Gestational diabetes mellitus

Impact of family income on the development of gestational diabetes mellitus and the associated birth outcomes: A nationwide study

AIMS/INTRODUCTION

The relationship between economic disadvantages and the risk of developing gestational diabetes mellitus (GDM), as well as its impact on birth outcomes, remains uncertain.

MATERIALS AND METHODS

From the Taiwan Maternal and Child Health Database, we identified 984,712 pregnant women between 1 January 2007 and 31 December 2018. Using propensity score matching, we selected 5,068 pairs of women across four income levels: very low, low, middle and high. We used a multivariable Cox regression model to assess the risk of GDM in these pregnant women and analyzed the birth outcomes.

RESULTS

The mean age of the pregnant women was 30.89 years. We found no significant difference in GDM risk among pregnant women with different family income. However, newborns of women with GDM and very low-income were at higher risk for several adverse conditions, such as small for gestational age (adjusted odds ratio (aOR) 1.17, 95% confidence interval (CI) 1.04-1.31), large for gestational age (aOR 1.27, 95% CI 1.08-1.51), hypoxic-ischemic encephalopathy (aOR 3.19, 95% CI 1.15-8.86), respiratory distress (aOR 1.58, 95% CI 1.14-2. 19), congenital anomalies (aOR 1.32, 95% CI 1.08-1.62), jaundice requiring phototherapy or exchange transfusion (aOR 1.14, 95% CI 1.05-1.24) and so on.

CONCLUSIONS

This study found that low family income alone was not associated with GDM development. However, for a GDM pregnancy, pregnant women with lower income had worse birth outcomes. Improving maternal health and nutrition among low-income pregnant women with GDM might be critical to improving birth outcomes.

Rising Prevalence of Gestational Diabetes Mellitus in Ontario: A Population-based Study

OBJECTIVES

Gestational diabetes mellitus (GDM) is a common pregnancy complication. Studies have shown that the prevalence of GDM is rising worldwide. In this study, we aimed to describe the prevalence of GDM in Ontario, Canada, between 2015 and 2021.

METHODS

Population-based linked health-care administrative databases were used to identify women with GDM via a validated algorithm. Age-standardized GDM prevalence was described for each year between 2015 and 2021. Crude GDM prevalence trends were stratified according to age and income, and trend over time was evaluated using negative binomial regression.

RESULTS

Crude GDM prevalence was 9.5% within this period, with age-standardized prevalence increasing by 35% over the duration of the study (p<0.0001). Prevalence declined in the first year of the COVID-19 pandemic, but it rose again the next year. Prevalence was directly associated with age (p<0.0001) and inversely associated with income (p=0.04), but these disparities did not change over time.

CONCLUSIONS

GDM prevalence is rising, but the transient decline in the first year of the pandemic may reflect forgone GDM screening. Disparities in prevalence by age and income are not worsening. GDM is creating a growing burden for the health-care system, particularly for lower income individuals.

Impact of an exercise program combined with dietary advice on avoiding insulin prescription in women with gestational diabetes: a randomized controlled trial

OBJECTIVE

To assess the effectiveness of an exercise intervention, in addition to standard care, in preventing or delaying insulin prescription in women with gestational diabetes mellitus (GDM).

DESIGN

Randomised controlled trial.

SETTING

University hospital.

POPULATION

Pregnant women at 25-35 weeks of gestation diagnosed with GDM.

METHODS

Women in the intervention group participated in weekly, supervised, 30-45 min exercise sessions and were encouraged to accumulate more than 5000 steps per day, tracked by a pedometer, in addition to receiving usual care. The control group received standard care only.

MAIN OUTCOME MEASURE

Insulin prescription.

RESULTS

From February 2008 through April 2013, 109 women were randomized into the intervention group (n = 57) or the usual care group (n = 52). Two women in the intervention group were excluded from the analysis (one was randomised in error and one was lost to follow-up). Six women never attended the exercise sessions, and two attended fewer than two sessions. However, two-third of women were considered as compliant to the intervention (attended more than 50% of sessions and/or averaged more than 5000 steps/day). The incidence of insulin prescription did not differ between the groups: 31 women (56%) in the intervention group versus 24 women (46%) in the control group (RR 1.22, 95% CI 0.84 to 1.78). The median time from randomization to insulin prescription was also similar between groups (14 days in the intervention group and 13 days in the control group).

