban disparities existed for DM and GDM, and increased over time for GDM. These rural-urban disparities were generally worse among those of Hispanic race/ethnicity and in women who lived in the South. These findings have implications for delivering equitable diabetes care in pregnancy in rural US communities.

The role of lipid dysregulation in gestational diabetes mellitus: Early prediction and postpartum prognosis

Gestational diabetes mellitus (GDM) is a pathological condition during pregnancy characterized by impaired glucose tolerance, and the failure of pancreatic beta-cells to respond appropriately to an increased insulin demand. However, while the majority of women with GDM will return to normoglycemia after delivery, they have up to a seven times higher risk of developing type 2 diabetes during midlife, compared with those with no history of GDM. Gestational diabetes mellitus also increases the risk of multiple metabolic disorders, including non-alcoholic fatty liver disease, obesity, and cardiovascular diseases. Lipid metabolism undergoes significant changes throughout the gestational period, and lipid dysregulation is strongly associated with GDM and the progression to future type 2 diabetes. In addition to common lipid variables, discovery-based omics techniques, such as metabolomics and lipidomics, have identified lipid biomarkers that correlate with GDM. These lipid species also show considerable potential in predicting the onset of GDM and subsequent type 2 diabetes post-delivery. This review aims to update the current knowledge of the role that lipids play in the onset of GDM, with a focus on potential lipid biomarkers or metabolic pathways. These biomarkers may be useful in establishing predictive models to accurately predict the future onset of GDM and type 2 diabetes, and early intervention may help to reduce the complications associated with GDM.

In-hospital and 1-year outcomes of patients without modifiable risk factors presenting with acute coronary syndrome undergoing PCI: a Sex-stratified analysis

Aim

A considerable proportion of patients admitted with acute coronary syndrome (ACS) have no standard modifiable cardiovascular risk factors (SMuRFs: hypertension, diabetes mellitus, dyslipidemia, and cigarette smoking). The outcomes of this population following percutaneous coronary intervention (PCI) are debated. Further, sex differences within this population have yet to be established.

Methods

This retrospective cohort study included 7,847 patients with ACS who underwent PCI. The study outcomes were in-hospital mortality, all-cause mortality, and major adverse cardio-cerebrovascular events (MACCE). The association between the absence of SMuRFs (SMuRF-less status) and outcomes among all the patients and each sex was assessed using logistic and Cox proportional hazard regressions.

Results

Approximately 11% of the study population had none of the SMuRFs. During 12.13 [11.99-12.36] months of follow-up, in-hospital mortality (adjusted-odds ratio (OR):1.51, 95%confidence interval (CI): 0.91-2.65, P:0.108), all-cause mortality [adjusted-hazard ratio (HR): 1.01, 95%CI: 0.88-1.46, P: 0.731], and MACCE (adjusted-HR: 0.93, 95%CI:0.81-1.12, P: 0.412) did not differ between patients with and without SMuRFs. Sex-stratified analyses recapitulated similar outcomes between SMuRF+ and SMuRF-less men. In contrast, SMuRF-less women had significantly higher in-hospital (adjusted-OR: 3.28, 95%CI: 1.92-6.21, P < 0.001) and all-cause mortality (adjusted-HR:1.41, 95%CI: 1.02-3.21, P: 0.008) than SMuRF+ women.

Conclusions

Almost one in 10 patients with ACS who underwent PCI had no SMuRFs. The absence of SMuRFs did not confer any benefit in terms of in-hospital mortality, one-year mortality, and MACCE. Even worse, SMuRF-less women paradoxically had an excessive risk of in-hospital and one-year mortality.

Oral Glucose Tolerance Test in Pregnancy and Subsequent Maternal Hypertension

OBJECTIVE

The aim of the study is to evaluate whether values and the shape of the glucose curve during the oral glucose tolerance test (OGTT) in pregnancy identify women at risk of developing hypertension (HTN) later in life.

