Diabetes and pregnancy

Maternal exposure to bisphenols, phthalates, perfluoroalkyl acids, and trace elements and their associations with gestational diabetes mellitus in the APrON cohort

The increasing global prevalence of gestational diabetes mellitus (GDM) has been hypothesized to be associated with maternal exposure to environmental chemicals. Here, among 420 women participating in the Alberta Pregnancy Outcomes and Nutrition (APrON) cohort study, we examined associations between GDM and second trimester blood or urine concentrations of endocrine disrupting chemicals (EDCs): bisphenol-A (BPA), bisphenol-S (BPS), twelve phthalate metabolites, eight perfluoroalkyl acids (PFAAs), and eleven trace elements. Fifteen (3.57%) of the women were diagnosed with GDM, and associations between the environmental chemical exposures and GDM diagnosis were examined using multiple logistic and LASSO regression analyses in single- and multi-chemical exposure models, respectively. In single chemical exposure models, BPA and mercury were associated with increased odds of GDM, while a significant inverse association was observed for zinc. Double-LASSO regression analysis selected mercury (AOR: 1.51, CI: 1.12-2.02), zinc (AOR: 0.017, CI: 0.0005-0.56), and perfluoroundecanoic acid (PFUnA), a PFAAs, (AOR: 0.43, CI: 0.19-0.94) as the best predictors of GDM. The combined data for this Canadian cohort suggest that second trimester blood mercury was a robust predictor of GDM diagnosis, whereas blood zinc and PFUnA were protective factors. Research into mechanisms that underlie the associations between mercury, zinc, PFUnA, and the development of GDM is needed.

Dietary Intakes of Women with Gestational Diabetes Mellitus and Pregnancy Outcomes: A Prospective Observational Study

Purpose

Nutrient intake for pregnant women with gestational diabetes mellitus (GDM) is important to ensure satisfactory birth outcomes. This study aims to explore the dietary profiles of patients with GDM, compare the results with the Chinese dietary guidelines or Dietary Reference Intakes (DRIs) from China and investigate the relationship between maternal dietary intake and pregnancy outcomes.

Patients and Methods

A total of 221 patients with GDM in the second trimester were included in the cohort. Dietary intake data were collected using a 24-hour recall method for three consecutive days. The pregnancy outcomes of these participants were subsequently monitored. Both univariate logistic regression and multivariate logistic regression analyses were conducted to explore the associations between dietary intake variables or general characteristics variables and adverse pregnancy outcomes.

Results

Participants with adverse pregnancy outcomes showed a lower intake of iodine and vitamin D, a lower percentage of dietary energy intake from carbohydrates and a higher percentage of dietary energy intake from fats, compared to participants without adverse pregnancy outcomes. The gestational weight gain and family history of diabetes were associated with an increased risk of adverse pregnancy outcomes. Conversely, regular exercise, the intake of iodine and Vitamin D, and the percentage of dietary energy intake from carbohydrates were associated with a decreased risk.

Conclusion

The daily diet of pregnant women with GDM in China did not meet the dietary guidelines or DRIs. The low intake of Vitamin D and iodine, the low dietary carbohydrate ratio, family history of diabetes, lack of exercise, and high gestational weight gain were associated with increased risk of adverse pregnancy outcomes in pregnant women with GDM.

Effect of arsenic on the risk of gestational diabetes mellitus: a systematic review and meta-analysis

BACKGROUND

Gestational diabetes mellitus (GDM) is a complication of pregnancy associated with numerous adverse outcomes. There may be a potential link between GDM and arsenic (As) exposure, but this hypothesis remains controversial. This meta-analysis summarizes the latest studies evaluating the association between As and GDM.

METHODS

A comprehensive search of the PubMed, Embase, and Scopus databases up to September 2023 was performed. The pooled estimates with 95% CIs were presented using forest plots. Estimates were calculated with random effects models, and subgroup and sensitivity analyses were conducted to address heterogeneity.

RESULTS

A total of 13 eligible studies involving 2575 patients with GDM were included in this meta-analysis. The results showed that women exposed to As had a significantly increased risk of GDM (OR 1.47, 95% CI: 1.11 to 1.95, P = 0.007). Subgroup analyses suggested that the heterogeneity might be attributed to the years of publication. In addition, sensitivity analysis confirmed the robust and reliable results.

CONCLUSIONS

This analysis suggested that women exposed to As have a greater risk of GDM. However, the significant heterogeneity across studies requires careful interpretation.

REGISTRATION

The PROSPERO registration ID is CRD42023461820.

Gestational diabetes in twin pregnancies-a pathology requiring treatment or a benign physiological adaptation?

There is level-1 evidence that screening for and treating gestational diabetes in singleton pregnancies reduce maternal and neonatal morbidity. However, similar data for gestational diabetes in twin pregnancies are currently lacking. Consequently, the current approach for the diagnosis and management of gestational diabetes in twin pregnancies is based on the same diagnostic criteria and glycemic targets used in singleton pregnancies. However, twin pregnancies have unique physiological characteristics, and many of the typical gestational diabetes-related complications are less relevant for twin pregnancies. These differences raise the question of whether the greater increase in insulin resistance observed in twin pregnancies (which is often diagnosed as diet-treated gestational diabetes) should be considered physiological and potentially beneficial in which case alternative criteria should be used for the diagnosis of gestational diabetes in twin pregnancies. In this review, we summarize the most up-to-date evidence on the epidemiology, pathophysiology, and clinical consequences of gestational diabetes in twin pregnancies and review the available data on twin-specific screening and diagnostic criteria for gestational diabetes. Although twin pregnancies are associated with a higher incidence of diet-treated gestational diabetes, diet-treated gestational diabetes in twin pregnancies is less likely to be associated with adverse outcomes and accelerated fetal growth than in singleton pregnancies and may reduce the risk for intrauterine growth restriction. In addition, there is currently no evidence that treatment of diet-treated gestational diabetes in twin pregnancies improves outcomes, whereas preliminary data suggest that strict glycemic control in such cases might increase the risk for intrauterine growth restriction. Overall, these findings provide support to the hypothesis that the greater transient increase in insulin resistance observed in twin pregnancies is merely a physiological exaggeration of the normal increase in insulin resistance observed in singleton pregnancies (that is meant to support 2 fetuses) rather than a pathology that requires treatment. These data illustrate the need to develop twin-specific screening and diagnostic criteria for gestational diabetes to avoid overdiagnosis of gestational diabetes and to reduce the risks associated with overtreatment of diet-treated gestational diabetes in twin pregnancies. Although data on twin-specific screening and diagnostic criteria are presently scarce, preliminary data suggest that the optimal screening and diagnostic criteria in twin pregnancies are higher than those currently used in singleton pregnancies.

Integrated health system intervention aimed at reducing type 2 diabetes risk in women after gestational diabetes in South Africa (IINDIAGO): a randomised controlled trial protocol

INTRODUCTION

South Africa has a high prevalence of gestational diabetes mellitus (GDM; 15%) and many of these women (48%) progress to type 2 diabetes mellitus (T2DM) within 5 years post partum. A significant proportion (47%) of the women are not aware of their diabetes status after the index pregnancy, which may be in part to low postnatal diabetes screening rates. Therefore, we aim to evaluate a intervention that reduces the subsequent risk of developing T2DM among women with recent GDM. Our objectives are fourfold: (1) compare the completion of the nationally recommended 6-week postpartum oral glucose tolerance test (OGTT) between intervention and control groups; (2) compare the diabetes risk reduction between control and intervention groups at 12 months' post partum; (3) assess the process of implementation; and (4) assess the cost-effectiveness of the proposed intervention package.

METHODS AND ANALYSES

Convergent parallel mixed-methods study with the main component being a pragmatic, 2-arm individually randomised controlled trial, which will be carried out at five major referral centres and up to 26 well-baby clinics in the Western Cape and Gauteng provinces of South Africa. Participants (n=370) with GDM (with no prior history of either type 1 or type 2 diabetes) will be recruited into the study at 24-36 weeks' gestational age, at which stage first data collection will take place. Subsequent data collection will take place at 6-8 weeks after delivery and again at 12 months. The primary outcome for the trial is twofold: first, the completion of the recommended 2-hour OGTT at the well-baby clinics 6-8 weeks post partum, and second, a composite diabetes risk reduction indicator at 12 months. Process evaluation will assess fidelity, acceptability, and dose of the intervention.

ETHICS AND DISSEMINATION

Ethics approval has been granted from University of Cape Town (829/2016), University of the Witwatersrand, Johannesburg (M170228), University of Stellenbosch (N17/04/032) and the University of Montreal (2019-794). The results of the trial will be disseminated through publication in peer-reviewed journals and presentations to key South African Government stakeholders and health service providers.

PROTOCOL VERSION

1 December 2022 (version #2). Any protocol amendments will be communicated to investigators, Human Ethics Research Committees, trial participants, and trial registries.

TRIAL REGISTRATION NUMBER

PAN African Clinical Trials Registry (https://pactr.samrc.ac.za) on 11 June 2018 (identifier PACTR201805003336174).

Temporal Trends in Type 1, Type 2, and Gestational Diabetes in Pregnancy: Impact of Rural Residence, Ethnicity, and Material Deprivation

OBJECTIVE

Our aim in this study was to implement a newly validated algorithm to identify pregnant women with type 1 diabetes mellitus (T1DM), type 2 diabetes mellitus (T2DM), and gestational diabetes mellitus (GDM), and to identify temporal trends in rates over the last decade. We also compared obstetric and neonatal outcomes of pregnancies with and without diabetes mellitus (DM).

METHODS

Among women with live births between 2005 and 2018 in Alberta, we calculated yearly rates of T1DM, T2DM, and GDM, overall, and stratified by ethnicity, urban or rural residence, material deprivation score, and maternal age.

RESULTS

Between 2005 and 2018, GDM rates increased from 42.3 to 101.8 per 1,000 deliveries (p<0.0001), T2DM rates increased from 2.6 to 6.4 per 1,000 deliveries (p<0.0001), whereas T1DM remained constant at 3.0 per 1,000 deliveries each year (p=0.4301). Higher GDM and T2DM rates were observed among Chinese and South Asian women, respectively, and among women who were materially deprived and living in urban areas. Women with T2DM were older and had the highest rates of pre-existing hypertension (16%). In contrast, women with T1DM were younger and had the highest rates of gestational hypertension (12%), pre-eclampsia (12%), and cesarean section deliveries (62%). Children of women with T1DM had the highest rates of large for gestational age (46%), neonatal hypoglycemia (41.1%), respiratory distress syndrome (7.7%), and jaundice (29.3%).

CONCLUSIONS

Diabetes-in-pregnancy rates have more than doubled over the last decade, driven primarily by increases in GDM and T2DM. These trends may have significant implications for the future health of mothers and children in Alberta.

