Type 2 diabetes mellitus in pregnancy: The impact of maternal weight and early glycaemic control on outcomes

Increased risk of admission to neonatal intensive care unit in neonates born to mothers with pregestational diabetes

The purpose of this study was to describe how maternal diabetes impacts admission to the neonatal intensive care unit to support healthcare professionals when counselling patients. The primary outcome was admission rates. A retrospective observational cohort study of 25,238 births was conducted at an Irish tertiary maternity hospital from January 2018 to December 2020. Cases of pregestational and gestational diabetes were examined for neonatal intensive care admission outcomes. R statistical analysis software was used. There were 3905 live neonates born between 34 and 42 weeks to mothers with diabetes (N = 67 type 1 diabetes, N = 60 type 2 diabetes, N = 3712 gestational diabetes, N = 5 mature onset diabetes, excluded N = 61). There was a statistically significant difference in mean gestational age: 37 + 1 (weeks/days) (95% CI 36 + 6-37 + 4), 38 + 1 (95% CI 37 + 5-38 + 3, p = 0.0019), and 39 (95% CI 38 + 6-39 + 1, p ≤ 0.001) in type 1, type 2, and gestational diabetes cohorts. Admission rate was 13.4% with significant differences between the subgroups: 41.8% [95% CI 2.33-4.58, RR 3.32], 31.1% [95% CI 1.55-3.50, RR 3.89], and 12.5% [95% CI 0.12-0.14, RR 0.133] in type 1, type 2, and gestational diabetes cohorts. A higher percentage of mothers with pregestational diabetes (42.9% and 31.5%) were discharged before their infants, versus 21.2% of gestational diabetes.

CONCLUSION

Neonates of mothers with pregestational diabetes have a significantly higher admission rate. The type 1 diabetes cohort were born earlier and had higher birth weight centiles. Hypoglycaemia remains a significant risk for all subgroups.

WHAT IS KNOWN

• Infants of mothers with T1DM are born earlier and have higher morbidity rates compared to infants of mothers with T2DM or GDM.

WHAT IS NEW

• A higher proportion of neonates born to T2DM mothers were admitted due to severe/refractory hypoglycemia, however hypoglycemia was detected after admission in many neonates transferred to NICU for other reasons. It remains a significant risk and requires vigilance of all neonates born to mothers with pregestational or gestational diabetes. • Mothers with pre-gestational diabetes were more likely to be discharged home while their infant remains in NICU.

Predictors of Composite Maternal and Fetal Outcomes among Pregnant Women with Early-Onset Type 2 Diabetes: A Cross-Sectional Study

INTRODUCTION

The most common form of pregestational diabetes in pregnancy is type 2 diabetes, requiring strict metabolic monitoring owing to the risk of adverse pregnancy outcomes. Our study aimed to identify predictors of composite maternal outcome (CMO) and fetal outcome (CFO) separately in pregnant women with early-onset type 2 diabetes (PwEOT2D).

METHODS

The cross-sectional pilot study included 60 PwEOT2D by recording age, socioeconomic determinants, preconception body mass index (pBMI), preconception (pHbA1c) and trimester-specific glycated hemoglobin (HbA1c), gestational weight gain (GWG), and pregnancy outcomes. We defined CMO as at least one of the following: gestational hypertension, preeclampsia, eclampsia, preterm delivery, or emergency section. CFO included at least one of the following: small or large for gestational age, macrosomia, neonatal hypoglycemia, or admission to the neonatal intensive care unit.