STUDY DESIGN

This category includes the secondary analysis of a follow-up from a mild gestational diabetes mellitus (GDM) study that included a treatment trial for mild GDM (n = 458) and an observational cohort of participants with abnormal 1-hour glucose loading test only (normal OGTT, n = 430). Participants were assessed at a median of 7 (IQR 6-8) years after their index pregnancy, and trained staff measured their blood pressure (systolic blood pressure [SBP]; diastolic blood pressure [DBP]). The association between values and the shape of the glucose curve during OGTT in the index pregnancy and the primary outcome defined as elevated BP (SBP ≥120, DBP ≥80 mm Hg, or receiving anti-HTN medications), and secondary outcome defined as stage 1 or higher (SBP ≥130, DBP ≥80 mm Hg, or receiving anti-HTN medications) at follow-up were evaluated using multivariable regression, adjusting for maternal age, body mass index, and pregnancy-associated hypertension during the index pregnancy.

RESULTS

There was no association between fasting, 1-hour OGTT, and the outcomes. However, the 2-hour OGTT value was positively associated (adjusted odds ratio [aRR] per 10-unit increase 1.04, 95% CI 1.01-1.08), and the 3-hour was inversely associated (aRR per 10-unit increase 0.96, 95% CI 0.93-0.99) with the primary outcome. When the shape of the OGTT curve was evaluated, a monophasic OGTT response (peak at 1 hour followed by a decline in glucose) was associated with increased risk of elevated BP (41.3vs. 23.5%, aRR 1.66, 95% CI 1.17-2.35) and stage 1 HTN or higher (28.5 vs. 14.7%, aRR 1.83, 95% CI 1.15-2.92), compared with a biphasic OGTT response.

CONCLUSION

Among persons with mild GDM or lesser degrees of glucose intolerance, the shape of the OGTT curve during pregnancy may help identify women who are at risk of HTN later in life, with biphasic shape to be associated with lower risk.

KEY POINTS

· The shape of the Oral Glucose Tolerance Test curve may help identify patients who are at risk of having elevated BP or HTN 5 to 10 years following pregnancy.. · The 2-hour Oral Glucose Tolerance Test values is positively associated with elevated BP 5 to 10 years following pregnancy.. · This supports the concept of pregnancy as a window to future health and represents a potential novel biomarker for maternal cardiovascular health screening..

Association of Gestational Diabetes With Subsequent Long-Term Risk of Mortality

Importance

Gestational diabetes has been associated with numerous chronic diseases. However, few studies have examined the association of gestational diabetes with long-term mortality risk.

Objective

To investigate the associations between gestational diabetes and long-term risks of total and cause-specific mortality.

Design, Setting, and Participants

This cohort study analyzed participants of the Nurses' Health Study II who were followed for 30 years (1989-2019). Participants included US female nurses aged 25 to 42 years who reported at least 1 pregnancy (≥6 months) at 18 years or older across their reproductive life span. Data were analyzed from May 1, 2022, to May 25, 2023.

Exposure

Gestational diabetes across the reproductive life span.

Main Outcomes and Measures

Hazard ratios (HRs with 95% CIs) for total and cause-specific mortality were estimated by Cox proportional hazards regression models.

Results

A total of 91 426 parous participants were included, with a mean (SD) age of 34.9 (4.7) years and a body mass index of 24.1 (4.7) at baseline. During a follow-up period of 2 609 753 person-years, 3937 deaths were documented, including 255 deaths from cardiovascular disease and 1397 from cancer. Participants with a history of gestational diabetes had a higher crude mortality rate than those without a history of gestational diabetes (1.74 vs 1.49 per 1000 person-years; absolute difference = 0.25 per 1000 person-years). The corresponding HR for total mortality was 1.28 (95% CI, 1.13-1.44), which did not materially change after additional adjustment for potential confounders and lifestyle factors during the reproductive life span (HR, 1.25; 95% CI, 1.11-1.41). The association persisted regardless of the subsequent development of type 2 diabetes and was more robust among participants who adopted less healthy lifestyles; experienced gestational diabetes in 2 or more pregnancies (HR, 1.48; 95% CI, 0.99-2.19); had gestational diabetes both in the initial and subsequent pregnancies (HR, 1.71; 95% CI, 1.11-2.63); and concurrently reported hypertensive disorders in pregnancy (HR, 1.80; 95% CI, 1.21-2.67), preterm birth (HR, 2.46; 95% CI, 1.66-3.64), or low birth weight (HR, 2.11; 95% CI, 1.21-3.68). Cause-specific mortality analyses revealed that gestational diabetes was directly associated with the risk of mortality due to cardiovascular disease (HR, 1.59; 95% CI, 1.03-2.47). Additionally, gestational diabetes was inversely associated with cancer mortality (HR, 0.76; 95% CI, 0.59-0.98); however, it was only evident among participants who later developed type 2 diabetes.

