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Cantacorps L, Zhu J, Yagoub S, Coull BM, Falck J, Chesters RA, Ritter K, Serrano-Lope M, Tscherepentschuk K, Kasch LS, Paterson M, Täger P, Baidoe-Ansah D, Pandey S, Igual-Gil C, Braune A, Lippert RN. Developmental metformin exposure does not rescue physiological impairments derived from early exposure to altered maternal metabolic state in offspring mice. Mol Metab 2024; 79:101860. [PMID: 38142972 PMCID: PMC10792763 DOI: 10.1016/j.molmet.2023.101860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 12/18/2023] [Accepted: 12/20/2023] [Indexed: 12/26/2023] Open
Abstract
OBJECTIVE The incidence of gestational diabetes mellitus (GDM) and metabolic disorders during pregnancy are increasing globally. This has resulted in increased use of therapeutic interventions such as metformin to aid in glycemic control during pregnancy. Even though metformin can cross the placental barrier, its impact on offspring brain development remains poorly understood. As metformin promotes AMPK signaling, which plays a key role in axonal growth during development, we hypothesized that it may have an impact on hypothalamic signaling and the formation of neuronal projections in the hypothalamus, the key regulator of energy homeostasis. We further hypothesized that this is dependent on the metabolic and nutritional status of the mother at the time of metformin intervention. Using mouse models of maternal overnutrition, we aimed to assess the effects of metformin exposure on offspring physiology and hypothalamic neuronal circuits during key periods of development. METHODS Female C57BL/6N mice received either a control diet or a high-fat diet (HFD) during pregnancy and lactation periods. A subset of dams was fed a HFD exclusively during the lactation. Anti-diabetic treatments were given during the first postnatal weeks. Body weights of male and female offspring were monitored daily until weaning. Circulating metabolic factors and molecular changes in the hypothalamus were assessed at postnatal day 16 using ELISA and Western Blot, respectively. Hypothalamic innervation was assessed by immunostaining at postnatal days 16 and 21. RESULTS We identified alterations in weight gain and circulating hormones in male and female offspring induced by anti-diabetic treatment during the early postnatal period, which were critically dependent on the maternal metabolic state. Furthermore, hypothalamic agouti-related peptide (AgRP) and proopiomelanocortin (POMC) neuronal innervation outcomes in response to anti-diabetic treatment were also modulated by maternal metabolic state. We also identified sex-specific changes in hypothalamic AMPK signaling in response to metformin exposure. CONCLUSION We demonstrate a unique interaction between anti-diabetic treatment and maternal metabolic state, resulting in sex-specific effects on offspring brain development and physiological outcomes. Overall, based on our findings, no positive effect of metformin intervention was observed in the offspring, despite ameliorating effects on maternal metabolic outcomes. In fact, the metabolic state of the mother drives the most dramatic differences in offspring physiology and metformin had no rescuing effect. Our results therefore highlight the need for a deeper understanding of how maternal metabolic state (excessive weight gain versus stable weight during GDM treatment) affects the developing offspring. Further, these results emphasize that the interventions to treat alterations in maternal metabolism during pregnancy need to be reassessed from the perspective of the offspring physiology.
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Affiliation(s)
- Lídia Cantacorps
- Department of Neurocircuit Development and Function, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany; German Center for Diabetes Research (DZD), München-Neuherberg, Germany
| | - Jiajie Zhu
- Department of Neurocircuit Development and Function, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany
| | - Selma Yagoub
- Department of Neurocircuit Development and Function, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany
| | - Bethany M Coull
- Department of Neurocircuit Development and Function, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany
| | - Joanne Falck
- Department of Neurocircuit Development and Function, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany
| | - Robert A Chesters
- Department of Neurocircuit Development and Function, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany
| | - Katrin Ritter
- Department of Neurocircuit Development and Function, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany
| | - Miguel Serrano-Lope
- Department of Neurocircuit Development and Function, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany
| | - Katharina Tscherepentschuk
- Department of Neurocircuit Development and Function, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany
| | - Lea-Sophie Kasch
- Department of Neurocircuit Development and Function, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany
| | - Maya Paterson
- Department of Neurocircuit Development and Function, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany
| | - Paula Täger
- Department of Neurocircuit Development and Function, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany
| | - David Baidoe-Ansah
- Department of Neurocircuit Development and Function, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany
| | - Shuchita Pandey
- Department of Neurocircuit Development and Function, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany
| | - Carla Igual-Gil
- Department of Physiology of Energy Metabolism, German Institute of Human Nutrition Potsdam-Rehbruecke (DIfE), Nuthetal, Germany
| | - Annett Braune
- Research Group Intestinal Microbiology, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany
| | - Rachel N Lippert
- Department of Neurocircuit Development and Function, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany; German Center for Diabetes Research (DZD), München-Neuherberg, Germany; NeuroCure Cluster of Excellence, Charité-Universitätsmedizin, Berlin, Germany.