RESULTS

CMO was detected in 55% and CFO in 35% of PwEOT2D. The majority of PwEOT2D with CMO lived in suburban areas (73.1%), while those without CMO mostly lived in rural areas (51.9%, p = 0.014). Moreover, PwEOT2D with CMO had comparable pBMI to those without CMO (31.45 ± 6.27 versus 28.99 ± 6.28 kg/m2, p = 0.136). However, PwEOT2D with CMO had higher pHbA1c (7.28 ± 0.95 versus 6.46 ± 0.96%, p = 0.002) and first trimester HbA1c (7.24 ± 1.08 versus 6.42 ± 0.97%, p = 0.003). Similarly, PwEOT2D with CFO had higher pHbA1c (7.84 ± 0.95 versus 6.41 ± 0.67%, p < 0.001) and first trimester (7.29 ± 1.07 versus 6.65 ± 1.07%, p = 0.032) and second trimester HbA1c (6.45 ± 0.87 versus 5.96 ± 0.82%, p = 0.038). Additionally, GWG was higher in the second (4.38 ± 2.01 versus 3.33 ± 1.61 kg, p = 0.032) and third trimester (5.66 ± 2.93 versus 3.89 ± 2.61 kg, p = 0.002) compared with those without CMO. Regression analysis identified pHbA1c, first trimester of pregnancy, and community type as predictors of CMO, while pHbA1c and the occurrence of CMO were predictors of CFO.

CONCLUSIONS

Our results imply that preconception and first trimester of pregnancy HbA1c, as well as community disparities, are predictors of CMO, while the predictors of CFO were only preconception HbA1c and the occurrence of CMO in pregnant women with EOT2D. Therefore, tailoring preventive strategies, followed by achieving and sustaining trimester-specific metabolic control, might improve pregnancy outcomes in women with EOT2D.

Pre-existing Diabetes and Stillbirth or Perinatal Mortality: A Systematic Review and Meta-analysis

OBJECTIVE

Despite the well-recognized association between pre-existing diabetes mellitus and stillbirth or perinatal mortality, there remain knowledge gaps about the strength of association across different populations. The primary objective of this systematic review and meta-analysis was to quantify the association between pre-existing diabetes and stillbirth or perinatal mortality, and secondarily, to identify risk factors predictive of stillbirth or perinatal mortality among those with pre-existing diabetes.

DATA SOURCES

MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials from inception to April 2022.

METHODS OF STUDY SELECTION

Cohort studies and randomized controlled trials in English or French that examined the association between pre-existing diabetes and stillbirth or perinatal mortality (as defined by the original authors) or identified risk factors for stillbirth and perinatal mortality in individuals with pre-existing diabetes were included. Data extraction was performed independently and in duplicate with the use of prespecified inclusion and exclusion criteria. Assessment for heterogeneity and risk of bias was performed. Meta-analyses were completed with a random-effects model.

TABULATION, INTEGRATION, AND RESULTS

From 7,777 citations, 91 studies met the inclusion criteria. Pre-existing diabetes was associated with higher odds of stillbirth (37 studies; pooled odds ratio [OR] 3.74, 95% CI, 3.17-4.41, I2 =82.5%) and perinatal mortality (14 studies; pooled OR 3.22, 95% CI, 2.54-4.07, I2 =82.7%). Individuals with type 1 diabetes had lower odds of stillbirth (pooled OR 0.81, 95% CI, 0.68-0.95, I2 =0%) and perinatal mortality (pooled OR 0.73, 95% CI, 0.61-0.87, I2 =0%) compared with those with type 2 diabetes. Prenatal care and prepregnancy diabetes care were significantly associated with lower odds of stillbirth (OR 0.26, 95% CI, 0.11-0.62, I2 =87.0%) and perinatal mortality (OR 0.41, 95% CI, 0.29-0.59, I2 =0%).

CONCLUSION

Pre-existing diabetes confers a more than threefold increased odds of both stillbirth and perinatal mortality. Maternal type 2 diabetes was associated with a higher risk of stillbirth and perinatal mortality compared with maternal type 1 diabetes.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42022303112.

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

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

Early Methylglyoxal Exposure Leads to Worsened Cardiovascular Function in Young Rats

BACKGROUND

Though maternal diabetes effects are well described in the literature, the effects of maternal diabetes in postnatal phases are often overlooked. Diabetic individuals have higher levels of circulating glycotoxins, and there is a positive correlation between maternal-derived glycotoxins and circulating glycotoxins in their progeny. Previous studies evaluated the metabolic effects of high glycotoxin exposure during lactation in adult animals. However, here we focus on the cardiovascular system of juvenile rats.