Conclusions and Relevance

Results of this cohort study suggest that participants who reported a history of gestational diabetes exhibited a small but elevated risk of subsequent mortality over 30 years. The findings emphasize the importance of considering gestational diabetes as a critical factor in later-life mortality risk.

Sugar-Sweetened Beverage Taxes and Perinatal Health: A Quasi-Experimental Study

INTRODUCTION

One in 5 pregnant individuals report consuming sugar-sweetened beverages at least once per day. Excess sugar consumption during pregnancy is associated with several perinatal complications. As sugar-sweetened beverage taxes become increasingly common public health measures to reduce sugar-sweetened beverage consumption, evidence of the downstream effects of sugar-sweetened beverage taxes on perinatal health remains limited.

METHODS

This longitudinal retrospective study examines whether sugar-sweetened beverage taxes in 5 U.S. cities were associated with decreased risk of perinatal complications, leveraging 2013-2019 U.S. national birth certificate data and a quasi-experimental difference-in-differences approach to estimate changes in perinatal outcomes. Analysis occurred from April 2021 through January 2023.

RESULTS

The sample included 5,324,548 pregnant individuals and their live singleton births in the U.S. from 2013 through 2019. Sugar-sweetened beverage taxes were associated with a 41.4% decreased risk of gestational diabetes mellitus (-2.2 percentage points; 95% CI= -4.2, -0.2), a -7.9% reduction in weight-gain-for-gestational-age z-score (-0.2 standard deviations; 95% CI= -0.3, -0.01), and decreased risk of infants born small for gestational age (-4.3 percentage points; 95% CI= -6.5, -2.1). There were heterogeneous effects across subgroups, particularly for weight-gain-for-gestational-age z-score.

CONCLUSIONS

Sugar-sweetened beverage taxes levied in five U.S. cities were associated with improvements in perinatal health. Sugar-sweetened beverage taxes may be an effective policy instrument for improving health during pregnancy, a critical window during which short-term dietary exposures can have lifelong consequences for the birthing person and child.

Association Between Maternal Glucose Levels in Gestational Diabetes Screening and Subsequent Hypertension

BACKGROUND

We assessed the association between maternal glucose levels in pregnancy and subsequent hypertension.

METHODS

This population-level, retrospective cohort study examined women aged 12 to 54 years with singleton pregnancies completed at ≥29 weeks of gestation from October 1, 2008 to December 1, 2018 followed until March 31, 2019 in Alberta, Canada. Women were stratified by results in the 50-gram glucose challenge test and by 75-gram oral glucose tolerance test subtypes (normal oral glucose tolerance test, elevated fasting plasma glucose only [elevated fasting], elevated postload glucose only, or both elevated fasting and postload glucose [combined]. Time to development of hypertension was modeled using Cox proportional hazards models.

RESULTS

Of 313 361 women, 231 008 (79.1%) underwent a glucose challenge test only while 60 909 (20.9%) underwent either an oral glucose tolerance test only or both. Nine thousand five hundred eighty (3.1%) developed hypertension, and 2824 (0.9%) developed cardiovascular disease over a median follow-up of 5.7 years. Every 1-mmol/L increase in glucose in the glucose challenge test increased the risk of subsequent hypertension by 15% (adjusted hazard ratio and 95% CI, 1.15 [1.14-1.16]). Among those who underwent the oral glucose tolerance test, the combined group conferred the highest risk of subsequent hypertension, followed by elevated fasting, then elevated postload glucose only (reference: glucose challenge test ≤7.1 mmol/L, adjusted hazard ratio [95% CI]: elevated postload glucose only, 1.83 [1.68-2.00]; elevated fasting 2.02 [1.70-2.40]; combined, 2.65 [2.33-3.01]). No significant associations between maternal glucose levels and cardiovascular disease were observed.

