Proposed diagnostic thresholds for gestational diabetes mellitus according to a 75-g oral glucose tolerance test. Maternal and perinatal outcomes in 3260 Danish women

Optical Coherence Tomography Angiography Evaluation of Retinochoroidal Microvascular Circulation Differences in Pregnant Women with Pregestational and Gestational Diabetes Mellitus

PURPOSE

In this study, the changes in microvascular circulation caused by pregestational and gestational diabetes were observed, without focusing on retinal findings, to reveal the effect of diabetes regulation.

METHODS

A total of 135 subjects were included: 30 with gestational diabetes (GDM), 30 pregestational diabetes (PGDM), 30 healthy pregnant normoglycemic subjects, and 45 healthy non-pregnant subjects. All subjects were examined by optical coherence tomography (OCT) and angiography. The retina, retinal nerve fiber layer (RNFL), ganglion cell layer (GCL), choroidal thickness (CT), superficial capillary plexus (SCP), deep capillary plexus (DCP), choriocapillaris (CC), vascular density (VD), and foveal avascular zone (FAZ) areas were measured.

RESULTS

The foveal VD of SCP and DCP was significantly lower in the PGDM and GDM groups compared to the control groups (p:0.006 and p:0.001, respectively). CC VD was significantly higher in all pregnant groups compared to non-pregnant controls (p<0.001). The choroidal thickness values were highest in the healthy pregnant group and lowest in the PGDM group. There was no significant difference in FAZ area, retina, RNFL and GCL thickness between the groups. In the PGDM group, a negative correlation was observed between the FAZ area and the HbA1c level (r:- 0.417, p:0.043).

CONCLUSION

There was a decrease in vascular density in pregnant women with diabetes compared to healthy pregnant women and controls. In the pregnant group with PGDM, a narrowing of the FAZ area was observed with increasing worsening of diabetes control. Diabetes type and glycemic control could influence the microvascular changes even in the absence of clinical or retinal findings.

Maternal caffeine, coffee and cola drink intake and the risk of gestational diabetes - Kuopio Birth Cohort

AIMS

Coffee intake is associated with a decreased risk of type 2 diabetes among non-pregnant people. We aimed to investigate the association between caffeine, coffee and cola drink intake in early pregnancy and the risk of gestational diabetes (GDM).

METHODS

Kuopio Birth Cohort (KuBiCo) is a prospective cohort study including pregnant women who were followed at the prenatal clinics in outpatient healthcare centers and gave birth in Kuopio University Hospital, Finland (n=2214). Maternal diet during the first trimester of pregnancy was assessed using a 160-item food frequency questionnaire. GDM was diagnosed by oral glucose tolerance test according to the Finnish national guidelines mainly between 24 and 28 gestational weeks.

RESULTS

Women with moderate coffee intake in the first trimester were less likely diagnosed with GDM than women without coffee intake in an age-adjusted model (OR 0.87; 95% CI 0.76-0.99; p = 0.03), but the association was attenuated in multi-adjusted models (p = 0.11). No association was found between caffeine intake and GDM. One third (32.4%) of pregnant women consumed caffeine over the recommendation (> 200 mg/d). Women who consumed cola drinks more than the median (33.3 mL/d) had an increased risk of GDM (OR 1.29; 95% CI 1.02-1.63, p = 0.037) in multi-adjusted model compared to those who consumed less.

CONCLUSIONS

Caffeine intake during the first trimester of pregnancy was not associated with the risk of GDM but a minor non-significant decrease was seen with moderate coffee intake. Although the average consumption of cola drinks was low in the KuBiCo cohort, higher consumption was associated with an increased risk of GDM. Further studies are needed to evaluate the safe amount of coffee during pregnancy, since the recommended caffeine intake was exceeded in almost half of the coffee drinkers.

Association of Placental Tissue Metabolite Levels with Gestational Diabetes Mellitus: a Metabolomics Study

The purpose of the study is to investigate the metabolic characteristics of placental tissue in patients diagnosed with gestational diabetes mellitus (GDM). Ultra-performance liquid chromatography-mass spectrometry (UPLC-MS/MS) was employed to qualitatively and quantitatively analyze the metabolites in placental tissues obtained from 25 healthy pregnant women and 25 pregnant women diagnosed with GDM. Multilevel statistical methods are applied to process intricate metabolomics data. Meanwhile, we applied machine learning techniques to identify biomarkers that could potentially predict the risk of long-term complications in patients with GDM as well as their offspring. We identified 1902 annotated metabolites, out of which 212 metabolites exhibited significant differences in GDM placentas. In addition, the study identifies a set of risk biomarkers that effectively predict the likelihood of long-term complications in both pregnant women with GDM and their offspring. The accuracy of this panel was measured by the area under the receiver operating characteristic curve (ROC), which was found to be 0.992 and 0.960 in the training and validation sets, respectively. This study enhances our understanding of GDM pathogenesis through metabolomics. Furthermore, the panel of risk markers identified could prove to be a valuable tool in predicting potential long-term complications for both GDM patients and their offspring.

Health promotion intervention among women with recent gestational diabetes mellitus: penetration, participation, and baseline findings from the Face-it randomized controlled trial

INTRODUCTION

Face-it is a randomized controlled trial for women with recent gestational diabetes mellitus (GDM) and their families designed to evaluate the effect of a health promotion intervention on type 2 diabetes mellitus (T2DM) risk and quality of life. This study examined (1) the penetration and participation rates for the Face-it trial, (2) the characteristics of the participating women and the potential differences in characteristics according to partner participation status, and (3) representativity of the women at baseline.

RESEARCH DESIGN AND METHODS

We identified women with GDM during pregnancy and invited them and their partners to a baseline examination 10-14 weeks after delivery. Representativity was assessed by comparing the baseline participants with non-participating women, the general population of women with GDM delivering in Denmark, and populations from other intervention trials.

RESULTS

The penetration rate was 38.0% (867/2279) and the participation rate was 32.9% (285/867). The 285 women who attended baseline had a mean age of 32.7 (±4.8) years and body mass index (BMI) of 28.1 (±5.4) kg/m2, and 69.8% had a partner who participated. The women participating with a partner were more often primiparous, born in Denmark (82.8% vs 68.2%), were younger, and more often had a BMI ≤24.9 kg/m2 (35.7% vs 21.2%) compared with women without a partner. Compared with the general population of women with GDM in Denmark, these women broadly had similar degree of heterogeneity, but had higher rates of primiparity and singleton deliveries, and lower rates of preterm delivery and prepregnancy obesity.

CONCLUSIONS

The penetration and participation rates were acceptable. We found a high rate of partner participation. Overall, women participating with a partner were comparable with those participating without a partner. Participating women were broadly similar to the general national GDM population, however with prepregnancy obesity, multiparity, preterm delivery, and multiple pregnancy being less represented.

TRIAL REGISTRATION NUMBER

NCT03997773.

Cardiovascular and metabolic morbidity in women with previous gestational diabetes mellitus: a nationwide register-based cohort study

Background

Gestational diabetes mellitus (GDM) is associated with adverse pregnancy outcomes and has maternal health implications reaching beyond the perinatal period. We aimed to investigate the incidence and severity of cardiovascular and metabolic morbidity in women with previous GDM in a Danish population and to study whether proxies of impaired beta cell function—insulin treatment during GDM pregnancy and development of subsequent manifest diabetes mellitus—influence incident risk of cardiovascular and metabolic morbidity.