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Zhang X, Rehemutula R, Jin H, Teng Y, Ma J, Mei S, Long Y, Zhao X, Zeng F, Huang Y, Liu F, Gao X, Zhu C. Risk Factors for Hypoglycemia Among Neonates: A Prospective Cohort Study Among Pregnant People With Gestational Diabetes Mellitus. J Perinat Neonatal Nurs 2024; 38:65-72. [PMID: 38278645 DOI: 10.1097/jpn.0000000000000723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2024]
Abstract
OBJECTIVE Neonatal hypoglycemia (NH) is the most frequent complication in neonates born to pregnant people with gestational diabetes mellitus (GDM) and an important cause of brain damage and death of neonates. We explored the risk factors for NH in neonates of pregnant people with GDM. METHODS A prospective cohort study was conducted involving 322 pregnant people with GDM at the Guangzhou Women and Children's Medical Centre. Maternal sociodemographic, clinical, and biochemical data, as well as general characteristics of neonates, were collected to analyze their associations with NH in neonates of pregnant people with GDM. RESULTS The incidence of NH among neonates of pregnant people with GDM was 19.57% (63/322). After adjustment for confounders, the factors significantly associated with an increased risk of NH were cesarean delivery (relative risk [RR] = 3.44; 95% confidence interval [CI], 1.83-6.45), red blood cell (RBC) count (RR = 2.19; 95% CI, 1.22-3.96), and 1-hour postprandial glucose (RR = 2.35; 95% CI, 1.23-4.46) during pregnancy, whereas later gestational age (RR = 0.58; 95% CI, 0.42-0.80) and multiparity (RR = 0.32; 95% CI, 0.16-0.66) were associated with a reduced risk of NH. CONCLUSION Cesarean delivery, maternal 1-hour glucose of the oral glucose tolerance test, and increased RBC count of pregnant people with GDM are independent risk factors for NH, while later gestational age and multiparity are protective factors.
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Affiliation(s)
- Xiaoyan Zhang
- Obstetric Emergency Centre (Zhang), and Department of Obstetrics (Mei), and Department of Laboratory (Long, Zhao, and Liu), and Department of Health Care (Zeng), Guangzhou Women and Children's Medical Centre, and Department of Epidemiology and Health Statistics, School of Public Health (Rehemutula, Jin, Teng, Ma, Huang, and Zhu), Guangzhou Medical University, Guangzhou, PR China; and Faculty of Dentistry (Gao) and Saw Swee Hock School of Public Health (Gao), National University of Singapore, Singapore
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Wang W, Fan Y, Lin Q. Metformin combined with insulin aspart for ameliorating blood glucose levels and maternal and neonatal outcomes in women with gestational diabetes mellitus and chronic hypertension. Am J Transl Res 2021; 13:5596-5602. [PMID: 34150163 PMCID: PMC8205779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 02/19/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To investigate the effect of metformin combined with insulin aspart on blood glucose levels and maternal and neonatal outcomes in women with gestational diabetes mellitus (GDM) accompanied by chronic hypertension (CH). METHODS A prospective study was conducted on 112 women with GDM and CH. The patients were divided into the control group and the observation group according to a random number table method, with 56 patients in each group. The control group received injections of insulin aspart based on blood pressure control, and the observation group received injections of insulin aspart combined with oral metformin based on blood pressure control. Besides, blood glucose levels, maternal pregnancy outcomes and neonatal complications before and after intervention were compared between the two groups. RESULTS Before intervention, there was no significant difference in blood glucose and blood pressure levels between the two groups (P > 0.05). After intervention, the observation group showed significantly decreased fasting blood glucose, 2-h postprandial plasma glucose and glycosylated hemoglobin levels than the control group (P < 0.05); the blood pressure in the observation group was significantly lower as compared with that before intervention (P < 0.05). Additionally, the incidences of adverse pregnancy outcomes (e.g., premature rupture of membranes) and neonatal jaundice and macrosomia were significantly lower in the observation group than in the control group after intervention (both P < 0.05). CONCLUSION Metformin combined with insulin aspart for treating GDM and CH can effectively control blood glucose and blood pressure levels and reduce the risk of adverse perinatal and neonatal outcomes, which exerts positive effect in clinical treatment.