CONCLUSION

This study did not demonstrate that an exercise program reduces or delays insulin prescription in women with GDM. Low adherence to the intervention, a small sample size, and the short duration of the program may explain the lack of observed benefit.

REGISTERED

At clinicaltrials.gov, NCT03174340, 02/06/2017.

Insulin Blood Levels in Gestational Diabetes Mellitus in Relation to Ethnicity and Age in the Kingdom of Bahrain: A Cross-Sectional Study

BACKGROUND

Gestational diabetes mellitus (GDM) is one of the most common complications of pregnancy. It may be attributed to certain placental hormones during pregnancy which render insulin less effective. Our study aimed to focus on the levels of insulin in gestational diabetic women in the Kingdom of Bahrain as compared with non-diabetic pregnant women. Furthermore, we studied the correlation between insulin levels by ethnicity and age of the pregnant women.  Methods: A cross-sectional study was conducted on 75 pregnant participants: 41 with GDM (test group) and 34 without GDM (control group). Insulin levels were determined in patients with GDM and compared to non-diabetic pregnant women. A comparison between Bahraini and non-Bahraini women was carried out in two different age groups: below and above 30 years of age. P values < 0.05 were considered significant.

RESULTS

The results showed higher mean values of fasting blood glucose (FBG), random blood glucose (RBG), and insulin levels in the test group when compared to the control group. There was no significant difference in FBG, RBG, and insulin levels among Bahraini women with GDM and non-Bahraini women (Indian, Pakistani. Bengali, and Filipino) with GDM. Age, less than 30 vs more than 30 years, had no significant effect on women with GDM.

CONCLUSION

Insulin levels were higher in pregnant women with GDM irrespective of their ethnicity or age. The lack of blood glucose control in GDM even in the presence of high insulin secretion may suggest loss of insulin effectiveness due to other factors such as stress and lactogenic placental hormones.

The role of neutrophils and neutrophil extracellular traps (NETs) in stages, outcomes and pregnancy complications

Neutrophils are the main components of innate immunity to eliminate infectious pathogens. Neutrophils play a role in several stages of the reproductive cycle, and their presence in the female reproductive system is highly regulated, so their function may change during pregnancy. Emerging evidence suggests that neutrophils are important at all stages of pregnancy, from implantation, placentation, and connective tissue regeneration to birth, as well as birth itself. Neutrophil extracellular traps (NETs) are defined as extracellular strands of unfolded DNA together with histone complexes and neutrophil granule proteins. NET formation is a new mechanism of these cells for their defense function. These strands containing DNA and antimicrobial peptides were initially recognized as one of the defense mechanisms of neutrophils, but later it was explained that they are involved in a variety of non-infectious diseases. Since the source of inflammation and tissue damage is the irregular activity of neutrophils, it is not surprising that NETosis are associated with a number of inflammatory conditions and diseases. The overexpression of NET components or non-principled NET clearance is associated with the risk of production and activation of autoantibodies, which results in participation in autoinflammatory and autoimmune disorders (SLE, RA), fibrosis, sepsis and other disorders such as vascular diseases, for example, thrombosis and atherosclerosis. Recent published articles have shown the role of neutrophils and extracellular traps (NETs) in pregnancy, childbirth and pregnancy-related diseases. The aim of this study was to identify and investigate the role of neutrophils and neutrophil extracellular traps (NETs) in the stages of pregnancy, as well as the complications caused by these cells.

Epidemiology of hyperglycemia during pregnancy in Ethiopia: prevalence, associated factors, and feto-maternal outcomes: systematic review and meta-analysis

BACKGROUND

Hyperglycemia in pregnancy (HIP) is a significant medical complication affecting pregnant women globally and is considered a public health burden due to the negative outcomes it can cause for both mother and infant. The aim of this systematic review and meta-analysis was to examine the prevalence, risk factors, and feto-maternal outcomes of HIP in Ethiopia.

METHODS

To gather relevant information for this study, both published and unpublished studies were searched for in several major databases, including PubMed, Embase, HINARI, Web of Science direct, and Google Scholar, as well as other sources. The Joanna Briggs Institute (JBI) tool was used to evaluate the methodological quality of the findings from these studies. Data was then extracted and summarized using a template in Microsoft Excel software, and the extracted data was analyzed using Stata software version 16.0. If significant heterogeneity was found between studies, subgroup analyses were conducted to further examine the data.