METHODS

For this, we used two experimental models: 1. High Methylglyoxal (MG) environment: pregnant Wistar rats were injected with PBS (VEH group) or Methylglyoxal (MG group; 60 mg/kg/day; orally, postnatal day (PND) 3 to PND14). 2. GLO-1 inhibition: pregnant Wistar rats were injected with dimethyl sulfoxide (VEH group) or a GLO-1 inhibitor (BBGC group; 5 mg/kg/day; subcutaneously, PND1-PND5). The offspring were evaluated at PND45.

RESULTS

MG offspring presented cardiac dysfunction and subtly worsened vasomotor responses in the presence of perivascular adipose tissue, without morphological alterations. In addition, an endogenous increase in maternal glycotoxins impacts offspring vasomotricity due to impaired redox status.

CONCLUSIONS

Our data suggest that early glycotoxin exposure led to cardiac and vascular impairments, which may increase the risk for developing cardiovascular diseases later in life.

A Review of Fetal Development in Pregnancies with Maternal Type 2 Diabetes Mellitus (T2DM)-Associated Hypothalamic-Pituitary-Adrenal (HPA) Axis Dysregulation: Possible Links to Pregestational Prediabetes

Research has identified fetal risk factors for adult diseases, forming the basis for the Developmental Origins of Health and Disease (DOHaD) hypothesis. DOHaD suggests that maternal insults during pregnancy cause structural and functional changes in fetal organs, increasing the risk of chronic diseases like type 2 diabetes mellitus (T2DM) in adulthood. It is proposed that altered maternal physiology, such as increased glucocorticoid (GC) levels associated with a dysregulated hypothalamic-pituitary-adrenal (HPA) axis in maternal stress and T2DM during pregnancy, exposes the fetus to excess GC. Prenatal glucocorticoid exposure reduces fetal growth and programs the fetal HPA axis, permanently altering its activity into adulthood. This programmed HPA axis is linked to increased risks of hypertension, cardiovascular diseases, and mental disorders in adulthood. With the global rise in T2DM, particularly among young adults of reproductive age, it is crucial to prevent its onset. T2DM is often preceded by a prediabetic state, a condition that does not show any symptoms, causing many to unknowingly progress to T2DM. Studying prediabetes is essential, as it is a reversible stage that may help prevent T2DM-related pregnancy complications. The existing literature focuses on HPA axis dysregulation in T2DM pregnancies and its link to fetal programming. However, the effects of prediabetes on HPA axis function, specifically glucocorticoid in pregnancy and fetal outcomes, are not well understood. This review consolidates research on T2DM during pregnancy, its impact on fetal programming via the HPA axis, and possible links with pregestational prediabetes.

Diabetes and pregnancy study (DAPSY): a 10-year single-center cohort study of pregnancies affected by diabetes

PURPOSE

The aim of our study was to investigate to what degree clinical characteristics can contribute to incidence and structure of pregnancy and childbirth complications in women with diabetes, and to reveal key risk factors for adverse outcomes.

METHODS

We conducted a retrospective single-center cohort study from January 2008 through December 2017, including 3069 singleton pregnancies, affected by type 1 diabetes (T1D, n = 498), type 2 diabetes (T2D, n = 214), and gestational diabetes mellitus (GDM, n = 2357).

RESULTS

More than 10 years duration of T1D associated with increased risk for preterm birth (RR 2.03, 95% CI 1.28-3.20) and preeclampsia (RR 1.57, 95% CI 1.09-2.26). Diabetic nephropathy, same as diabetic proliferative retinopathy, was associated with increased risk of C-section, preeclampsia development, SGA delivery. In patients with T1D who received CSII (12%), we do not report superior outcomes compared to MDI. Pre-pregnancy HbA1c level less than 6.5% reduced the risk of preeclampsia for T1D (RR 0.28, 95% CI 0.19-0.67) and risk of LGA birth for T2D (RR 0.43, 95% CI 0.19-0.92). Achieving glycemic target values by full-term pregnancy reduced the risk of excessive fetal adiposity (RR 0.81 for T1D, RR 0.39 for T2D). For T2D and GDM, the leading risk factors were obesity and chronic hypertension. For patients with GDM, insulin administration and early diagnosis of GDM were the significant risk factors for adverse outcomes.