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Affiliation(s)
- Wei Wang
- Department of Pharmacy, Yantai Yuhuangding HospitalYantai, Shandong Province, China
| | - Yanchun Fan
- Department of Obstetrics, Liaocheng City Dong Changfuqu Maternity and Infant Healthy InstituteLiaocheng, Shandong Province, China
| | - Qun Lin
- Department of Pharmacy, Tiantai Hospital of Hangzhou Medical CollegeTaizhou, Zhejiang Province, China
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Krishnakumar S, Govindarajulu Y, Vishwanath U, Nagasubramanian VR, Palani T. Impact of patient education on KAP, medication adherence and therapeutic outcomes of metformin versus insulin therapy in patients with gestational diabetes: A Hospital based pilot study in South India. Diabetes Metab Syndr 2020; 14:1379-1383. [PMID: 32755838 DOI: 10.1016/j.dsx.2020.07.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 07/11/2020] [Accepted: 07/14/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND AND AIM The study assessed the impact of continuous patient education on Knowledge, Attitude, Practice (KAP), medication adherence and extent of glycemic control in pregnant women with gestational diabetes on insulin or metformin therapy. METHODS 81 women with gestational diabetes (37 on insulin and 44 on metformin) were assessed for KAP using a validated questionnaire and medication adherence using the 8-items Morisky medication adherence scale, fasting, and postprandial blood glucose levels at the baseline and after two education sessions on drug therapy at one and three months intervals. The difference in mean KAP, medication adherence scores, fasting, and postprandial blood glucose levels and the extent of glycemic control with insulin or metformin therapy were assessed statistically. RESULTS There was a highly significant difference in the mean KAP, medication adherence scores, fasting and postprandial blood glucose levels from baseline to follow-up after three months, (P < 0.0001) indicating that continuous patient education had a positive impact on their KAP, medication adherence, blood glucose levels. CONCLUSION The study identified that continuous patient education improved their knowledge and practice of medication adherence which reflected on lowered fasting and postprandial blood glucose levels. Glycemic control was found to be the same with metformin and insulin in gestational diabetes.
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Affiliation(s)
- Sneha Krishnakumar
- Sri Ramachandra Institute of Higher Education and Research (Deemed to Be University), India
| | - Yeswanth Govindarajulu
- Sri Ramachandra Hospital, Sri Ramachandra Institute of Higher Education and Research (Deemed to Be University), India
| | - Usha Vishwanath
- Department of Obstetrics and Gynecology, Sri Ramachandra Institute of Higher Education and Research (Deemed to Be University), India
| | - Vanitha Rani Nagasubramanian
- Department of Pharmacy Practice, Sri Ramachandra Institute of Higher Education and Research (Deemed to Be University), Porur, Chennai, Tamil Nadu, India.
| | - Thennarasu Palani
- Department of Pharmacy Practice, Sri Ramachandra Institute of Higher Education and Research (Deemed to Be University), Porur, Chennai, Tamil Nadu, India
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Contreras-Duarte S, Carvajal L, Garchitorena MJ, Subiabre M, Fuenzalida B, Cantin C, Farías M, Leiva A. Gestational Diabetes Mellitus Treatment Schemes Modify Maternal Plasma Cholesterol Levels Dependent to Women´s Weight: Possible Impact on Feto-Placental Vascular Function. Nutrients 2020; 12:E506. [PMID: 32079298 PMCID: PMC7071311 DOI: 10.3390/nu12020506] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 02/11/2020] [Indexed: 12/19/2022] Open
Abstract
: Gestational diabetes mellitus (GDM) associates with fetal endothelial dysfunction (ED), which occurs independently of adequate glycemic control. Scarce information exists about the impact of different GDM therapeutic schemes on maternal dyslipidemia and obesity and their contribution to the development of fetal-ED. The aim of this study was to evaluate the effect of GDM-treatments on lipid levels in nonobese (N) and obese (O) pregnant women and the effect of maternal cholesterol levels in GDM-associated ED in the umbilical vein (UV). O-GDM women treated with diet showed decreased total cholesterol (TC) and low-density lipoproteins (LDL) levels with respect to N-GDM ones. Moreover, O-GDM women treated with diet in addition to insulin showed higher TC and LDL levels than N-GDM women. The maximum relaxation to calcitonin gene-related peptide of the UV rings was lower in the N-GDM group compared to the N one, and increased maternal levels of TC were associated with even lower dilation in the N-GDM group. We conclude that GDM-treatments modulate the TC and LDL levels depending on maternal weight. Additionally, increased TC levels worsen the GDM-associated ED of UV rings. This study suggests that it could be relevant to consider a specific GDM-treatment according to weight in order to prevent fetal-ED, as well as to consider the possible effects of maternal lipids during pregnancy.
