Prevalence and predictors of postpartum glucose intolerance in Italian women with gestational diabetes mellitus

Association between breastfeeding duration and diabetes mellitus in menopausal women: a machine-learning analysis using population-based retrospective study

BACKGROUND

Breastfeeding resets insulin resistance caused by pregnancy however, studies on the association between breastfeeding and diabetes mellitus (DM) have reported inconsistent results. Therefore, we aimed to investigate the risk of DM according to breastfeeding duration in large-scale population-based retrospective study. In addition, machine-learning prediction models for DM and hemoglobin A1c (HbA1c) were developed to further evaluate this association.

METHODS

We used the Korean National Health and Nutrition Examination Surveys database, a nationwide and population-based health survey from 2010 to 2020. We included 15,946 postmenopausal women with a history of delivery, whom we divided into three groups according to the average breastfeeding duration: (1) no breastfeeding, (2) < 12 months breastfeeding, and (3) ≥ 12 months breastfeeding. Prediction models for DM and HbA1c were developed using an artificial neural network, decision tree, logistic regression, Naïve Bayes, random forest, and support vector machine.

RESULTS

In total, 2248 (14.1%) women had DM and 14,402 (90.3%) had a history of breastfeeding. The prevalence of DM was the lowest in the < 12 breastfeeding group (no breastfeeding vs. < 12 months breastfeeding vs. ≥ 12 months breastfeeding; 161 [10.4%] vs. 362 [9.0%] vs. 1,725 [16.7%], p < 0.001). HbA1c levels were also the lowest in the < 12 breastfeeding group (HbA1c: no breastfeeding vs. < 12 months breastfeeding vs. ≥ 12 months breastfeeding; 5.9% vs. 5.9% vs. 6.1%, respectively, p < 0.001). After adjustment for covariates, the risk of DM was significantly increased in both, the no breastfeeding (adjusted odds ratio [aOR] 1.29; 95% CI 1.29, 1.62]) and ≥ 12 months of breastfeeding groups (aOR 1.18; 95% CI 1.01, 1.37) compared to that in the < 12 months breastfeeding group. The accuracy and the area under the receiver-operating-characteristic curve of the DM prediction model were 0.93 and 0.95, respectively. The average breastfeeding duration was ranked among the top 15 determinants of DM, which supported the strong association between breastfeeding duration and DM. This association was also observed in a prediction model for HbA1c.

CONCLUSIONS

Women who did not breasted had a higher risk of developing DM than those who breastfed for up to 12 months.

Efficacy of a phone reminder to improve adherence to post-partum glucose tolerance testing after gestational diabetes and clinical predictors of post-partum follow-up compliance

AIM

To assess the effectiveness of a phone reminder to improve adherence to post-partum glucose tolerance testing in women with gestational diabetes mellitus (GDM) and to identify clinical predictors of adherence to post-partum follow-up.

METHODS

Retrospective study including 543 women with GDM. We assessed the adherence rate to post-partum glucose tolerance testing in women who received a phone reminder (n = 297) compared to women not alerted (n = 246). Demographic and clinical variables were collected to identify the predictors of adherence to the post-partum oral glucose tolerance test (OGTT).

RESULTS

The adherence to post-partum OGTT was higher in women who received the phone reminder compared to those not alerted (60.6 % vs. 35.4 %, p < 0.001). Women less compliant compared to those more compliant, had a higher pre-pregnancy body mass index (BMI) (29.3 ± 7.9 vs. 27.0 ± 6.1 Kg/m2, p = 0.03). The adherence was lower in pre-pregnant obese compared to non-obese women (42.7 % vs. 52.0 %, p < 0.05), in women with only one, compared to multiple OGTT alterations during pregnancy (44.5 % vs. 57.8 %, p < 0.05), and in women non-insulin treated compared to those insulin-treated (40.0 % vs. 57.1 % vs, p < 0.001).

CONCLUSIONS

The phone reminder improved post-partum follow-up adherence. Pre-pregnancy BMI, number of OGTT alterations and type of therapy could identify poorly adherent women.

Investigating the causal impact of polycystic ovary syndrome on gestational diabetes mellitus: a two-sample Mendelian randomization study

Introduction

Determining the causal relationship between polycystic ovary syndrome (PCOS) and gestational diabetes mellitus (GDM) holds significant implications for GDM prevention and treatment. Despite numerous observational studies suggesting an association between PCOS and GDM, it remains unclear whether a definitive causal relationship exists between these two conditions and which specific features of PCOS contribute to increased incidence of GDM.

Methods

The causal relationship between polycystic ovary syndrome (PCOS), its characteristic indices, and gestational diabetes mellitus (GDM) was investigated using a two-sample Mendelian randomization study based on publicly available statistics from genome-wide association studies (GWAS). The inverse-variance weighted method was employed as the primary analytical approach to examine the association between PCOS, its characteristic indices, and GDM. MR Egger intercept was used to assess pleiotropy, while Q values and their corresponding P values were utilized to evaluate heterogeneity. It is important to note that this study adopts a two-sample MR design where PCOS and its characteristic indices are considered as exposures, while GDM is treated as an outcome.

Results

The study results indicate that there is no causal relationship between PCOS and GDM (all methods P > 0.05, 95% CI of OR values passed 1). The IVW OR value was 1.007 with a 95% CI of 0.906 to 1.119 and a P value of 0.904. Moreover, the MR Egger Q value was 8.141 with a P value of 0.701, while the IVW Q value was also 8.141 with a P value of 0.774, indicating no significant heterogeneity. Additionally, the MR Egger intercept was 0.0004, which was close to zero with a P value of 0.988, suggesting no pleiotropy. However, the study did find a causal relationship between several other factors such as testosterone, high-density lipoprotein, sex hormone-binding globulin, body mass index, waist-hip ratio, apolipoprotein A-I, number of children, diabetes illnesses of mother, father and siblings, hemoglobin A1c, fasting insulin, fasting blood glucose, years of schooling, and GDM based on the IVW method.

Conclusion

We observed no association between genetically predicted PCOS and the risk of GDM, implying that PCOS itself does not confer an increased susceptibility to GDM. The presence of other PCOS-related factors such as testosterone, high-density lipoprotein, and sex hormone-binding globulin may elucidate the link between PCOS and GDM. Based on these findings, efforts aimed at preventing GDM in individuals with PCOS should prioritize those exhibiting high-risk features rather than encompassing all women with PCOS.

Risk factors associated with early postpartum glucose intolerance in women with a history of gestational diabetes mellitus: a systematic review and meta-analysis

PURPOSE

This meta-analysis was aimed at exploring the incidence and risk factors of glucose intolerance in women with gestational diabetes mellitus (GDM) at 6-12 weeks postpartum to inform the development of preventive strategies.

METHOD

We searched Pubmed, Embase, Web of Science, the Cochrane Library, Ovid, China Knowledge Resource Integrated Database (CNKI), Wanfang Database and China Biology Medicine Database for entries between January 1990 and September 2022. The search terms included gestational diabetes mellitus, postpartum, glucose intolerance and type 2 diabetes. The meta-analysis was conducted using Stata 14.0.

RESULT

We included 37 studies, with 21 and 16 having low and medium risk of bias, respectively. The incidence of glucose intolerance in women with GDM 6-12 weeks postpartum was 27% (95% CI: 0.22-0.33). The following risk factors for GDM 6-12 weeks postpartum were identified: insulin use during pregnancy (OR = 3.23; 95% CI: 2.35-4.44), family history of diabetes (OR = 2.94; 95% CI: 1.98-4.33), abnormal fasting glucose levels at 24-28 weeks of gestation (OR = 1.15; 95% CI: 1.07-1.25), high pre-pregnancy BMI (OR = 1.63; 95% CI: 1.23-2.15), abnormal triglyceride levels during 28-40 weeks of gestation (OR = 2.18; 95% CI: 1.18-4.03), abnormal HbA1c levels at 28-40 weeks of gestation (OR = 6.62; 95% CI: 4.71-9.30), history of previous GDM (OR = 2.11; 95% CI: 1.27-3.49), and high 1-h glucose levels at 24-28 weeks of gestation (OR = 1.16; 95% CI:1.06-1.28).

CONCLUSION

The incidence of glucose intolerance in GDM patients at 6-12 weeks postpartum was high. To prevent early postpartum glucose intolerance, healthcare providers should develop individualized interventions for GDM patients, depending on existing risk factors.

Factors associated with compliance to the recommendations for postpartum diabetes mellitus screening among women with gestational diabetes mellitus

OBJECTIVE

Since women with GDM have an increased risk to develop type 2 DM, a 75 g OGTT is recommended 6-12 weeks postpartum for all women with GDM. However, screening rates remain low. The aim of this study was to find factors affect the rate of postpartum DM screening.

MATERIALS AND METHODS

A retrospective cohort study between 2016 and 2017 at the Soroka Medical Center, comparing women with GDM who underwent postpartum DM screening test to those who did not.

RESULTS

257 women who had a diagnosis of GDM and met the inclusion criteria were included. 53 (20.6%) had a postpartum DM screening test and 204 (79.4%) did not complete the postpartum DM screening. Women who underwent a DM screening postpartum were more likely to be older, with significantly higher rates of vacuum-assisted delivery, more likely to be diagnosed with GDMA2 as compared to GDMA1 during pregnancy and, with high probability of receiving recommendations for screening at a postpartum visit.