Free triiodothyronine (FT3)-to-free thyroxine (FT4) ratio identified as a risk factor for gestational diabetes in euthyroid pregnant women: insights from a Chinese population cohort study

Background

To explore the association between thyroid hormones and gestational diabetes mellitus in euthyroid pregnant women, with the aim of preventing the occurrence of gestational diabetes mellitus.

Methods

In this prospective study, a total of 1222 euthyroid pregnant women in their first trimester were recruited at Peking University International Hospital between December 2017 and March 2019. These participants underwent an oral glucose tolerance test during the 24-28 weeks of gestation.

Results

During early pregnancy, the gestational diabetes mellitus group displayed lower levels of free thyroxine when compared to the non-gestational diabetes mellitus group. Additionally, the ratio of free triiodothyronine to free thyroxine in the gestational diabetes mellitus group during early pregnancy was significantly higher (p<0.05). The ratio of free triiodothyronine to free thyroxine during early pregnancy showed a positive correlation with blood glucose levels at 0, 60, and 120 min both before and after glucose loading (all p<0.05). During early pregnancy, there was a negative relationship between free thyroxine levels and fasting blood glucose. The free triiodothyronine levels were positively correlated to blood glucose levels at 120 min following glucose loading (all p<0.05).

Conclusion

The ratio of free triiodothyronine-to-free thyroxine is an independent risk factor for gestational diabetes mellitus and has the potential to be a predictor for gestational diabetes mellitus in euthyroid pregnant women.

A culturally tailored personaliseD nutrition intErvention in South ASIan women at risk of Gestational Diabetes Mellitus (DESI-GDM): a randomised controlled trial protocol

INTRODUCTION

South Asians are more likely to develop gestational diabetes mellitus (GDM) than white Europeans. Diet and lifestyle modifications may prevent GDM and reduce undesirable outcomes in both the mother and offspring. Our study seeks to evaluate the effectiveness and participant acceptability of a culturally tailored, personalised nutrition intervention on the glucose area under the curve (AUC) after a 2-hour 75 g oral glucose tolerance test (OGTT) in pregnant women of South Asian ancestry with GDM risk factors.

METHODS AND ANALYSIS

A total of 190 South Asian pregnant women with at least 2 of the following GDM risk factors-prepregnancy body mass index>23, age>29, poor-quality diet, family history of type 2 diabetes in a first-degree relative or GDM in a previous pregnancy will be enrolled during gestational weeks 12-18, and randomly assigned in a 1:1 ratio to: (1) usual care, plus weekly text messages to encourage walking and paper handouts or (2) a personalised nutrition plan developed and delivered by a culturally congruent dietitian and health coach; and FitBit to track steps. The intervention lasts 6-16 weeks, depending on week of recruitment. The primary outcome is the glucose AUC from a three-sample 75 g OGTT 24-28 weeks' gestation. The secondary outcome is GDM diagnosis, based on Born-in-Bradford criteria (fasting glucose>5.2 mmol/L or 2 hours post load>7.2 mmol/L).

ETHICS AND DISSEMINATION

The study has been approved by the Hamilton Integrated Research Ethics Board (HiREB #10942). Findings will be disseminated among academics and policy-makers through scientific publications along with community-orientated strategies.

TRIAL REGISTRATION NUMBER

NCT03607799.

Exercise during pregnancy for preventing gestational diabetes mellitus and hypertensive disorders: An umbrella review of randomised controlled trials and an updated meta-analysis

OBJECTIVE

This study aimed to provide, through an umbrella review, an overview of the effect of single exercise interventions during pregnancy on gestational diabetes mellitus (GDM) and hypertensive disorders of pregnancy (HDP). Also, to update the current evidence through an updated meta-analysis.

DESIGN

Umbrella review.

SETTING

PubMed, EMBASE, Web of Science, Cochrane database of systematic reviews, Epistemonikos, SPORTDiscus, Clinicaltrials.gov, and PROSPERO register were searched from the database inception until August 2021.

POPULATION

Peer-reviewed systematic reviews and meta-analyses of randomised controlled trials (RCTs) and RCTs samples.

METHODS

Random-effects model was used to calculate relative risk with 95% confidence interval in the updated meta-analysis. The reference category was the groups that received usual prenatal care. AMSTAR 2 and the Cochrane Collaboration tool were used to assess the quality and GRADE approach was used to assess the overall certainly of evidence.

MAIN OUTCOME MEASURES

GDM and HDP relative risk.

RESULTS

Twenty-three systematic reviews and meta-analyses; and 63 RCTs were included. Single exercise interventions reduced the incidence of GDM and HDP in most systematic reviews and meta-analyses. Moreover, exercise interventions during pregnancy decrease the incidence of developing GDM and GH, particularly when they are supervised, have a low to moderate intensity level, and are initiated during the first trimester of pregnancy.

CONCLUSION

Based on the findings, obstetric and physical exercise professionals could recommend exercise interventions during pregnancy as an effective strategy to improve maternal outcomes.

Incidence of gestational diabetes mellitus in the United Arab Emirates; comparison of six diagnostic criteria: The Mutaba'ah Study

Background

For more than half a century, there has been much research and controversies on how to accurately screen for and diagnose gestational diabetes mellitus (GDM). There is a paucity of updated research among the Emirati population in the United Arab Emirates (UAE). The lack of a uniform GDM diagnostic criteria results in the inability to accurately combine or compare the disease burden worldwide and locally. This study aimed to compare the incidence of GDM in the Emirati population using six diagnostic criteria for GDM.

Methods

The Mutaba'ah study is the largest multi-center mother and child cohort study in the UAE with an 18-year follow-up. We included singleton pregnancies from the Mutaba'ah cohort screened with the oral glucose tolerance test (OGTT) at 24-32 weeks from May 2017 to March 2021. We excluded patients with known diabetes and with newly diagnosed diabetes. GDM cumulative incidence was determined using the six specified criteria. GDM risk factors were compared using chi-square and t-tests. Agreements among the six criteria were assessed using kappa statistics.

Results

A total of 2,546 women were included with a mean age of 30.5 ± 6.0 years. Mean gravidity was 3.5 ± 2.1, and mean body mass index (BMI) at booking was 27.7 ± 5.6 kg/m2. GDM incidence as diagnosed by any of the six criteria collectively was 27.1%. It ranged from 8.4% according to the EASD 1996 criteria to 21.5% according to the NICE 2015 criteria. The two most inclusive criteria were the NICE 2015 and the IADPSG criteria with GDM incidence rates of 21.5% (95% CI: 19.9, 23.1) and 21.3% (95% CI: 19.8, 23.0), respectively. Agreement between the two criteria was moderate (k = 0.66; p < 0.001). The least inclusive was the EASD 1996 criteria [8.4% (95% CI: 7.3, 9.6)]. The locally recommended IADPSG/WHO 2013 criteria had weak to moderate agreement with the other criteria, with Cohen's kappa coefficient ranging from (k = 0.51; p < 0.001) to (k = 0.71; p < 0.001). Most of the GDM risk factors assessed were significantly higher among those with GDM (p < 0.005) identified by all criteria.

Conclusions

The findings indicate discrepancies among the diagnostic criteria in identifying GDM cases. This emphasizes the need to unify GDM diagnostic criteria in this population to provide accurate and reliable incidence estimates for healthcare planning, especially because the agreement with the recommended criteria was not optimal.

Association of Concomitant Gestational Hypertensive Disorders and Gestational Diabetes With Cardiovascular Disease

IMPORTANCE

Accruing evidence suggests that gestational hypertensive disorders (GHTD) and gestational diabetes (GD) are each associated with an increased risk of cardiovascular disease (CVD). However, the extent to which the co-occurrence of GHTD and GD is associated with the risk of CVD remains largely unknown.

OBJECTIVE

To estimate the individual and joint associations of GHTD and GD with incident CVD.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study used the Ministry of Health and Long-Term Care of Ontario (Canada) health care administrative databases. All women in Ontario with a GHTD and/or GD diagnosis, and a live-birth singleton delivery between July 1, 2007, and March 31, 2018, were considered for inclusion. Women with pregravid diabetes, hypertension, or cardiovascular disease were excluded. Statistical analysis was performed from November 2021 to September 2022.

EXPOSURES

GD and/or GHTD, defined using diagnosis coding.

MAIN OUTCOMES AND MEASURES

Individual and joint associations of GHTD and GD with incident CVD (including a composite of myocardial infarction, acute coronary syndrome, stroke, coronary artery bypass grafting, percutaneous coronary intervention, or carotid endarterectomy), estimated using Cox regression models, adjusting for relevant cardiometabolic risk factors. The follow-up extended from the index pregnancy until March 31, 2020.

RESULTS

Among 886 295 eligible women (mean [SD] age, 30 [5.6] years; 43 861 [4.9%] with isolated GHTD, 54 061 [6.1%] with isolated GD, and 4975 [0.6%] with GHTD and GD), there were 1999 CVD events over 12 years of follow-up. In the early postpartum phase (first 5 years post partum), there was no association of co-occurrence of GTHD and GD (adjusted hazard ratio [aHR], 1.42, 95% CI, 0.78-2.58) or GD alone (aHR, 0.80; 95% CI, 0.60-1.06) with CVD; there was an association between isolated GTHD and incident CVD compared with no GTHD and no GD (aHR, 1.90; 95% CI, 1.51-2.35). In the late postpartum period (after the initial 5 years post partum), compared with no GD and no GHTD, isolated GHTD (aHR, 1.41, 95% CI, 1.12-1.76) and co-occurrence of GHTD and GD (aHR, 2.43, 95% CI, 1.60-3.67) were each associated with a higher risk of incident CVD. There was no association between isolated GD and incident CVD.

CONCLUSIONS AND RELEVANCE

In this cohort study, GHTD was associated with a high risk of CVD post partum, and the co-occurrence of GD and GHTD was associated with a much greater postpartum CVD risk. These findings suggest that CVD preventive care is particularly needed in the aftermath of combined GD and GHTD.

Screening Accuracy of the 50 g-Glucose Challenge Test in Twin Compared With Singleton Pregnancies

CONTEXT

The optimal 50 g-glucose challenge test (GCT) cutoff for the diagnosis of gestational diabetes mellitus (GDM) in twin pregnancies is unknown.

OBJECTIVE

This work aimed to explore the screening accuracy of the 50 g-GCT and its correlation with the risk of large for gestational age (LGA) newborn in twin compared to singleton pregnancies. A population-based retrospective cohort study (2007-2017) was conducted in Ontario, Canada. Participants included patients with a singleton (n = 546 892 [98.4%]) or twin (n = 8832 [1.6%]) birth who underwent screening for GDM using the 50 g-GCT.

METHODS

We compared the screening accuracy, risk of GDM, and risk of LGA between twin and singleton pregnancies using various 50 g-GCT cutoffs.