CONCLUSIONS

Increasing maternal glucose levels in pregnancy were associated with increasing risk of subsequent hypertension. These findings may help identify higher-risk women who should be targeted for earlier postpartum cardiovascular risk reduction.

The utility of plasma glycated CD59 in predicting postpartum glucose intolerance: A prospective study of women diagnosed with GDM during a period of universal GDM screening

AIMS

Gestational diabetes (GDM) is associated with the development of postpartum (PP) glucose intolerance. Plasma glycated CD59 (pGCD59) is an emerging biomarker for the detection of hyperglycaemia. The aim of this study was to assess the ability of PP pGCD59 to predict the development of PP GI as defined by the 2 h 75 g OGTT using the ADA criteria, in a cohort of women diagnosed with prior GDM in the index pregnancy using the 2 h 75 g OGTT at 24-28 weeks of gestation according to the World Health Organization (WHO) 2013 criteria.

METHODS

Of the 2017 pregnant women recruited prospectively 140 women with gestational diabetes had samples for pGCD59 taken PP at the time of the OGTT. The ability of pGCD59 to predict the results of the PP OGTT was assessed using nonparametric receiver operating characteristic (ROC) curves.

RESULTS

Women with PP glucose intolerance had significantly higher PP pGCD59 levels compared to women with normal glucose tolerance PP (3.8 vs. 2.7 SPU). PP pGCD59 identified women who developed glucose intolerance PP with an AUC of 0.80 (95% CI: 0.70-0.91). A PP pGCD59 cut-off value of 1.9 SPU generated a sensitivity of 100% (95% CI: 83.9-100), specificity of 16.9% (95% CI: 9.8-26.3), positive predictive value of 22.1% (95% CI: 21.0-22.6), and negative predictive value of 100% (95% CI: 87.4-100). PP fasting plasma glucose generated an AUC of 0.96 (95% CI: 0.89-0.99) for the identification of PP glucose intolerance.

CONCLUSION

Our study found that PP pGCD9 may be a promising biomarker to identify women not requiring PP glucose intolerance screening using the traditional OGTT. While the diagnostic accuracy of pGCD59 is good, fasting plasma glucose remains a better test for the identification of PP glucose intolerance.

Modeling spatially varying compliance effects of PM2.5 exposure reductions on gestational diabetes mellitus in southern California: Results from electronic health record data of a large pregnancy cohort

Gestational diabetes mellitus (GDM) is a major pregnancy complication affecting approximately 14.0% of pregnancies around the world. Air pollution exposure, particularly exposure to PM2.5, has become a major environmental issue affecting health, especially for vulnerable pregnant women. Associations between PM2.5 exposure and adverse birth outcomes are generally assumed to be the same throughout a large geographical area. However, the effects of air pollution on health can very spatially in subpopulations. Such spatially varying effects are likely due to a wide range of contextual neighborhood and individual factors that are spatially correlated, including SES, demographics, exposure to housing characteristics and due to different composition of particulate matter from different emission sources. This combination of elevated environmental hazards in conjunction with socioeconomic-based disparities forms what has been described as a "double jeopardy" for marginalized sub-populations. In this manuscript our analysis combines both an examination of spatially varying effects of a) unit-changes in exposure and examines effects of b) changes from current exposure levels down to a fixed compliance level, where compliance levels correspond to the Air Quality Standards (AQS) set by the U.S. Environmental Protection Agency (EPA) and World Health Organization (WHO) air quality guideline values. Results suggest that exposure reduction policies should target certain "hotspot" areas where size and effects of potential reductions will reap the greatest rewards in terms of health benefits, such as areas of southeast Los Angeles County which experiences high levels of PM2.5 exposures and consist of individuals who may be particularly vulnerable to the effects of air pollution on the risk of GDM.

A Mobile Clinical Decision Support System for High-Risk Pregnant Women in Rural India (SMARThealth Pregnancy): Pilot Cluster Randomized Controlled Trial

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death in women in India. Early identification is crucial to reducing deaths. Hypertensive disorders of pregnancy (HDP) and gestational diabetes mellitus (GDM) carry independent risks for future CVD, and antenatal care is a window to screen and counsel high-risk women. In rural India, community health workers (CHWs) deliver antenatal and postnatal care. We developed a complex intervention (SMARThealth Pregnancy) involving mobile clinical decision support for CHWs and evaluated it in a pilot cluster randomized controlled trial (cRCT).