CONCLUSIONS

The rates of postpartum DM screening for women with GDM are low and need to increase. Age greater than 25, vacuum delivery, GDMA2, and having received a recommendation for postpartum screening increased the likelihood of undergoing a postpartum DM screening.

Microbiome Changes in Pregnancy Disorders

The human microbiota comprises all microorganisms, such as bacteria, fungi, and viruses, found within a specific environment that live on our bodies and inside us. The last few years have witnessed an explosion of information related to the role of microbiota changes in health and disease. Even though the gut microbiota is considered the most important in maintaining our health, other regions of the human body, such as the oral cavity, lungs, vagina, and skin, possess their own microbiota. Recent work suggests a correlation between the microbiota present during pregnancy and pregnancy complications. The aim of our literature review was to provide a broad overview of this growing and important topic. We focused on the most significant changes in the microbiota in the four more common obstetric diseases affecting women's health. Thus, our attention will be focused on hypertensive disorders, gestational diabetes mellitus, preterm birth, and recurrent miscarriage. Pregnancy is a unique period in a woman's life since the body undergoes different adaptations to provide an optimal environment for fetal growth. Such changes also involve all the microorganisms, which vary in composition and quantity during the three trimesters of gestation. In addition, special attention will be devoted to the potential and fundamental advances in developing clinical applications to prevent and treat those disorders by modulating the microbiota to develop personalized therapies for disease prevention and tailored treatments.

Predictors of postpartum glucose metabolism disorders in women with gestational diabetes mellitus

BACKGROUND AND AIMS

Postpartum glucose metabolism disorders are a common problem in women with gestational diabetes mellitus (GDM). They are often underdiagnosed since many patients do not attend the postpartum screening. This study aims to assess predictors of postpartum glucose metabolism disorders and type 2 diabetes mellitus (T2DM) after GDM.

MATERIAL AND METHODS

Retrospective study in women with GMD who underwent postpartum screening for glucose metabolism disorders (n = 2688). Logistic regression was used in the statistical analysis.

RESULTS

24.6% of women had postpartum glucose metabolism disorder. In multivariate analysis, pre-pregnancy body mass index (BMI) 25-30 kg/m² (OR 1.46, 95%CI 1.05 to 2.02) or BMI ≥30 kg/m² (OR 2.62, 95%CI 1.72 to 3.96), diagnosis of GDM before 20 weeks of pregnancy (OR 2.33, 95%CI 1.57 to 3.46), fasting plasma glucose after diagnosis of GDM ≥90 mg/dl (OR 2.12, 95%CI 1.50 to 2.98), postprandial glucose ≥100 mg/dl (OR 1.47, 95%CI 1.09 to 2.99), and HbA1c in the third trimester of pregnancy ≥5.3% (2.04, 95%CI, 1.52 to 2.75) were independent predictors for any postpartum glucose metabolism disorder.

CONCLUSION

postpartum screening for T2DM should be performed in all women with GDM, and it is especially important not to lose follow-up in those with one or more predictive factors.

Metabolic Effects of Breastfeeding in Women with Previous Gestational Diabetes Mellitus: A Meta-Analysis

Objective: To investigate the effects of breastfeeding (BF) on metabolic-related outcomes in women with previous gestational diabetes mellitus. Methods: Databases, including PubMed, Embase, Cochrane Library, and Web of Science, were searched until March 5, 2020. Finally, 14 high-quality articles were included. Relative risk (RR) and weighted mean difference (WMD) with 95% confidence interval (CI) were pooled using Stata14.0 Software. Results: Subjects in the BF group had a lower incidence of diabetes (RR: 0.611, 95% CI: 0.452-0.826, p < 0.001) and lower fasting plasma glucose level (WMD: -4.762, 95% CI: -5.552 to -3.973, p < 0.001), fasting insulin level (WMD: -21.513, 95% CI: -37.594 to -5.431, p = 0.009), homeostasis model assessment of insulin resistance (HOMA-IR) (WMD: -1.107, 95% CI: -1.683 to -0.532, p < 0.001), and triglyceride level (WMD: -33.951, 95% CI: -50.714 to -17.189, p < 0.001) than those in the non-BF group. The high-density lipoprotein level (WMD: 3.855, 95% CI: 2.629-5.081, p < 0.001), low-density lipoprotein level (WMD: 4.223, 95% CI: 0.6712-7.774, p = 0.020), and insulin sensitivity index (WMD: 1.503, 95% CI: 0.857-2.160, p < 0.001) in the BF group were higher than that in the non-BF group. No difference was found in the 2-hour postprandial blood glucose (WMD: -3.804, 95% CI: -8.237 to 0.630, p = 0.093), incidence of prediabetes mellitus (RR: 0.870, 95% CI: 0.750-1.009, p = 0.065), or cholesterol level (WMD: 1.377, 95% CI: -8.178 to 10.931, p = 0.778) between the two groups. Conclusion: BF may improve several metabolic markers and decrease the risk of developing diabetes.

Clinical Characteristics, Outcomes, and Progression to Type 2 Diabetes in Women with Hyperglycemia in Pregnancy

CONTEXT

Women with hyperglycemia in pregnancy (HIP) are at increased risk of developing type 2 diabetes (T2D).

AIM

The present study intended to study the incidence of postpartum diabetes among HIP women and predict its risk factors.

SETTINGS AND DESIGN

This was a prospective observational study done on 178 women with HIP diagnosed after the first trimester, attending the tertiary care hospitals between December 2018 and March 2020.

MATERIALS AND METHODS

Demographics, clinical variables, and feto-maternal outcomes were recorded. The postpartum glycemic status was determined using a 75 g oral glucose tolerance test (OGTT) at 1 and 6 months.

STATISTICAL ANALYSIS

All analyses were performed with SPSS software (version 21.0).

RESULTS

The mean age of women with HIP was 30.2 ± 6.1 years, with 38% having a family history of diabetes. Eighty percent of the women delivered full-term babies and 71.3% underwent a cesarean section. Gestational hypertension was present in 21.9% of patients. Macrosomia was present in 4.6% of the babies, hypoglycemia in 6.7%, and spontaneous abortion occurred in 7.7%. Postpartum OGTT at 6 months was completed by 76.4% of participants. The incidence of diabetes and glucose intolerance postpartum was 11.7 and 16.2%, respectively at 6 months. Logistic regression analysis showed that maternal obesity, diagnosis of HIP at an earlier trimester (<24 weeks), need for insulin treatment during pregnancy, signs of insulin resistance and fasting and 2-h plasma glucose >100 (>5.6 mmol/L) and >195 mg/dL (>10.9 mmol/L), respectively, and glycated hemoglobin > 6.5% (>48 mmol/mol) increased the risk of having postpartum diabetes significantly.

CONCLUSION

The incidence of postpartum glucose intolerance in women with HIP is high. Prospective diabetes evaluation is required and intervention should be considered in women with HIP who have obesity, diagnosis of HIP at an earlier trimester, signs of insulin resistance, and require insulin treatment during pregnancy.

Gestational diabetes mellitus and the role of intercurrent type 2 diabetes on long-term risk of cardiovascular events

Recent studies have shown that gestational diabetes mellitus (GDM) is associated with an increased risk for cardiovascular disease. GDM has also been shown to be a risk factor for type 2 diabetes (T2DM) after pregnancy. However, there is limited evidence regarding the role of intercurrent T2DM on the relationship between GDM and future CVD. Thus, we investigated the risks of incident cardiovascular events among women with GDM during pregnancy compared to women without GDM and whether the increased CVD risk is dependent on intercurrent development of T2DM. We conducted a population-based retrospective cohort study using the Korean National Health Insurance Service claims database. Outcomes were the first occurrence of any CVD (myocardial infarction, treatment with coronary revascularization, heart failure, and cerebrovascular disease). Cox proportional hazard models were used to assess the association between GDM and incident CVD events, using landmark analysis at 4 years. A total of 1,500,168 parous women were included in the analysis, of which 159,066 (10.60%) had GDM. At a median follow-up of 12.8 years, 13,222 incident cases of total CVD were observed. Multivariable-adjusted hazard ratio for total CVD among women with prior GDM, compared with those without GDM, was 1.08 (95% CI 1.02-1.14). Further classifying GDM by progression to T2DM in relation to total CVD risk indicated a positive association for GDM with progression to T2DM vs no GDM or T2DM (HR 1.74; 95% CI 1.40-2.15), and no statistically significant association for GDM only (HR 1.06; 95% CI 1.00-1.12). GDM with subsequent progression to T2DM were linked with an increased risk of cardiovascular diseases. These findings highlight the need for more vigilant postpartum screening for diabetes and the implementation of diabetes interventions in women with a history of GDM to reduce future CVD risk.

Prevalence and Metabolic Predictors for Early Diagnosed Prediabetes in Women with Previous Gestational Diabetes: Observational Cohort Study

INTRODUCTION

Women with previous gestational diabetes (pGD) are at higher risk of prediabetes (PD) after delivery. The aim of this study was to determine the prevalence of and predictors for PD among women with pGD.

METHODS

The study included 186 women with pGD treated by lifestyle modification. After delivery, the women were divided into group A (n = 80) with PD and group B (n = 106) with normal glucose tolerance (NGT), defined by the results of the 2-h oral glucose tolerance test at 4-12 weeks after delivery. We recorded age, body mass index (BMI) at conception and after delivery, fasting glucose (FG), glycated hemoglobin (HbA1c), total cholesterol (TC), triglycerides (Tg), low density lipoprotein cholesterol (LDL-c), high-density lipoprotein cholesterol (HDL-c) and the Tg/HDL-c ratio measured in the third trimester of pregnancy.