Methods

A nationwide register-based cohort study was conducted on the complete cohort of 700,648 women delivering in Denmark during 1997–2018. The exposure variable was GDM and primary outcome was overall cardiovascular and metabolic morbidity. Secondary outcomes were major cardiovascular disease (ischemic heart disease, heart failure, and/or stroke/transient cerebral ischemia), hypertension, dyslipidemia, and venous thrombosis. Severity of morbidity was assessed using number of hospital contacts with diagnosis codes related to cardiovascular and metabolic morbidity and number of redemptions of prescribed medication related to cardiovascular and metabolic morbidity in women who developed cardiovascular and metabolic morbidity after pregnancy.

Results

The median follow-up period was 10.2–11.9 years with a total range of 0–21.9 years. GDM was associated with increased risk of any cardiovascular and metabolic morbidity (adjusted HR 2.13 [95% CI 2.07–2.20]), major cardiovascular disease (adjusted HR 1.69 [95% CI 1.55–1.84]), hypertension (adjusted HR 1.89 [95% CI 1.82–1.96], dyslipidemia (adjusted HR 4.48 [95% CI 4.28–4.69]), and venous thrombosis (adjusted HR 1.32 [95% CI 1.16–1.50]). Insulin treatment during pregnancy and subsequent development of manifest diabetes exacerbated the risk estimates. Previous GDM was associated with more hospital contacts and more redeemed prescriptions in women developing cardiovascular and metabolic morbidity (p < 0.001).

Conclusions

Previous GDM was associated with significantly higher risk of cardiovascular and metabolic morbidity, especially incident dyslipidemia. Risks were exacerbated by proxies of beta cell impairment. Severity of morbidity was significantly worse if GDM preceded cardiovascular and metabolic morbidity.

Deep Insight of the Pathophysiology of Gestational Diabetes Mellitus

Diabetes mellitus is a severe metabolic disorder, which consistently requires medical care and self-management to restrict complications, such as obesity, kidney damage and cardiovascular diseases. The subtype gestational diabetes mellitus (GDM) occurs during pregnancy, which severely affects both the mother and the growing foetus. Obesity, uncontrolled weight gain and advanced gestational age are the prominent risk factors for GDM, which lead to high rate of perinatal mortality and morbidity. In-depth understanding of the molecular mechanism involved in GDM will help researchers to design drugs for the optimal management of the condition without affecting the mother and foetus. This review article is focused on the molecular mechanism involved in the pathophysiology of GDM and the probable biomarkers, which can be helpful for the early diagnosis of the condition. The early diagnosis of the metabolic disorder, most preferably in first trimester of pregnancy, will lead to its effective long-term management, reducing foetal developmental complications and mortality along with safety measures for the mother.

Elevated blood pressure in pregnant women with gestational diabetes according to the WHO criteria: importance of overweight

OBJECTIVE

Hypertension before and during early pregnancy has been associated with an increased risk of gestational diabetes mellitus (GDM) in retrospective analyses. We aimed to investigate the prospective blood pressure trackings in a population-based cohort of pregnant women, who were stratified according to their metabolic status in early third trimester.

METHODS

We recorded blood pressure longitudinally during pregnancy in 1230 women from the Odense Child Cohort, Denmark. Fasting glucose and insulin were measured at gestational weeks 28-30. Metabolic status was evaluated according to the WHO 2013 threshold for GDM (GDM-WHO: fasting plasma glucose ≥5.1 mmol/l), insulin and homeostatic model assessment of insulin resistance (HOMA-IR). Relationships between metabolic status in third trimester and blood pressure trajectories were evaluated with adjusted linear mixed models. Trajectory was defined as blood pressure records in pregnancy per 4 weeks interval.

RESULTS

Prevalence of GDM-WHO was 40% (498/1230). GDM-WHO was associated with 1.46 (0.22-2.70) mmHg higher SBP and 1.04 (0.07-2.01) mmHg higher DBP trajectories in the overall cohort. The associations were driven by differences in the overweight group, with 3.14 (1.05-5.25) mmHg higher SBP and 1.94 (0.42-3.47) mmHg higher DBP per 4 weeks in women with GDM-WHO compared with women without GDM-WHO. GDM-WHO was not associated with blood pressure in women with normal weight. Blood pressure trajectories were elevated across quartiles of insulin resistance.

CONCLUSION

GDM-WHO is associated with higher blood pressure in pregnancy, and there appears to be a stronger effect in overweight women.

Gestational diabetes mellitus and adverse pregnancy outcomes: systematic review and meta-analysis

OBJECTIVE

To investigate the association between gestational diabetes mellitus and adverse outcomes of pregnancy after adjustment for at least minimal confounding factors.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Web of Science, PubMed, Medline, and Cochrane Database of Systematic Reviews, from 1 January 1990 to 1 November 2021.

REVIEW METHODS

Cohort studies and control arms of trials reporting complications of pregnancy in women with gestational diabetes mellitus were eligible for inclusion. Based on the use of insulin, studies were divided into three subgroups: no insulin use (patients never used insulin during the course of the disease), insulin use (different proportions of patients were treated with insulin), and insulin use not reported. Subgroup analyses were performed based on the status of the country (developed or developing), quality of the study, diagnostic criteria, and screening method. Meta-regression models were applied based on the proportion of patients who had received insulin.

RESULTS

156 studies with 7 506 061 pregnancies were included, and 50 (32.1%) showed a low or medium risk of bias. In studies with no insulin use, when adjusted for confounders, women with gestational diabetes mellitus had increased odds of caesarean section (odds ratio 1.16, 95% confidence interval 1.03 to 1.32), preterm delivery (1.51, 1.26 to 1.80), low one minute Apgar score (1.43, 1.01 to 2.03), macrosomia (1.70, 1.23 to 2.36), and infant born large for gestational age (1.57, 1.25 to 1.97). In studies with insulin use, when adjusted for confounders, the odds of having an infant large for gestational age (odds ratio 1.61, 1.09 to 2.37), or with respiratory distress syndrome (1.57, 1.19 to 2.08) or neonatal jaundice (1.28, 1.02 to 1.62), or requiring admission to the neonatal intensive care unit (2.29, 1.59 to 3.31), were higher in women with gestational diabetes mellitus than in those without diabetes. No clear evidence was found for differences in the odds of instrumental delivery, shoulder dystocia, postpartum haemorrhage, stillbirth, neonatal death, low five minute Apgar score, low birth weight, and small for gestational age between women with and without gestational diabetes mellitus after adjusting for confounders. Country status, adjustment for body mass index, and screening methods significantly contributed to heterogeneity between studies for several adverse outcomes of pregnancy.

CONCLUSIONS

When adjusted for confounders, gestational diabetes mellitus was significantly associated with pregnancy complications. The findings contribute to a more comprehensive understanding of the adverse outcomes of pregnancy related to gestational diabetes mellitus. Future primary studies should routinely consider adjusting for a more complete set of prognostic factors.

REVIEW REGISTRATION

PROSPERO CRD42021265837.

Adapting fasting plasma glucose threshold for GDM diagnosis according to the population distribution - An approach to the Danish paradox

AIMS

To examine third trimester fasting venous plasma glucose (FVPG) according to the distribution of a Danish population of pregnant women and identify potential local FVPG thresholds for GDM diagnosis related to risks of adverse pregnancy outcomes.

METHODS

In the observational Odense Child Cohort (OCC) study, 1516 women had FVPG measured at 27-28 weeks' gestation and were considered normal by Danish criteria and remained untreated. Maternal FVPG from OCC were standardized according to the local FVPG mean and standard deviation calibrated to data from the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study. Associations between maternal FVPG and clinical and anthropometric outcomes were analysed. Potential FVPG cut points were identified.