RESULTS

For any given 50 g-GCT result, the probability of GDM was higher (P = .0.007), whereas the probability of LGA was considerably lower in the twin compared with the singleton group, even when a twin-specific growth chart was used to diagnose LGA in the twin group (P < .001). The estimated false-positive rate (FPR) for GDM was higher in twin compared with singleton pregnancies irrespective of the 50 g-GCT cutoff used. The cutoff of 8.2 mmol/L (148 mg/dL) in twin pregnancies was associated with an estimated FPR (10.7%-11.1%) that was similar to the FPR associated with the cutoff of 7.8 mmol/L (140 mg/dL) in singleton pregnancies (10.8%).

CONCLUSION

The screening performance of the 50 g-GCT for GDM and its correlation with LGA differ between twin and singleton pregnancies.

Lower versus Higher Glycemic Criteria for Diagnosis of Gestational Diabetes

BACKGROUND

Treatment of gestational diabetes improves maternal and infant health, although diagnostic criteria remain unclear.

METHODS

We randomly assigned women at 24 to 32 weeks' gestation in a 1:1 ratio to be evaluated for gestational diabetes with the use of lower or higher glycemic criteria for diagnosis. The lower glycemic criterion was a fasting plasma glucose level of at least 92 mg per deciliter (≥5.1 mmol per liter), a 1-hour level of at least 180 mg per deciliter (≥10.0 mmol per liter), or a 2-hour level of at least 153 mg per deciliter (≥8.5 mmol per liter). The higher glycemic criterion was a fasting plasma glucose level of at least 99 mg per deciliter (≥5.5 mmol per liter) or a 2-hour level of at least 162 mg per deciliter (≥9.0 mmol per liter). The primary outcome was the birth of an infant who was large for gestational age (defined as a birth weight above the 90th percentile according to Fenton-World Health Organization standards). Secondary outcomes were maternal and infant health.

RESULTS

A total of 4061 women underwent randomization. Gestational diabetes was diagnosed in 310 of 2022 women (15.3%) in the lower-glycemic-criteria group and in 124 of 2039 women (6.1%) in the higher-glycemic-criteria group. Among 2019 infants born to women in the lower-glycemic-criteria group, 178 (8.8%) were large for gestational age, and among 2031 infants born to women in the higher-glycemic-criteria group, 181 (8.9%) were large for gestational age (adjusted relative risk, 0.98; 95% confidence interval, 0.80 to 1.19; P = 0.82). Induction of labor, use of health services, use of pharmacologic agents, and neonatal hypoglycemia were more common in the lower-glycemic-criteria group than in the higher-glycemic-criteria group. The results for the other secondary outcomes were similar in the two trial groups, and there were no substantial between-group differences in adverse events. Among the women in both groups who had glucose test results that fell between the lower and higher glycemic criteria, those who were treated for gestational diabetes (195 women), as compared with those who were not (178 women), had maternal and infant health benefits, including fewer large-for-gestational-age infants.

CONCLUSIONS

The use of lower glycemic criteria for the diagnosis of gestational diabetes did not result in a lower risk of a large-for-gestational-age infant than the use of higher glycemic criteria. (Funded by the Health Research Council of New Zealand and others; GEMS Australian New Zealand Clinical Trials Registry number, ACTRN12615000290594.).

Effect of Different Types of Diagnostic Criteria for Gestational Diabetes Mellitus on Adverse Neonatal Outcomes: A Systematic Review, Meta-Analysis, and Meta-Regression

BACKGROUND

Evidence supporting various diagnostic criteria for diagnose gestational diabetes mellitus (GDM) are consensus-based, needs for additional evidence related to outcomes. Therefore, the aim of this systematic-review and meta-analysis was to assess the impact of different GDM diagnostic-criteria on the risk of adverse-neonatal-outcomes.

METHODS

Electronic databases including Scopus, PubMed, and Web of Sciences were searched to retrieve English original, population-based studies with the universal GDM screening approach, up to January-2020. GDM diagnostic criteria were classified in seven groups and International Association of the Diabetes and Pregnancy Study Groups (IADPSG) was considered as reference one. We used the Mantel-Haenszel method to calculate the pooled odds of events. The possibility of publication bias was examined by Begg's test.

RESULTS

A total of 55 population-based studies consisting of 1,604,391 pregnant women with GDM and 7,770,855 non-GDM counterparts were included. Results showed that in all diagnostic-criteria subgroups, the risk of adverse neonatal outcomes including macrosomia, hyperbilirubinemia, respiratory distress syndrome, neonatal hypoglycemia, neonatal intensive care unit admission, preterm birth, and birth-trauma were significantly higher than the non-GDM counterparts were significantly higher than non-GDM counterparts. Meta-regression analysis revealed that the magnitude of neonatal risks in all diagnostic-criteria subgroups are similar.

CONCLUSION

Our results showed that the risk of adverse-neonatal-outcome increased among women with GDM, but the magnitude of risk was not different among those women who were diagnosed through more or less intensive strategies. These findings may help health-care-providers and policy-makers to select the most cost-effective approach for the screening of GDM among pregnant women.

Screening auf Gestationsdiabetes mellitus (GDM) – Welchen Weg weisen die neuen Studien? Übersicht und Kommentar

Das Screening auf Gestationsdiabetes mellitus (GDM) wird international nicht einheitlich durchgeführt. In Deutschland wird allen Schwangeren ein zweizeitiges Screening angeboten, zunächst ein 50-g Vortest (nicht nüchtern), im positiven Fall gefolgt von einem 75-g oralen Gluksetoleranztest (oGTT) über 2 h (nüchtern). Im Jahr 2021 sind zwei randomisierte Screeningstudien publiziert worden, in denen einzeitiges Screenen ohne Vortest mit dem zweizeitigen Screenen verglichen wurde. Einzeitiges Screenen erhöht die GDM-Prävalenz um das 2,3-fache ohne Vorteile für klinisch relevante Endpunkte von Müttern und Neugeborenen und um den Preis unnötiger Pharmakotherapie sowie Belastung der Ressourcen bei den Betreuern. Beim zweizeitigen Screening benötigen nur 20% der Frauen einen oGTT. Darüber hinaus wird die zweizeitige Strategie von den Frauen präferiert.

Studies to Improve Perinatal Health through Diet and Lifestyle among South Asian Women Living in Canada: A Brief History and Future Research Directions

South Asians (i.e., people who originate from India, Pakistan, Sri Lanka, Nepal, and Bangladesh) have higher cardiovascular disease rates than other populations, and these differences persist in their offspring. Nutrition is a critical lifestyle-related factor that influences fetal development, and infant and child health in early life. In high-income countries such as Canada, nutrition-related health risks arise primarily from overnutrition, most strikingly for obesity and associated non-communicable diseases. Evidence for developmental programming during fetal life underscores the critical influence of maternal diet on fetal growth and development, backed by several birth cohort studies including the Pune Maternal Nutrition Study, the South Asian Birth Cohort Study, and the Born in Bradford Study. Gestational diabetes mellitus is a strong risk factor for type 2 diabetes, future atherosclerosis and cardiovascular disease in the mother and increases the risk of type 2 diabetes in her offspring. Non-pharmacological trials to prevent gestational diabetes are few, often not randomized, and are heterogeneous with respect to design, and outcomes have not converged upon a single optimal prevention strategy. The aim of this review is to provide an understanding of the current knowledge around perinatal nutrition and gestational diabetes among the high-risk South Asian population as well as summarize our research activities investigating the role of culturally-tailored nutrition advice to South Asian women living in high-income settings such as Canada. In this paper, we describe these qualitative and quantitative studies, both completed and underway. We conclude with a description of the design of a randomized trial of a culturally tailored personalized nutrition intervention to reduce gestational glycaemia in South Asian women living in Canada and its implications.

Oral Glucose Tolerance Test Results in Pregnancy Can Be Used to Individualize the Risk of Future Maternal Type 2 Diabetes Mellitus in Women With Gestational Diabetes Mellitus

OBJECTIVE

We aimed to quantify the risk of future maternal type 2 diabetes mellitus (T2DM) in women with gestational diabetes mellitus (GDM) based on the type and number of abnormal 75-g oral glucose tolerance test (OGTT) values and the diagnostic criteria used for the diagnosis of GDM.

RESEARCH DESIGN AND METHODS

We conducted a population-based retrospective cohort study of all nulliparous women with a live singleton birth who underwent testing for GDM using a 75-g OGTT in Ontario, Canada (2007-2017). We estimated the incidence rate (per 1,000 person-years), overall risk (expressed as adjusted hazard ratio [aHR]), and risk at 5 years after the index pregnancy of future maternal T2DM. Estimates were stratified by the type and number of abnormal OGTT values, as well as by the diagnostic criteria for GDM (Diabetes Canada [DC] vs. International Association of the Diabetes and Pregnancy Study Groups [IADPSG] criteria).

RESULTS

A total of 55,361 women met the study criteria. The median duration of follow-up was 4.4 (interquartile range 2.8-6.3; maximum 10.3) years. Using women without GDM as reference (incidence rate 2.18 per 1,000 person-years), women with GDM were at an increased risk of future T2DM; this risk was greater when using the DC compared with the IADPSG criteria (incidence rate 18.74 [95% CI 17.58-19.90] vs. 14.07 [95% CI 13.24-14.91] per 1,000 person-years, respectively). The risk of future maternal T2DM increased with the number of abnormal OGTT values and was highest for women with three abnormal values (incidence rate 49.93 per 1,000 person-years; aHR 24.57 [95% CI 21.26-28.39]). The risk of future T2DM was also affected by the type of OGTT abnormality: women with an abnormal fasting value had the greatest risk, whereas women with an abnormal 2-h value had the lowest risk (aHR 14.09 [95% CI 12.46-15.93] vs. 9.22 [95% CI 8.19-10.37], respectively). Similar findings to those described above were observed when the risk of T2DM at a fixed time point of 5 years after the index pregnancy was considered as the outcome of interest.

CONCLUSIONS

In women with GDM, individualized information regarding the future risk of T2DM can be provided based on the type and number of abnormal OGTT values, as well as the diagnostic criteria used for the diagnosis of GDM.

DEVELOPING twin-specific 75-g oral glucose tolerance test diagnostic thresholds for gestational diabetes based on the risk of future maternal diabetes: a population-based cohort study

OBJECTIVE

To develop twin-specific outcome-based oral glucose tolerance test (OGTT) diagnostic thresholds for GDM based on the risk of future maternal type-2 diabetes.

DESIGN

A population-based retrospective cohort study (2007-2017).

SETTING

Ontario, Canada.

METHODS

Nulliparous women with a live singleton (n = 55 361) or twin (n = 1308) birth who underwent testing for gestational diabetes mellitus (GDM) using a 75-g OGTT in Ontario, Canada (2007-2017). We identified the 75-g OGTT thresholds in twin pregnancies that were associated with similar incidence rates of future type-2 diabetes to those associated with the standard OGTT thresholds in singleton pregnancies.