RESULT

Eighteen studies were included in this systematic review and meta-analysis, involving a total sample size of 50,816 pregnant women in Ethiopia. The prevalence of HIP among pregnant women varied considerably across the primary studies, ranging from 0.4 to 26.2%. The pooled prevalence of HIP among pregnant women in Ethiopia was found to be 6.9% (95% C 2.2-11.6). Pregnant women with a family history of diabetes had 2.5 times higher odds of developing HIP compared to those without a family history of diabetes (OR = 2.49; 95% CI = 2.02, 2.96). However, there was no significant association found between HIP and maternal obesity (OR 2.31, 95% CI = 0.85, 3.78) or previous history of abortion (OR 3.89; 95% CI 0.85, 6.94). The common fetal outcomes associated with HIP were admission to the intensive care unit (46.2; 95% CI 27.4, 65.1), macrosomia (27.3%; 95% CI 9.4%, 45.1%), and preterm birth (16.9; 95% CI 12.5, 21.3). Additionally, hypertensive disorders of pregnancy (28.0%; 95% CI 15.2, 40.8) and operative delivery (51.4%; 95% CI 35.9, 66.8) were more common among women with HIP in Ethiopia.

CONCLUSION

Although there was some variation between studies, the meta-analysis revealed that approximately seven out of 100 pregnant women in Ethiopia had HIP. A family history of diabetes was found to be a significant predictor of HIP in Ethiopia. Additionally, HIP was associated with various serious adverse outcomes for both mothers and infants in Ethiopia. These findings highlight the need for national guidelines to ensure that pregnant women are uniformly screened for HIP.

Awareness of Gestational Diabetes Mellitus Maternal and Neonatal Outcomes Among Women Attending Primary Healthcare Centers in Qassim, Saudi Arabia

Background Gestational diabetes mellitus (GDM), diagnosed during pregnancy, can harm both mothers and neonates. GDM awareness among women varies among various countries. Understanding the level of awareness is vital for designing effective health interventions. Objectives This study aimed to evaluate GDM awareness among married females at primary healthcare centers (PHCCs) in Qassim, Saudi Arabia, focusing on knowledge regarding adverse maternal and fetal outcomes of GDM. Methods An observational cross-sectional study was conducted among married females at PHCCs in Qassim, from June 2023 to October 2023. A two-stage cluster sampling method was used. Four PHCCs were selected in the first stage, and study participants were selected from these centers in the second stage. A self-administered questionnaire was used. Statistical Product and Service Solutions (SPSS, version 23; IBM SPSS Statistics for Windows, Armonk, NY) was used for statistical analysis. Results Of the 270 participants, the majority (72.2%) demonstrated 'poor' knowledge about GDM adverse outcomes for both mothers and neonates, 17.8% demonstrated a 'fair' level, and only 10% displayed a 'good' knowledge. Participants' educational level, personal history of diabetes, and age were associated with knowledge levels. Awareness of specific outcomes related to GDM, both maternal and neonatal, varied among participants. Information on GDM was mainly obtained from mass media and personal networks, while healthcare providers were reported as the least common source. Conclusion Based on the results of our study, we conclude that educational interventions, especially involving healthcare providers, are essential to improve awareness about GDM adverse outcomes. Strategies involving educational sessions by healthcare providers and health education materials at PHCCs can improve awareness leading to effective management of GDM and improved maternal and neonatal outcomes.

Investigation of the effects of gestational diabetes and hypertension on retinal and choroidal microvascular circulation using swept-source optical coherence tomography angiography

PURPOSE

The aim of this study was to investigate the microvascular changes in the retina and choroid in gestational diabetes mellitus (GDM) and pregnancy-induced hypertension (PIH) and to compare the results with those of healthy pregnant subjects.

METHODS

Twenty-nine pregnant subjects with coexisting GDM and PIH (group 1) and 36 healthy pregnant subjects (group 2) were enrolled in the study. All subjects were examined by optical coherence tomography (OCT) and angiography (OCTA). 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) were measured.

RESULTS

We observed that the values of CT and VD were lower in group 1 than in group 2. No significant difference was found between groups in RT, FAZ area and CC VD. SCP and DCP VD values were higher in group 2 in all quadrants. We observed a significant increase in FAZ area and CC VD with increasing systolic blood pressure. No correlation was observed between diastolic blood pressure and FBS with other parameters. In group 1, FAZ area was significantly higher in the diet-treated group than in the insulin-treated group.