RESULTS

Of the 186 women with pGD enrolled in the study, 43% showed prediabetes at 4-12 weeks after delivery, with 13.9% of these women showing impaired FG (IFG), 12.9% showing impaired glucose tolerance (IGT) and 16.2% with IFG/IGT. The groups differed in terms of age and BMI at conception and after delivery. In the third trimester of pregnancy, HbA1c was higher in women in group A than in those in group B (mean ± standard deviation: 5.6 ± 0.4 vs. 5.2 ± 0.3%; p < 0.001), while FG was comparable. Compared to women in group B, women in group A had higher TC (7.1 ± 0.8 vs. 6.6 ± 1.0 mmol/L), Tg (2.7 ± 0.9 vs. 2.1 ± 0.6 mmol/L) and LDL-c (4.7 ± 0.8 vs. 4.3 ± 1.0 mmol/L) (all p < 0.001), lower HDL-c (1.0 ± 0.2 vs. 1.4 ± 1.0; p < 0.001) and higher median Tg/HDL-c (5.4 [range 4.6-14.3] vs. 4.9 [range 1.1-11.5]; p < 0.001). Univariate analysis found an association between prediabetes and age, BMI at conception and after delivery, HbA1c, TC, LDL-c, HDL-c, Tg and Tg/HDL-c ratio. Of these variables, the multivariate analysis showed age (odds ratio [OR] 1.19; p < 0.001), HbA1c (OR 31.06; p < 0.001), Tg (OR 4.09; p < 0.001) and LDL-c (OR 2.00; p = 0.005) as predictors for prediabetes.

CONCLUSION

High prevalence of early diagnosed PD in women with pGD was accompanied by advanced age and higher BMI at conception and after delivery. Moreover, age, HbA1c, Tg and LDL-c were predictors for PD.

Association of lactation with maternal risk of type 2 diabetes: A systematic review and meta-analysis of observational studies

AIM

To investigate the association between lactation and maternal risk of type 2 diabetes, including a potential graded association according to lactation duration.

METHODS

A systematic review and meta-analysis of observational studies that investigated the reported association between lactation (irrespective of duration, intensity or mode) and maternal risk of type 2 diabetes was conducted.

RESULTS

A total of 22 studies (17 cohort studies and five cross-sectional studies) were included in this systematic review, and 16 contributed to the meta-analysis. Studies that investigated the association of lactation with risk of type 2 diabetes in the first months after birth in women with gestational diabetes reported conflicting results. Studies with a longer follow-up showed a graded protective association for lactation and the risk of type 2 diabetes, with a potentially larger risk reduction in women with gestational diabetes than in those without gestational diabetes. Overall, ever versus never lactation was associated with a 27% lower risk of type 2 diabetes (RR 0.73, 95% CI [0.65, 0.83]). Each additional month of lactation was associated with a 1% lower risk of type 2 diabetes (RR 0.99, 95% CI [0.98, 0.99]). However, the overall quality of the studies was modest.

CONCLUSIONS

Lactation is associated with a significantly reduced risk of maternal type 2 diabetes over the life course, particularly in women with gestational diabetes. The protective effect seems to increase with longer duration of lactation. Further research is warranted to understand whether this association is modified by exposure to other risk factors.

Increased risk markers in women with polycystic ovary syndrome and gestational diabetes mellitus during mid-pregnancy

Objective

This study aimed to investigate application of the urine albumin-to-creatinine ratio (ACR), serum beta 2-microglobulin (β2-MG), and cystatin C as risk markers in a cohort of women with polycystic ovary syndrome (PCOS) for the incidence of gestational diabetes mellitus (GDM).

Methods

In this cross-sectional study, we analyzed 312 pregnant women with PCOS and classified them as those with and without GDM. For all participants, elbow venous blood and clean middle urine were collected in the morning after 8 hours of an empty stomach.

Results

Logistic regression analysis showed that the ACR, urine β2-MG levels, and serum cystatin C levels were important markers for women with PCOS concomitant with GDM. Receiver operating characteristic curve analysis showed that the area under the curve of CysC was 0.81 with the threshold based on >0.93 and that of β2-MG was 0.72 with the threshold based on >1.25.

Conclusions

Increased levels of β2-MG and cystatin C and a high ACR might be risk factors for Chinese women with PCOS and GDM during mid-pregnancy.

Risk factors associated with postpartum impaired glucose regulation in women with previous gestational diabetes

AIMS

For women with previous gestational diabetes (GDM), international guidelines recommend 75 g oral glucose tolerance test (OGTT) at 4-12 weeks after delivery to assess glucose tolerance, considering their increased risk of type 2 diabetes. We evaluated prevalence of postpartum impaired glucose regulation (IGR) and identified associated risk factors.

METHODS

We retrospectively collected data from 749 women with previous GDM (IADPSG criteria) who underwent postpartum OGTT for type 2 diabetes screening between 2011 and 2019. IGR was identified according to ADA criteria.

RESULTS

Prevalence of IGR was 12.7%, lower in women with pre-pregnancy normal weight, higher in women with family history of type 2 diabetes and in those treated with insulin during pregnancy. Prevalence of IGR raised with increasing number of altered glucose values at OGTT performed during pregnancy for GDM screening. HbA1c and triglycerides measured during the third trimester of pregnancy were higher in women with postpartum IGR. At postpartum screening, women with IGR had higher BMI, waist, blood pressure. At multivariate logistic regression analysis, family history of diabetes (OR 2.21; 95% CI: 1.33-3.69; p < 0.01) and presence of all three glucose values exceeding threshold at OGTT during pregnancy (OR 2.89; 95% CI: 1.42-5.86; p < 0.01) were independently associated with IGR.

CONCLUSIONS

In women with GDM, persistence of IGR in the immediate postpartum period is associated with family history of diabetes and the presence of all three glucose values exceeding diagnostic threshold for GDM at OGTT in pregnancy, suggesting that these women should undergo specific diabetes monitoring and prevention programs.

Adherence to a follow-up program after gestational diabetes

AIM

The aim of this study was to examine attendance for early postpartum follow-up among women with gestational diabetes mellitus (GDM), and to identify factors that influenced their likelihood of attending.

METHODS

One thousand eight hundred and nineteen women with GDM were retrospectively analyzed. During pregnancy, the following data were collected: age, family history of diabetes, ethnicity, prepregnancy BMI, fasting plasma glucose, glycated hemoglobin, gestational week of GDM diagnosis, timing and mode of delivery, newborn's birth weight and length. Glycemia and insulinemia during OGTT, lipid profile and postpartum BMI were assessed at follow-up. Based on the OGTT, women were classified as having normal glucose tolerance (NGT) or abnormal glucose tolerance (AGT), which included impaired fasting glucose (IFG), impaired glucose tolerance (IGT), IFG + IGT, and DM2. Factors predicting postpartum attendance for follow-up and onset of AGT were considered.

RESULTS

Of the 889 (48.9%) who attended the scheduled postpartum OGTT, 741 (83.4%) had NGT, while 148 (16.6%) had AGT (IFG 6.7%, IGT 7.7%, IFG + IGT 0.8%, DM2 1.5%). The predictors of adherence to follow-up were: not belonging to an immigrant group; family history of DM2; and insulin therapy in pregnancy. The same factors were also predictive of AGT. Our data suggest a role of ethnicity in both attendance for postpartum follow-up and its outcome.

CONCLUSION

Despite efforts to provide care for women with GDM, postpartum screening rates are still low among Italian women, and especially among immigrants. Hence, the need to improve these patients' awareness of the severe risk of developing diabetes after pregnancy, concentrating efforts especially on women belonging to the most at risk ethnic groups.

Gestational diabetes: A link between OGTT, maternal-fetal outcomes and maternal glucose tolerance after childbirth

BACKGROUND AND AIM

The relationship among distribution of pathological values at the Oral Glucose Tolerance Test (OGTT), metabolic risk factors and pregnancy outcomes in women with Gestational Diabetes (GDM), has not been clearly identified. We retrospectively compared metabolic and therapeutic parameters, maternal-fetal outcomes and post-partum OGTTs, with respect to the number and distribution of altered values of diagnostic OGTT in pregnancy. Secondly, we assessed whether insulin therapy predictive factors were identifiable.

METHODS AND RESULTS

This analysis included 602 pregnant women with GDM, followed in Diabetes and Pregnancy Unit of Perugia Hospital from diagnosis to childbirth. All women were diagnosed diabetic upon 75g OGTT, according IADPSG criteria. Women were divided into 3 groups, respect to distribution of diagnostic blood glucose (BG) values at OGTT: Group 1: only fasting BG (OGTT0h); Group 2: 1 and/or 2h (OGTT1-2h); Group 3: both fasting and 1 h and/or 2h (OGTT0+1-2h) BG. Pregnant women with fasting hyperglycemia at OGTT (Groups 1 and 3) had similar metabolic characteristics (weight, prevalence of obesity, gestational weight gain, HbA1c), a greater need for insulin therapy, and a higher risk of impaired glucose tolerance persistence after childbirth, as compared to Group 2. No significant differences were observed in terms of maternal and neonatal outcomes (p > 0.05), except for a greater prevalence of caesarean sections in Group 3.

CONCLUSION

The metabolic characteristics of GDM women are mirrored by OGTT values at diagnosis, but are not associated with adverse pregnancy outcomes. Intensive management and a tailored treatment of GDM improve maternal-neonatal outcomes, regardless of diagnostic values distribution and pre-gestational metabolic characteristics.