OBJECTIVE

The aim of the study is to co-design a theory-informed intervention for CHWs to screen, refer, and counsel pregnant women at high risk of future CVD in rural India and evaluate its feasibility and acceptability.

METHODS

In phase 1, we used qualitative methods to explore community priorities for high-risk pregnant women in rural areas of 2 diverse states in India. In phase 2, informed by behavior change theory and human-centered design, we used these qualitative data to develop the intervention components and implementation strategies for SMARThealth Pregnancy in an iterative process with end users. In phase 3, using mixed methods, we evaluated the intervention in a cRCT with an embedded qualitative substudy across 4 primary health centres: 2 in Jhajjar district, Haryana, and 2 in Guntur district, Andhra Pradesh.

RESULTS

SMARThealth Pregnancy embedded a total of 15 behavior change techniques and included (1) community awareness programs; (2) targeted training, including point-of-care blood pressure and hemoglobin measurement; and (3) mobile clinical decision support for CHWs to screen women in their homes. The intervention focused on 3 priority conditions: anemia, HDP, and GDM. The evaluation involved a total of 200 pregnant women, equally randomized to intervention or enhanced standard care (control). Recruitment was completed within 5 months, with minimal loss to follow-up (4/200, 2%) at 6 weeks postpartum. A total of 4 primary care doctors and 54 CHWs in the intervention clusters took part in the study. Fidelity to intervention practices was 100% prepandemic. Over half the study population was affected by moderate to severe anemia at baseline. The prevalence of HDP (2.5%) and GDM (2%) was low in our study population. Results suggest a possible improvement in mean hemoglobin (anemia) in the intervention group, although an adequately powered trial is needed. The model of home-based care was feasible and acceptable for pregnant or postpartum women and CHWs, who perceived improvements in quality of care, self-efficacy, and professional recognition.

CONCLUSIONS

SMARThealth Pregnancy is an innovative model of home-based care for high-risk pregnant women during the transitions between antenatal and postnatal care and adult health services. The use of theory and co-design during intervention development facilitated acceptability of the intervention and implementation strategies. Our experience has informed the decision to initiate a larger-scale cRCT.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03968952; https://clinicaltrials.gov/ct2/show/NCT03968952.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.3389/fgwh.2021.620759.

Feasibility of a Postpartum Web- and Phone-Based Lifestyle Program for Women with a History of Preeclampsia or Gestational Diabetes: A Pilot Intervention Study

Background

Women with a history of preeclampsia (PE) or gestational diabetes mellitus (GDM) are at increased risk of diabetes and cardiovascular disease (CVD) later in life. Increased awareness of pregnancy complications as early warning signs for CVD has called for postpartum primordial prevention strategies. The aim of this study was to evaluate the feasibility of a postpartum web- and phone-based lifestyle program promoting healthy lifestyle behaviors to women after a pregnancy complicated by PE or GDM.

Materials and Methods

Women with a validated history of PE or GDM were invited to participate in a nonrandomized pilot intervention study 3-12 months after delivery. The intervention was delivered over 6 months. All participants received tailored lifestyle counseling by a registered dietitian and access to information material on healthy lifestyle behaviors on the study's website. After inclusion, participants were invited to three study visits at baseline, 3 months, and 6 months. Feasibility outcomes included assessment of recruitment, retention, and acceptability. Secondary outcomes were changes in lifestyle behaviors and cardiovascular risk factors.

Results

Of the 207 women invited, 44 were enrolled in the feasibility study and 40 women completed the intervention, corresponding to a recruitment rate of 21% and a retention rate of 91%. At the 3-month study visit, 94.6% of participants reported they had used the website. A total of 41.7% of the participants reported that they had achieved their personal goals during the intervention period.

Conclusions

This study suggested the feasibility and potential acceptability of a web- and phone-based lifestyle intervention for mothers with recent PE or GDM.