RESULTS

For any given 75-g OGTT value, the incidence rate of future maternal type-2 diabetes was lower for women with a twin than women with a singleton pregnancy. Using women with a negative OGTT as reference, the risk of future maternal type-2 diabetes in twin pregnancies with a positive OGTT based on the standard OGTT thresholds (9.86 per 1000 person years, adjusted hazard ratio (aHR) 4.79, 95% CI 2.69-8.51) was lower than for singleton pregnancies with a positive OGTT (18.74 per 1000 person years, aHR 8.22, 95% CI 7.38-9.16). The twin-specific OGTT fasting, 1-hour and 2-hour thresholds identified in the current study based on correlation with future maternal type-2 diabetes were 5.8 mmol/l (104 mg/dl), 11.8 mmol/l (213 mg/dl) and 10.4 mmol/l (187 mg/dl), respectively.

CONCLUSIONS

We identified potential twin-specific OGTT thresholds for GDM that are associated with a similar risk of future type-2 diabetes to that observed in women diagnosed with GDM in singleton pregnancies based on standard OGTT thresholds.

TWEETABLE ABSTRACT

Potential twin-specific OGTT thresholds for GDM were identified.

The effect of oat bran consumption on gestational diabetes: a randomized controlled clinical trial

BACKGROUND

Gestational diabetes is the most common medical complication in pregnancy, and it has many side effects for the mother and the fetus. The aim of this study was to evaluate the effect of oat bran consumption on gestational diabetes.

METHODS

This study is a randomized clinical trial that was performed on 112 women with gestational diabetes treated with diet. Participants were randomly divided into two groups of 56. Participants in both groups were given a diet for gestational diabetes. In addition to the diet, the intervention group received 30 g of oat bran daily for 4 weeks at lunch and dinner. Tests of fasting blood glucose and two-hour postprandial (2hpp) glucose were taken from both groups: before the intervention, and 2 and 4 weeks after the start of the intervention. Data analysis was performed using SPSS statistical software (version 22) using independent t-test, as well as Chi-square and Mann-Whitney tests. P values less than 0.05 were considered statistically significant.

RESULTS

There was no statistically significant difference between the two groups in terms of mean blood glucose before the intervention, while 2 and 4 weeks after the intervention, mean fasting blood glucose and two-hour postprandial (2hpp) glucose decreased significantly in the intervention group compared with the control group (P < 0.001).

CONCLUSION

Based on the results of this study, the addition of oat bran to the standard diet for pregnant women with gestational diabetes reduced fasting blood glucose and two-hour postprandial (2hpp) glucose. More detailed studies with higher sample sizes are recommended to prove the effectiveness of this valuable dietary supplement.

TRIAL REGISTRATION

IRCT registration number: IRCT20191220045828N1 . Registration date: 2020-04-18. Registered while recruiting.

BMI and risk of gestational diabetes among women of South Asian and Chinese ethnicity: a population-based study

AIMS/HYPOTHESIS

The aim of this study was to examine how BMI influences the association between Asian ethnicity and risk of gestational diabetes (GDM).

METHODS

This population-based cohort study included pregnant women without pre-existing diabetes mellitus in Ontario, Canada between 2012 and 2014. Women of Chinese and South Asian ethnicity were identified using a validated surname algorithm. GDM was ascertained using hospitalisation codes. The relationship between ethnicity and GDM was modelled using modified Poisson regression, adjusted for maternal age, pre-pregnancy BMI, parity, previous GDM, long-term residency status, income quintile and smoking status. An interaction term between ethnicity and pre-pregnancy BMI was tested.

RESULTS

Of 231,618 pregnant women, 9289 (4.0%) were of South Asian ethnicity and 12,240 (5.3%) were of Chinese ethnicity. Relative to women from the general population, in whom prevalence of GDM was 4.3%, the adjusted RR of GDM was higher among those of South Asian ethnicity (1.81 [95% CI 1.64, 1.99]) and Chinese ethnicity (1.66 [95% CI 1.53, 1.80]). The association between GDM and Asian ethnicity remained significant across BMI categories but differed according to BMI. The prevalence of GDM exceeded 5% at an estimated BMI of 21.5 kg/m² among South Asian women, 23.0 kg/m² among Chinese women and 29.5 kg/m² among the general population.

CONCLUSIONS/INTERPRETATION

The risk of GDM is significantly higher in South Asian and Chinese women, whose BMI is lower than that of women in the general population. Accordingly, targeted GDM prevention strategies may need to consider lower BMI cut-points for Asian populations.

Pregnancy and development of diabetes in First Nations and non-First Nations women in Alberta, Canada

AIM

To conduct a retrospective population-based study to examine the risk of developing diabetes after delivery in First Nations and non-First Nations women in Alberta.

METHODS

Delivery records (1999-2014) were linked to provincial administrative data, which allowed for a maximum follow-up of 16 years after delivery. Prevalence of pregnancy risk factors were compared by First Nations status. Hazard ratios for diabetes after delivery by First Nations status, high pre-pregnancy body weight (≥91 kg) and gestational diabetes status were estimated using the Cox proportional hazards model.

RESULTS

Age-adjusted prevalence of gestational diabetes (7.9% vs 4.6%; P<0.0001), high pre-pregnancy body weight (18.8% vs 10.2%; P<0.0001) and diabetes after delivery (3.9% vs 1.1%; P<0.0001) were higher in First Nations women than in non-First Nations women. Development of diabetes after delivery was higher with First Nations status (hazard ratio 3.0, 95% CI 2.6-3.4), high pre-pregnancy body weight (hazard ratio 3.6, 95% CI 3.3-4.0) and gestational diabetes status (hazard ratio 19.2, 95% CI 17.9-20.6). The highest risk was within First Nations women with high pre-pregnancy body weight and gestational diabetes (hazard ratio 54.8, 95% CI 45.2-66.5) compared to women without these three risk factors. Reduced prenatal visits per pregnancy (8.4 vs 10.7; P<0.0001) and delayed first prenatal visit (time to delivery 23.7 vs 26.7 weeks; P<0.0001) were observed in First Nations women compared to non-First Nations women.

CONCLUSION

First Nations women are at greater risk of developing diabetes after pregnancy, with gestational diabetes being the strongest predictor. Strategies that target the specific needs of First Nations women before, during and after pregnancy are required.

Trends in National Canadian Guideline Recommendations for the Screening and Diagnosis of Gestational Diabetes Mellitus over the Years: A Scoping Review

Canada's largest national obstetric and diabetology organizations have recommended various algorithms for the screening of gestational diabetes mellitus (GDM) over the years. Though uniformity across recommendations from clinical practice guidelines (CPGs) is desirable, historically, national guidelines from Diabetes Canada (DC) and the Society of Obstetricians and Gynaecologists of Canada (SOGC) have differed. Lack of consensus has led to variation in screening approaches, rendering precise ascertainment of GDM prevalence challenging. To highlight the reason and level of disparity in Canada, we conducted a scoping review of CPGs released by DC and the SOGC over the last thirty years and distributed a survey on screening practices among Canadian physicians. Earlier CPGs were based on expert opinion, leading to different recommendations from these organizations. However, as a result of the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study, disparities between DC and the SOGC no longer exist and many Canadian physicians have adopted their recent recommendations. Given that Canadian guidelines now recommend two different screening programs (one step vs. two step), lack of consensus on a single diagnostic threshold continues to exist, resulting in differing estimates of GDM prevalence. Our scoping review highlights these disparities and provides a step forward towards reaching a consensus on one unified threshold.

Pharmacological therapy in gestational diabetes - a comparison between insulin and oral therapy

BACKGROUND

The appropriate medical treatment for gestational diabetes mellitus (GDM) is controversial and recommendations vary between different organizations.

OBJECTIVE

To compare the safety and efficacy of glyburide and insulin as treatments for GDM.

METHODS

Retrospective analysis of all pregnant women diagnosed with GDM and treated with either glyburide or insulin. Demographic features, clinical characteristics, maternal and neonatal outcomes were compared according to type of pharmacological treatment.

RESULTS

Included in the study were 323 women, of whom 269 (83.28%) were treated with glyburide and 54 (16.72%) with insulin. There were no significant differences between the groups, apart from a higher one-hour oral glucose tolerance test (OGTT) value (191.80 mg/dl in the glyburide group, 204.33 in the insulin group, p = .01). Optimal glucose control was achieved in 130 women in the glyburide group (48.32%) and 15 in the insulin group (27.77%), p = .007. This difference remained significant after adjustment for age, BMI, and fasting glucose during OGTT (aOR = 2.22). Mean gestational weight gain was lower in the glyburide group vs. insulin group (10.01 vs. 11.99 kg, p = .048). Apart from higher maternal hypoglycemia rate (12.64% in glyburide group vs. 1.85% in insulin group, p = .016), there were no other differences in maternal and neonatal outcomes between the groups. Glyburide failure rate was 13.38%, and associated with higher fasting OGTT value (100.70 mg/dl in glyburide failure group vs. 94.67 mg/dl in the glyburide treatment until delivery group, p = .041).

CONCLUSIONS

Glyburide is at least as safe and effective as insulin except for higher rates of maternal hypoglycemia. Considering its advantages compared to insulin (ease of use and storage, increased patient responsiveness, and lower cost), it may be considered as first line treatment in GDM, especially when fasting OGTT value is not high.

Risk prediction model of gestational diabetes mellitus based on nomogram in a Chinese population cohort study

To build a risk prediction model of gestational diabetes mellitus using nomogram to provide a simple-to-use clinical basis for the early prediction of gestational diabetes mellitus (GDM). This study is a prospective cohort study including 1385 pregnant women. (1) It is showed that the risk of GDM in women aged ≥ 35 years was 5.5 times higher than that in women aged < 25 years (95% CI: 1.27–23.73, p < 0.05). In the first trimester, the risk of GDM in women with abnormal triglyceride who were in their first trimester was 2.1 times higher than that of lipid normal women (95% CI: 1.12–3.91, p < 0.05). The area under the ROC curve of the nomogram of was 0.728 (95% CI: 0.683–0.772), the sensitivity and specificity of the model were 0.716 and 0.652, respectively. This study provides a simple and economic nomogram for the early prediction of GDM risk in the first trimester, and it has certain accuracy.

Early and late pregnancy loss in women with polycystic ovary syndrome undergoing IVF/ICSI treatment: a retrospective cohort analysis of 21 820 pregnancies

OBJECTIVE

To examine early and late pregnancy loss in women with and without polycystic ovary syndrome (PCOS) undergoing IVF/ICSI transfers.

DESIGN

Retrospective cohort study.

SETTING

Reproductive medicine centre at a tertiary hospital.

POPULATION

We studied women with a positive β-human chorionic gonadotropin (β-hCG) after in vitro fertilisation/intra-cytoplasmic sperm injection (IVF/ICSI) treatment from May 2014 to April 2019.

METHODS

Odds ratios (OR) for early (≤13 weeks) and late (>13 weeks) pregnancy loss were calculated among women with and without PCOS for plurality of the pregnancy with adjustment for confounding factors.