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Affiliation(s)
- Susana Contreras-Duarte
- Department of Obstetrics, School of Medicine, Pontificia Universidad Católica de Chile, Santiago 8330024, Chile; (L.C.); (M.J.G.); (M.S.); (B.F.); (C.C.); (M.F.)
| | - Lorena Carvajal
- Department of Obstetrics, School of Medicine, Pontificia Universidad Católica de Chile, Santiago 8330024, Chile; (L.C.); (M.J.G.); (M.S.); (B.F.); (C.C.); (M.F.)
| | - María Jesús Garchitorena
- Department of Obstetrics, School of Medicine, Pontificia Universidad Católica de Chile, Santiago 8330024, Chile; (L.C.); (M.J.G.); (M.S.); (B.F.); (C.C.); (M.F.)
| | - Mario Subiabre
- Department of Obstetrics, School of Medicine, Pontificia Universidad Católica de Chile, Santiago 8330024, Chile; (L.C.); (M.J.G.); (M.S.); (B.F.); (C.C.); (M.F.)
| | - Bárbara Fuenzalida
- Department of Obstetrics, School of Medicine, Pontificia Universidad Católica de Chile, Santiago 8330024, Chile; (L.C.); (M.J.G.); (M.S.); (B.F.); (C.C.); (M.F.)
| | - Claudette Cantin
- Department of Obstetrics, School of Medicine, Pontificia Universidad Católica de Chile, Santiago 8330024, Chile; (L.C.); (M.J.G.); (M.S.); (B.F.); (C.C.); (M.F.)
| | - Marcelo Farías
- Department of Obstetrics, School of Medicine, Pontificia Universidad Católica de Chile, Santiago 8330024, Chile; (L.C.); (M.J.G.); (M.S.); (B.F.); (C.C.); (M.F.)
| | - Andrea Leiva
- Department of Obstetrics, School of Medicine, Pontificia Universidad Católica de Chile, Santiago 8330024, Chile; (L.C.); (M.J.G.); (M.S.); (B.F.); (C.C.); (M.F.)
- School of Medical Technology, Health Sciences Faculty, Universidad San Sebastian, Santiago 8330024, Chile
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Viswanathan V, Krishnan D, Kalra S, Chawla R, Tiwaskar M, Saboo B, Baruah M, Chowdhury S, Makkar BM, Jaggi S. Insights on Medical Nutrition Therapy for Type 2 Diabetes Mellitus: An Indian Perspective. Adv Ther 2019; 36:520-547. [PMID: 30729455 PMCID: PMC6824451 DOI: 10.1007/s12325-019-0872-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Indexed: 02/07/2023]
Abstract
It is critical to integrate medical nutrition therapy (MNT) provided by a registered dietician (RD) into primary care of type 2 diabetes mellitus (T2DM). This is necessary to achieve the goals of improving overall metabolic measures beyond calorie restriction and weight loss. Misconceptions about nutrition in T2DM add to the challenges of executing MNT in a culturally sensitive population. The current review provides insights into MNT for the prevention and management of T2DM in India, based on both evidence and experience. It revisits historical Indian studies and provides information on appropriate dietary intake of carbohydrates (60-70%), proteins (~ 20%) and fats (10%) that will be acceptable and beneficial in an Indian T2DM population. It discusses nuances of types of carbohydrates and fats and explains associations of increased dietary fiber intake, balanced intake of low and high glycemic index foods and substitution of saturated fats with plant-based polyunsaturated fats in improving outcomes of T2DM and attenuating risk factors. The article also deliberates upon special patient populations with comorbid conditions and diseases and the necessary adjustments needed in their nutritional care. It outlines a step-wise approach to MNT involving a careful interplay of nutrition assessment, diagnosis, individualization and patient counseling. Overall, the success of MNT relies on providing accurate, acceptable and appropriate dietary choices for continued patient adherence. Collaborative efforts from diabetologists, endocrinologists, internists and RDs are required to prioritize and implement MNT in diabetes practice in India.Funding: Signutra Inc.
