Third trimester glycemic profiles and fetal growth

A Review of Third-Trimester Complications in Pregnancies Complicated by Diabetes Mellitus

Pregnancies affected by both pregestational and gestational diabetes mellitus carry an increased risk of adverse maternal and neonatal outcomes. While the risks associated with diabetes in pregnancy have been well documented and span across all trimesters, maternal and neonatal morbidity have been associated with select third-trimester complications. Further, modifiable risk factors have been identified that can help improve pregnancy outcomes. This review aims to examine the relationship between select third-trimester complications (large for gestational age, intrauterine fetal demise, hypertensive disorders of pregnancy, preterm birth, perineal lacerations, shoulder dystocia, and cesarean delivery) and the aforementioned modifiable risk factors, specifically glycemic control, blood pressure control, and gestational weight gain. It also highlights how early optimization of these modifiable risk factors can reduce adverse maternal, fetal, and neonatal outcomes. KEY POINTS: · Diabetes mellitus in pregnancy increases the risk of third-trimester complications.. · Modifiable risk factors exist for these complications.. · Optimizing these modifiable risk factors improves maternal and neonatal outcomes..

Effectiveness of Insulin Analogs Compared with Human Insulins in Pregnant Women with Diabetes Mellitus: Systematic Review and Meta-analysis

Diabetes during pregnancy has been linked to unfavorable maternal-fetal outcomes. Human insulins are the first drug of choice because of the proven safety in their use. However, there are still questions about the use of insulin analogs during pregnancy. The objective of the present study was to determine the effectiveness of insulin analogs compared with human insulin in the treatment of pregnant women with diabetes through a systematic review with meta-analysis. The search comprised the period since the inception of each database until July 2017, and the following databases were used: MEDLINE, CINAHL, EMBASE, ISI Web of Science, LILACS, Scopus, SIGLE and Google Scholar. We have selected 29 original articles: 11 were randomized clinical trials and 18 were observational studies. We have explored data from 6,382 participants. All of the articles were classified as having an intermediate to high risk of bias. The variable that showed favorable results for the use of insulin analogs was gestational age, with a mean difference of - 0.26 (95 % confidence interval [CI]: 0.03-0.49; p = 0.02), but with significant heterogeneity (Higgins test [I2] = 38%; chi-squared test [χ2] = 16.24; degree of freedom [DF] = 10; p = 0.09). This result, in the clinical practice, does not compromise the fetal well-being, since all babies were born at term. There was publication bias in the gestational age and neonatal weight variables. To date, the evidence analyzed has a moderate-to-high risk of bias and does not allow the conclusion that insulin analogs are more effective when compared with human insulin to treat diabetic pregnant women.

Neonatal outcomes according to different therapies for gestational diabetes mellitus

OBJECTIVES

To compare different neonatal outcomes according to the different types of treatments used in the management of gestational diabetes mellitus.

METHODS

This was a retrospective cohort study. The study population comprised pregnant women with gestational diabetes treated at a public maternity hospital from July 2010 to August 2014. The study included women aged at least 18 years, with a singleton pregnancy, who met the criteria for gestational diabetes mellitus. Blood glucose levels, fetal abdominal circumference, body mass index and gestational age were considered for treatment decision-making. The evaluated neonatal outcomes were: type of delivery, prematurity, weight in relation to gestational age, Apgar at 1 and 5min, and need for intensive care unit admission.

RESULTS

The sample consisted of 705 pregnant women. The neonatal outcomes were analyzed based on the treatment received. Women treated with metformin were less likely to have children who were small for gestational age (95% CI: 0.09-0.66) and more likely to have a newborn adequate for gestational age (95% CI: 1.12-3.94). Those women treated with insulin had a lower chance of having a preterm child (95% CI: 0.02-0.78). The combined treatment with insulin and metformin resulted in higher chance for a neonate to be born large for gestational age (95% CI: 1.14-11.15) and lower chance to be born preterm (95% CI: 0.01-0.71). The type of treatment did not affect the mode of delivery, Apgar score, and intensive care unit admission.

CONCLUSIONS

The pediatrician in the delivery room can expect different outcomes for diabetic mothers based on the treatment received.

Timing of peak blood glucose after breakfast meals of different glycemic index in women with gestational diabetes

This study aims to determine the peak timing of postprandial blood glucose level (PBGL) of two breakfasts with different glycemic index (GI) in gestational diabetes mellitus (GDM). Ten women with diet-controlled GDM who were between 30 and 32 weeks of gestation were enrolled in the study. They consumed two carbohydrate controlled, macronutrient matched bread-based breakfasts with different GI (low vs. high) on two separate occasions in a random order after an overnight fast. PBGLs were assessed using a portable blood analyser. Subjects were asked to indicate their satiety rating at each blood sample collection. Overall the consumption of a high GI breakfast resulted in a greater rise in PBGL (mean ± SEM peak PBGL: low GI 6.7 ± 0.3 mmol/L vs. high GI 8.6 ± 0.3 mmol/L; p < 0.001) and an earlier peak PBGL time (16.9 ± 4.9 min earlier; p = 0.015), with high variability in PBGL time between subjects. There was no significant difference in subjective satiety throughout the test period. In conclusion, the low GI breakfast produced lower postprandial glycemia, and the peak PBGL occurred closer to the time recommended for PBGL monitoring (i.e., 1 h postprandial) in GDM than a macronutrient matched high GI breakfast.