CONCLUSION

Diabetes during pregnancy is challenging for the clinician, but optimizing glycemic control, treatment regimens, and close attention to comorbidities can help to reduce the risks and ensure appropriate quality diabetes management.

An overview of diabetes mellitus in pregnant women with obesity

Rates of obesity are increasing world-wide with an estimated 1billion people projected to be obese by 2030 if current trends remain unchanged. Obesity currently considered one of the most significant associated factors of non-communicable diseases poses the greatest threat to health. Diabetes mellitus is an important metabolic disorder closely associated with obesity. It is therefore expected that with the increasing rates of obesity, the rates of diabetes in pregnancy will also be rising. This disorder may pre-date pregnancy (diagnosed or undiagnosed and diagnosed for the first time in pregnancy) or may be of onset in pregnancy. Irrespective of the timing of onset, diabetes in pregnancy is associated with both fetal and maternal complications. Outcomes are much better if control is maximised. Early diagnosis, multidisciplinary care and tailored management with optimum glycaemic control is associated with a significant reduction in not only pregnancy complications but long-term consequences on both the mother and offspring. This review brings together the current understanding of the pathogenesis of the endocrine derangements that are associated with diabetes in pregnancy how screening should be offered and management including pre-pregnancy care and the role of newer agents in management.

Call for a More Specific Diagnosis of Infant of a Diabetic Mother to Optimize Neonatal Care

Hyperglycemia is the diagnostic feature of diabetes mellitus (DM), and during pregnancy, hyperglycemia has numerous serious implications for organogenesis and fetal growth. Each type of DM has different neonatal implications based on pathogenesis, length of disease, and comorbidities. Currently, limited attention is given to the woman's type of DM when evaluating risks for neonates. The diagnosis of infant of a diabetic mother is not sufficient because of the varying pathophysiology of diabetes classifications and associated neonatal outcomes. By expanding the diagnosis to include the woman's classification and glucose control, maternity and neonatal care providers could develop plans of care based on potential neonatal outcomes, including anticipatory guidance for families. In this commentary, we propose a more specific diagnosis, rather than infant of a diabetic mother, to better serve these infants.

Glycosylated haemoglobin as an indicator of diabetes control in pregnancy: A 10-year review of the relationship between HbA1c trends and delivery outcome in type I and type II diabetes

BACKGROUND

Pregestational diabetes mellitus (PGDM) confers an increased risk of adverse maternal and neonatal outcomes [1,2]. Glycaemic control in the medium and long term is commonly evaluated by examining glycosylated haemoglobin (HbA1c) levels. However, the value of HbA1c in pregnancy may be diminished by increased level of red cell turnover characteristic of pregnancy [3,4]. We sought to examine the impact of HbA1c in the first trimester and pre-delivery, and the within-patient change throughout gestation on mode of delivery and birthweight in pregnancies complicated by a pre-pregnancy diagnosis of type I or type II diabetes.

METHODS

A 10-year consecutive cohort of pregnancies complicated by PGDM, from Jan 2010 until Dec 2019, was examined for HbA1c data in the first trimester and within 6 weeks of delivery. Perinatal outcome data, including gestational age at delivery, mode of delivery and birthweight centile, were obtained from hospital records. The Spearman Rank correlation was used to correlate HcA1c levels in the first trimester with birthweight centiles. Non-parametric summaries and rank-based tests, Signed-rank test and Kruskal-Wallis test, were used to compare Hba1c levels.

RESULTS

During the 10-year study period, a consecutive cohort of 396 pregnancies that attained a viable gestational age (>24 weeks' gestation) and complicated by pregestational diabetes was identified; representing 81 % of the population of pregestational diabetic pregnancies managed by this service during the study period. The median [IQR] HbA1c levels (mmol/mol) in the first trimester, pre-delivery and the differential across gestation were 51 [19] mmol/mol, 43 [11] mmol/mol and -8 [13] mmol/mol, respectively. A statistically significant reduction in HbA1c levels throughout gestation was observed (p < 0.001). The median [IQR] birthweight centile was 69 [50 - 96]. The distributions in HbA1c levels and birthweight centiles were heavily skewed. No correlation was identified between HbA1c levels and mode of delivery.