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Affiliation(s)
- Vijay Viswanathan
- M.V. Hospital for Diabetes and Prof. M. Viswanathan Diabetes Research Centre (WHO Collaborating Centre for Research, Education and Training in Diabetes), Chennai, Tamil Nadu, India
| | | | - Sanjay Kalra
- Bharti Research Institute of Diabetes & Endocrinology (BRIDE), Karnal, Haryana, India.
| | | | | | - Banshi Saboo
- Dia Care-Diabetes and Hormone Centre, Ahmedabad, Gujarat, India
| | | | - Subhankar Chowdhury
- Institute of Postgraduate Medical Education and Research/SSKM Hospital, Kolkata, India
| | - B M Makkar
- Diabetes and Obesity Center, New Delhi, India
| | - Shalini Jaggi
- Dr. Mohan's Diabetes Specialties Centre, New Delhi, India
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Xu YXZ, Xi S, Qian X. Evaluating Traditional Chinese Medicine and Herbal Products for the Treatment of Gestational Diabetes Mellitus. J Diabetes Res 2019; 2019:9182595. [PMID: 31886289 PMCID: PMC6915007 DOI: 10.1155/2019/9182595] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 11/19/2019] [Indexed: 12/17/2022] Open
Abstract
Gestational diabetes mellitus is the most common metabolic disorder during pregnancy with health consequences for both lives during and after pregnancy. Studies found that many pregnant women turn to complementary and alternative medicine for health maintenance or symptom relief, such as herbal medicine and acupuncture from traditional Chinese medicine. With the growing popularity of traditional Chinese medicine, we conducted a systemic search in PubMed, Web of Science, and Embase databases on research studies that investigated traditional Chinese medicine during pregnancy. The resultant hits were further searched in relation to all diabetes mellitus. In total, we found three major herbal medicine/herbal products that were associated with glycemic control in gestational diabetes, including Zuo Gui Wan, red raspberry leaves, and Orthosiphon stamineus. We further reviewed them and their relatives in relation to type 2 diabetes mellitus and found more evidence of metabolic benefits. None of the herbal medicine and products examined reported toxicity in the experimental models. Overall, treatments of gestational diabetes by western or alternative interventions are grossly understudied. It is critical to have a standardized protocol when evaluating efficacy of herbal medicine and produce quality results for women and their health-care providers to make informed treatment decisions.
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Affiliation(s)
- Yang Xin Zi Xu
- Physiology and Pathophysiology, University of Manitoba, Winnipeg, Canada
| | - Shengyan Xi
- Department of Traditional Chinese Medicine, School of Medicine, Xiamen University, Xiamen, Fujian Province, China
| | - Xiaoyan Qian
- Department of Traditional Chinese Medicine, School of Medicine, Xiamen University, Xiamen, Fujian Province, China
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Kintiraki E, Goulis DG. Gestational diabetes mellitus: Multi-disciplinary treatment approaches. Metabolism 2018; 86:91-101. [PMID: 29627447 DOI: 10.1016/j.metabol.2018.03.025] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 03/25/2018] [Accepted: 03/27/2018] [Indexed: 02/08/2023]
Abstract
Gestational diabetes mellitus (GDM) is the most common metabolic disease of pregnancy, associated with several perinatal complications. Adequate glycemic control has been proved to decrease risk of GDM-related complications. Several studies have shown the beneficial effect of exercise and medical nutrition treatment on glycemic and weight control in GDM-affected women. Moreover, pharmacological agents, such as insulin and specific oral anti-diabetic agents can be prescribed safely during pregnancy, decreasing maternal blood glucose and, thus, perinatal adverse outcomes. Multi-disciplinary treatment approaches that include both lifestyle modifications (medical nutritional therapy and daily physical exercise) and pharmacological treatment, in cases of failure of the former, constitute the most effective approach. Insulin is the gold standard pharmacological agent for GDM treatment. Metformin and glyburide are two oral anti-diabetic agents that could serve as alternative, although not equal in terms of effectiveness and safety, treatment for GDM. As studies on short-term safety of metformin are reassuring, in some countries it is considered as first-line treatment for GDM management. More studies are needed to investigate the long-term effects on offspring. As safety issues have been raised on the use of glyburide during pregnancy, it must be used only when benefits surpass possible risks.