RESULTS

Unadjusted areas under the ROC curve for FVPG to discriminate for large for gestational age (LGA) and hypertensive disorders of pregnancy were 0.61 (95% CI 0.56, 0.67) and 0.57 (95% CI 0.52, 0.63), respectively. The Youden FVPG cut point for LGA was 5.5 mmol/L and 5.0 mmol/L for hypertensive disorders of pregnancy.

CONCLUSIONS

This study identified a potential locally appropriate third trimester FVPG cut point between 5.5 and 5.7 mmol/L based on LGA risk in pregnancy. This cut point should be validated prospectively in other Danish cohorts.

Gestational diabetes mellitus

Hyperglycaemia that develops during pregnancy and resolves after birth has been recognized for over 50 years, but uniform worldwide consensus is lacking about threshold hyperglycaemic levels that merit a diagnosis of 'gestational diabetes mellitus' (GDM) and thus treatment during pregnancy. GDM is currently the most common medical complication of pregnancy, and prevalence of undiagnosed hyperglycaemia and even overt diabetes in young women is increasing. Maternal overweight and obesity, later age at childbearing, previous history of GDM, family history of type 2 diabetes mellitus and ethnicity are major GDM risk factors. Diagnosis is usually performed using an oral glucose tolerance test (OGTT), although a non-fasting, glucose challenge test (GCT) is used in some parts of the world to screen women for those requiring a full OGTT. Dietary modification and increased physical activity are the primary treatments for GDM, but pharmacotherapy, usually insulin, is used when normoglycaemia is not achieved. Oral hypoglycaemic agents, principally metformin and glibenclamide (glyburide), are also used in some countries. Treatment improves immediate pregnancy outcomes, reducing excess fetal growth and adiposity and pregnancy-related hypertensive disorders. GDM increases the risk of long-term complications, including obesity, impaired glucose metabolism and cardiovascular disease, in both the mother and infant. Optimal management of mother and infant during long-term follow-up remains challenging, with very limited implementation of preventive strategies in most parts of the world.

Aldosterone, Salt, and Potassium Intakes as Predictors of Pregnancy Outcome, Including Preeclampsia

The mineralocorticoid aldosterone increases in plasma in healthy pregnancy along with renin and angiotensin II and plays a key role in the physiological plasma volume expansion. In mice, aldosterone contributes to an optimal fetal development by enhancing PlGF (placental growth factor) expression and trophoblast cell proliferation. In preeclampsia, there is coincident suppression of aldosterone and impaired placental development. We hypothesized that aldosterone independently contributes to placental and birth weight in humans, and high dietary sodium and low potassium intakes affect this relationship adversely. We analyzed 24-hour urine collections and plasma samples from gestational week 29 in a subsample of 569 pregnant women from the Odense Child Cohort-a Danish population-based longitudinal cohort study. Plasma and urinary aldosterone were measured by ELISA, sodium and potassium excretions by flame photometer. Predictive values of aldosterone levels and sodium and potassium intakes were assessed by multiple and Cox regression analyses. Primary outcomes were placental weight and birth weight. Secondary outcome was preeclampsia. Urinary aldosterone excretion at gestational week 29 independently contributed to placental and birth weights (adjusted β-coefficients [95% CI], 24.50 [9.66-39.35] and 9.59 [4.57-14.61], respectively). Aldosterone levels were not associated to preeclampsia incidence. Salt intake >6 g/d was associated with development of preeclampsia (hazard ratio [95% CI], 5.68 [1.51-21.36]). At gestational week 29, urinary aldosterone excretion is an independent predictor of placental and birth weights. High salt intake is a risk factor for preeclampsia. In perspective, suppression of aldosterone in pregnancy has adverse trophic effects.

Gestational diabetes mellitus in association with macrosomia in Iran: a meta-analysis

PURPOSE

This meta-analysis aimed to estimate the association between gestational diabetes mellitus (GDM) and occurrence of macrosomia for the first time among Iranian population.

METHODS

A systematic review was done of national and international databases. Lists of relevant articles were checked to increase sensitivity of the search reference. Also, access to unpublished articles and documents were accessed by negotiation with related individuals and research centers. These published epidemiological studies (cross-sectional, case-control and cohort studies) were used for comparisons to determine whether GDM was associated with macrosomia. Finally, the Mantel-Haenszel method and the fixed and random-effect models based on heterogeneity of the primary studies were used according to pool results and estimate the odds ratio of macrosomia in women with GDM.

RESULTS

Of 1870 articles, thirty relevant articles were eligible for the current meta-analysis. Our findings showed that 335 of 2524 women with GDM had macrosomia while only 775 of 26,592 women without GDM had macrosomia. Using random-effect model, the pooled odds ratio (OR) relation between GDM and occurrence of macrosomia was estimated as of 5.49 (95% CI: 4.27-7.04). Subgroup analysis showed no difference regarding different study designs and definitions of macrosomia. There was no evidence of publication bias based on the result of Egger's test (β = 0.1, P = 0.70).

CONCLUSIONS

This meta-analysis shows that GDM is directly associated with the risk of macrosomia in the Iranian population. This confirms the findings of previous studies in the wider scientific literature.

First-trimester proteomic profiling identifies novel predictors of gestational diabetes mellitus

Background

Gestational diabetes mellitus (GDM) is a common pregnancy complication associated with adverse outcomes including preeclampsia, caesarean section, macrosomia, neonatal morbidity and future development of type 2 diabetes in both mother and child. Current selective screening strategies rely on clinical risk factors such as age, family history of diabetes, macrosomia or GDM in a previous pregnancy, and they possess a relatively low specificity. Here we hypothesize that novel first trimester protein predictors of GDM can contribute to the current selective screening strategies for early and accurate prediction of GDM, thus allowing for timely interventions.

Methods

A proteomics discovery approach was applied to first trimester sera from obese (BMI ≥27 kg/m²) women (n = 60) in a nested case-control study design, utilizing tandem mass tag labelling and tandem mass spectrometry. A subset of the identified protein markers was further validated in a second set of serum samples (n = 210) and evaluated for their contribution as predictors of GDM in relation to the maternal risk factors, by use of logistic regression and receiver operating characteristic analysis.

Results

Serum proteomic profiling identified 25 proteins with significantly different levels between cases and controls. Three proteins; afamin, serum amyloid P-component and vitronectin could be further confirmed as predictors of GDM in a validation set. Vitronectin was shown to contribute significantly to the predictive power of the maternal risk factors, indicating it as a novel independent predictor of GDM.

Conclusions

Current selective screening strategies can potentially be improved by addition of protein predictors.

Polycystic ovary syndrome and hyperglycaemia in pregnancy. A narrative review and results from a prospective Danish cohort study

BACKGROUND

Insulin resistance is common in polycystic ovary syndrome (PCOS). PCOS may be associated with increased risk of gestational diabetes mellitus (GDM).

OBJECTIVES

To (1) review literature regarding PCOS and hyperglycaemia in pregnancy and (2) present original data from Odense Child Cohort (OCC) regarding GDM in PCOS.

METHODS

Literature search including original studies from 2000-18. OCC included 2548 pregnant women, 9.5% (n = 241) had PCOS. Fasting plasma glucose was measured in 1519 and 659 oral glucose tolerance tests were performed (with risk factor for GDM, n = 384, without risk factors, n = 275), applying two different GDM criteria.