Effects of metformin and insulin therapy regimens on postpartum oral glucose tolerance test results in pregnant women with gestational diabetes mellitus: a comparative study

OBJECTIVES

The main purpose of this study was to compare the effects of two regimens of metformin and insulin therapy on postpartum oral glucose tolerance test (OGTT) results in pregnant women with gestational diabetes mellitus (GDM).

METHODS

In this single-blind randomized clinical trial (RCT), a total number of 60 pregnant women meeting the inclusion criteria were assigned to two groups with a randomized block design (RBD): insulin therapy (IT) group (30 patients) and metformin therapy (MT) group (30 patients). At baseline, the data were comprised of prenatal maternal age, gestational age, GDM diagnosis, and maternal weight/height. During the postpartum period, 5-cc blood samples were taken from the pregnant women concerned to analyze their fasting blood sugar (FBS) levels. Then, the patients were asked to come back four days and six weeks later after delivery to check the OGTT results. At six weeks postpartum, in addition to OGTT, the glycated hemoglobin (HbA₁C) test was performed for all mothers. Finally, six weeks after delivery, these mothers were evaluated with regard to weight loss and body mass index (BMI).

RESULTS

Six weeks postpartum, the maternal weight and BMI significantly decreased in the MT group compared with the IT one, while there was no significant difference between both groups at baseline. On the fourth day, the OGTT results in the MT group were significantly lower in comparison with those in the IT group (p=0.012). At sixth weeks postpartum, the OGTT results were comparably lower in the MT group than those reported for the IT one; however, such a difference was not statistically significant (p=0.087).

CONCLUSIONS

According to the study results, metformin could be an effective and safe treatment for pregnant women suffering from GDM instead of insulin therapy.

Predictors of postpartum glucose intolerance in women with gestational diabetes mellitus: a prospective cohort study in Ethiopia based on the updated diagnostic criteria

OBJECTIVES

To identify the incidence of postpartum glucose intolerance and develop a prediction model based on antenatal characteristics to predict postpartum glucose intolerance.

DESIGN

Prospective cohort study.

SETTING

Gondar town public health facilities in Northwest Ethiopia.

PARTICIPANTS

Women who had gestational diabetes mellitus were advised to undergo postpartum oral glucose tolerance test at 6-12 weeks of delivery.

MAIN OUTCOME

Postpartum glucose intolerance.

DATA ANALYSIS

Predictors of postpartum glucose intolerance were identified using multivariable logistic regression analysis. The discriminative power of the predictor variables for postpartum glucose intolerance and the model accuracy were computed by area under the receiver operating characteristic curve and estimated by area under the curve (AUC) with 95% CI.

RESULTS

A total of 112 (85.5%) women with gestational diabetes mellitus returned and completed the postpartum oral glucose tolerance test. The incidence of postpartum glucose intolerance was 21.4% (95% CI14.3 to 28.4), inclusive of 18.7% pre-diabetes and 2.7% diabetes. Multivariable logistic regression analysis revealed that advanced maternal age, high fasting plasma glucose level at diagnosis, overweight and/or obesity, and antenatal depression were predictors of postpartum glucose intolerance. The AUC of the final reduced model to predict postpartum glucose intolerance was 0.884 (95% CI 0.822 to 0.937). Fasting plasma glucose at diagnosis of gestational diabetes mellitus (AUC=0.736, 95% CI0.616 to 0.845) and overweight and/or obesity (AUC=0.718, 95% CI 0.614 to 0.814) were better predictors of postpartum glucose intolerance. Moreover, the AUC for the combined predictors of fasting plasma glucose at diagnosis and mid-upper arm circumference was 0.822 (95% CI 0.722 to 0.907), which was the best predictor.

CONCLUSIONS

The incidence of postpartum glucose intolerance was high among women with gestational diabetes mellitus. Antenatal predictors modestly predicted postpartum glucose intolerance. The findings suggest ongoing glucose screening is indicated for all women with gestational diabetes mellitus.

Association between neonatal birthweight and risk of maternal glucose intolerance after gestational diabetes mellitus

Aims/Introduction

To evaluate whether the neonatal birthweight (NBW) is associated with early postpartum glucose intolerance in women with gestational diabetes mellitus.

Materials and Methods

A total of 1,113 women diagnosed with gestational diabetes mellitus who completed an oral glucose tolerance test at 6–9 weeks postpartum between 1 April 2014 and 8 January 2020 were included in this observational prospective cohort study. They were grouped by neonatal birthweight quartiles, and the odds ratios of postpartum glucose intolerance for different levels of neonatal birthweight were assessed.

Results

A lower NBW quartile was associated with an increased maternal risk of postpartum glucose intolerance after gestational diabetes mellitus. The adjusted odds ratios for maternal glucose intolerance were 1.69 (95% confidence interval 1.13–2.51) in the lowest NBW quartile (NBW 1,980–2,930 g) when compared with the highest NBW quartile (NBW 3,410–4,610 g). The association between lower NBW and maternal glucose intolerance was significantly stronger in women who delivered a girl. Additionally, NBW ≥3,100 g appears to be associated with a lower risk of maternal glucose intolerance postpartum.

Conclusions

Our findings suggest that low NBW is a previously unrecognized risk factor for maternal glucose intolerance after gestational diabetes in early postpartum in South China.

The relationship between total cholesterol and postpartum impaired glucose tolerance in women with gestational diabetes mellitus

Background

History of gestational diabetes mellitus (GDM) and serum lipid abnormalities were associated with postpartum impaired glucose tolerance. To investigate the association between concentration of total cholesterol (TC), at the time of GDM diagnosis, and risk of postpartum glucose intolerance.

Methods

Women who were diagnosed GDM with a live singleton delivery between January 1, 2013 and December 31, 2017 were included. Women were grouped based on the TC quartiles at the time of GDM diagnosis and had an OGTT at 6–12 weeks after delivery. The relationship between TC and the risk of postpartum glucose intolerance was assessed by COX regression.

Results

A total of 845 women were in the final analysis. Higher TC quartile at diagnosis of GDM was associated with a decreased risk of postpartum glucose intolerance. Women in the highest TC quartile (>7.0 mmol L^− 1) had approximately only half-risk of any postpartum glucose intolerance, compared with women in the lowest TC quartile (<5.5 mmol L^− 1).

Conclusions

The decreased concentration of TC, at the time of GDM diagnosis, was related to an increased risk of postpartum abnormal glucose regulation in GDM women. Therefore, because both excessively increased and decreased TC were associated with pregnancy and postpartum complications, the optimal concentration of maternal TC throughout pregnancy remained to be further researched.

Adherence to postpartum diabetes mellitus screening, do associated pregnancy complications make a difference?

AIMS

We aimed to investigate the impact of Gestational Diabetes Mellitus (GDM) complications on compliance with postpartum Diabetes screening.

METHODS

A retrospective cohort study was conducted comparing screening rates of women with and without GDM associated complications who delivered at the Soroka University Medical Center, between 2016 and 2017. The screening test of choice was a 2-hour 75 g oral glucose tolerance test, taken 6-12 weeks after delivery. GDM associated complications included one or more of the following: polyhydramnios, macrosomia, shoulder dystocia or cesarean section. Univariate analysis was used in order to examine if GDM associated complications were associated with postpartum diabetes screening.

RESULTS

During the study period a 164 women were included, of which, 82 women had suffered from GDM associated complications and comprised the study group and 82 women with GDM but without complications comprised the comparison group. Women in the study group were significantly older with a higher parity order. Induction rates were significantly higher among the comparison group, whereas, cesarean section rates were higher among the study group. No difference was noted with regard to neonatal outcomes. Women in the study group were not found to be more likely to be given screening recommendations at discharge (P = 0.50), at their postpartum visit (P = 0.36) or to perform DM screening postpartum (P = 0.17).

CONCLUSION

Women with GDM associated complications had a higher rate of compliance to postpartum DM screening recommendations. However, in the current study this difference did not reach statistical significance.

Appropriate Timing of Gestational Diabetes Mellitus Diagnosis in Medium- and Low-Risk Women: Effectiveness of the Italian NHS Recommendations in Preventing Fetal Macrosomia

BACKGROUND

Screening strategies for gestational diabetes mellitus (GDM) earlier than 24-28 weeks of gestation should be considered to prevent adverse pregnancy outcomes. Nonetheless, there is uncertainty about which women would benefit most from early screening and which screening strategies should be offered to women with GDM. The Italian National Healthcare Service (NHS) recommendations on selective screening for GDM at 16-18 weeks of gestation are effective in preventing fetal macrosomia in high-risk (HR) women, but the appropriateness of timing and effectiveness of these recommendations in medium- (MR) and low-risk (LR) women are still controversial. Patients and Methods. We retrospectively enrolled 769 consecutive singleton pregnant women who underwent both anomaly scan at 19-21 weeks of gestation and screening for GDM at 16-18 and/or 24-28 weeks of gestation, in agreement with the NHS recommendations and risk stratification criteria. Comparison of maternal characteristics, fetal biometric parameters at anomaly scan (head circumference (HC), biparietal diameter (BPD), abdominal circumference (AC), femur length (FL), estimated fetal weight (EFW)), and neonatal birth weight (BW) percentile among risk groups was examined.