MAIN OUTCOME MEASURES

Early pregnancy loss (EPL) and late pregnancy loss (LPL).

RESULTS

From 21 820 women identified with a positive β-hCG, 2357 (10.8%) women had PCOS, and 19 463 (89.2%) women did not. EPL occurred in 16.6% (391) of women with PCOS versus 18.3% (3565) in women with non-PCOS (OR 0.89, 95% CI 0.79-0.99, P = 0.04). After adjustment for age and other confounders, the rate of EPL was not statistically significantly associated with PCOS status (adjusted OR [aOR] 0.91, 95% CI 0.80-1.05). Women with PCOS demonstrated a higher rate of LPL (6.4% in PCOS versus 3.6% in non-PCOS, OR 1.81, 95% CI 1.48-2.21, P < 0.001). In multivariable analysis, the potential impact of PCOS was less strong (aOR 1.38, 95% CI 0.96-1.98), with BMI and maternal comorbidities also associated with LPL (aOR 1.08, 95% CI 1.04-1.1 and aOR 2.07, 95% CI 1.43-3.00, respectively).

CONCLUSIONS

Polycystic ovary syndrome was not independently associated with EPL. There was an increased risk of LPL but this difference was not statistically significant.

TWEETABLE ABSTRACT

Polycystic ovary syndrome women are at increased risk of late pregnancy loss, partly driven by elevated BMI and maternal comorbidities.

Maternal Arsenic Exposure and Gestational Diabetes: A Systematic Review and Meta-Analysis

Gestational diabetes mellitus (GDM) is a metabolic complication associated with adverse outcomes for mother and fetus. Arsenic (As) exposure has been suggested as a possible risk factor for its development. The aim of this meta-analysis was to provide a comprehensive overview of published evidence on the association between As and GDM. The systematic search from PubMed, MEDLINE, and Scopus was limited to full-length manuscripts published in peer-reviewed journals up to April 2020, identifying fifty articles. Ten studies met the inclusion criteria, nine for quantitative synthesis with a total of n = 1984 GDM cases. The overall pooled risk was 1.56 (95% Confidence Interval - CI = 1.23, 1.99) with moderate heterogeneity (χ² = 21.95; I²% = 64). Several differences among the included studies that may account for heterogeneity were investigated. Stratification for exposure indicator confirmed a positive association for studies assessing urine As. A slightly higher risk was detected pooling studies based in Asia rather than in North America. Stratification for GDM diagnostic criteria showed higher risks when diagnosis was made according to the Canadian Diabetes Association (CDA-SOGC) or World Health Organization (WHO) criteria, whereas a lower risk was observed when adopting the American Diabetes Association (ADA) criteria. These results provide additional evidence for a possible association between As exposure and GDM, although the data need to be interpreted with caution due to heterogeneity.

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.

Obstetric and perinatal outcomes of intracytoplasmic sperm injection versus conventional in vitro fertilization in couples with nonsevere male infertility

OBJECTIVE

To determine whether intracytoplasmic sperm injection (ICSI) is associated with improved outcomes compared with conventional in vitro fertilization (IVF) for patients with nonsevere male factor infertility.

DESIGN

Retrospective cohort.

SETTING

University-affiliated reproductive endocrinology unit.

PATIENT(S)

Couples who received their first-cycle embryo transfer without severe oligoasthenozoospermia (OA) between January 2012 and December 2016 were included in this study.

INTERVENTION(S)

Six subgroup analyses were performed according to the proposed indications for the use of ICSI as follows: non-male factor infertility, advanced maternal age (≥38 years), unexplained infertility, low oocyte yield (≤6), mild OA, and moderate OA.

MAIN OUTCOME MEASURE(S)

Live birth rates and selected perinatal outcomes.

RESULT(S)

ICSI resulted in live birth rates similar to those achieved with IVF (41.68% vs. 44.31%). There were no significant differences in the incidences of gestational diabetes mellitus, hypertension disorder of pregnancy, placental previa, postpartum hemorrhage, cesarean delivery, fetal macrosomia, small for gestational age, large for gestational age, neonatal intensive care unit (NICU) admission, and congenital anomalies between the two groups. Subgroup analyses showed that ICSI resulted in a lower rate of NICU admission in couples with moderate OA.

CONCLUSION(S)

Our results suggested that routine use of ICSI for all causes of infertility did not result in better pregnancy and perinatal outcomes compared with conventional IVF in the first cycle. ICSI might be associated with a lower risk of NICU admission when used in couples with moderate OA. Large prospective studies are required to validate our current findings.

Maternal Sleep-Disordered Breathing in Pregnancy and Increased Nocturnal Glucose Levels in Women with Gestational Diabetes Mellitus

BACKGROUND

Women with hyperglycemia during pregnancy are at high risk for adverse perinatal outcomes. Maternal sleep-disordered breathing (SDB) during pregnancy is common and is a risk factor for gestational diabetes mellitus (GDM). However, the relationship between SDB severity and glucose control is unknown.

RESEARCH QUESTION

Is there an association between SDB severity and glucose levels as assessed by continuous glucose monitoring in GDM?

STUDY DESIGN AND METHODS

Women with GDM underwent sleep recordings and 72-hour continuous glucose monitoring. Linear mixed models were used to estimate the association of the apnea-hypopnea index (AHI), rapid eye movement (REM)-AHI, and non-REM-AHI with mean glucose levels during nighttime (two periods: 11 pm to 3 am and 3 am to 6 am), daytime (8 am to 9 pm), and 24-hours. Models were adjusted for BMI and antihyperglycemic medications.

RESULTS

In 65 participants who were 35 ± 5 (mean ± SD) years of age with BMI of 33 ± 7 kg/m², 31% were undergoing insulin and/or metformin therapy. A ten-unit increase in AHI was associated with elevated nocturnal glucose levels (11 pm to 3 am: 0.20 mmol/L [95% CI, 0.04-0.40]) with persistent elevations into the morning (8 am: 0.26 mmol/L [95% CI, 0.08-0.4]) when adjusted for BMI and medications. REM-AHI was also associated with higher nocturnal and morning glucose levels, whereas non-REM was not. AHI was not associated with either mean daytime or 24-hour glucose levels.

INTERPRETATION

Greater severity of SDB was associated with higher nocturnal and morning glucose levels in women with GDM.

Impact of dietary counseling on the perception of diet in patients with gestational diabetes mellitus

Aims/introduction

Medical nutrition therapy is the cornerstone of gestational diabetes mellitus (GDM) treatment. Patients with GDM should receive dietary counseling regarding diet and exercise.

Materials and methods

To study patients' perception level of diet and their level of understanding after dietary counseling, we analyzed 225 reports of dietary counseling of patients with GDM prepared by dieticians. We also assessed the patients' level of understanding after dietary counseling by asking questions regarding the counseling content. The answers to the questions were aggregated, and substantially similar answers were grouped and categorized.

Results

The dieticians' suggestions were well understood by the patients. Moreover, the patients also identified their previous incorrect eating habits, such as excessive carbohydrate restriction or inappropriate fruit intake. Although distributed frequent meals were recommended by the dieticians, few patients actually practiced this for various reasons. Some patients were apparently influenced by dietary information from the mass media.

Conclusion

Dietary counseling was regarded as helpful and acceptable to most patients with GDM in our hospital, and many suggestions were recognized as informative for modification of previous dietary habits. By providing the results of the questionnaire survey to the dieticians, they can improve the quality of their counseling, which is expected to result in better individual care of the patients.

Have pregnancy outcomes improved with the introduction of the International Association of Diabetes and Pregnancy Study Groups criteria in Japan?

AIMS/INTRODUCTION

This study aimed to investigate the effects of the introduction of the International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria for diagnosing gestational diabetes mellitus (GDM) on maternal and neonatal outcomes in Japan.

MATERIALS AND METHODS

This was a retrospective study carried out at a tertiary center in Japan. Previously in Japan, GDM was diagnosed if two or more of the following Japan Society of Obstetrics and Gynecology (JSOG) criteria were met: fasting plasma glucose ≥100 mg/dL, 1-h value ≥180 mg/dL or 2-h value ≥150 mg/dL on the 75-g oral glucose tolerance. Since 2010, GDM has been diagnosed if one or more of the following IADPSG criteria are met: fasting plasma glucose ≥92 mg/dL, 1-h value ≥180 mg/dL or 2-h value ≥153 mg/dL on the 75-g oral glucose tolerance. We compared the pregnancy outcomes of all pregnant women with singleton pregnancies after 22 weeks' gestation at our hospital before (JSOG period) and after (IADPSG period) the IADPSG criteria were adopted.

RESULTS

There were 3,912 women in the JSOG period and 4,772 in the IADPSG period. GDM prevalence increased from 2.9% in the JSOG period to 13% in the IADPSG period (P < 0.001). No significant differences between the groups were found in rates of macrosomia, or large for gestational age, and no significant differences were found in birthweight. The neonatal hypoglycemia rate and neonatal intensive care unit admission rate were significantly lower in the IADPSG period (adjusted odds ratio 0.51 and 0.78, respectively).

CONCLUSIONS

Introduction of the IADPSG criteria for diagnosing GDM increased GDM diagnosis frequency fourfold, but reduced neonatal intensive care unit admission and neonatal hypoglycemia rates significantly.

Interventions to prevent women from developing gestational diabetes mellitus: an overview of Cochrane Reviews

BACKGROUND

The prevalence of gestational diabetes mellitus (GDM) is increasing, with approximately 15% of pregnant women affected worldwide, varying by country, ethnicity and diagnostic thresholds. There are associated short- and long-term health risks for women and their babies.

OBJECTIVES

We aimed to summarise the evidence from Cochrane systematic reviews on the effects of interventions for preventing GDM.

METHODS

We searched the Cochrane Database of Systematic Reviews (6 August 2019) with key words 'gestational diabetes' OR 'GDM' to identify reviews pre-specifying GDM as an outcome. We included reviews of interventions in women who were pregnant or planning a pregnancy, irrespective of their GDM risk status. Two overview authors independently assessed eligibility, extracted data and assessed quality of evidence using ROBIS and GRADE tools. We assigned interventions to categories with graphic icons to classify the effectiveness of interventions as: clear evidence of benefit or harm (GRADE moderate- or high-quality evidence with a confidence interval (CI) that did not cross the line of no effect); clear evidence of no effect or equivalence (GRADE moderate- or high-quality evidence with a narrow CI crossing the line of no effect); possible benefit or harm (low-quality evidence with a CI that did not cross the line of no effect or GRADE moderate- or high-quality evidence with a wide CI); or unknown benefit or harm (GRADE low-quality evidence with a wide CI or very low-quality evidence).