CONCLUSION

Neither baseline HbA1c levels, pre-delivery values, nor trends across gestation appear to impact birthweight centile or mode of delivery in PGDM. While optimising glycaemic control can affect the long term health of the mother, these indices cannot be relied upon to reflect the impact of glycaemic control on fetal growth aberrations that influence mode of delivery.

Impact of Carbohydrate Counting Method during Pregnancy in Women with Pregestational Diabetes Mellitus: A Controlled Clinical Trial

OBJECTIVE

 To evaluate the effect of the carbohydrate counting method (CCM) on glycemic control, maternal, and perinatal outcomes of pregnant women with pregestational diabetes mellitus (DM).

METHODS

 Nonrandomized controlled clinical trial performed with 89 pregnant women who had pregestational DM and received prenatal care in a public hospital in Rio de Janeiro, state of Rio de Janeiro, Brazil, between 2009 and 2014, subdivided into historic control group and intervention group, not simultaneous. The intervention group (n = 51) received nutritional guidance from the carbohydrate counting method (CCM), and the historical control group (n = 38), was guided by the traditional method (TM). The Mann-Whitney test or the Wilcoxon test were used to compare intra- and intergroup outcomes and analysis of variance (ANOVA) for repeated measures, corrected by the Bonferroni post-hoc test, was used to assess postprandial blood glucose.

RESULTS

 Only the CCM group showed a reduction in fasting blood glucose. Postprandial blood glucose decreased in the 2nd (p = 0.00) and 3rd (p = 0.00) gestational trimester in the CCM group, while in the TM group the reduction occurred only in the 2nd trimester (p = 0.015). For perinatal outcomes and hypertensive disorders of pregnancy, there were no differences between groups. Cesarean delivery was performed in 82% of the pregnant women and was associated with hypertensive disorders (gestational hypertension or pre-eclampsia; p = 0.047).

CONCLUSION

 Both methods of nutritional guidance contributed to the reduction of postprandial glycemia of women and no differences were observed for maternal and perinatal outcomes. However, CCM had a better effect on postprandial glycemia and only this method contributed to reducing fasting blood glucose throughout the intervention.

REBEC CLINICAL TRIALS DATABASE

 The present study was registered in the ReBEC Clinical Trials Database (Registro Brasileiro de Ensaios Clínicos, number RBR-524z9n).

Aspirin and pre-eclampsia prevention in women with pre-existing diabetes: a retrospective study

BACKGROUND

Aspirin is routinely prescribed in high-risk pregnancies to prevent pre-eclampsia; however, there is a paucity of data in women with pre-existing diabetes.

AIMS

To assess the efficacy and safety of aspirin in women with pre-existing diabetes in preventing pre-eclampsia.

METHODS

A retrospective review of women with pre-existing diabetes who attended antenatal clinics in a tertiary referral hospital between 2013 and 2019 was conducted. Cases were those receiving aspirin prior to 16 weeks, with pre-eclampsia as the primary outcome. The relationship between early pregnancy glycaemic control and pre-eclampsia was also assessed.

RESULTS

Of the 164 women included in the study, 45 received aspirin. There were no differences in pre-eclampsia (odds ratio (OR) 0.9 (0.3-3.0), P = 0.924) or any other measure of placental insufficiency (OR 1.7 (0.7-4.3), P = 0.243) between the aspirin and control groups after adjusting for baseline differences. Aspirin therapy was associated with an increased risk of postpartum haemorrhage (PPH) (OR 3.1 (1.1-9.1), P = 0.041). The incidence of pre-eclampsia increased stepwise according to early pregnancy HbA1c subgroups of ≤6.0% (n = 47), 6.1-7.5% (n = 57) and > 7.5% (n = 39), with rates of 0, 12.3 and 20.5% (P = 0.007) respectively.

CONCLUSIONS

The aspirin group had a higher baseline risk of pre-eclampsia and placental insufficiency, therefore the absence of difference between the groups favoured the efficacy of aspirin. PPH was highlighted as a potential complication of therapy, and early pregnancy HbA1c as a novel risk stratification tool for pre-eclampsia in women with pre-existing diabetes.