CONCLUSION

Monitoring and treatment of pregnant women with PIH and GDM is important because of the risks that may occur during pregnancy. We believe that changes in microvascular circulation can be detected noninvasively with OCTA, even in the absence of clinical or retinal findings.

Flat maternal glucose response curve and adverse pregnancy outcome

OBJECTIVE

The significance of a flat oral glucose tolerance test (OGTT) response curve in pregnancy remains unclear. We investigated the association of a flat curve with pregnancy outcomes.

STUDY DESIGN

Retrospective cohort study. Flat OGTT curve was defined by an area under the curve below the 10th percentile. Pregnancy outcomes were compared between flat and normal curve.

RESULTS

Of the 2673 eligible women, 269 had a flat response curve. Compared with the normal-response group, the flat-curve group had a lower mean birthweight (3363 ± 547 g vs. 3459 ± 519 g, p < 0.005), higher probability of small for gestational age (SGA) (19% vs. 12%, p < 0.005, aOR = 1.75, 95% CI 1.24-2.47), and 5-min Apgar score < 7 (1.12% vs. 0.29%, p < 0.05, aOR = 3.95, 95% CI 1.01-15.5). There were no differences in obstetric or maternal outcomes.

CONCLUSIONS

Flat OGTT is associated with lower birthweight, higher rates of SGA, and low Apgar scores. Detecting this previously unrecognized risk group, could potentially reduce these complications.

Proteins and metabolites fingerprints of gestational diabetes mellitus forming protein-metabolite interactomes are its potential biomarkers

Gestational diabetes mellitus (GDM) is a consequence of glucose intolerance with an inadequate production of insulin that happens during pregnancy and leads to adverse health consequences for both mother and fetus. GDM patients are at higher risk for preeclampsia, and developing diabetes mellitus type 2 in later life, while the child born to GDM mothers are more prone to macrosomia, and hypoglycemia. The universally accepted diagnostic criteria for GDM are lacking, therefore there is a need for a diagnosis of GDM that can identify GDM at its early stage (first trimester). We have reviewed the literature on proteins and metabolites fingerprints of GDM. Further, we have performed protein-protein, metabolite-metabolite, and protein-metabolite interaction network studies on GDM proteins and metabolites fingerprints. Notably, some proteins and metabolites fingerprints are forming strong interaction networks at high confidence scores. Therefore, we have suggested that those proteins and metabolites that are forming protein-metabolite interactomes are the potential biomarkers of GDM. The protein-metabolite biomarkers interactome may help in a deep understanding of the prognosis, pathogenesis of GDM, and also detection of GDM. The protein-metabolites interactome may be further applied in planning future therapeutic strategies to promote long-term health benefits in GDM mothers and their children.

Association between serum lipid profile during the first and second trimester of pregnancy as well as their dynamic changes and gestational diabetes mellitus in twin pregnancies: a retrospective cohort study

BACKGROUND

Abnormal lipid metabolism is associated with gestational diabetes mellitus (GDM) in singleton pregnancies. Data were lacking on twin pregnancies with GDM. We explored the association between serum lipid profiles in the first and second trimesters as well as their dynamic changes and GDM in twin pregnancies.

METHODS

This was a retrospective cohort study of 2739 twin pregnancies that underwent a 75-g oral glucose tolerance test (OGTT) and were selected from the Beijing Birth Cohort Study from June 2013 to May 2021. Cholesterol (CHO), triglyceride (TG), high-density lipoprotein (HDL) and low-density lipoprotein (LDL) levels were measured at mean 9 and 25 weeks of gestation. We described maternal lipid levels in different tertiles that were associated with the risk of GDM stratified for age, pre-BMI, and fertilization type. GDM patients were divided into two groups according to OGTT: elevated fasting plasma glucose only (FPG group) and the rest of the GDM (non-FPG group). We estimated the relative risk of GDM with multivariable logistic regression models.