MAIN RESULTS

We included 11 Cochrane Reviews (71 trials, 23,154 women) with data on GDM. Nine additional reviews pre-specified GDM as an outcome, but did not identify GDM data in included trials. Ten of the 11 reviews were judged to be at low risk of bias and one review at unclear risk of bias. Interventions assessed included diet, exercise, a combination of diet and exercise, dietary supplements, pharmaceuticals, and management of other health problems in pregnancy. The quality of evidence ranged from high to very low. Diet Unknown benefit or harm: there was unknown benefit or harm of dietary advice versus standard care, on the risk of GDM: risk ratio (RR) 0.60, 95% CI 0.35 to 1.04; 5 trials; 1279 women; very low-quality evidence. There was unknown benefit or harm of a low glycaemic index diet versus a moderate-high glycaemic index diet on the risk of GDM: RR 0.91, 95% CI 0.63 to 1.31; 4 trials; 912 women; low-quality evidence. Exercise Unknown benefit or harm: there was unknown benefit or harm for exercise interventions versus standard antenatal care on the risk of GDM: RR 1.10, 95% CI 0.66 to 1.84; 3 trials; 826 women; low-quality evidence. Diet and exercise combined Possible benefit: combined diet and exercise interventions during pregnancy versus standard care possibly reduced the risk of GDM: RR 0.85, 95% CI 0.71 to 1.01; 19 trials; 6633 women; moderate-quality evidence. Dietary supplements Clear evidence of no effect: omega-3 fatty acid supplementation versus none in pregnancy had no effect on the risk of GDM: RR 1.02, 95% CI 0.83 to 1.26; 12 trials; 5235 women; high-quality evidence. Possible benefit: myo-inositol supplementation during pregnancy versus control possibly reduced the risk of GDM: RR 0.43, 95% CI 0.29 to 0.64; 3 trials; 502 women; low-quality evidence. Possible benefit: vitamin D supplementation versus placebo or control in pregnancy possibly reduced the risk of GDM: RR 0.51, 95% CI 0.27 to 0.97; 4 trials; 446 women; low-quality evidence. Unknown benefit or harm: there was unknown benefit or harm of probiotic with dietary intervention versus placebo with dietary intervention (RR 0.37, 95% CI 0.15 to 0.89; 1 trial; 114 women; very low-quality evidence), or probiotic with dietary intervention versus control (RR 0.38, 95% CI 0.16 to 0.92; 1 trial; 111 women; very low-quality evidence) on the risk of GDM. There was unknown benefit or harm of vitamin D + calcium supplementation versus placebo (RR 0.33, 95% CI 0.01 to 7.84; 1 trial; 54 women; very low-quality evidence) or vitamin D + calcium + other minerals versus calcium + other minerals (RR 0.42, 95% CI 0.10 to 1.73; 1 trial; 1298 women; very low-quality evidence) on the risk of GDM. Pharmaceutical Possible benefit: metformin versus placebo given to obese pregnant women possibly reduced the risk of GDM: RR 0.85, 95% CI 0.61 to 1.19; 3 trials; 892 women; moderate-quality evidence. Unknown benefit or harm:eight small trials with low- to very low-quality evidence showed unknown benefit or harm for heparin, aspirin, leukocyte immunisation or IgG given to women with a previous stillbirth on the risk of GDM. Management of other health issues Clear evidence of no effect: universal versus risk based screening of pregnant women for thyroid dysfunction had no effect on the risk of GDM: RR 0.93, 95% CI 0.70 to 1.25; 1 trial; 4516 women; moderate-quality evidence. Unknown benefit or harm: there was unknown benefit or harm of using fractional exhaled nitrogen oxide versus a clinical algorithm to adjust asthma therapy on the risk of GDM: RR 0.74, 95% CI 0.31 to 1.77; 1 trial; 210 women; low-quality evidence. There was unknown benefit or harm of pharmacist led multidisciplinary approach to management of maternal asthma versus standard care on the risk of GDM: RR 5.00, 95% CI 0.25 to 99.82; 1 trial; 58 women; low-quality evidence.

AUTHORS' CONCLUSIONS

No interventions to prevent GDM in 11 systematic reviews were of clear benefit or harm. A combination of exercise and diet, supplementation with myo-inositol, supplementation with vitamin D and metformin were of possible benefit in reducing the risk of GDM, but further high-quality evidence is needed. Omega-3-fatty acid supplementation and universal screening for thyroid dysfunction did not alter the risk of GDM. There was insufficient high-quality evidence to establish the effect on the risk of GDM of diet or exercise alone, probiotics, vitamin D with calcium or other vitamins and minerals, interventions in pregnancy after a previous stillbirth, and different asthma management strategies in pregnancy. There is a lack of trials investigating the effect of interventions prior to or between pregnancies on risk of GDM.

Comparative impact of pharmacological treatments for gestational diabetes on neonatal anthropometry independent of maternal glycaemic control: A systematic review and meta-analysis

BACKGROUND

Fetal growth in gestational diabetes mellitus (GDM) is directly linked to maternal glycaemic control; however, this relationship may be altered by oral anti-hyperglycaemic agents. Unlike insulin, such drugs cross the placenta and may thus have independent effects on fetal or placental tissues. We investigated the association between GDM treatment and fetal, neonatal, and childhood growth.

METHODS AND FINDINGS

PubMed, Ovid Embase, Medline, Web of Science, ClinicalTrials.gov, and Cochrane databases were systematically searched (inception to 12 February 2020). Outcomes of GDM-affected pregnancies randomised to treatment with metformin, glyburide, or insulin were included. Studies including preexisting diabetes or nondiabetic women were excluded. Two reviewers independently assessed eligibility and risk of bias, with conflicts resolved by a third reviewer. Maternal outcome measures were glycaemic control, weight gain, and treatment failure. Offspring anthropometric parameters included fetal, neonatal, and childhood weight and body composition data. Thirty-three studies (n = 4,944), from geographical locations including Europe, North Africa, the Middle East, Asia, Australia/New Zealand, and the United States/Latin America, met eligibility criteria. Twenty-two studies (n = 2,801) randomised women to metformin versus insulin, 8 studies (n = 1,722) to glyburide versus insulin, and 3 studies (n = 421) to metformin versus glyburide. Eleven studies (n = 2,204) reported maternal outcomes. No differences in fasting blood glucose (FBS), random blood glucose (RBS), or glycated haemoglobin (HbA1c) were reported. No studies reported fetal growth parameters. Thirty-three studies (n = 4,733) reported birth weight. Glyburide-exposed neonates were heavier at birth (58.20 g, 95% confidence interval [CI] 10.10-106.31, p = 0.02) with increased risk of macrosomia (odds ratio [OR] 1.38, 95% CI 1.01-1.89, p = 0.04) versus neonates of insulin-treated mothers. Metformin-exposed neonates were born lighter (-73.92 g, 95% CI -114.79 to -33.06 g, p < 0.001) with reduced risk of macrosomia (OR 0.60, 95% CI 0.45-0.79, p < 0.001) than insulin-exposed neonates. Metformin-exposed neonates were born lighter (-191.73 g, 95% CI -288.01 to -94.74, p < 0.001) with a nonsignificant reduction in macrosomia risk (OR 0.32, 95% CI 0.08-1.19, I2 = 0%, p = 0.09) versus glyburide-exposed neonates. Glyburide-exposed neonates had a nonsignificant increase in total fat mass (103.2 g, 95% CI -3.91 to 210.31, p = 0.06) and increased abdominal (0.90 cm, 95% CI 0.03-1.77, p = 0.04) and chest circumferences (0.80 cm, 95% CI 0.07-1.53, p = 0.03) versus insulin-exposed neonates. Metformin-exposed neonates had decreased ponderal index (-0.13 kg/m3, 95% CI -0.26 to -0.00, p = 0.04) and reduced head (-0.21, 95% CI -0.39 to -0.03, p = 0.03) and chest circumferences (-0.34 cm, 95% CI -0.62 to -0.05, p = 0.02) versus the insulin-treated group. Metformin-exposed neonates had decreased ponderal index (-0.09 kg/m3, 95% CI -0.17 to -0.01, p = 0.03) versus glyburide-exposed neonates. Study limitations include heterogeneity in dosing, heterogeneity in GDM diagnostic criteria, and few studies reporting longitudinal growth outcomes.

CONCLUSIONS

Maternal randomisation to glyburide resulted in heavier neonates with a propensity to increased adiposity versus insulin- or metformin-exposed groups. Metformin-exposed neonates were lighter with reduced lean mass versus insulin- or glyburide-exposed groups, independent of maternal glycaemic control. Oral anti-hyperglycaemics cross the placenta, so effects on fetal anthropometry could result from direct actions on the fetus and/or placenta. We highlight a need for further studies examining the effects of intrauterine exposure to antidiabetic agents on longitudinal growth, and the importance of monitoring fetal growth and maternal glycaemic control when treating GDM. This review protocol was registered with PROSPERO (CRD42019134664/CRD42018117503).

Experiences of pregnant women with gestational diabetes mellitus: a systematic review of qualitative evidence protocol

INTRODUCTION

The incidence of gestational diabetes mellitus (GDM) is increasing and an issue of global concern. GDM can cause severe adverse effects for pregnant women and their fetuses. This systematic review is proposed to explore women's experiences during the pregnancy with GDM. This review will provide insights into the physical, psychological and social adaptation experiences of women with GDM that can help to identify challenges of glycaemic control and provide targeted care and interventions to improve maternal and child health.

METHODS AND ANALYSIS

The databases we will search include English databases (ie, PubMed, CINAHL, Embase, the Cochrane Library, Web of Science, Joanna Briggs Institute (JBI) Database of Systematic Reviews, PsycINFO, OpenGrey and Deep Blue) and Chinese databases (ie, China Biology Medicine disc, China National Knowledge Infrastructure, and VIP Database for Chinese Technical Periodicals). Published qualitative evidence of life changes or experiences of the women with GDM will be searched. There will be no limits on publication year. Two reviewers will independently use the JBI Critical Appraisal Checklist for Qualitative Research for methodological validity prior to inclusion in this review. Any disagreements regarding article evaluation will be resolved through discussion or with a third reviewer. Data will be extracted using the standardised data extraction tool from JBI System for the Unified Management, Assessment and Review of Information. Synthesis will include in-depth reading of the original text and the discovery of the results, and then summarising similar categories for more advanced synthesised findings. The final synthesised findings will be graded according to the ConQual approach for establishing confidence.

ETHICS AND DISSEMINATION

This study does not require ethical approval as primary data will not be collected. Results of this systematic review will be submitted to peer-reviewed international journals for publication and be presented in relevant international conferences.

PROSPERO REGISTRATION NUMBER

CRD42019132065.

Effect of pregravid obesity on perinatal outcomes in singleton pregnancies following in vitro fertilization and the weight-loss goals to reduce the risks of poor pregnancy outcomes: A retrospective cohort study

Objective

In the present study, we aimed to determine whether pregravid obesity independently predicts increased risks of perinatal complications following in vitro fertilization (IVF) and the weight loss goals to reduce the risk of poor pregnancy outcomes.