Validation and reproducibility of a FFQ focused on pregnant women living in Northeastern Brazil

OBJECTIVE

The aim of the current study is to assess the validity and reproducibility of a FFQ focused on pregnant women living in Northeastern Brazil.

DESIGN

Three 24-hour-dietary recalls (24 hR) and two FFQ were applied at 15-d intervals between research stages in order to confirm the validity and reproducibility of the FFQ. Validity assessment was based on Pearson's correlation coefficient (PCC) or Spearman's correlation coefficient (SCC) between FFQ and the mean of three 24 hR (the 24 hR was used as reference standard), whereas reproducibility assessment was based on the intraclass correlation coefficient (ICC) among FFQ, and P < 0·05 was set as significance level.

SETTING

Public health network of a capital city in Northeastern Brazil.

PARTICIPANTS

Overall, 100 pregnant women were included in the study.

RESULTS

The PCC or SCC adopted in the validity analysis recorded the recommended values (from 0·4 and 0·7) for energy (0·44; P < 0·001), carbohydrate (0·40; P < 0·001), vitamins B2 (0·40; P < 0·001), B5 (0·40; P < 0·001), E (0·47; P < 0·001), B12 (0·48; P < 0·001), phosphorus (0·92; P < 0·001), Mg (0·81; P < 0·001), Se (0·70; P < 0·001), cholesterol (0·64; P < 0·001), saturated (0·76; P < 0·001), polyunsaturated (0·73; P < 0·001) and monounsaturated fats (0·87; P < 0·001) and fibres (0·77; P < 0·001). Mg (0·72; P < 0·001), Fe (0·65; P < 0·001), lipid (0·56; P < 0·001) and energy (0·55; P < 0·001) presented ICC within the recommended reproducibility values.

CONCLUSIONS

The FFQ developed in the current study is a useful tool to assess the usual food intake of pregnant women.

FKBPL and SIRT-1 Are Downregulated by Diabetes in Pregnancy Impacting on Angiogenesis and Endothelial Function

Diabetes in pregnancy is associated with adverse pregnancy outcomes including preterm birth. Although the mechanisms leading to these pregnancy complications are still poorly understood, aberrant angiogenesis and endothelial dysfunction play a key role. FKBPL and SIRT-1 are critical regulators of angiogenesis, however, their roles in pregnancies affected by diabetes have not been examined before in detail. Hence, this study aimed to investigate the role of FKBPL and SIRT-1 in pre-gestational (type 1 diabetes mellitus, T1D) and gestational diabetes mellitus (GDM). Placental protein expression of important angiogenesis proteins, FKBPL, SIRT-1, PlGF and VEGF-R1, was determined from pregnant women with GDM or T1D, and in the first trimester trophoblast cells exposed to high glucose (25 mM) and varying oxygen concentrations [21%, 6.5%, 2.5% (ACH-3Ps)]. Endothelial cell function was assessed in high glucose conditions (30 mM) and following FKBPL overexpression. Placental FKBPL protein expression was downregulated in T1D (FKBPL; p<0.05) whereas PlGF/VEGF-R1 were upregulated (p<0.05); correlations adjusted for gestational age were also significant. In the presence of GDM, only SIRT-1 was significantly downregulated (p<0.05) even when adjusted for gestational age (r=-0.92, p=0.001). Both FKBPL and SIRT-1 protein expression was reduced in ACH-3P cells in high glucose conditions associated with 6.5%/2.5% oxygen concentrations compared to experimental normoxia (21%; p<0.05). FKBPL overexpression in endothelial cells (HUVECs) exacerbated reduction in tubule formation compared to empty vector control, in high glucose conditions (junctions; p<0.01, branches; p<0.05). In conclusion, FKBPL and/or SIRT-1 downregulation in response to diabetic pregnancies may have a key role in the development of vascular dysfunction and associated complications affected by impaired placental angiogenesis.

Undiagnosed type 2 diabetes during pregnancy is associated with increased perinatal mortality: a large population-based cohort study in Ontario, Canada

AIM

To compare perinatal outcomes in women with undiagnosed diabetes with gestational diabetes alone, pre-existing diabetes and women without diabetes, and to identify risk factors which distinguish them from women with gestational diabetes alone.