RESULTS

30 studies were eligible using 12 different sets of diagnostic criteria for GDM. Ten studies included n > 50, control group, assessment of GDM and BMI. Results were not uniform, but supported that higher BMI, higher age, Asian ethnicity, and fertility treatment increased the risk of GDM in PCOS. In OCC, women with PCOS and controls had similar prevalences of GDM independent of different sets of criteria for GDM.

CONCLUSION

PCOS may not be an individual risk factor for GDM. Pregnancies in PCOS are characterized by factors known to increase risk of GDM, especially high BMI and fertility treatment.

Gestational Diabetes Mellitus: Does One Size Fit All? A Challenge to Uniform Worldwide Diagnostic Thresholds

OBJECTIVE

To define the prevalence and pregnancy outcomes related to elevated fasting venous plasma glucose (FVPG) in a Danish pregnancy cohort.

RESEARCH DESIGN AND METHODS

This was an observational cohort study including 1,516 women without gestational diabetes mellitus (GDM) by Danish criteria. FVPG measured at 28 weeks' gestation was related to pregnancy outcomes.

RESULTS

With use of the World Health Organization (WHO) 2013 threshold of FVPG ≥5.1 mmol/L, 40.1% of the cohort qualified as having GDM. There was no evidence of excess fetal growth, hypertension in pregnancy, or cesarean delivery in women with FVPG <5.6 mmol/L.

CONCLUSIONS

The WHO 2013 FVPG threshold for GDM is unsuitable for Denmark. It inappropriately labels as having GDM an unmanageably large number of women who are at low absolute risk of pregnancy complications.

Risk factor screening to identify women requiring oral glucose tolerance testing to diagnose gestational diabetes: A systematic review and meta-analysis and analysis of two pregnancy cohorts

BACKGROUND

Easily identifiable risk factors including: obesity and ethnicity at high risk of diabetes are commonly used to indicate which women should be offered the oral glucose tolerance test (OGTT) to diagnose gestational diabetes (GDM). Evidence regarding these risk factors is limited however. We conducted a systematic review (SR) and meta-analysis and individual participant data (IPD) analysis to evaluate the performance of risk factors in identifying women with GDM.

METHODS

We searched MEDLINE, Medline in Process, Embase, Maternity and Infant Care and the Cochrane Central Register of Controlled Trials (CENTRAL) up to August 2016 and conducted additional reference checking. We included observational, cohort, case-control and cross-sectional studies reporting the performance characteristics of risk factors used to identify women at high risk of GDM. We had access to IPD from the Born in Bradford and Atlantic Diabetes in Pregnancy cohorts, all pregnant women in the two cohorts with data on risk factors and OGTT results were included.

RESULTS

Twenty nine published studies with 211,698 women for the SR and a further 14,103 women from two birth cohorts (Born in Bradford and the Atlantic Diabetes in Pregnancy study) for the IPD analysis were included. Six studies assessed the screening performance of guidelines; six examined combinations of risk factors; eight evaluated the number of risk factors and nine examined prediction models or scores. Meta-analysis using data from published studies suggests that irrespective of the method used, risk factors do not identify women with GDM well. Using IPD and combining risk factors to produce the highest sensitivities, results in low specificities (and so higher false positives). Strategies that use the risk factors of age (>25 or >30) and BMI (>25 or 30) perform as well as other strategies with additional risk factors included.

CONCLUSIONS

Risk factor screening methods are poor predictors of which pregnant women will be diagnosed with GDM. A simple approach of offering an OGTT to women 25 years or older and/or with a BMI of 25kg/m2 or more is as good as more complex risk prediction models. Research to identify more accurate (bio)markers is needed. Systematic Review Registration: PROSPERO CRD42013004608.

First-trimester multimarker prediction of gestational diabetes mellitus using targeted mass spectrometry

AIMS/HYPOTHESIS

Gestational diabetes mellitus (GDM) is associated with an increased risk of pre-eclampsia, macrosomia and the future development of type 2 diabetes mellitus in both mother and child. Although an early and accurate prediction of GDM is needed to allow intervention and improve perinatal outcome, no single protein biomarker has yet proven useful for this purpose. In the present study, we hypothesised that multimarker panels of serum proteins can improve first-trimester prediction of GDM among obese and non-obese women compared with single markers.

METHODS

A nested case-control study was performed on first-trimester serum samples from 199 GDM cases and 208 controls, each divided into an obese group (BMI ≥27 kg/m(2)) and a non-obese group (BMI <27 kg/m(2)). Based on their biological relevance to GDM or type 2 diabetes mellitus or on their previously reported potential as biomarkers for these diseases, a number of proteins were selected for targeted nano-flow liquid chromatography (LC) MS analysis. This resulted in the development and validation of a 25-plex multiple reaction monitoring (MRM) MS assay.

RESULTS

After false discovery rate correction, six proteins remained significantly different (p<0.05) between obese GDM patients (n=135) and BMI-matched controls (n=139). These included adiponectin, apolipoprotein M and apolipoprotein D. Multimarker models combining protein levels and clinical data were then constructed and evaluated by receiver operating characteristic (ROC) analysis. For the obese, non-obese and all GDM groups, these models achieved marginally higher AUCs compared with adiponectin alone.

CONCLUSIONS/INTERPRETATION

Multimarker models combining protein markers and clinical data have the potential to predict women at a high risk of developing GDM.

Gestational diabetes: Glycaemic predictors for fetal macrosomia and maternal risk of future diabetes

AIMS

To investigate how glucose levels at diagnosis of gestational diabetes (GDM) are associated with infant birth weight and long-term risk of manifest diabetes mellitus in the mother.

METHODS

In a case control study GDM pregnancies (n=2085) were compared with non-GDM pregnancies matched for day of delivery and obstetric unit (n=3792). GDM was defined as capillary blood glucose (cB-glucose) ≥9.0mmol/l (plasma glucose ≥10.0mmol/l) after a 75g oral glucose tolerance test (OGTT). The GDM cohort were followed up 8.5-13.5yrs after initial diagnosis with a questionnaire, answered by 1324 GDM women (65%).

RESULTS

GDM women had higher mean infant birth-weight compared with controls (3682g vs. 3541g, P<0.001). In multiple linear regression analysis, birth weight was positively correlated to fasting cB-glucose at GDM diagnosis (P<0.001), increased week of gestation (P<0.001) and BMI before pregnancy (P<0.003), while 2h OGTT cB-glucose values ≥9.0mmol/l were not related. Infants born to mothers with fasting cB-glucose ≤4.5mmol/l had no increased mean birth-weight or macrosomia (≥4500g) compared to controls. In the follow up 334/1324 women (25%) of the GDM women had developed diabetes, 215 type 2 diabetes, 46 type 1 diabetes and 72 unclassified diabetes. In logistic regression fasting cB-glucose and 2h OGTT cB-glucose at diagnosis of GDM as well as BMI >25 and origin outside Europe were risk factors for manifest diabetes.

CONCLUSIONS

Fasting blood glucose at diagnosis of GDM gives important information besides 2h OGTT glucose about pregnancy outcome and future risk for maternal diabetes.

Gestational diabetes: A clinical update

Gestational diabetes mellitus (GDM) is increasing in prevalence in tandem with the dramatic increase in the prevalence of overweight and obesity in women of childbearing age. Much controversy surrounds the diagnosis and management of gestational diabetes, emphasizing the importance and relevance of clarity and consensus. If newly proposed criteria are adopted universally a significantly growing number of women will be diagnosed as having GDM, implying new therapeutic challenges to avoid foetal and maternal complications related to the hyperglycemia of gestational diabetes. This review provides an overview of clinical issues related to GDM, including the challenges of screening and diagnosis, the pathophysiology behind GDM, the treatment and prevention of GDM and the long and short term consequences of gestational diabetes for both mother and offspring.