Design

Retrospective cohort study.

Population

All pregnancies after first the fresh IVF cycle from January 2014 to December 2016 in the Reproductive Center affiliated to Shandong University were reviewed. A total of 3,962 eligible singleton births were stratified into cohorts based on the body mass index (BMI) definitions of the Working Group on Obesity in China (WGOC).

Main outcome measures

Adverse perinatal outcomes.

Results

Pregravid overweight and obesity were associated with increased risks of gestational diabetes mellitus (GDM), hypertensive disorders of pregnancy (HDP), including gestational hypertension (GH) and pre-eclampsia (PE), polyhydramnios, preterm premature rupture of the membranes (PPROM), placental abruption, preterm birth (PTB) <37 weeks, caesarean section (CS), fetal macrosomia, large for gestational age (LGA) >90th percentile, neonatal respiratory distress syndrome (NRDS), neonatal intensive care unit (NICU) admission and congenital anomalies as compared with the normal-weight group after adjustment of differences in age, parity, polycystic ovary syndrome (PCOS) and type of controlled ovarian hyperstimulation (COH). The increased risks of PPROM, NRDS and congenital anomalies were eliminated after adjustment of GDM development, whereas the increased risk of NRDS disappeared after adjustment of HDP. Placenta previa was not significantly different between the obese group and reference group (REF). Moreover, the rates of postpartum hemorrhage (PPH), PTB<32 weeks, small for gestational age (SGA) >90th percentile and perinatal mortality were also not significantly different between above-mentioned two groups. For obese women, a 10%-15% reduction in prepregnancy BMI was associated with significantly decreased risks of GH, CS and fetal macrosomia. For overweight women, just a 5% reduction in BMI could significantly reduce the risks of GDM, CS and fetal macrosomia.

Conclusions

Pregravid obesity could independently predict a higher risk of adverse pregnancy outcomes after adjustment of differences in maternal age, parity, PCOS, and type of COH in IVF pregnancies. The potential mechanism that obesity potentiated the risks of some poor perinantal outcomes might occur through the development of GDM and HDP. A 10%-15% reduction in pregravid BMI for obese women and a 5% reduction for overweight women were associated with a significant reduction of poor perinatal complications.

Dietary phenylalanine requirements during early and late gestation in healthy pregnant women

BACKGROUND

Phenylalanine is an indispensable amino acid and, via tyrosine, is the precursor for the neurotransmitters dopamine, norepinephrine, and epinephrine. Currently, dietary requirements for phenylalanine during pregnancy are unknown.

OBJECTIVES

This study's aim was to determine phenylalanine requirements (in the presence of excess tyrosine) during early and late gestation using direct amino acid oxidation (DAAO; with l-[1-13C]phenylalanine) and indicator amino acid oxidation (IAAO; with l-[1-13C]leucine).

METHODS

Twenty-three healthy women (age: 30.4 ± 3.1 y, mean ± SD) were studied at a range of phenylalanine intakes (5.5-30.5 mg · kg-1 · d-1 in early and late pregnancy using DAAO, and 2.5-30.5 mg · kg-1 · d-1 in late pregnancy using IAAO) for a total of 76 study days. Test intakes were provided as 8 isocaloric and isonitrogenous meals with 1.5 g · kg-1 · d-1 protein and energy at 1.7 times the measured resting energy expenditure. Breath samples were analyzed on an isotope ratio mass spectrometer for 13C enrichment. Phenylalanine requirement was determined using a 2-phase linear regression crossover model to identify a breakpoint in 13CO2 production (representing the mean requirement) in response to phenylalanine intakes.

RESULTS

Phenylalanine requirement during early pregnancy was determined to be 15 mg · kg-1 · d-1 (95% CI: 10.4, 19.9 mg · kg-1 · d-1); during late pregnancy, it was determined to be 21 mg · kg-1 · d-1 by DAAO (95% CI: 17.4, 24.7 mg · kg-1 · d-1) and IAAO (95% CI: 10.5, 32.2 mg · kg-1 · d-1).

CONCLUSIONS

Our results suggest a higher requirement (40%) for phenylalanine during late pregnancy than during early pregnancy. Moreover, the early pregnancy requirements are higher than the previous adult male requirement (9.1 mg · kg-1 · d-1; 95% CI: 4.6, 13.6 mg · kg-1 · d-1), although the 95% CIs overlap. Both DAAO and IAAO methods provided similar breakpoints in late pregnancy, showing that the DAAO method was appropriate even though low phenylalanine intakes could not be tested. These results have potential implications for gestation stage-specific dietary phenylalanine recommendations in future.This trial was registered at clinicaltrials.gov as NCT02669381.

Elevated fasting vs post-load glucose levels and pregnancy outcomes in gestational diabetes: a population-based study

AIMS

To examine the relative association between fasting plasma glucose vs post-load (1-h and 2-h) glucose levels based on the oral glucose tolerance test in pregnancy and large-for-gestational-age and hypertensive disorders of pregnancy outcomes.

METHODS

All live singleton births between October 2008 and December 2014 in Alberta, Canada were included. Gestational diabetes mellitus was diagnosed using Diabetes Canada criteria. Logistic regression models were used to examine the association between fasting plasma glucose vs post-load values and large-for-gestational-age infants and hypertensive disorders of pregnancy after adjusting for maternal characteristics and pharmaceutical intervention in gestational diabetes pregnancies.

RESULTS

Among 257 547 pregnancies, 208 344 (80.9%) had negative 50-g glucose challenge tests, 36 261 (14.1%) had negative 75-g oral glucose tolerance tests, and 12 942 (5.0%) had gestational diabetes based on either elevated fasting plasma glucose (n=4130, 1.6%) or elevated 1-h and/or 2-h oral glucose tolerance test values (n=8812, 3.4%). Large-for-gestational-age and hypertensive disorders of pregnancy rates were 8.1% and 5.1% in negative glucose challenge test pregnancies, 11.0% and 7.0% in negative oral glucose tolerance test pregnancies, 22.4% and 11.9% in gestational diabetes pregnancies with elevated fasting plasma glucose, and 9.1% and 8% in gestational diabetes pregnancies with elevated post-load levels, respectively. Among gestational diabetes pregnancies, those with elevated fasting plasma glucose were at higher risk of large-for-gestational age (adjusted odds ratio 2.66, 95% CI 2.39-2.96) and hypertensive disorders of pregnancy (adjusted odds ratio 1.51, 95% CI 1.33-1.72) outcomes relative to pregnancies with post-load glucose elevations only. Fasting plasma glucose remained significantly associated with adverse outcomes in gestational diabetes pregnancies with and without pharmacological intervention.

CONCLUSIONS

Elevated fasting plasma glucose in women with gestational diabetes is a stronger predictor of large-for-gestational-age and hypertensive disorders of pregnancy outcomes than elevated post-load glucose.

Effects of Nutritional Strategies on Glucose Homeostasis in Gestational Diabetes Mellitus: A Systematic Review and Network Meta-Analysis

BACKGROUND

Gestational diabetes mellitus (GDM) is one of the most common complications of pregnancy, and nutritional therapy is the basis of GDM treatment. However, the effects of different forms of nutritional supplementation on improving gestational diabetes are uncertain.

OBJECTIVE

We conducted a network meta-analysis to evaluate the effects of supplementation with different nutrients on glucose metabolism in women with GDM.

METHODS

We conducted a literature search using PubMed, EMBASE, and the Cochrane Library to identify randomized controlled trials (RCTs) comparing the differences between different nutritional strategies in women with GDM. The Cochrane tool was used to assess the risk of bias. Pairwise meta-analysis and network meta-analysis were used to compare and rank the effects of nutritional strategies for the improvement of fasting plasma glucose (FPG), serum insulin, and homeostasis model assessment-insulin resistance (HOMA-IR).

RESULTS

We included thirteen RCTs with a total of 754 participants. Compared with placebo, omega-3, magnesium, vitamin D, zinc, and probiotics were more beneficial for improving FPG, serum insulin, and HOMA-IR. Network analysis showed that vitamin D supplementation was superior to omega-3 (-3.64 mg/dL, 95% CI: -5.77 to -1.51), zinc (-5.71 mg/dL, 95% CI: -10.19 to -1.23), probiotics (-6.76 mg/dL, 95% CI: -10.02 to -3.50), and placebo (-12.13 mg/dL, 95% CI: -14.55 to -9.70) for improving FPG. Magnesium supplementation was more beneficial for decreasing serum insulin compared with probiotics (-5.10 μIU/mL, 95% CI: -9.32 to -0.88) and placebo (-7.80 μIU/mL, 95% CI: -9.32 to -0.88) and placebo (-7.80 .

CONCLUSION

Vitamin D supplementation significantly reduced FPG and regulated HOMA-IR. Magnesium supplementation was superior in decreasing serum insulin than supplementation with other nutrients. Nutrient supplementation seemed to have an effect on glucose homeostasis maintenance in patients with GDM and may be considered an adjunctive therapy.

Quality appraisal of gestational diabetes mellitus guidelines with AGREE II: a systematic review

Background

Several societies and associations have produced and disseminated clinical practice guidelines (CPGs) for gestational diabetes mellitus (GDM). However, the quality of such guidelines has not been appraised so far. This study aims to evaluate the quality of CPGs for GDM published in the last decade using the AGREE II instrument.

Methods

A systematic search of the National Institute for Health and Care Excellence, New Zealand Guidelines Group, Scottish Intercollegiate Guidelines Network, Medlive, American Diabetes Association, Canadian Diabetes Association, International Diabetes Federation, as well as PubMed, Web of Science, Embase, China National Knowledge Infrastructure, Wanfang Chinese Periodical Database, and VIP Chinese Periodical Database was conducted from inception to June 2018. The quality was assessed by four trained researchers independently, using the AGREE IIinstrument.

Results

A total of 13 guidelines, published from 2009 to 2018, were finally included. Among them, 11 guidelines were evidence-based guidelines, and 2 were expert consensus. Scores for each of the six AGREE II domains(Median ± IQR) were 94 ± 11, 89 ± 53, 58 ± 37, 100 ± 6, 79 ± 48, 100 ± 71 and 67% ± 42%, and guidelines based on expert consensus generally scored lower than evidence-based guidelines (Z = -2.201, p = 0.028). Overall score of 10 guidelines were 5 points and above, and four guidelines were 7 points. Among six domains, two domains: Scope and Purpose, and Clarity of Presentation, had high scores; however, the domains of Rigor of Development, Stakeholder Involvement and Editorial Independence received lower scores.

Conclusions

In general, the methodological quality of GDM guidelines is high, and evidence-based guidelines are superior to expert consensus. However, the domains of Rigor of Development, Stakeholder Involvement and Editorial Independence still need improvement. A systematic approach in the development of these guidelines and updating timely is needed. In some regions, more attention for guideline adaptation is recommended.