RESULTS

219 (28.5%) women were diagnosed with GDM, while 550 (71.5%) were normal glucose-tolerant women. Out of 164 HR women, only 62 (37.8%) underwent the recommended early screening for GDM at 16-18 weeks of gestation. AC and EFW percentiles, as well as neonates' BW percentiles, were significantly higher in HR women diagnosed with GDM at 24-28 weeks of gestation with respect to normal glucose-tolerant women, as well as MR and LR women who tested positive for GDM. Comparative analysis between MR and LR women with GDM and women with normal glucose tolerance revealed significant differences in both AC and EFW percentiles (P < 0.05), while there was no significant difference in neonatal BW percentiles.

CONCLUSION

In MR and LR women with GDM, a mild acceleration of fetal growth can be detected at the time of anomaly scan. However, in these at-risk categories, the NHS recommendations for screening and treatment of GDM at 24-28 weeks of gestation are still effective in normalizing BW and preventing fetal macrosomia, thus supporting a risk factor-based selective screening program for GDM.

First Trimester Combined Test (FTCT) as a Predictor of Gestational Diabetes Mellitus

Background—The first trimester combined test (FTCT) is an effective screening tool to estimate the risk of fetal aneuploidy. It is obtained by the combination of maternal age, ultrasound fetal nuchal translucency (NT) measurement, and the maternal serum markers free β-human chorionic gonadotropin (β-hCG) and pregnancy-associated plasma protein A (PAPP-A). However, conflicting data have been reported about the association of FTCT, β-hCG, or PAPP-A with the subsequent diagnosis of gestational diabetes mellitus (GDM). Research design and methods—2410 consecutive singleton pregnant women were retrospectively enrolled in Calabria, Southern Italy. All participants underwent examinations for FTCT at 11–13 weeks (plus 6 days) of gestation, and screening for GDM at 16–18 and/or 24–28 weeks of gestation, in accordance with current Italian guidelines and the International Association Diabetes Pregnancy Study Groups (IADPSG) glycemic cut-offs. Data were examined by univariate and logistic regression analyses. Results—1814 (75.3%) pregnant women were normal glucose tolerant, while 596 (24.7%) were diagnosed with GDM. Spearman univariate analysis demonstrated a correlation between FTCT values and subsequent GDM diagnosis (ρ = 0.048, p = 0.018). The logistic regression analysis showed that women with a FTCT <1:10000 had a major GDM risk (p = 0.016), similar to women with a PAPP-A <1 multiple of the expected normal median (MoM, p = 0.014). Conversely, women with β-hCG ≥2.0 MoM had a reduced risk of GDM (p = 0.014). Conclusions—Our findings indicate that GDM susceptibility increases with fetal aneuploidy risk, and that FTCT and its related maternal serum parameters can be used as early predictors of GDM.

Clinical and genetic characteristics of abnormal glucose tolerance in Japanese women in the first year after gestational diabetes mellitus

AIMS/INTRODUCTION

Risk factors of type 2 diabetes mellitus in Japanese women with recent gestational diabetes mellitus are unknown. The objective of the present study was to investigate the clinical and genetic characteristics associated with postpartum abnormal glucose tolerance in Japanese women with gestational diabetes mellitus.

MATERIALS AND METHODS

A total of 213 Japanese women with recent gestational diabetes mellitus who underwent a postpartum 2-h oral glucose tolerance test were investigated. The association between antepartum clinical characteristics and postpartum abnormal glucose tolerance (diabetes or prediabetes based on the Japan Diabetes Society criteria) was examined. Frequencies of 45 known type 2 diabetes mellitus-associated genetic variants were also compared between women with and without postpartum abnormal glucose tolerance.

RESULTS

A total of 59 women showed postpartum abnormal glucose tolerance (prediabetes, n = 51; diabetes, n = 8). Plasma glucose levels at 1 or 2 h, the insulinogenic index and the insulin secretion-sensitivity index-2 of the antepartum oral glucose tolerance test were independent of postpartum abnormal glucose tolerance risk factors (P = 0.006, P = 0.00002, P = 0.01 and P = 0.006, respectively). Four genetic variants (rs266729 [ADIPOQ], rs6017317 [HNF4A], rs5215 [KCNJ11] and rs7177055 [HMG20A]) showed a nominally significant association with postpartum abnormal glucose tolerance (P < 0.05, respectively). Among these, three were related to insulin secretion. Postpartum abnormal glucose tolerance risk significantly increased with increasing risk-allele number (P = 0.0005; odds ratio 1.91).

CONCLUSIONS

Clinical features and genetic variants related to impaired insulin secretion are risk factors of postpartum abnormal glucose tolerance in Japanese women with recent gestational diabetes mellitus.

Effect of postpartum glucose tolerance results on subsequent weight retention in women with recent gestational diabetes: A retrospective cohort study

AIMS

Glucose tolerance normalizes postpartum in most women with gestational diabetes (GDM), which may provide false reassurance and decrease weight-reducing behaviours. We evaluated whether awareness of normal postpartum glucose tolerance was associated with higher weight retention than being unaware of glucose tolerance.

METHODS

This cohort study of women with GDM collected survey data during pregnancy and in the first and second postpartum year. We compared women who reported normal glucose tolerance ('aware, normal') in the first year to those reporting no testing or unsure of results ('unaware'). The primary outcome was self-reported weight in the second year compared between groups using multivariable linear regression.

RESULTS

Among 319 women, 110 (34.5%) were 'aware, normal'; 183 (57.4%) were 'unaware'; and 26 (8.2%) were 'aware, abnormal'. After adjusting for baseline weight and covariates, women with normal results had a mean 3.66 kg higher weight (CI 1.08-6.24 kg, p = 0.0056) by the second year than those unaware of results.

CONCLUSIONS

Women with GDM with normal postpartum glucose tolerance had significantly higher weight by the second year than those unaware of their results. Normal glucose tolerance after pregnancy may be misinterpreted as resolution of diabetes risk and decrease risk-reducing behaviours.

Metabolic effects of breastfeed in women with prior gestational diabetes mellitus: A systematic review and meta-analysis

This study was undertaken to provide comprehensive analyses of current research developments in the field of breastfeed (BF) and metabolic-related outcomes among women with prior gestational diabetes mellitus (GDM). Database PubMed, Embase, BIOSIS Previews, Web of Science, and Cochrane Library were searched through December 3, 2017. Odds ratio (OR) and weighted mean difference (WMD) with 95% confidence interval (CI) were pooled by random-effects model using Stata version 12.0. Twenty-three observational studies were included in quantitative synthesis. Reduced possibility of progression to type 2 diabetes mellitus (T2DM; OR = 0.79; 95% CI, 0.68-0.92) and pre-DM (OR = 0.66; 95% CI, 0.51-0.86) were found among women with longer BF of any intensity after GDM pregnancy. The positive effect of longer BF on progression to T2DM gradually became prominent with the extension of follow-up period. Compared with women with shorter BF, those with longer BF manifested more favourable metabolic parameters, including significant lower body mass index, fasting glucose, triglyceride, and higher insulin sensitivity index. The findings support that BF may play an important role in protection against the development of T2DM-related outcomes in midlife of women with prior GDM. However, further studies are needed to reveal the etiological mechanism.

Incidence and contributing factors of glucose intolerance in Saudi postpartum women: Sub-group analysis from RAHMA study

Objectives

The objectives of this study were to determine incidence and risk factors of glucose intolerance one year after delivery in a sub-cohort of Riyadh Mother and Baby Cohort Study (RAHMA) study.

Methods

This is a follow-up study of a sub-cohort from RAHMA study from King Khalid University Hospital (KKUH). All women from RAHMA database who completed one year since delivery at KKUH were contacted by phone to participate in the study. Previously collected data from RAHMA registry for each participant were linked to this study data. Clinical data measured for each participant included current weight and height to calculate the BMI and waist circumference. Blood tests done for each participant were fasting blood glucose (FPG) and HbA1c. Based on the blood tests results, participants were classified into three groups; diabetic, pre-diabetic and normal. The incidence of diabetes and prediabetes was calculated for the whole cohort. Clinical, biochemical, and sociodemographic predictors of glucose intolerance were compared between the three groups. Risk factors with P-value less than 0.05 were tested in multivariate regression model with bootstrapping to calculate the relative risk (RR) and its 95% Bias corrected Confidence Interval (C.I.)

Results

From the sub-cohort, 407 women fulfilled the inclusion criteria and agreed to participate in the study. From the study participants; 250 (61.4%) women were normoglycemic, 142 (35%) women had prediabetes and 15 (3.6%) women were diabetic. Following multivariable regression analysis only history of gestational diabetes mellitus (GDM), (RR 1.74, 95% CI (1.06 to 2.84), P = 0.01), obesity (RR 1.69, 95% CI (1.01–3.11), P = 0.04) and diastolic blood pressure, (RR 1.04, 95% CI (1.01–1.09), P = 0.03) remained as predictors of postpartum glucose intolerance.

Conclusion

The incidence of postpartum glucose intolerance (diabetes and prediabetes) is very high in Saudi women. Both GDM and obesity are strong predictors of glucose intolerance.

Predictors of Insulin Treatment During Pregnancy and Abnormal Postpartum Glucose Metabolism in Patients with Gestational Diabetes Mellitus

BACKGROUND

To investigate the potential predictors of insulin treatment during pregnancy and abnormal postpartum glucose metabolism in gestational diabetes mellitus (GDM).