METHODS

This population-based cohort study included administrative data on all women who gave birth in Ontario, Canada, during 2002-2015. Maternal/neonatal outcomes were compared across groups using logistic regression, adjusting for confounders. A nested case control study compared women with undiagnosed type 2 diabetes with women with gestational diabetes alone to determine risk factors that would help identify these women.

RESULTS

Among 995 990 women, 68 163 had gestational diabetes (6.8%) and, of those women with gestational diabetes,1772 had undiagnosed type 2 diabetes (2.6%). Those with undiagnosed type 2 diabetes were more likely to be older, from a lower income area, have parity > 3 and BMI ≥ 30 kg/m² compared with gestational diabetes alone. Infants had a higher risk of perinatal mortality (OR 2.3 [1.6-3.4]), preterm birth (OR 2.6 [2.3-2.9]), congenital anomalies (OR 2.1 [1.7-2.5]), neonatal intensive care unit admission (OR 3.1 [2.8-3.5]) and neonatal hypoglycaemia (OR 406.0 [357-461]), which were similar to women with pre-existing diabetes. The strongest predictive risk factors included early gestational diabetes diagnosis, previous gestational diabetes and chronic hypertension.

CONCLUSIONS

Women diagnosed with gestational diabetes who develop diabetes within 1 year postpartum are at higher risk of adverse pregnancy outcomes, including perinatal mortality. This highlights the need for earlier diagnosis, preferably pre-pregnancy, and more aggressive treatment and surveillance of suspected type 2 diabetes during pregnancy.

Reproductive health in women with type 2 diabetes mellitus

As type 2 diabetes mellitus (T2DM) reaches epidemic proportions in the developed world and the age at diagnosis decreases, more women of reproductive age are being affected. In this article, we provide a synoptic view on potential mechanisms and relevant factors underlying menstrual cycle disorders and fertility issues in women with T2DM. The article discusses the function of the hypothalamic-pituitary-ovarian (HPO) axis, the central role of the hypothalamus in the homeostasis of this system, the central modulators of the axis, and the peripheral metabolic signals involved in neuroendocrine control of reproduction. The available literature on the relationship between T2DM and the female reproductive lifespan, menstrual cycle disorders, fertility issues, and gestational health in women with T2DM are also discussed. The data so far indicate that there is a "U-shaped" relationship between menarche, menopause, and T2DM, both early and late menarche/menopause being risk factors for T2DM. Hyperglycemia and its consequences may be responsible for the effects of T2DM on reproductive health in women, but the exact mechanisms are not as yet fully understood; thus, more studies are needed in order to identify factors causing disruption of the HPO axis.

Maternal and birth cohort studies in the Gulf Cooperation Council countries: a systematic review and meta-analysis

BACKGROUND

We systematically reviewed and chronicled exposures and outcomes measured in the maternal and birth cohort studies in the Gulf Cooperation Council (GCC) countries and quantitatively summarized the weighted effect estimates between maternal obesity and (1) cesarean section (CS) and (2) fetal macrosomia.

METHODS

We searched MEDLINE-PubMed, Embase, Cochrane Library, Scopus, and Web of Science electronic databases up to 30 June 2019. We considered all maternal and birth cohort studies conducted in the six GCC countries (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and United Arab Emirates (UAE)). We categorized cohort studies on the basis of the exposure(s) (anthropometric, environmental, medical, maternal/reproductive, perinatal, or socioeconomic) and outcome(s) (maternal or birth) being measured. Adjusted weighted effect estimates, in the form of relative risks, between maternal obesity and CS and fetal macrosomia were generated using a random-effects model.

RESULTS

Of 3502 citations, 81 published cohort studies were included. One cohort study was in Bahrain, eight in Kuwait, seven in Qatar, six in Oman, 52 in Saudi Arabia, and seven in the UAE. Majority of the exposures studied were maternal/reproductive (65.2%) or medical (39.5%). Birth and maternal outcomes were reported in 82.7% and in 74.1% of the cohort studies, respectively. In Saudi Arabia, babies born to obese women were at a higher risk of macrosomia (adjusted relative risk (aRR), 1.15; 95% confidence interval (CI), 1.10-1.20; I2 = 50%) or cesarean section (aRR, 1.21; 95% CI, 1.15-1.26; I2 = 62.0%). Several cohort studies were only descriptive without reporting the magnitude of the effect estimate between the assessed exposures and outcomes.