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Affiliation(s)
- Evangelia Kintiraki
- Unit of Reproductive Endocrinology, First Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - Dimitrios G Goulis
- Unit of Reproductive Endocrinology, First Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Martis R, Crowther CA, Shepherd E, Alsweiler J, Downie MR, Brown J. Treatments for women with gestational diabetes mellitus: an overview of Cochrane systematic reviews. Cochrane Database Syst Rev 2018; 8:CD012327. [PMID: 30103263 PMCID: PMC6513179 DOI: 10.1002/14651858.cd012327.pub2] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Successful treatments for gestational diabetes mellitus (GDM) have the potential to improve health outcomes for women with GDM and their babies. OBJECTIVES To provide a comprehensive synthesis of evidence from Cochrane systematic reviews of the benefits and harms associated with interventions for treating GDM on women and their babies. METHODS We searched the Cochrane Database of Systematic Reviews (5 January 2018) for reviews of treatment/management for women with GDM. Reviews of pregnant women with pre-existing diabetes were excluded.Two overview authors independently assessed reviews for inclusion, quality (AMSTAR; ROBIS), quality of evidence (GRADE), and extracted data. MAIN RESULTS We included 14 reviews. Of these, 10 provided relevant high-quality and low-risk of bias data (AMSTAR and ROBIS) from 128 randomised controlled trials (RCTs), 27 comparisons, 17,984 women, 16,305 babies, and 1441 children. Evidence ranged from high- to very low-quality (GRADE). Only one effective intervention was found for treating women with GDM.EffectiveLifestyle versus usual careLifestyle intervention versus usual care probably reduces large-for-gestational age (risk ratio (RR) 0.60, 95% confidence interval (CI) 0.50 to 0.71; 6 RCTs, N = 2994; GRADE moderate-quality).PromisingNo evidence for any outcome for any comparison could be classified to this category.Ineffective or possibly harmful Lifestyle versus usual careLifestyle intervention versus usual care probably increases the risk of induction of labour (IOL) suggesting possible harm (average RR 1.20, 95% CI 0.99 to 1.46; 4 RCTs, N = 2699; GRADE moderate-quality).Exercise versus controlExercise intervention versus control for return to pre-pregnancy weight suggested ineffectiveness (body mass index, BMI) MD 0.11 kg/m², 95% CI -1.04 to 1.26; 3 RCTs, N = 254; GRADE moderate-quality).Insulin versus oral therapyInsulin intervention versus oral therapy probably increases the risk of IOL suggesting possible harm (RR 1.3, 95% CI 0.96 to 1.75; 3 RCTs, N = 348; GRADE moderate-quality).Probably ineffective or harmful interventionsInsulin versus oral therapyFor insulin compared to oral therapy there is probably an increased risk of the hypertensive disorders of pregnancy (RR 1.89, 95% CI 1.14 to 3.12; 4 RCTs, N = 1214; GRADE moderate-quality).InconclusiveLifestyle versus usual careThe evidence for childhood adiposity kg/m² (RR 0.91, 95% CI 0.75 to 1.11; 3 RCTs, N = 767; GRADE moderate-quality) and hypoglycaemia was inconclusive (average RR 0.99, 95% CI 0.65 to 1.52; 6 RCTs, N = 3000; GRADE moderate-quality).Exercise versus controlThe evidence for caesarean section (RR 0.86, 95% CI 0.63 to 1.16; 5 RCTs, N = 316; GRADE moderate quality) and perinatal death or serious morbidity composite was inconclusive (RR 0.56, 95% CI 0.12 to 2.61; 2 RCTs, N = 169; GRADE moderate-quality).Insulin versus oral therapyThe evidence for the following outcomes was inconclusive: pre-eclampsia (RR 1.14, 95% CI 0.86 to 1.52; 10 RCTs, N = 2060), caesarean section (RR 1.03, 95% CI 0.93 to 1.14; 17 RCTs, N = 1988), large-for-gestational age (average RR 1.01, 95% CI 0.76 to 1.35; 13 RCTs, N = 2352), and perinatal death or serious morbidity composite (RR 1.03; 95% CI 0.84 to 1.26; 2 RCTs, N = 760). GRADE assessment was moderate-quality for these outcomes.Insulin versus dietThe evidence for perinatal mortality was inconclusive (RR 0.74, 95% CI 0.41 to 1.33; 4 RCTs, N = 1137; GRADE moderate-quality).Insulin versus insulinThe evidence for insulin aspart versus lispro for risk of caesarean section was inconclusive (RR 1.00, 95% CI 0.91 to 1.09; 3 RCTs, N = 410; GRADE moderate quality).No conclusions possibleNo conclusions were possible for: lifestyle versus usual care (perineal trauma, postnatal depression, neonatal adiposity, number of antenatal visits/admissions); diet versus control (pre-eclampsia, caesarean section); myo-inositol versus placebo (hypoglycaemia); metformin versus glibenclamide (hypertensive disorders of pregnancy, pregnancy-induced hypertension, death or serious morbidity composite, insulin versus oral therapy (development of type 2 diabetes); intensive management versus routine care (IOL, large-for-gestational age); post- versus pre-prandial glucose monitoring (large-for-gestational age). The evidence ranged from moderate-, low- and very low-quality. AUTHORS' CONCLUSIONS Currently there is insufficient high-quality evidence about the effects on health outcomes of relevance for women with GDM and their babies for many of the comparisons in this overview comparing treatment interventions for women with GDM. Lifestyle changes (including as a minimum healthy eating, physical activity and self-monitoring of blood sugar levels) was the only intervention that showed possible health improvements for women and their babies. Lifestyle interventions may result in fewer babies being large. Conversely, in terms of harms, lifestyle interventions may also increase the number of inductions. Taking insulin was also associated with an increase in hypertensive disorders, when compared to oral therapy. There was very limited information on long-term health and health services costs. Further high-quality research is needed.
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Affiliation(s)
- Ruth Martis
- The University of AucklandLiggins InstitutePark RoadGraftonAucklandNew Zealand1142
| | - Caroline A Crowther
- The University of AucklandLiggins InstitutePark RoadGraftonAucklandNew Zealand1142
- The University of AdelaideARCH: Australian Research Centre for Health of Women and Babies, Robinson Research Institute, Discipline of Obstetrics and GynaecologyWomen's and Children's Hospital72 King William RoadAdelaideSouth AustraliaAustralia5006
| | - Emily Shepherd
- The University of AdelaideARCH: Australian Research Centre for Health of Women and Babies, Robinson Research Institute, Discipline of Obstetrics and GynaecologyWomen's and Children's Hospital72 King William RoadAdelaideSouth AustraliaAustralia5006
| | - Jane Alsweiler
- Auckland HospitalNeonatal Intensive Care UnitPark Rd.AucklandNew Zealand
| | - Michelle R Downie
- Southland HospitalDepartment of MedicineKew RoadInvercargillSouthlandNew Zealand9840
| | - Julie Brown
- The University of AucklandDepartment of Obstetrics and GynaecologyPark RdGraftonAucklandNew Zealand1142
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Martis R, Brown J, Alsweiler J, Downie MR, Crowther CA. Treatments for women with gestational diabetes mellitus: an overview of Cochrane systematic reviews. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2016. [DOI: 10.1002/14651858.cd012327] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Ruth Martis
- The University of Auckland; Liggins Institute; Park Road Grafton Auckland New Zealand 1142
| | - Julie Brown
- The University of Auckland; Liggins Institute; Park Road Grafton Auckland New Zealand 1142
| | - Jane Alsweiler
- Auckland Hospital; Neonatal Intensive Care Unit; Park Rd. Auckland New Zealand
| | - Michelle R Downie
- Southland Hospital; Department of Medicine; Kew Road Invercargill Southland New Zealand 9840
| | - Caroline A Crowther
- The University of Auckland; Liggins Institute; Park Road Grafton Auckland New Zealand 1142
- The University of Adelaide; ARCH: Australian Research Centre for Health of Women and Babies, Robinson Research Institute, Discipline of Obstetrics and Gynaecology; Women's and Children's Hospital 72 King William Road Adelaide South Australia Australia 5006
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Could Metformin Manage Gestational Diabetes Mellitus instead of Insulin? Int J Reprod Med 2016; 2016:3480629. [PMID: 27597988 PMCID: PMC5002295 DOI: 10.1155/2016/3480629] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Revised: 06/19/2016] [Accepted: 07/12/2016] [Indexed: 12/16/2022] Open
Abstract