METHODS

A total of 534 patients with GDM, who were diagnosed based on 75 g oral glucose tolerance test (OGTT) during pregnancy, were divided into the diet group (n=354) and insulin group (n=180) according to the treatment of hyperglycemia in pregnancy. Based on 75 g OGTT after delivery, 178 of the 534 patients were divided into the normal glucose tolerance (NGT; n=104) and the abnormal glucose tolerance (AGT; n=74) groups. Characteristics and metabolic indicators were compared. Logistic regression analysis was developed to assess the potential predictors of insulin treatment and abnormal postpartum glucose metabolism. Receiver operating characteristic curve was performed to determine the cut-off values.

RESULTS

Fasting plasma glucose (FPG), 1 h plasma glucose, and hemoglobin A1c (HbA1c) at GDM diagnosis were higher in the insulin group compared with the diet group (P <0.05). FPG, 1 h plasma glucose, HbA1c, maternal age, pre-gestational weight and maximum weight, pre-gestational body mass index, maternal birth weight, family history of diabetes in first-degree relatives, acanthosis nigricans, and prenatal weight were risk factors for insulin treatment (P <0.05), and the cut-offs of FPG, 1 h plasma glucose and HbA1c were 5.7 mmol/L, 11.4 mmol/L and 5.3%. Simultaneously, FPG at GDM diagnosis, insulin treatment during pregnancy, maternal age, family history of diabetes in first-degree relatives, acanthosis nigricans, and prenatal weight were risk factors of abnormal postpartum glucose metabolism (P <0.05), and the cut-off of FPG was 5.7 mmol/L.

CONCLUSION

Patients with FPG >5.7 mmol/L, 1 h plasma glucose >11.4 mmol/L, or HbA1c >5.3% at GDM diagnosis required insulin treatment, and patients with FPG >5.7 mmol/L had a greater risk of abnormal postpartum glucose metabolism. FPG at GDM diagnosis was the most important predictor.

Barriers to Postpartum Glucose Intolerance Screening in an Italian Population

Background: Gestational diabetes mellitus (GDM) is a strong risk factor for type 2 diabetes mellitus (T2D) and the postpartum period is crucial for early treatment in at-risk women. However, despite recommendations, only a fraction of women undergo a postpartum screening for glucose intolerance (ppOGTT). The present study aims to verify the reason(s) for poor adherence in our population. Research design and methods: This retrospective study includes 451 women in which GDM was diagnosed between 2015⁻2016. During 2017, we verified by phone interview how many women underwent ppOGTT at 6⁻12 weeks postpartum, as recommended by the Italian guidelines. The non-compliant women were asked about the reason(s) for failing to screen. The non-parametric Mann-Whitney test and the 2-tailed Fisher exact test were used to compare continuous and categorical features, respectively, among women performing or non-performing ppOGTT. Results: Out of 451 women with GDM diagnosis, we recorded information from 327. Only 97 (29.7%) performed ppOGTT. The remaining 230 women (70.3%) provided the following explanation for non-compliance: (1) newborn care (30.4%); (2) misunderstood importance (28.3%); (3) oversight (13.0%); (4) unavailability of test reservation in the nearest centers (10.4%); (5) normal glycemic values at delivery (8.3%); (6) discouragement by primary care physician (5.6%). Conclusions: In our population, most women with recent GDM failed to perform ppOGTT. Our results indicated that the prominent barriers could potentially be overcome.

Lactation and progression to type 2 diabetes in patients with gestational diabetes mellitus: A systematic review and meta-analysis of cohort studies

Aims/Introduction

To explore the association between lactation and type 2 diabetes incidence in women with prior gestational diabetes.

Materials and Methods

We searched PubMed, Embase and the Cochrane Library for cohort studies published through 12 June 2017 that evaluated the effect of lactation on the development of type 2 diabetes in women with prior gestational diabetes. A random effects model was used to estimate relative risks (RRs) with 95% confidence intervals (CIs).

Results

A total of 13 cohort studies were included in the meta‐analysis. The pooled result suggested that compared with no lactation, lactation was significantly associated with a lower risk of type 2 diabetes (RR 0.66, 95% CI 0.48–0.90, I² = 72.8%, P < 0.001). This relationship was prominent in a study carried out in the USA (RR 0.66, 95% CI 0.43–0.99), regardless of study design (prospective design RR 0.56, 95% CI 0.41–0.76; retrospective design RR 0.63, 95% CI 0.40–0.99), smaller sample size (RR 0.52, 95% CI 0.30–0.92, P = 0.024) and follow‐up duration >1 years (RR 0.75, 95% CI 0.56–1.00), and the study used adjusted data (RR 0.69, 95% CI 0.50–0.94). Finally, by pooling data from three studies, we failed to show that compared with no lactation, long‐term lactation (>1 to 3 months postpartum) was associated with the type 2 diabetes risk (RR 0.69, 95% CI 0.41–1.17).

Conclusions

The present meta‐analysis showed that lactation was associated with a lower risk of type 2 diabetes in women with prior gestational diabetes. Furthermore, no significant relationship between long‐term lactation and type 2 diabetes risk was detected. The impact of long‐term lactation and the risk of type 2 diabetes should be verified in further large‐scale studies.

Postpartum glucose intolerance: an updated overview

The prevalence of type 2 diabetes mellitus has increased worldwide over the past three decades, as a consequence of the more westernized lifestyle, which is responsible for the increasing obesity rate in the modern adult's life. Concomitant with this increase there has been a gradual rise in the overall prevalence of gestational diabetes mellitus, a condition that strongly predisposes to overt diabetes later in life. Many women with previous gestational diabetes mellitus show glucose intolerance in the early postpartum period. Although the best screening strategy for postpartum glucose intolerance is still debated, numerous evidences indicate that identification of these women at this time is of critical importance, as efforts to initiate early intensive lifestyle modification, including hypocaloric diet and physical activity, and to ameliorate the metabolic profile of these high-risk subjects can prevent or delay the onset of type 2 diabetes mellitus. Nevertheless, less than one fifth of women attend the scheduled postpartum screening following gestational diabetes mellitus and they are at increased risk to develop type 2 diabetes mellitus later in their lives. Unsatisfying results have also come from early intervention strategies and tools that have been developed during the last few years to help improving the rate of adherence to postpartum glycemic testing, thereby indicating that more effective strategies are needed to improve women's participation in postpartum screening.

Prevalence and Risk Factors for Glucose Intolerance among Saudi Women with Gestational Diabetes

OBJECTIVES

The objective of this study was to determine the incidence and risk factors of glucose intolerance one year after delivery in women with gestational diabetes (GDM).

METHODS

All women who had GDM and completed one year since delivery at King Khalid University Hospital were contacted to participate in the study. Based on to the American Diabetes Association criteria and the results of fasting blood glucose (FPG) and HbA1c, participants were classified into three groups: diabetic, impaired glucose tolerance (IGT), and normal. The incidence of diabetes and IGT was calculated. Clinical, biochemical, and sociodemographic predictors of glucose intolerance were compared between the three groups. Odds ratio (OR) for risk factors with P value less than 0.05 was calculated.

RESULTS

From a total 316 eligible women, 133 fulfilled the inclusion criteria and agreed to participate in the study. From the study participants, 58 (44%) women were normoglycemic, 60 (45%) women had IGT, and 15 (11%) women were diabetic. The odds of developing IGT or diabetes increased to nearly fourfold when women needed insulin for the control of GDM during pregnancy (OR 3.8, 95% CI 0.81-18.3, P = 0.08) and to nearly one-and-a-half-fold when they have positive family history of T2DM (OR 1.2, 95% CI 0.74-2.09, P = 0.40). Nevertheless, none of the odds ratios was statistically significant.

CONCLUSION

The incidence of postpartum hyperglycemia (diabetes and IGT) is very high in Saudi women with GDM. Family history of diabetes and insulin treatment of GDM may be predictors of postpartum hyperglycemia.

Postpartum screening practices, progression to abnormal glucose tolerance and its related risk factors in Asian women with a known history of gestational diabetes: A systematic review and meta-analysis

AIMS

Rate of postpartum screening and progression to glucose intolerance (diabetes and/or pre-diabetes) in Asian women with prior GDM and risk factors of diversion to abnormal glucose tolerance were reviewed.

MATERIALS AND METHODS

We searched Pub Med, Cochrane Library, Web of Science, EMBASE, and Ovid data base. About 1300 studies were screened and 27 articles were selected. Meta-analysis using Comprehensive Meta -Analysis software was conducted. All results were reported at the pooled ORs and 95% CI. Quantitative heterogeneity (I²) was assessed. To estimate the variances between studies, the statistical method "tau-squared" was applied. Statistical models like fixed effect or Mantel-Haenszel, and random effect (REM) or Dersimonian-laird were used for the analysis and integration of results.

RESULTS

Rate of glucose testing ranged from 13.1% to 81.9%. Prevalence of pre-diabetes was 3.9%-50.9%. Diabetes was reported in 2.8%-58% of women with history of gestational diabetes based on length of follow-up. Factor associated with postpartum diabetes mellitus included family History of diabetes mellitus, gestational age at diagnosis of GDM, insulin use during pregnancy and pre-pregnancy BMI.

CONCLUSIONS

Rate of postpartum screening in most of the Asian countries population is sub-optimal, in spite of high rate of glucose intolerance in this high risk group of women. Risk factors of progression to pre-diabetes and diabetes are similar to previous reported in developed countries.

Dyslipidemia incidence and the trend of lipid parameters changes in women with history of gestational diabetes: a 15-year follow-up study

PURPOSE

Evidence shows that patients with gestational diabetes mellitus (GDM) may exhibit features of dyslipidemic phenotype later in life. We aimed to examine and compare dyslipidemia incidence rate and the trend of lipid changes over a 15-years follow-up between the women with the history of GDM and their healthy peers.