RESULTS

In this study, we found that 599 (21.9%, 599/2739) twin pregnancies developed GDM. They had increased CHO, TG, LDL, and LDL/HDL, decreased HDL levels in the first trimester, and increased TG as well as decreased HDL in the second trimester in univariate analyses, each P < 0.05. In multivariate analysis, when TG > 1.67 mmol/l (upper tertile) in elderly individuals, nonoverweight and ART groups increased the risk of GDM by 2.7-fold, 2.3-fold and 2.2-fold, respectively, compared with TG < 0.96 mmol/l (lower tertile). This effect remained in the abovementioned groups in the second trimester. Moreover, high TGs increased the risk of GDM in the FPG group (OR = 2.076, 95% CI 1.130-3.815) and non-FPG group (OR = 2.526, 95% CI 1.739-3.67) in the first trimester when TG > 1.67 mmol/l, and the rising risk in the non-FPG group as the TG tertile increased remained in the second trimester. HDL predominantly showed a negative association with elevated FPG in the second trimester (p < 0.05).

CONCLUSIONS

Twin pregnancies with GDM have higher lipid levels. Increased TGs in the first and second trimesters are strongly associated with GDM, especially in elderly individuals, nonoverweight and ART groups. Lipid profiles varied among different GDM subtypes.

Extracellular vesicles are dynamic regulators of maternal glucose homeostasis during pregnancy

Homeostatic regulation of the maternal milieu during pregnancy is critical for maternal and fetal health. The placenta facilitates critical communication between maternal and fetal compartments, in part, through the production of extracellular vesicles (EVs). EVs enable tissue synchrony via cell-cell and long-distance communication and are at their highest circulating concentration during pregnancy. While much work has been done investigating how physiological challenges in pregnancy affect the fetus, the role of placental communication in maternal health has not been well examined. We previously identified placental O-glycosyl transferase (OGT), a glucose-sensing enzyme, as a target of maternal stress where OGT levels and activity affected the O-glycosylation of proteins critical for EV cargo loading and secretion. Here, we hypothesized that placental OGT plays an essential role in maternal homeostatic regulation during pregnancy via its regulation of maternal circulating EV concentrations. Our studies found that changes to key metabolic factors over the circadian cycle, including glucocorticoids, insulin, and glucose, were significantly associated with changes in circulating EV concentration. Targeting placental OGT in mice, we found a novel significant positive relationship between placental OGT and maternal circulating EV concentration that was associated with improving maternal glucose tolerance during pregnancy. Finally, an intravenous elevation in EVs, matching the concentration of EVs during pregnancy, shifted non-pregnant female glucose sensitivity, blunted glucose variance, and improved synchrony of glucose uptake. These data suggest an important and novel role for circulating EVs as homeostatic regulators important in maternal health during pregnancy.

Self-Efficacy and Readiness to Change Among Women with Recent Gestational Diabetes Engaging in a Web-Based Lifestyle Intervention: The Balance After Baby Intervention Trial

Few evidence-based programs exist to help women with a history of gestational diabetes reduce their risk of developing type 2 diabetes. In secondary analyses from a randomized clinical trial of a web-based lifestyle intervention program for postpartum women with recent gestational diabetes, we studied changes in self-efficacy for diet and physical activity and readiness to change health behaviors. Women were randomized at ∼6 weeks postpartum and completed questionnaires at 6 weeks and 6, 12, 18, and 24 months. Our study included 181 women (mean age 32.4 ± 5.2 years; 48% White, 19% Asian, 14% Black or African American, 17% other/mixed race; 34% Hispanic). In a linear mixed effects model, women in the intervention had significantly greater improvement in overall self-efficacy scores for physical activity compared with the control group at 24 months (difference in change scores between groups .35, 95% CI: .03 to .67, P = .03). The intervention group also demonstrated significantly greater improvement in self-efficacy scores for both physical activity subdomains, specifically “sticking to it” at 24 months and “making time” at 12 months. Participants in the intervention did not experience a significant difference in change in self-efficacy for diet or readiness to change compared with those in the control arm.