Nutrition and human health from a sex-gender perspective

Nutrition exerts a life-long impact on human health, and the interaction between nutrition and health has been known for centuries. The recent literature has suggested that nutrition could differently influence the health of male and female individuals. Until the last decade of the 20th century, research on women has been neglected, and the results obtained in men have been directly translated to women in both the medicine and nutrition fields. Consequently, most modern guidelines are based on studies predominantly conducted on men. However, there are many sex-gender differences that are the result of multifactorial inputs, including gene repertoires, sex steroid hormones, and environmental factors (e.g., food components). The effects of these different inputs in male and female physiology will be different in different periods of ontogenetic development as well as during pregnancy and the ovarian cycle in females, which are also age dependent. As a result, different strategies have evolved to maintain male and female body homeostasis, which, in turn, implies that there are important differences in the bioavailability, metabolism, distribution, and elimination of foods and beverages in males and females. This article will review some of these differences underlying the impact of food components on the risk of developing diseases from a sex-gender perspective.

Impact of growth patterns and early diet on obesity and cardiovascular risk factors in young children from developing countries

Non-communicable chronic diseases are now a worldwide epidemic. Diet and physical activity throughout life are among its main determinants. In countries undergoing the early stages of the nutrition transition weight gain from birth to 2 years of life is related to lean mass gain, while ponderal gain after age 2 years is related to adiposity and later diabetes and CVD risk. Evidence from developing countries undergoing the more advanced stages of the nutrition transition is limited. The early growth patterns of a cohort of Chilean children born in 2002 with normal birth weight who at 4 years had a high prevalence of obesity and CVD risk factors have been assessed. Results indicate that BMI gain in early life, particularly from 6 months to 24 months, is positively associated with adiposity and CVD risk status at 4 years. These results together with existing evidence suggest that actions to prevent obesity and nutrition-related chronic diseases in developing countries should start early in life, possibly after 6 months of age. This approach should consider assessing the effect of mode of feeding and the amount and type of energy fed, as well as the resulting growth patterns. The challenge for researchers addressing the nutrition transition is to define the optimal nutrition in early life, considering not only the short- and long-term health consequences but also taking into account the stage of the nutritional transition for the given population of interest. The latter will probably require redefining optimal postnatal growth based on the context of maternal size and fetal growth.

Conference on "Multidisciplinary approaches to nutritional problems". Rank Prize Lecture. Global nutrition challenges for optimal health and well-being

Optimal health and well-being are now considered the true measures of human development. Integrated strategies for infant, child and adult nutrition are required that take a life-course perspective to achieve life-long health. The major nutrition challenges faced today include: (a) addressing the pending burden of undernutrition (low birth weight, severe wasting, stunting and Zn, retinol, Fe, iodine and folic acid deficits) affecting those individuals living in conditions of poverty and deprivation; (b) preventing nutrition-related chronic diseases (obesity, diabetes, CVD, some forms of cancer and osteoporosis) that, except in sub-Saharan Africa, are the main causes of death and disability globally. This challenge requires a life-course perspective as effective prevention starts before conception and continues at each stage of life. While death is unavoidable, premature death and disability can be postponed by providing the right amount and quality of food and by maintaining an active life; (c) delaying or avoiding, via appropriate nutrition and physical activity interventions, the functional declines associated with advancing age. To help tackle these challenges, it is proposed that the term 'malnutrition in all its forms', which encompasses the full spectrum of nutritional disorders, should be used to engender a broader understanding of global nutrition problems. This term may prove particularly helpful when interacting with policy makers and the public. Finally, a greater effort by the UN agencies and private and public development partners is called for to strengthen local, regional and international capacity to support the much needed change in policy and programme activities focusing on all forms of malnutrition with a unified agenda.

Endocrine regulation of human fetal growth: the role of the mother, placenta, and fetus

The environment in which the fetus develops is critical for its survival and long-term health. The regulation of normal human fetal growth involves many multidirectional interactions between the mother, placenta, and fetus. The mother supplies nutrients and oxygen to the fetus via the placenta. The fetus influences the provision of maternal nutrients via the placental production of hormones that regulate maternal metabolism. The placenta is the site of exchange between mother and fetus and regulates fetal growth via the production and metabolism of growth-regulating hormones such as IGFs and glucocorticoids. Adequate trophoblast invasion in early pregnancy and increased uteroplacental blood flow ensure sufficient growth of the uterus, placenta, and fetus. The placenta may respond to fetal endocrine signals to increase transport of maternal nutrients by growth of the placenta, by activation of transport systems, and by production of placental hormones to influence maternal physiology and even behavior. There are consequences of poor fetal growth both in the short term and long term, in the form of increased mortality and morbidity. Endocrine regulation of fetal growth involves interactions between the mother, placenta, and fetus, and these effects may program long-term physiology.