Is gestational diabetes mellitus an independent risk factor for macrosomia: a meta-analysis?

PURPOSE

The aim of our meta-analysis was to explore whether gestational diabetes mellitus (GDM) is an independent risk factor for macrosomia or not.

METHODS

Three databases were systematically reviewed and reference lists of relevant articles were checked. Meta-analysis of published epidemiological studies (cohort and case-control studies) comparing whether GDM was associated with macrosomia. Calculations of pooled estimates were conducted in random-effect models. Heterogeneity was tested by using Chi square test and I (2) statistics. Publication bias was estimated from Egger's test (linear regression method) and Begg's test (rank correlation method).

RESULTS

Twelve studies met the inclusion criteria, including five cohort studies and seven case-control studies. The meta-analysis showed that GDM was associated with macrosomia independent of other risk factors. The adjusted odds ratio was 1.71, 95% CI (1.52, 1.94) in random-effect model, stratified analyses showed no differences regarding different study design, quality grade, definition of macrosomia, location of study and number of confounding factors adjusted for. There was no indication of a publication bias either from the result of Egger's test or Begg's test.

CONCLUSION

Our findings indicate that GDM should be considered as an independent risk factor for newborn macrosomia. To adequately evaluate the clinical evolution of GDM need to be carefully assessed and monitored.

Screening, diagnosis and management of gestational diabetes mellitus: A national survey

BACKGROUND AND METHODS

We conducted a National survey between February and June 2012 to evaluate the practices concerning screening, diagnosis and management of Gestational Diabetes (GDM) in England.

RESULTS

A total of 102/126 (80%) maternity units responded. The National Institute of Health and Clinical Excellence (NICE) recommended screening criteria were used by 83% of units. All the units performed 2 h 75 g oral glucose tolerance test (OGTT) between 24 and 28 weeks. There was a wide variation in the diagnostic blood glucose values used by different units. About 86% of units used a 2 h blood glucose value of ≥7.8 mmol/l and 45% of units used fasting value ≥6.1 mmol/l to diagnose GDM. Only 26% of units advised self-monitoring of blood glucose pre meal and 1 h post-meal, whereas 64% of units advised monitoring 2 h after the meal. Metformin was started when women did not respond to dietary measures in 101 units (99%). Regular growth scans every four weeks from 28 weeks onwards were performed by 99 units (97%). Women on metformin with no complications were offered induction of labour at 38 completed weeks in 97 units (95%). 84 maternity units (82.3%) offered OGTT six weeks postnatally.

CONCLUSION

Our survey has shown consistency in screening using the NICE criteria, use of 2 h 75 g OGTT at 24-28 weeks, in providing dietary support, use of metformin and ultrasound for fetal growth. But there is wide variation in the criteria used to diagnose GDM, self-monitoring of blood glucose, induction of labour and six weeks postnatal testing.

Diagnostic thresholds for gestational diabetes and their impact on pregnancy outcomes: a systematic review

AIMS

To assess different diagnostic thresholds for gestational diabetes on outcomes for mothers and their offspring in the absence of treatment for gestational diabetes. This information was used to inform a National Institutes of Health consensus conference on diagnosing gestational diabetes.

METHODS

We searched 15 electronic databases from 1995 to May 2012. Study selection was conducted independently by two reviewers. Randomized controlled trials or cohort studies were eligible if they involved women without known pre-existing diabetes mellitus and who did not undergo treatment for gestational diabetes. One reviewer extracted, and a second reviewer verified, data for accuracy. Two reviewers independently assessed methodological quality.

RESULTS

Thirty-eight studies were included. Three large, methodologically strong studies showed a continuous positive relationship between increasing glucose levels and the incidence of Caesarean section and macrosomia. When data were examined categorically (i.e. women meeting or not meeting specific diagnostic thresholds), women with gestational diabetes across all glucose criteria had significantly more Caesarean sections, shoulder dystocia, macrosomia (except for International Association of Diabetes in Pregnancy Study Groups' criteria) and large for gestational age. Higher glucose thresholds did not consistently demonstrate greater risk for all outcomes.

CONCLUSIONS

Higher glucose thresholds did not consistently demonstrate greater risk, possibly because studies did not compare mutually exclusive groups of women. A pragmatic approach for diagnosis of gestational diabetes using Hyperglycemia and Adverse Pregnancy Outcome Study odds ratio 2.0 thresholds warrants further consideration until additional analysis of the data comparing mutually exclusive groups of women is provided and large randomized controlled trials investigating different diagnostic and treatment thresholds are completed.

Placental growth factor as a new marker for predicting abnormal glucose challenge test results

BACKGROUND

To differentiate placental growth factor (PlGF) levels in pregnancies with normal and abnormal glucose challenge test (GCT) results.

METHODS

A total of 94 pregnant women underwent a 50 -g GCT as part of our routine antenatal screening protocol from September 2011 to January 2012. The patients were divided into three groups: (i) normal GCT, (ii) abnormal GCT and (iii) gestational diabetes mellitus (GDM) based on the screening results for gestational diabetes. The main outcome measure of the study was the relationship between PlGF and GCT results in non-diabetic pregnancies. The Kolmogorov-Smirnov test was used to check the normality of the variables' distributions. The Kruskal-Wallis and analysis of variance tests (Tukey's test) were used to analyze the qualitative parameters.

RESULTS

There were 53 (56.4%), 22 (23.4%) and 19 (20.2%) patients in the normal GCT, abnormal GCT and GDM groups, respectively. The PlGF level in the abnormal GCT group was 518 ± 307.6 pg/mL, which was the highest level in the study population, and there was a statistically significant difference compared with the other groups (p = 0.006). There were no statistically significant differences with respect to fetal birth weight among the three groups in our study.

CONCLUSION

PlGF can be used as a laboratory marker to predict which patients will have abnormal GCT results.

Incidence of adverse outcomes associated with gestational diabetes mellitus in low- and middle-income countries

BACKGROUND

The contribution of medical conditions such as diabetes mellitus to maternal and neonatal ill-health in low- and middle-income countries is not well documented.

OBJECTIVES

To ascertain the incidence of adverse outcomes associated with gestational diabetes mellitus (GDM) in these countries.

SEARCH STRATEGY

Electronic databases were searched between 1990 and 2011.

SELECTION CRITERIA

Observational, experimental, and quasi-experimental studies reporting adverse outcomes associated with GDM in mothers and their infants in low- and middle-income countries were included.

DATA COLLECTION AND ANALYSIS

Titles and abstracts were screened, and full-text articles were independently assessed by at least 2 reviewers. Characteristics of studies were tabulated and quality assessment performed. Median and interquartile range (IQR) were computed for each adverse outcome.

MAIN RESULTS

25 articles were included from an initial 1282 citations. High median incidences of cesarean (43.8%; IQR, 34.9%-65.9%), neonatal jaundice (17.1%; IQR, 8.5%-22.9%), and macrosomia (17.0%; IQR, 8.3%-32.5%) were reported in women with GDM.

CONCLUSIONS

The high incidence of some complications of GDM is a concern and may indicate poorer care for women with GDM in low-resource settings. The wide IQRs found indicate uncertainty about the burden of GDM in these settings.