Correlations between parameters of glycaemic variability and foetal growth, neonatal hypoglycaemia and hyperbilirubinemia in women with gestational diabetes

The diagnosis of gestational diabetes mellitus (GDM) is important to prevent maternal and neonatal complications. This study aimed to investigate the feasibility of parameters of glycaemic variability to predict neonatal complications in women with GDM. A retrospective study was conducted on pregnant women tested positive at the oral glucose tolerance test (OGTT) during 16-18 or 24-28 weeks of gestation. Glycaemic measures were extracted from patients' glucometers and expanded to obtain parameters of glycaemic variability. Data on pregnancy outcomes were obtained from clinical folders. Descriptive group-level analysis was used to assess trends in glycaemic measures and foetal outcomes. Twelve patients were included and analysed, accounting for 111 weeks of observations. The analysis of trends in parameters of glycaemic variability showed spikes of glycaemic mean, high blood glucose index and J-index at 30-31 weeks of gestation for cases with foetal macrosomia, defined as foetal growth >90° percentile, neonatal hypoglycaemia and hyperbilirubinemia. Specific trends in parameters of glycaemic variability observed at third trimester correlate with foetal outcomes. Further research is awaited to provide evidence that monitoring of glycaemic variability trends could be more clinically informative and useful than standard glycaemic checks to manage women with GDM at delivery.

The gestational diabetes future diabetes prevention study (GODDESS): A partially randomised feasibility controlled trial

OBJECTIVES

To assess the feasibility of an ante- and post-natal lifestyle intervention for women with gestational diabetes mellitus (GDM) to reduce type 2 diabetes risk.

DESIGN

A partially randomised patient preference feasibility trial.

SETTING

Diabetes antenatal clinics in two inner-London hospitals, UK.

PARTICIPANTS

Pregnant women ≥18 years with a GDM diagnosis and pre-pregnancy body mass index of ≥25kg/m2.

INTERVENTION

Participants in the intervention group were offered four motivational interview-based sessions (two antenatally and two postnatally, at 3 and 6 months postpartum), a WhatsApp support group, a FitBit and electronic self-help resources.

OUTCOME MEASURES

Recruitment; retention; intervention dose received; data completion; adaptions; proportion achieving ≥5% weight loss; weight change, blood glucose; blood pressure; diet, physical activity, breastfeeding and depression. Clinical outcomes were measured at baseline and 6 months postpartum.

RESULTS

50 participants were recruited from 155 eligible women (32% recruitment rate). Thirty-four were recruited to the intervention group (23 following randomisation (RI-group) and 11 based on preference (PI-group)); and 16 to the control group (13 randomised (RC-group) and 3 preference (PC-group)). Attrition was 44% (n = 22/50). Forty-six percent (n = 6) of the intervention group (25% (n = 2) of the RI-group and 80% (n = 4) of the PI-group) achieved ≥5% weight loss compared to 8% (n = 1) in the control group (95% confidence interval (CI) -0.69 to 0.07). Mean weight change was -2.1kg±9.0 in the intervention group (0kg±5.4 in the RI-group and -5.4kg±13.0 in the PI-group) compared to +4.4kg±4.9 in the control group (RC +4.4kg ±5.3 and PC +4.7kg ±3.1, 95% CI -12.4 to 0.2).

CONCLUSIONS

Recruitment was feasible, but strategies to improve retention are needed. The findings suggest the intervention can support women with GDM to lose weight. The observed weight loss was primarily in women who preferred the intervention. Therefore, future trials may need to adopt a preference design and consider factors associated with preference.

TRIAL REGISTRATION

Trial registration: ISRCTN52675820 https://www.isrctn.com/ISRCTN52675820?q=ISRCTN52675820&filters=&sort=&offset=1&totalResults=1&page=1&pageSize=10&searchType=basic-search.

Association of ambient fine particulate matter exposure with gestational diabetes mellitus and blood glucose levels during pregnancy

BACKGROUND

Previous studies have examined the associations between ambient fine particulate matter (PM_2.5) exposure and gestational diabetes mellitus (GDM). However, limited studies explored the relationships between PM_2.5 exposure and blood glucose levels during pregnancy, especially in highly polluted areas.

OBJECTIVES

To examine the associations of prenatal ambient PM_2.5 exposure with GDM and blood glucose levels, and to identify the sensitive exposure windows in a highly air-polluted area.

METHODS

From July 2016 to October 2017, a birth cohort study was conducted in Beijing, China. Participants were interviewed in each trimester regarding demographics, lifestyle, living and working environment, and medical conditions. Participant's daily ambient PM_2.5 levels from 3 m before last menstrual period (LMP) to the third trimester was estimated by a hybrid spatiotemporal model. Indoor air quality index was calculated based on environmental tobacco smoke, ventilation, cooking, painting, pesticide, and herbicide use. Distributed lag non-linear model was applied to explore the sensitive weeks of PM_2.5 exposure.