Gestational diabetes mellitus (GDM) complicates a significant number of pregnancies. Blood glucose control improves perinatal outcomes. Medical nutrition therapy is the foundation in management. Aim of This Study. To evaluate efficacy of metformin in comparison to insulin for managing GDM. Methods. In prospective randomized comparative study, 150 antenatal women whose pregnancies had been complicated by GDM and did not respond to diet alone were recruited from antenatal clinics at Obstetrics Department in Zagazig University Hospitals from November 2012 to December 2014. They were divided randomly into two groups, 75 patients in each, and were subjected to either insulin or metformin medication. Outcomes were comparing the effects of both medications on maternal glycemic control, antenatal complications, and neonatal outcome. Results. No significant difference in controlling high blood sugar in GDM with the use of metformin or insulin (P = 0.95, 0.15). Maternal complications in both groups had no significant difference and fetal outcomes were as well similar except the fact that the hypoglycemia occurred more in insulin group with P value 0.01. Conclusion. Glycaemic control in GDM can be achieved by using metformin orally without increasing risk of maternal hypoglycemia with satisfying neonatal outcome.
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Mpondo BCT, Ernest A, Dee HE. Gestational diabetes mellitus: challenges in diagnosis and management. J Diabetes Metab Disord 2015; 14:42. [PMID: 25977899 PMCID: PMC4430906 DOI: 10.1186/s40200-015-0169-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Accepted: 05/04/2015] [Indexed: 12/11/2022]
Abstract
Gestational diabetes mellitus (GDM) is a well-characterized disease affecting a significant population of pregnant women worldwide. It has been widely linked to undue weight gain associated with factors such as diet, obesity, family history, and ethnicity. Poorly controlled GDM results in maternal and fetal morbidity and mortality. Improved outcomes therefore rely on early diagnosis and tight glycaemic control. While straightforward protocols exist for screening and management of diabetes mellitus in the general population, management of GDM remains controversial with conflicting guidelines and treatment protocols. This review highlights the diagnostic and management options for GDM in light of recent advances in care.
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Affiliation(s)
- Bonaventura C. T. Mpondo
- />School of Medicine and Dentistry, College of Health Sciences, University of Dodoma, Dodoma, Tanzania
- />Department of Internal Medicine, College of Health Sciences, Dodoma, Tanzania
| | - Alex Ernest
- />School of Medicine and Dentistry, College of Health Sciences, University of Dodoma, Dodoma, Tanzania
- />Department of Obstetrics and Gynaecology, College of Health Sciences, PO Box 395, Dodoma, Tanzania
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Poomalar GK. Changing trends in management of gestational diabetes mellitus. World J Diabetes 2015; 6:284-95. [PMID: 25789109 PMCID: PMC4360421 DOI: 10.4239/wjd.v6.i2.284] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Revised: 10/18/2014] [Accepted: 12/29/2014] [Indexed: 02/05/2023] Open
Abstract
Gestational diabetes mellitus (GDM) is on the rise globally. In view of the increasing prevalence of GDM and fetal and neonatal complications associated with it, there is a splurge of research in this field and management of GDM is undergoing a sea change. Trends are changing in prevention, screening, diagnosis, treatment and future follow up. There is emerging evidence regarding use of moderate exercise, probiotics and vitamin D in the prevention of GDM. Regarding treatment, newer insulin analogs like aspart, lispro and detemir are associated with better glycemic control than older insulins. Continuous glucose monitoring systems and continuous subcutaneous insulin systems may play a role in those who require higher doses of insulin for sugar control. Evidence exists that favors metformin as a safer alternative to insulin in view of good glycemic control and better perinatal outcomes. As the risk of developing GDM in subsequent pregnancies and also the risk of overt diabetes in later life is high, regular assessment of these women is required in future. Lifestyle interventions or metformin should be offered to women with a history of GDM who develop pre-diabetes. Further studies are required in the field of prevention of GDM for optimizing obstetric outcome.
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