Diagnostic criteria for gestational diabetes mellitus

AIM

To answer two questions: is there a threshold for pathological hyperglycaemia after 24 weeks of gestation? What are the diagnostic criteria for gestational diabetes mellitus?

MATERIALS AND METHODS

Review of the literature considering the relationships between glucose values and complications during pregnancy in women without specific care for this condition. Only the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study meets sufficient quality criteria.

RESULTS

Increasing glucose values during pregnancy, either at fasting and after a 75-g oral glucose tolerance test, are independently associated according to a continuum with an increased risk of maternal-foetal complications, especially birth weight above the 90th percentile for gestational age, Caesarean delivery and foetal hyperinsulinemia. There is no obvious threshold at which risks increase. The International Association of Diabetes Pregnancy Study Group has proposed the following criteria, considering the glycemic values associated with a 1.75-fold increased risk of macrosomia, foetal hyperinsulinemia and adiposity in the HAPO study: fasting plasma glucose ≥ 0.92 g/L (5.1 mmol/L) and/or 1-hour plasma glucose value ≥ 1.80 g/L (10.0 mmol/L) and/or 2-hour plasma glucose value ≥ 1.53 g/L (8.5 mmol/L).

CONCLUSION

The choice of glycemic thresholds for defining gestational diabetes mellitus is necessarily arbitrary because of a continuum (NP2). Only experts may propose definition criteria.

Maternal outcome of gestational diabetes mellitus

OBJECTIVE

To estimate maternal outcome of treated or untreated gestational diabetes mellitus (GDM).

METHODS

French and English publications were searched using PubMed and the Cochrane library.

RESULTS

The diagnosis of GDM includes a high risk population for preeclampsia and Caesarean sections (EL3). The risks are positively correlated with the level of hyperglycaemia in a linear way (EL2). Intensive treatment of mild GDM compared with routine care reduces the risk of pregnancy-induced hypertension (preeclampsia, gestational hypertension). Moreover, it does not increase the risk of operative vaginal delivery, Caesarean section and postpartum haemorrhage (EL1). Being overweight, obesity and maternal hyperglycaemia are independent risk factors for preeclampsia (EL2). Their association with GDM increases the risk of preeclampsia and Caesarean section compared to diabetic women with a normal body mass index (EL3). The association of several risk factors (such as advanced maternal age, pre-existing chronic hypertension, pre-existing nephropathy, obesity, suboptimal glycaemic control) increases the risk of preeclampsia. In that case, the classic follow-up (blood pressure measurement, proteinuria) should be more frequent than monthly (professional consensus). The risk of Caesarean section is increased by macrosomia, whether suspected prenatally or not, but this increased risk remains whatever the birth weight (EL3). Diagnosis and treatment of GDM do not reduce the risk of severe perineal lesions, operative vaginal delivery and postpartum haemorrhage (EL2). Some psychological symptoms, such as anxiety and alteration of self-perception, can occur upon diagnosis of GDM (EL3). The treatment of GDM appears to reduce the risk of postpartum depression symptoms (EL2).

CONCLUSION

Most of the information published on GDM covers the risks of preeclampsia and Caesarean section; intensive care of GDM reduces these risks. Pregnancy care should be adjusted to the risk factors.

Maternal and neonatal outcomes and time trends of gestational diabetes mellitus in Sweden from 1991 to 2003

AIMS

To determine maternal and neonatal outcomes for women with gestational diabetes mellitus (GDM) in Sweden during 1991-2003, and to compare the outcomes in the two time periods.

METHODS

This is a population-based cohort study using the Swedish Medical Birth Register data for the period 1991-2003. There were 1,260,297 women with singleton pregnancies registered during this time, of whom 10 525 were diagnosed with GDM, based on a 75 g oral glucose tolerance test. The main diagnostic criteria were fasting capillary whole blood glucose>or=6.1 mmol/l and 2 h blood glucose>or=9.0 mmol/l.

RESULTS

Maternal characteristics differed significantly between the GDM and non-GDM group. Adjusted odds ratios (OR) were as follows: for pre-eclampsia, 1.81 (95% confidence interval (CI) 1.64-2.00); for shoulder dystocia, 2.74 (2.04-3.68); and for Caesarean section, 1.46 (1.38-1.54). No difference was seen in perinatal mortality, stillbirth rates, Apgar scores, fetal distress or transient tachypnoea. There was a markedly higher risk of large for gestational age, OR 3.43 (3.21-3.67), and Erb's palsy, OR 2.56 (1.96-3.32), in the GDM group, and statistically significant differences in prematurity<37 weeks, birth weight>4.5 kg, and major malformation, OR 1.19-1.71. No statistically significant improvement in outcomes was seen between the two study periods.

CONCLUSIONS

Women with GDM have higher risks of pre-eclampsia, shoulder dystocia and Caesarean section. Their infants are often large for gestational age and have higher risks of prematurity, Erb's palsy and major malformations. These outcomes did not improve over time.

Antenatal oral glucose-tolerance test values and pregnancy outcomes

Objective

The aim of the present study was to explore the impact of individual blood glucose values (n = 4; i.e. fasting and 1, 2 and 3 h following oral glucose administration) obtained during antenatal oral glucose-tolerance testing, together with two different sets of criteria used for diagnosis of gestational diabetes mellitus (GDM) — Carpenter and Coustan Criteria (CCC) and National Diabetes Data Group (NDDG) criteria — in predicting pregnancy outcomes and maternal insulin need.

Setting

Al Ain Hospital, United Arab Emirates.

Method

This observational uncontrolled cohort study gained its study subjects from a randomised, controlled, longitudinal, prospective clinical trial performed at Al Ain Hospital, Al Ain, United Arab Emirates. The eligible population was made up of all women (n = 720) who participated in an early screening programme for GDM. Those who had a positive oral glucose-tolerance test (OGTT) based on CCC were included in the study (n = 165). All recruited women with GDM were followed from time of recruitment to 6months postpartum. The sources of information used were maternal and neonatal medical records and laboratory findings for women both antenatally and postnatally.

Results

The maternal and neonatal outcomes indicated that the number of abnormally elevated antenatal OGTT values obtained during the diagnosis of GDM was significantly correlated with development of a number of pregnancy complications. Data analysis also indicated that the number of abnormal diagnostic antenatal OGTT values using CCC was significantly correlated with development of postpartum diabetes mellitus (P = 0.044) within 6months of delivery. The number of abnormal OGTT values significantly contributed to insulin need during the index pregnancy (P &lt; 0.05). The CCC approach was more sensitive than the NDDG methodology for predicting the onset of GDM and a number of the associated complications.

Conclusions

The study highlighted the importance of abnormal values for antenatal OGTT in identifying the need for insulin management in women with GDM.

Overweight and the metabolic syndrome in adult offspring of women with diet-treated gestational diabetes mellitus or type 1 diabetes

CONTEXT

In animal studies, exposure to intrauterine hyperglycemia increases the risk of cardiovascular disease through only partly understood epigenetic mechanisms. Human long-term follow-up studies on the same topic are few.

OBJECTIVE

The aim was to study the risk of overweight and the metabolic syndrome in adult offspring of women with diet-treated gestational diabetes mellitus (GDM) or type 1 diabetes, and additionally to study associations between estimates of maternal hyperglycemia and outcome in the offspring.

DESIGN AND SETTING

We conducted a follow-up study of 1066 primarily Caucasian women aged 18-27 yr in the Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark.