Gestational Diabetes: Glycemic Control in the Last Two Weeks Before Delivery Contributes to Newborn Insulinemia

INTRODUCTION

Fetal hyperinsulinemia in gestational diabetes mellitus (GDM) not only is important during intrauterine life, a time when it can result in macrosomia, but also at delivery, since it can result in neonatal hypoglycemia and hyperbilirubinemia. The question is, how long before delivery does maternal glycemic control contribute to newborn insulinemia in GDM?

METHODS

In 72 women with GDM, we calculated Spearman's rank (r_s) correlations between umbilical cord blood C-peptide at birth (a biomarker of insulin secretion), and both maternal glycosylated hemoglobin (HbA1c) and mean blood glucose (MBG) recorded in the last two visits prior to delivery. Iterative correlations were done between umbilical cord blood C-peptide at birth, and maternal glucose control, at 0, 1, 2, 3, 4, and 5 weeks before delivery.

RESULTS

At an early visit (32.95 ± 1.8 weeks), r_s = 0.353 (P = 0.07) between HbA1c and C-peptide, whereas r_s = 0.244 (P = 0.186) between MBG and C-peptide. At the latest visit (35.04 ± 1.6 weeks), r_s = 0.456 (P = 0.004) between HbA1c versus C-peptide, and r_s = 0.359 (P = 0.023) between MBG versus C-peptide. Iterative correlations between MBG and C-peptide became significant at 2 weeks before delivery.

CONCLUSION

To further reduce the risk of hypoglycemia and hyperbilirubinemia in infants born to women with GDM, besides applying a strict in-patient glucose control protocol at delivery, it is necessary to improve even more the quality of maternal glucose control during the last 2 weeks prior to delivery.

Antidepressant use during pregnancy and the risk of gestational diabetes mellitus: a nested case-control study

OBJECTIVES

The aim of this study was to determine the association between antidepressant (AD) classes, types and duration of use during pregnancy and the risk of gestational diabetes mellitus (GDM).

DESIGN AND SETTING

A nested case-control study was conducted within the Quebec Pregnancy Cohort (QPC), a Canadian provincial database which includes data on all pregnancies and children in Quebec from January 1998 to December 2015.

PRIMARY OUTCOME MEASURES

Gestational diabetes mellitus.

PARTICIPANTS

Cases of GDM were identified after week 20 of pregnancy and randomly matched 1:10 to controls on gestational age at index date (ie, calendar date of GDM) and year of pregnancy. AD exposure was assessed by filled prescriptions between the beginning of pregnancy (first day of last menstrual period) and index date. Conditional logistic regression models were used to estimate crude and adjusted odds ratios (aOR).

RESULTS

Among 20 905 cases and 209 050 matched controls, 9741 (4.2%) women were exposed to ADs. When adjusting for potential confounders, AD use was associated with an increased risk of GDM (aOR 1.19, 95% CI 1.08 to 1.30); venlafaxine (aOR 1.27, 95% CI 1.09 to 1.49) and amitriptyline (aOR 1.52, 95% CI 1.25 to 1.84) were also associated with an increased risk of GDM. Moreover, the risk of GDM was increased with longer duration of AD use, specifically for serotonin norepinephrine reuptake inhibitors, tricyclic ADs and combined use of two AD classes. No statistically significant association was observed for selective serotonin reuptake inhibitors.

CONCLUSION

The findings suggest that ADs-and specifically venlafaxine and amitriptyline-were associated with an increased risk of GDM.

The Avoiding Diabetes After Pregnancy Trial in Moms Program: Feasibility of a Diabetes Prevention Program for Women With Recent Gestational Diabetes Mellitus

OBJECTIVE

Our aim in this study was to evaluate the feasibility of a home-based diabetes prevention program, delivered by interdisciplinary certified diabetes educators (CDEs), and customized for postpartum women with recent gestational diabetes mellitus (GDM).

METHODS

This pilot randomized trial recruited women with GDM from 24 to 40 weeks gestation from 4 centres, and trained 10 CDEs in behaviour coaching, physical activity (PA) and low glycemic index education. Women were randomized after 3 months postpartum to standard care (1 visit) or 1 of 3 24-week coaching interventions (1 visit and 12 telephone calls): i) PA and diet, ii) PA only or iii) diet only. Feasibility outcomes included recruitment, retention, adherence and satisfaction.

RESULTS

Of 1,342 eligible patients, 392 were actively invited (29.3%) and 227 (16.9%) consented. Of these, 149 (65.6%) were randomized postpartum, of whom 131 (87.9%) started the program and 105 (70.5%) attended the final assessment. Intervention arm participants completed a median 75% (interquartile range, 50% to 92%) of telephone calls. Visit and call duration were a mean 71.4 (standard deviation, 13.8) and 18.1 (standard deviation, 6.5) minutes, respectively. Participants reported excellent/very good satisfaction 73% of the time, and 87% would recommend the program to others.

CONCLUSIONS

A home-based diabetes prevention program customized for postpartum women with GDM can be feasibly delivered by CDEs, and it is associated with >70% retention, adherence and satisfaction.

Research Gaps in Gestational Diabetes Mellitus: Executive Summary of a National Institute of Diabetes and Digestive and Kidney Diseases Workshop

The National Institute of Diabetes and Digestive and Kidney Diseases convened a workshop on research gaps in gestational diabetes mellitus (GDM) with a focus on 1) early pregnancy diagnosis and treatment and 2) pharmacologic treatment strategies. This article summarizes the proceedings of the workshop. In early pregnancy, the appropriate diagnostic criteria for the diagnosis of GDM remain poorly defined, and an effect of early diagnosis and treatment on the risk of adverse outcomes has not been demonstrated. Despite many small randomized controlled trials of glucose-lowering medication treatment in GDM, our understanding of medication management of GDM is incomplete as evidenced by discrepancies among professional society treatment guidelines. The comparative effectiveness of insulin, metformin, and glyburide remains uncertain, particularly with respect to long-term outcomes. Additional topics in need of further research identified by workshop participants included phenotypic heterogeneity in GDM and novel and individualized treatment approaches. Further research on these topics is likely to improve our understanding of the pathophysiology and treatment of GDM to improve both short- and long-term outcomes for mothers and their children.

Predictors of Large-for-Gestational-Age Birthweight Among Pregnant Women With Type 1 and Type 2 Diabetes: A Retrospective Cohort Study

OBJECTIVE

Our aim in this study was to compare the effects of risk factors for large-for-gestational-age (LGA) birthweight between women with type 1 and type 2 diabetes mellitus (TIDM and T2DM, respectively).

METHODS

A retrospective cohort study was conducted for women with T1DM (n=152) and T2DM (n=255) attending a diabetes/pregnancy clinic during the period from 2009 to 2016. Multiple logistic regression analysis was used to identify variables associated with LGA birthweight.

RESULTS

LGA was significantly higher in those with T1DM (39%) than T2DM (17%) (p<0.001). Among those with T1DM, there was a nonsignificant association between LGA and continuous subcutaneous insulin infusion (odds ratio, 1.17; 95% confidence interval, 0.99 to 1.39; p=0.06) and excess maternal weight gain (T1DM odds ratio, 1.19; 95% confidence interval, 0.99 to 1.43; p=0.069). In those with T2DM, there was an association between LGA and glycated hemoglobin at delivery (T2DM odds ratio, 1.10; 95% confidence interval, 1.02 to 1.19; p=0.01).

CONCLUSIONS

In the study population, glycemic control at delivery was predictive of LGA in women with T2DM, and there was a trend toward an association of maternal weight gain and continuous subcutaneous insulin infusion with LGA infants in T1DM. Further study is warranted to better guide targeted interventions to reduce high rates of LGA birthweight in T1DM/T2DM.

Evidence in support of the International Association of Diabetes in Pregnancy study groups' criteria for diagnosing gestational diabetes mellitus worldwide in 2019

Gestational diabetes mellitus, the most frequent medical complication of pregnancy, affects 5-6% of women in the United States with the use of the currently predominant Carpenter-Coustan criteria, which still represent the preferred approach of the American College of Obstetricians and Gynecologists. Alternative criteria proposed by the International Association of Diabetes in Pregnancy Study Groups would likely increase gestational diabetes mellitus prevalence to 15-20%, because of both a 1-step testing policy and the requirement for only 1 elevated glucose value for diagnosis. Increasing gestational diabetes mellitus prevalence relates to older maternal age and the increasing prevalence of overweight and obesity. This increased gestational diabetes mellitus prevalence is consistent with 29.3% prevalence of prediabetes and 4.5% prevalence of known diabetes outside pregnancy in US adults from 20-44 years of age. Gestational diabetes mellitus according to the International Association of Diabetes in Pregnancy Study Groups criteria is associated with almost twice the risk of large-for-gestational-age babies, increased fetal adiposity, neonatal hyperinsulinemia and preeclampsia, and a 50% higher risk of preterm delivery and shoulder dystocia. The recent publication of the Hyperglycemia and Adverse Pregnancy Outcome Follow Up Study provides further evidence regarding the influence of gestational diabetes mellitus on long-term maternal and infant health. This study clearly demonstrates that hyperglycemia in pregnancy, untreated and identified post hoc by the International Association of Diabetes in Pregnancy Study Groups criteria, carries a 41.5% risk of maternal prediabetes (odds ratio, 3.72; 95% confidence interval, 3.09-4.47) and 10.7% risk of type 2 diabetes (odds ratio, 7.63; 95% confidence interval, 5.33-10.95) after 11.4 years of follow up. Gestational diabetes mellitus was also associated with higher rates of childhood overweight and obesity (prevalence 39.3% with maternal gestational diabetes mellitus; odds ratio, 1.5; 95% confidence interval, 1.56-2.44). This article places these findings in the context of other recent studies that have demonstrated that interventions that include lifestyle measures and/or metformin offer a >50% reduction in the risk of women with gestational diabetes mellitus experiencing the development of overt diabetes mellitus after their index gestational diabetes mellitus pregnancy. Although prevention of obesity and prediabetes in offspring by pregnancy treatment of gestational diabetes mellitus has not been demonstrated to date, we argue that the immediate pregnancy benefits and opportunities for long-term improvements in maternal health justify a reevaluation of the current ambivalent approach taken by the American College of Obstetricians and Gynecologists to gestational diabetes mellitus diagnosis, which currently allow for a choice of alternative criteria. The Carpenter-Coustan or National Diabetes Data Group criteria, listed as preferred criteria by American College of Obstetricians and Gynecologists, markedly limit the frequency of gestational diabetes mellitus in comparison with the International Association of Diabetes in Pregnancy Study Groups criteria and limit the opportunity for immediate and long-term follow up and treatment. We consider that new information from the Hyperglycemia and Pregnancy Outcome Follow Up Study and other recent publications on long-term maternal and offspring risk provides compelling arguments for a more comprehensive approach to the promotion of maternal and infant health through all the life cycle.