Clinical Trial Registration

clinicaltrials.gov, www.clinicaltrials.gov, no. NCT03993145.

Long-term Outcomes Associated With Post-kidney Donation Pregnancy Complications

BACKGROUND

Kidney donors have increased risk of postdonation gestational hypertension (gHTN) and preeclampsia. In the general population, pregnancy complications are associated with long-term maternal risk. However, little data exist on whether donors with postdonation pregnancy-related complications have similar increased long-term risks. We studied whether postdonation gHTN, preeclampsia/eclampsia, or gestational diabetes (gDM) was associated with increased risk of developing hypertension, DM, cardiovascular disease, or estimated glomerular filtration rate <45 mL/min/1.73 m 2 .

METHODS

Postdonation pregnancies with complications were matched to pregnancies without complications based on time from donation. Incidence of outcomes was compared using sequential Cox regression with robust standard errors. Donors with predonation pregnancy complications were excluded. Models were adjusted for age at pregnancy, gravidity, year of donation, and family history of hypertension, DM, and heart disease.

RESULTS

Of the 384 donors with postdonation pregnancies (median [quartiles] follow-up of 27.0 [14.2-36.2] y after donation), 39 experienced preeclampsia/eclampsia, 29 gHTN without preeclampsia, and 17 gDM. Median interval from donation to first pregnancy with preeclampsia was 5.1 (2.9-8.6) y; for gHTN, 3.7 (1.9-7.8) y; and for gDM, 7.3 (3.7-10.3) y. Preeclampsia/eclampsia (hazard ratio [HR] 2.70; 95% confidence interval [CI], 1.53-4.77) and gHTN (HR 2.39; 95% CI, 1.24-4.60) were associated with development of hypertension. Preeclampsia/eclampsia (HR 2.15; 95% CI, 1.11-4.16) and gDM (HR 5.60; 95% CI, 1.41-22.15) were associated with development of DM. Pregnancy-related complications were not associated with increased risk of cardiovascular disease or estimated glomerular filtration rate <45 mL/min/1.73 m 2 .

CONCLUSIONS

In our single-center study, postdonation preeclampsia, gHTN, or gDM was associated with long-term risk of hypertension or DM.

Metabolic alteration of circulating steroid hormones in women with gestational diabetes mellitus and the related risk factors

Background

Abnormally changed steroid hormones during pregnancy are closely related to the pathological process of gestational diabetes mellitus (GDM). Our aim was to systematically profile the metabolic alteration of circulating steroid hormones in GDM women and screen for risk factors.

Methods

This study was a case-control study with data measured from 40 GDM women and 70 healthy pregnant women during their 24-28 gestational weeks. 36 kinds of steroid hormones, including 3 kinds of corticosteroids, 2 kinds of progestins, 5 kinds of androgens and 26 kinds of downstream estrogens in serum were systematically measured using a combined sensitive UPLC-MS/MS method. The flux of different metabolic pathways of steroid hormones was analyzed. Logistic regression and ROC curve model analyses were performed to identify potential steroid markers closely associated with GDM development.

Results

Serum corticosteroids, progestins and almost all the estrogen metabolites via 16-pathway from parent estrogens were higher in GDM women compared with healthy controls. Most of the estrogen metabolites via 4-pathway and more than half of the metabolites via 2-pathway were not significantly different. 16α-hydroxyestrone (16OHE1), estrone-glucuronide/sulfate (E1-G/S) and the ratio of total 2-pathway estrogens to total estrogens were screened as three indicators closely related to the risk of GDM development. The adjusted odds ratios of GDM for the highest quartile compared with the lowest were 72.22 (95% CI 11.27-462.71, P _trend <0.001) for 16OHE1 and 6.28 (95% CI 1.74-22.71, P _trend <0.05) for E1-G/S. The ratio of 2-pathway estrogens to total estrogens was negatively associated with the risk of GDM.

Conclusion

The whole metabolic flux from cholesterol to downstream steroid hormones increased in GDM condition. The most significant changes were observed in the 16-pathway metabolism of estrogens, rather than the 2- or 4-pathway or other types of steroid hormones. 16OHE1 may be a strong marker associated with the risk for GDM.