PARTICIPANTS

Offspring of women with diet-treated GDM (n = 168) and an unexposed reference group (n = 141) participated, as well as offspring of women with type 1 diabetes (n = 160) and offspring from the background population representing an unexposed reference group (n = 128). The follow-up rate was 56% (597 of 1066).

MAIN OUTCOME MEASURES

Women with body mass index of at least 25 kg/m(2) were considered overweight. The metabolic syndrome was determined by the International Diabetes Federation 2006 criteria.

RESULTS

The risk of overweight was doubled in offspring of women with diet-treated GDM or type 1 diabetes compared with offspring from the background population, whereas the risk of the metabolic syndrome was 4- and 2.5-fold increased, respectively. Offspring risk of the metabolic syndrome increased significantly with increasing maternal fasting blood glucose as well as 2-h blood glucose (during oral glucose tolerance test).

CONCLUSIONS

Adult offspring of women with diet-treated GDM or type 1 diabetes are risk groups for overweight and the metabolic syndrome. Intrauterine hyperglycemia may in addition to genetics and other factors contribute to the pathogenesis of overweight and the metabolic syndrome.

High prevalence of type 2 diabetes and pre-diabetes in adult offspring of women with gestational diabetes mellitus or type 1 diabetes: the role of intrauterine hyperglycemia

OBJECTIVE

The role of intrauterine hyperglycemia and future risk of type 2 diabetes in human offspring is debated. We studied glucose tolerance in adult offspring of women with either gestational diabetes mellitus (GDM) or type 1 diabetes, taking the impact of both intrauterine hyperglycemia and genetic predisposition to type 2 diabetes into account.

RESEARCH DESIGN AND METHODS

The glucose tolerance status following a 2-h 75-g oral glucose tolerance test (OGTT) was evaluated in 597 subjects, primarily Caucasians, aged 18-27 years. They were subdivided into four groups according to maternal glucose metabolism during pregnancy and genetic predisposition to type 2 diabetes: 1) offspring of women with diet-treated GDM (O-GDM), 2) offspring of genetically predisposed women with a normal OGTT (O-NoGDM), 3) offspring of women with type 1 diabetes (O-type 1), and 4) offspring of women from the background population (O-BP).

RESULTS

The prevalence of type 2 diabetes and pre-diabetes (impaired glucose tolerance or impaired fasting glucose) in the four groups was 21, 12, 11, and 4%, respectively. In multiple logistic regression analysis, the adjusted odds ratios (ORs) for type 2 diabetes/pre-diabetes were 7.76 (95% CI 2.58-23.39) in O-GDM and 4.02 (1.31-12.33) in O-type 1 compared with O-BP. In O-type 1, the risk of type 2 diabetes/pre-diabetes was significantly associated with elevated maternal blood glucose in late pregnancy: OR 1.41 (1.04-1.91) per mmol/l.

CONCLUSIONS

A hyperglycemic intrauterine environment appears to be involved in the pathogenesis of type 2 diabetes/pre-diabetes in adult offspring of primarily Caucasian women with either diet-treated GDM or type 1 diabetes during pregnancy.

Comparison of accuracy measures of two screening tests for gestational diabetes mellitus

OBJECTIVE

To compare the accuracy measures of the random glucose test and the 50-g glucose challenge test as screening tests for gestational diabetes mellitus (GDM).

RESEARCH DESIGN AND METHODS

In this prospective cohort study, pregnant women without preexisting diabetes in two perinatal centers in the Netherlands underwent a random glucose test and a 50-g glucose challenge test between 24 and 28 weeks of gestation. If one of the screening tests exceeded predefined threshold values, the 75-g oral glucose tolerance test (OGTT) was performed within 1 week. Furthermore, the OGTT was performed in a random sample of women in whom both screening tests were normal. GDM was considered present when the OGTT (reference test) exceeded predefined threshold values. Receiver operating characteristic (ROC) analysis was used to evaluate the performance of the two screening tests. The results were corrected for verification bias.

RESULTS

We included 1,301 women. The OGTT was performed in 322 women. After correction for verification bias, the random glucose test showed an area under the ROC curve of 0.69 (95% CI 0.61-0.78), whereas the glucose challenge test had an area under the curve of 0.88 (0.83-0.93). There was a significant difference in area under the curve of the two tests of 0.19 (0.11-0.27) in favor of the 50-g glucose challenge test.

CONCLUSIONS

In screening for GDM, the 50-g glucose challenge test is more useful than the random glucose test.

Outcomes of pregnancies affected by impaired glucose tolerance

OBJECTIVE

Gestational diabetes mellitus (GDM) is associated with an increase in both maternal and neonatal morbidity. There remains uncertainty, however, about the diagnostic criteria for GDM. We compared pregnancy outcomes across three groups of women, with the aim of establishing a threshold for diagnosis of GDM at our institution.

METHODS

Women with a glucose tolerance test (GTT) were identified on the hospital's pathology database. Those women with a singleton pregnancy, in whom a GTT had demonstrated a fasting value </=5.5mmol/L, 2-h blood sugar >/=7.8mmol/L and who confined </=34 weeks gestation were eligible for inclusion. Outcomes were collected from the medical records and obstetric database. These women were managed with either diet modification, regular endocrinologist review and standard antenatal care if the GTT met ADA criteria (n=265, TREATED), or standard antenatal care alone if the GTT did not fulfil ADA criteria (n=213, UNTREATED). A third group comprised of women with normal GTT who received identical treatment to the untreated group (n=197, COMPARISON). Statistical analysis was conducted with chi(2) and ANOVA.

RESULTS

In women with untreated GDM, there was significantly more macrosomia, shoulder dystocia, and preeclampsia, compared with the comparison group. These rates were similar between the treated and comparison groups. There were no significant differences in induction of labour, caesarean section rates, or gestational age at delivery between the groups.

CONCLUSION

Untreated GDM is associated with larger babies and more birth trauma. We recommend the diagnosis of GDM be made with fasting glucose >/=5.5mmol/L and/or 2h >/=7.8mmol/L on 75g GTT.

[Comparison of two routine screening strategies for gestational diabetes mellitus: the experience of Jean-Verdier Hospital]

OBJECTIVE

Screening strategies for gestational diabetes mellitus are controversial. Thus, we sought to determine the benefits of universal screening.

PATIENTS AND METHODS

Prospective study with 2121 women involved but 1610 really screened (75.9%). According to WHO's recommendations, the strategy implemented was one-step, universal screening with a 75g oral glucose tolerance test. Screening was performed between 24 and 28 weeks of gestation or earlier if risk factors were identified. Results were compared to previous year (2001) then only a selective screening was done.

RESULTS

Application of universal screening increased the prevalence of gestational diabetes mellitus (8.39% to 15.65%). Out of the 252 patients with gestational diabetes, 66 did not display any identified risk factor (26.19%). Some new risk factors have been identified: age>30, Asian, Indian or Pakistan ethnies. If these new risk factors were applied, this super selective screening would have a sensibility of 96%.

DISCUSSION AND CONCLUSION

Universal screening seems to be the most appropriate routine screening strategy because it is difficult to know exactly the specific risk factors of a population to do a super selective screening.

Diabetes and hypertension in pregnancy in a rural community of Bangladesh: a population-based study

AIMS

Gestational diabetes mellitus (GDM) is associated with increased infant mortality. Diabetes and infant mortality is higher in Bangladesh but the prevalence of diabetes and hypertension in pregnancy is not known. Thus, this study addressed the prevalence of diabetes and hypertension in pregnancy.