CONCLUSIONS

Cohort studies in the GCC have predominantly focused on reproductive and medical exposures. Obese pregnant women are at an increased risk of undergoing CS delivery or macrosomic births. Longer-term studies that explore a wider range of environmental and biological exposures and outcomes relevant to the GCC region are needed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017068910.

Effect of motivational interviewing on gestational weight gain and fetal growth in pregnant women with type 2 diabetes

Objective

To study how lifestyle coaching with motivational interviewing to improve adherence to healthy eating affects gestational weight gain and fetal growth in pregnant women with type 2 diabetes in a real-world setting.

Research design and methods

A cohort study including a prospective intervention cohort of consecutive, singleton pregnant, Danish-speaking women with type 2 diabetes included between August 2015 and February 2018 and a historical reference cohort included between February 2013 and August 2015. The intervention consisted of a motivational interviewing to improve adherence to healthy eating in addition to routine care. The reference cohort received routine care only. The main outcomes were gestational weight gain and large for gestational age (LGA) infants.

Results

Ninety-seven women were included in the intervention cohort and 92 in the reference cohort. Pre-pregnancy body mass index (32.8±6.9 kg/m2 vs 32.4±7.4 kg/m2, p=0.70), gestational weight gain (9.2±5.8 kg vs 10.2±5.8 kg, p=0.25), HbA1c in early pregnancy (6.7%±1.1% vs 6.5%±1.3% (50±12 mmol/mol vs 48±14 mmol/mol), p=0.32) and late pregnancy (5.9%±0.5% vs 6.0%±0.6% (41±6 mmol/mol vs 42±7 mmol/mol), p=0.34) were comparable in the two cohorts. LGA infants occurred in 20% vs 31%, p=0.07, respectively, and after adjustment for maternal characteristics 14% vs 27% delivered LGA infants (p=0.04). Birth weight z-score was 0.24±1.36 vs 0.61±1.38, p=0.06.

Conclusions

Motivational interviewing to improve adherence to healthy eating in addition to routine care in pregnant women with type 2 diabetes tended to reduce fetal overgrowth without major effect on gestational weight gain. Further studies investigating the cost-benefit of enhancing motivation are needed.

Trial registration number

NCT02883127.

Adherence to clinical evaluations in women with pre-existing diabetes during pregnancy: A call to action from an Italian real-life investigation

AIMS

Women with pre-existing diabetes should plan for optimal care of the disease before, during and after pregnancy. The aim of this study was to assess the quality of diabetes mellitus monitoring and care before, during and after pregnancy in a large cohort of women.

METHODS

1913 diabetic women resident in the Lombardy Region (Italy) who experienced at least a birth between 2011 and 2015 and exhibited signs of diabetes ≥2 years before delivery were identified using the healthcare utilization database. Antidiabetic care was defined via outpatient examinations (i.e., assessments of glycated haemoglobin, lipid profile, urine albumin excretion and serum creatinine, and dilated eye exams) and use of antidiabetic drugs. Differences in adherence to recommendations before, during and after pregnancy were assessed by the non-parametric McNemar's test among the whole cohort and among the subgroup with type 1 diabetes.

RESULTS

Adherence to recommendations was very poor before pregnancy, ranging from 13% to 42% for dilated eye and serum creatinine exam, respectively. During pregnancy, a significant portion of women increased adherence to all recommendations (e.g., glycated haemoglobin from 20% to 47%, p-value < 0.001), with the exception of lipid profile control. After pregnancy, adherence dropped to pre-pregnancy levels. A similar trend was observed in the use of antidiabetic drugs. Although women with type 1 diabetes showed better adherence across all periods, the same patterns emerged.

CONCLUSIONS

Besides an improvement in the indicators of clinical adherence during pregnancy, the management of diabetes among pregnant women remains sub-optimal both before and after the birth.