METHODS

This longitudinal study included 289 patients with GDM and 1183 women without GDM, aged 20-50 years. Pooled logistic regression model was utilized to estimate odds ratio of dyslipidemia. The generalized estimating equation was used to evaluate the trend of lipid parameters changes over time.

RESULTS

Person-time dyslipidemia incidence rate in women with previous GDM was 0.067 (CI: 0.038, 0.096) with a median progression time of 2.13 years and for those without GDM was 0.059 (CI: 0.046, 0.072) with the median time of 2.31 years ([Formula: see text] = 0.214). The generalized estimating equation (GEE) analysis revealed no significant difference in trend changes of lipid profiles between two groups.

CONCLUSIONS

Lipid disorder after GDM might be more influenced by other variables (BMI, anthropometric features, and smoking/lifestyle habits) rather than by the GDM status alone. Lipid profile changes of GDM women do not become significantly worse than their non-GDM counterparts, as time progresses.

The Placental Microbiota Is Altered among Subjects with Gestational Diabetes Mellitus: A Pilot Study

Gestational diabetes mellitus (GDM) has significant implications for the future health of the mother and child. However, the associations between human placental microbiota and GDM are poorly understood. We aimed to profile the placental microbiota of GDM and further define whether or not certain placental microbiota taxon correlates with specific clinical characteristics. Placenta were collected from GDM women and women with normal pregnancies (n = 10, in each group) consecutively recruited at Peking Union Medical College Hospital. The anthropometric parameters of mother and infant, and cord blood hormones, including insulin, leptin and insulin-like growth factor-1 (IGF-1) were measured. Bacterial genomic DNA was isolated using magnetic beads and the human placental microbiota was analyzed using the Illumina MiSeq Sequencing System based on the V3-V4 hypervariable regions of the 16S rRNA gene. It showed there was no statistical difference in the clinical characteristics of mothers and infants, such as BMI at the beginning of pregnancy and gestational weight gain (GWG), birth weight, and cord blood hormones, including insulin, leptin and IGF-1. We found that the placental microbiota is composed of four dominant phyla from Proteobacteria (the most abundant), Bacteroidetes, Actinobacteria and Firmicutes, with the proportion of Proteobacteria increased, and Bacteroidetes and Firmicutes were decreased of women with GDM. Further analyses suggested that bacterial taxonomic composition of placentas from the phylum level down to the bacteria level, differed significantly between women with GDM and non-GDM women with normal pregnancies. Regression analysis showed a cluster of key operational taxonomic units (OTUs), phyla and genera were significantly correlated with GWG during pregnancy of mothers, and cord blood insulin, IGF-1 and leptin concentrations. In conclusion, our novel study showed that a distinct placental microbiota profile is present in GDM, and is associated with clinical characteristics of mothers and infants. This study contributes to the theoretical foundation on the potential relationship between placental microbiota and GDM.

[Suitability of screening for diabetes mellitus in women with a history of gestational diabetes]

OBJECTIVE

To assess long-term suitability of screening for type 2 diabetes mellitus in women with a previous diagnosis of gestational diabetes in Primary Care. The secondary objectives were to determine if there were clinical factors that modified the usefulness of the screening.

MATERIAL AND METHODS

An observational cohort type study was performed, which included all patients with the diagnosis of gestational diabetes during the years 2000 to 2009 (n=470) in the University Hospital Complex of Ourense. The electronic medical records were reviewed to assess the existence of gestational diabetes and the year of the last fasting blood glucose. The mean follow-up time was 12.9 years. The screening for evidence of a fasting blood glucose in the last 3 years was considered adequate. The following variables were analysed: adequacy of screening for type 2 diabetes mellitus, age, body mass index, gestational diabetes in more than one gestation, and rural/urban environment. A descriptive analysis of the data was performed, using Chi2 and Student's t-test to determine differences between subgroups. Statistical significance was considered as P<.05 RESULTS: The long-term monitoring of these patients was very irregular. Only 67.08% of the study group underwent diabetes mellitus type 2 screening. The level of follow-up was not associated with age, BMI, the place of residence, or the year of diagnosis. In patients with more than one episode of gestational diabetes, subsequent blood glucose control was achieved in 94.1%.

CONCLUSION

The adequacy of the screening in our area is very irregular and highly improvable.

Barriers to postpartum screening for type 2 diabetes: a qualitative study of women with previous gestational diabetes

Introduction

Risk of developing type 2 diabetes is increased in women with previous gestational diabetes mellitus (GDM). Postpartum glycemic screening is recommended in women with recent GDM. But this screening rate is low and the reasons are unclear. The aim of this study was to explore the experiences of Iranian women with recent GDM on barriers of postpartum screening for diabetes.

Methods

This qualitative study was conducted in Tehran, Iran in 2016. Semi-structured interview was used for data collection. 22 women with recent GDM were interviewed. These women gave birth in Tehran hospitals at a minimum of 6 months before interview. The missed screening defined as not attending to laboratory for Fasting Blood Sugar and/or Oral Glucose Tolerance Test, 6 week to 6 month after their child birthing. The data was analyzed by content analysis method.

Results

Themes and sub-themes that illustrated the barriers to postpartum diabetes screening were: inadequate education (about developing diabetes in the future, implementation of the screening, and glucometer validity in diagnosis of diabetes), perceiving the screening as difficult (feeling comfortable with the glucometer, poor laboratory conditions, issues related to the baby/babies, and financial problems), improper attitudes toward the screening (unwilling to get diagnosed, not giving priority to oneself, having false beliefs) and procrastination (gap to intention and action, self-deception and self-regulation failure).

Conclusion

Women with recent GDM reported several barriers for postpartum diabetes screening. This study help to develop the evidence-based interventions for improving this screening rate.

Incidence and Contributing Factors of Persistent Hyperglycemia at 6-12 Weeks Postpartum in Iranian Women with Gestational Diabetes: Results from LAGA Cohort Study

Background. A history of gestational diabetes is an important predictor of many metabolic disturbances later in life. Method. Life after gestational diabetes Ahvaz Study (LAGAs) is an ongoing population-based cohort study. Up to February 2016, 176 women with gestational diabetes underwent a 75 g oral glucose tolerance test (OGTT) at 6-12 weeks postpartum in Ahvaz (southwestern of Iran). Gestational diabetes was diagnosed according to the International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria and the American Diabetes Association (ADA) criteria applied for diagnosis of postpartum prediabetes and diabetes. Univariate and multivariate regression analysis were done. Results. Overall incidence of early postpartum glucose intolerance was 22.2% (95% CI, 16.3-29.0), 17.6% prediabetes (95% CI, 12.3-24.1) and 4.5% diabetes (95% CI, 2.0-8.8%). Independent risk factors for glucose intolerance were FPG ≥ 100 at the time of OGTT (OR 3.86; 95% CI; 1.60-9.32), earlier diagnosis of GDM (OR 0.92; 95% CI; 0.88-0.97), systolic blood pressure (OR 1.02; 95% CI; 1.002-1.04), and insulin or metformin therapy (OR 3.14; 95% CI; 1.20-8.21). Conclusion. Results determined a relatively high rate of glucose intolerance at 6-12 weeks after GDM pregnancy. Early postpartum screening of type 2 diabetes is needed particularly in women at high risk of type 2 diabetes.

Risk of Type 2 Diabetes Mellitus following Gestational Diabetes Pregnancy in Women with Polycystic Ovary Syndrome

BACKGROUND

This study examines gestational diabetes mellitus (GDM) in women with polycystic ovary syndrome (PCOS) and the risk of type 2 diabetes mellitus (DM) following GDM pregnancy.

METHODS

A cohort of 988 pregnant women with PCOS who delivered during 2002-2005 was examined to determine the prevalence and predictors of GDM, with follow-up through 2010 among those with GDM to estimate the risk of DM.

RESULTS

Of the 988 pregnant women with PCOS, 192 (19%) developed GDM. Multivariable predictors of GDM included older age, Asian race, prepregnancy obesity, family history of DM, preconception metformin use, and multiple gestation. Among women with PCOS and GDM pregnancy, the incidence of DM was 2.8 (95% confidence interval (CI) 1.9-4.2) per 100 person-years and substantially higher for those who received pharmacologic treatment for GDM (6.6 versus 1.5 per 100 person-years, p < 0.01). The multivariable adjusted risk of DM was fourfold higher in women who received pharmacologic treatment for GDM (adjusted hazard ratio 4.1, 95% CI 1.8-9.6). The five-year incidence of DM was 13.1% overall and also higher in the pharmacologic treatment subgroup (27.0% versus 7.1%, p < 0.01).

CONCLUSIONS

The strongest predictors of GDM among women with PCOS included Asian race and prepregnancy obesity. Pharmacologic treatment of GDM is associated with fourfold higher risk of subsequent DM.

Abnormal glucose tolerance post-gestational diabetes mellitus as defined by the International Association of Diabetes and Pregnancy Study Groups criteria

OBJECTIVE

An increase in gestational diabetes mellitus (GDM) prevalence has been demonstrated across many countries with adoption of the International Association of the Diabetes and Pregnancy Study Groups (IADPSG) diagnostic criteria. Here, we determine the cumulative incidence of abnormal glucose tolerance among women with previous GDM, and identify clinical risk factors predicting this.