METHODS

We selected 10 villages randomly in a union council of Nandail subdistrict. Following a population census (n = 14 382: male/female = 7476/6906) on demography and marital status, we interviewed 2205 married women (18-44 years) for detection of pregnancy. Of a total of 172 pregnancies, we investigated 147 with a gestational age of 24-28 weeks for obstetrical history, clinical examination and blood pressure (BP). Fasting (FBG) and 2-h blood glucose (2hBG) were assessed by Hemocue cuvette. WHO diagnostic criteria were used.

RESULTS

The overall prevalence (95% CI) of diabetes was 6.8% (1.88-9.32) and 8.2% (3.74-12.64) according to FBG and 2hBG, respectively. The crude prevalence of systolic and diastolic hypertension was 6.8 and 5.4%, respectively. The median (interquartile range) values for age, BMI and FBG of the participants were 25.0 (21.0-30.0) years, 19.5 (18.2-21.2) and 3.9 (3.6-4.3), respectively. The history of abortion, neonatal death and stillbirth was found in 19.9, 11.4 and 9.6%, respectively. The prevalence of GDM was higher among those with the history of stillbirth (15.4 vs. 6.0%) and neonatal death (11.8 vs. 6.2%) than those without.

CONCLUSION

The prevalence of GDM in rural Bangladesh is comparable with any other population with higher prevalence of GDM. Increased morbidity and mortality among mothers and newborns in Bangladesh may, in part, be because of increased prevalence of GDM.

Features and outcome of pregnancies complicated by impaired glucose tolerance and gestational diabetes diagnosed using different criteria in a Spanish population

The main objective of this study was to determine the prevalence and risk of complications of a population of Spanish pregnant women with GDM diagnosed following the O'Sullivan-Mahan "standard" criteria, compared with pregnant women with GDM diagnosed using the "new" Carpenter-Coustan criteria. In Spain, limited data are published concerning as the prevalence of GDM and its morbidity. In this sense, the "new" criteria for GDM diagnosis has not been adopted in Spain due to the absence of adequate studies. We retrospectively reviewed all pregnancies handled at our center from 1999 to 2001 (n=6248). Using the standard and the new criteria, the prevalence of GDM was 6.46 and 6.75%, respectively. GDM patients diagnosed using the new criteria showed the same pregnancy evolution that patients diagnosed with the classic criteria. Those patients complicated only with impaired glucose intolerance (IGT) (0.94%) showed a worst outcome. Based on the pregnancy evolution observed, it is not recommended that the new GDM diagnostic criteria be adopted in Spain. More accurate follow-up of patients with IGT is needed.

Screening and diagnosis of gestational diabetes

Gestational diabetes mellitus (GDM) is a risk factor for the mother and foetus. The risks increase proportionally to the maternal blood sugar concentration along a glycaemic continuum. However, there is ongoing controversy about the objectives of active screening and diabetic and obstetrical management for GDM. Various screening and diagnostic tests are used. None of them offers the combination of qualities to be expected from a test: simplicity of use, reproducibility, specificity and sensitivity, but each of them provides a basis on which recommendations can be established. The need to screen GDM as a risk factor in the whole population of pregnant women has led us to propose the use of simple, universally applied test, such as the "practical" test constituted by the assay of fasting and post-prandial blood glucose levels. In addition to screening, a classification which will take into account the results of subsequent as well as initial blood glucose levels could be preferable to evaluate the management and results.

Increasing incidence of diabetes after gestational diabetes: a long-term follow-up in a Danish population

OBJECTIVE

To study the incidence of diabetes among women with previous diet-treated gestational diabetes mellitus (GDM) in the light of the general increasing incidence of overweight and diabetes and to identify risk factors for the development of diabetes.

RESEARCH DESIGN AND METHODS

Women with diet-treated GDM during 1978-1985 (old cohort, n = 241, also followed up around 1990) or 1987-1996 (new cohort, n = 512) were examined in 2000-2002. Women were classified by a 2-h, 75-g oral glucose tolerance test according to the World Health Organization criteria or an intravenous glucagon test supplemented by measurement of GAD antibodies. Historical data from index-pregnancy and anthropometrical measurements were collected.

RESULTS

A total of 481 (63.9%) women were examined (median 9.8 years [interquartile range 6.4-17.2]) after index pregnancy. Diabetes and impaired glucose tolerance (IGT)/impaired fasting glucose were present in 40.0 and 27.0% of women, respectively. In the new cohort, 40.9% had diabetes compared with 18.3% in the old cohort at the 1990 follow-up (P < 0.0005). Prepregnancy BMI was significantly higher in the new compared with the old cohort (26.0 [22.5-30.8] vs. 22.9 kg/m2 [20.2-28.0], P < 0.0005). Among others, new-cohort membership, prepregnancy overweight (BMI > or = 25 kg/m2), and IGT postpartum were identified as independent predictors of diabetes by multiple logistic regression analyses.

CONCLUSIONS

The incidence of diabetes among Danish women with previous diet-treated GDM was very high and had more than doubled over a 10-year period. This seems to be due to a substantial increase in BMI in women with GDM.

Lifestyle change after gestational diabetes

AIMS

Gestational diabetes mellitus (GDM) is a predictor for overt diabetes later in life. Thus, during pregnancy GDM patients are instructed to change lifestyle after pregnancy. The purpose of the present study was to assess the lifestyle changes made by these women.

METHODS

The study was a mailed survey with structured questions on diet, weight loss, exercise and worry about developing diabetes. One hundred and twenty-one (79%) women agreed to participate 11-42 months after pregnancy. Weight gain or loss was defined as a change >/=5 kg.

RESULTS

Among women with body mass index (BMI) >25 kg/m(2), only 18% lost weight and more than 33% gained weight. In total, more women gained than lost weight (P<0.05). Prior to pregnancy, 90 (74%) women followed a diet rich in fat. In contrast, only 57 women (47%) did so at follow-up (P<0.001). Further analysis showed that among these 57 women, only 7% had lost weight since pregnancy compared to 25% of women eating healthy (P<0.05). Eighty-six percent were worried to some extent about the risk for subsequent diabetes. The exercise level did not change after pregnancy. Nineteen women (16%) had overt diabetes mellitus and 22 (18%) impaired glucose tolerance (IGT) at follow-up.

CONCLUSIONS

Although the majority of the women were concerned about developing overt diabetes, only a few had changed their lifestyle and/or lost weight after pregnancy. This indicates that lifestyle instruction needs to be much more frequent and intensive in the period after pregnancy in these women.

Screening for gestational diabetes mellitus by a model based on risk indicators: a prospective study

OBJECTIVE

This study was performed to prospectively evaluate a screening model for gestational diabetes mellitus on the basis of clinical risk indicators.

STUDY DESIGN

In a prospective multicenter study with 5235 consecutive pregnant women, diagnostic testing with a 2-hour 75-g oral glucose tolerance test was routinely performed in women with risk indicators and offered to women without risk indicators as part of the study.

RESULTS

Forty-four percent of the women underwent testing, 43% declined participation, 6% did not speak Danish, and 7% could not be contacted. By extrapolation of the results from tested women to the whole group in question, a 2.4% prevalence of gestational diabetes mellitus was calculated. Sensitivity and specificity of the model was 80.6 (73.7-87.6) and 64.8 (63.5-66.1), respectively (95% CIs).

CONCLUSION

Under ideal conditions, sensitivity of the model was comparable with universal screening by fasting glucose or a 1-hour 50-g glucose challenge test. Both screening and diagnostic testing could be avoided in two thirds of all pregnant women.