DESIGN

Two hundred and seventy women with previous IADPSG-defined GDM were prospectively followed up for 5years (mean 2.6) post-index pregnancy, and compared with 388 women with normal glucose tolerance (NGT) in pregnancy.

METHODS

Cumulative incidence of abnormal glucose tolerance (using American Diabetes Association criteria for impaired fasting glucose, impaired glucose tolerance and diabetes) was determined using the Kaplan-Meier method of survival analysis. Cox regression models were constructed to test for factors predicting abnormal glucose tolerance.

RESULTS

Twenty-six percent of women with previous GDM had abnormal glucose tolerance vs 4% with NGT, with the log-rank test demonstrating significantly different survival curves (P<0.001). Women meeting IADPSG, but not the World Health Organization (WHO) 1999 criteria, had a lower cumulative incidence than women meeting both sets of criteria, both in the early post-partum period (4.2% vs 21.7%, P<0.001) and at longer-term follow-up (13.7% vs 32.6%, P<0.001). Predictive factors were glucose levels on the pregnancy oral glucose tolerance test, family history of diabetes, gestational week at testing, and BMI at follow-up.

CONCLUSIONS

The proportion of women developing abnormal glucose tolerance remains high among those with IADPSG-defined GDM. This demonstrates the need for continued close follow-up, although the optimal frequency and method needs further study.

A new predictive tool for the early risk assessment of gestational diabetes mellitus

AIMS

The Italian National Institute of Health has recently introduced a selective screening based on the risk profile of pregnant women, which while recommending against screening of women at low risk (LR) for GDM, it recommends an early test for women at high risk (HR) for GDM. Herein, we assessed the accuracy and cost-effectiveness of this screening and developed a new index that improves these requirements.

METHODS

We retrospectively enrolled 3974 pregnant women. GDM was diagnosed with a 2h 75-g OGTT at 16-18 weeks (early test) or 24-28 weeks of gestation, according to the IADPSG guidelines.

RESULTS

55.6% of HR women had GDM, although only 38.4% underwent early screening. Among 2654 women at medium risk, 20.9% had GDM; paradoxically, among 770 LR women, that would not have been screened, 26.6% received a GDM diagnosis. Based on these unsatisfactory results, we elaborated the Capula's index, that reduced both screening tests (p<0.001) and potentially undetected GDM cases (p<0.001), and corrected the paradoxical prevalence estimates of GDM obtained with the current Italian guidelines. Also, Capula's index improved correlation of GDM risk profile with obstetric and neonatal adverse events.

CONCLUSIONS

Capula's index improves accuracy of selective screening for GDM.

Quantification of the type 2 diabetes risk in women with gestational diabetes: a systematic review and meta-analysis of 95,750 women

AIMS/HYPOTHESIS

Women with gestational diabetes mellitus (GDM) are at risk of developing type 2 diabetes, but individualised risk estimates are unknown. We conducted a meta-analysis to quantify the risk of progression to type 2 diabetes for women with GDM.

METHODS

We systematically searched the major electronic databases with no language restrictions. Two reviewers independently extracted 2 × 2 tables for dichotomous data and the means plus SEs for continuous data. Risk ratios were calculated and pooled using a random effects model.

RESULTS

There were 39 relevant studies (including 95,750 women) BMI (RR 1.95 [95% CI 1.60, 2.31]), family history of diabetes (RR 1.70 [95% CI 1.47, 1.97]), non-white ethnicity (RR 1.49 [95% CI 1.14, 1.94]) and advanced maternal age (RR 1.20 [95% CI 1.09, 1.34]) were associated with future risk of type 2 diabetes. There was an increase in risk with early diagnosis of GDM (RR 2.13 [95% CI 1.52, 3.56]), raised fasting glucose (RR 3.57 [95% CI 2.98, 4.04]), increased HbA1c (RR 2.56 [95% CI 2.00, 3.17]) and use of insulin (RR 3.66 [95% CI 2.78, 4.82]). Multiparity (RR 1.23 [95% CI 1.01, 1.50]), hypertensive disorders in pregnancy (RR 1.38 [95% CI 1.32, 1.45]) and preterm delivery (RR 1.81 [95% CI 1.35, 2.43]) were associated with future diabetes. Gestational weight gain, macrosomia in the offspring or breastfeeding did not increase the risk.

CONCLUSIONS/INTERPRETATION

Personalised risk of progression to type 2 diabetes should be communicated to mothers with GDM.

SYSTEMATIC REVIEW REGISTRATION

www.crd.york.ac.uk/PROSPERO CRD42014013597.

Plasma Levels of the Interleukin-1-Receptor Antagonist Are Lower in Women with Gestational Diabetes Mellitus and Are Particularly Associated with Postpartum Development of Type 2 Diabetes

Diabetes mellitus is a group of diseases characterized by chronic hyperglycemia. Women who develops hyperglycemia for the first time during pregnancy receive the diagnosis gestational diabetes mellitus (GDM). Presently, there is no consensus about the diagnostic criteria for GDM. A majority of these women subsequently develop postpartum overt diabetes making it important to identify these patients as early as possible. In this study we investigated if plasma levels of the interleukin-1 receptor antagonist (IL-1Ra), an endogenous inhibitor of IL-1 signaling, can be used as a complementary biomarker for diagnosing GDM and predicting postpartum development of overt diabetes mellitus. Patients participating in this study (n = 227) were diagnosed with their first GDM 2004–2013 at Lund University Hospital, Lund, Sweden. Healthy pregnant volunteers (n = 156) were recruited from women’s welfare centers in the same region 2014–2015. Levels of IL-1Ra and C-peptide were analyzed in ethylenediaminetetraacetic acid (EDTA)-plasma or serum using enzyme linked immunosorbent assay (ELISA). GDM patients had significantly lower levels of IL-1Ra than the control group (p = 0.012). In addition, GDM patients that had developed impaired glucose tolerance (IGT) or type 2 diabetes mellitus postpartum had significantly lower levels of IL-1Ra, and significantly higher levels of C-peptide than GDM patients that had not developed diabetes mellitus postpartum (p = 0.023) and (p = 0.0011) respectively. An inverse correlation was found between IL-1Ra and serum C-peptide levels in the control group (r_s = -0.31 p = 0.0001). Our results show that IL-1Ra might be included in a future panel of biomarkers, both for diagnosing GDM to complement blood glucose, and also identifying GDM patients that are at risk of developing type 2 diabetes mellitus postpartum. However, the ROC curve analysis provided a sensitivity of 52.2% and specificity of 67.1%, which nonetheless may not be sufficient enough to use IL-1Ra as a sole biomarker.

Model for individual prediction of diabetes up to 5 years after gestational diabetes mellitus

Aims

To identify predictors of diabetes development up to 5 years after gestational diabetes mellitus (GDM) and to develop a prediction model for individual use.

Methods

Five years after GDM, a 75-g oral glucose tolerance test (OGTT) was performed in 362 women, excluding women already diagnosed with diabetes at 1- to 2-year follow-up or later (n = 45). All but 21 women had results from follow-up at 1–2 years, while 84 women were lost from that point. Predictive variables were identified by logistic regression analysis.

Results

Five years after GDM, 28/362 women (8 %) were diagnosed with diabetes whereas 187/362 (52 %) had normal glucose tolerance (NGT). Of the latter, 139/187 (74 %) also had NGT at 1- to 2-year follow-up. In simple regression analysis, using NGT at 1–2 years and at 5 years as the reference, diabetes at 1- to 2-year follow-up or later was clearly associated with easily assessable clinical variables, such as BMI at 1- to 2-year follow-up, 2-h OGTT glucose concentration during pregnancy, and non-European origin (P < 0.0001). A prediction model based on these variables resulting in 86 % correct classifications, with an area under the receiver-operating characteristic curve of 0.91 (95 % CI 0.86–0.95), was applied in a function-sheet line diagram illustrating the individual effect of weight on diabetes risk.

Conclusions

The results highlight the importance of BMI as a potentially modifiable risk factor for diabetes after GDM. Our proposed prediction model performed well, and should encourage validation in other populations in future studies.

Genetic Rodent Models of Obesity-Associated Ovarian Dysfunction and Subfertility: Insights into Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is the most common endocrinopathy affecting women and a leading cause of female infertility worldwide. Defined clinically by the presence of hyperandrogenemia and oligomenorrhoea, PCOS represents a state of hormonal dysregulation, disrupted ovarian follicle dynamics, and subsequent oligo- or anovulation. The syndrome's prevalence is attributed, at least partly, to a well-established association with obesity and insulin resistance (IR). Indeed, the presence of severe PCOS in human genetic obesity and IR syndromes supports a causal role for IR in the pathogenesis of PCOS. However, the molecular mechanisms underlying this causality, as well as the important role of hyperandrogenemia, remain poorly elucidated. As such, treatment of PCOS is necessarily empirical, focusing on symptom alleviation. The generation of knockout and transgenic rodent models of obesity and IR offers a promising platform in which to address mechanistic questions about reproductive dysfunction in the context of metabolic disease. Similarly, the impact of primary perturbations in rodent gonadotrophin or androgen signaling has been interrogated. However, the insights gained from such models have been limited by the relatively poor fidelity of rodent models to human PCOS. In this mini review, we evaluate the ovarian phenotypes associated with rodent models of obesity and IR, including the extent of endocrine disturbance, ovarian dysmorphology, and subfertility. We compare them to both human PCOS and other animal models of the syndrome (genetic and hormonal), explore reasons for their discordance, and consider the new opportunities that are emerging to better understand and treat this important condition.