RESULTS

Of 165 pregnant women, 23 (13.94%) developed GDM. After adjusting for potential confounders, PM_2.5 exposure during the 1^st trimester was associated with higher odds of GDM (10 μg/m³ increase: OR = 1.89, 95% CI: 1.04-3.49). Each 10 μg/m³ increase in PM_2.5 during the 2^nd trimester was associated with 17.70% (2.21-33.20), 15.99% (2.96-29.01), 18.82% (4.11-33.52), and 17.10% (3.28-30.92) increase in 1-h, 2-h, Δ1h-fasting (1-h minus fasting), and Δ2h-fasting (2-h minus fasting) blood glucose levels, respectively. PM_2.5 exposure at 24^th-27^th weeks after LMP was associated with increased GDM risk. We identified sensitive exposure windows of 21^st-24^th weeks for higher 1-h and 2-h blood glucose levels and of 20^th-22^nd weeks for increased Δ1h-fasting and Δ2h-fasting.

CONCLUSIONS

Ambient PM_2.5 exposure during the second trimester was associated with higher odds of GDM and higher blood glucose levels. Avoiding exposure to high air pollution levels during the sensitive windows might prevent women from developing GDM.

Role of the Gut Microbiota in the Increased Infant Body Mass Index Induced by Gestational Diabetes Mellitus

The connection between gestational diabetes mellitus (GDM) and the offspring's development, such as obesity, is well established. Emerging evidence indicates that the microbiota of the neonate's meconium is associated with maternal GDM status. To explore whether the association between GDM and infant body mass index (BMI) in early childhood is affected by the meconium microbiota, we recruited 120 mothers (60 healthy women and 60 with GDM) and their newborns from the Women's Hospital of Nanjing Medical University. Meconium of 120 neonates was collected within a few hours after birth and sequenced using 16S rRNA sequencing analysis. Children's BMI was measured at 12 months of age. The results revealed that infants born to mothers with GDM had increased BMI Z-scores at 12 months old and that the β-diversity of their meconium microbiota was reduced. Several genera were observed to be significantly different between the GDM and control groups. The genus Burkholderia-Caballeronia-Paraburkholderia and an untitled genus in the family Enterobacteriaceae enriched in neonates born to healthy mothers were found to be negatively associated with infant BMI by using regression analysis. A coabundance group depleted in the GDM group was correlated negatively with 12-month BMI and mediated 21.65% of the association between GDM and infant BMI by mediation analyses. This study provided evidence for the associations among maternal GDM, the meconium microbiota, and infant BMI. Maternal GDM was demonstrated to affect infant BMI, mediated by the gut microbiome. Gut microbiome interventions might represent a novel technique to decrease the risk of GDM-induced childhood obesity. IMPORTANCE Using 16S rRNA sequencing analysis, regression analysis and mediation analysis were used to explore whether maternal gestational diabetes mellitus (GDM) changed the function and composition of the meconium microbiota and whether this explained the GDM-induced alterations of infant body mass index (BMI). This study showed that gut microbiome dysbiosis induced by maternal GDM might play an important role in the increased infant BMI during the first 12 months of life. Therefore, gut microbiome interventions might represent a novel technique to decrease the risk of GDM-induced childhood obesity.

Gut Microbiome Changes in Gestational Diabetes

Gestational diabetes mellitus (GDM), one of the most common endocrine pathologies during pregnancy, is defined as any degree of glucose intolerance with onset or first discovery in the perinatal period. Physiological changes that occur in pregnant women can lead to inflammation, which promotes insulin resistance. In the general context of worldwide increasing obesity in young females of reproductive age, GDM follows the same ascending trend. Changes in the intestinal microbiome play a decisive role in obesity and the development of insulin resistance and chronic inflammation, especially in patients with type 2 diabetes mellitus (T2D). To date, various studies have also associated intestinal dysbiosis with metabolic changes in women with GDM. Although host metabolism in women with GDM has not been fully elucidated, it is of particular importance to analyze the available data and to discuss the actual knowledge regarding microbiome changes with potential impact on the health of pregnant women and newborns. We analyzed peer-reviewed journal articles available in online databases in order to summarize the most recent findings regarding how variations in diet and metabolic status of GDM patients can contribute to alteration of the gut microbiome, in the same way that changes of the gut microbiota can lead to GDM. The most frequently observed alteration in the microbiome of patients with GDM was either an increase of the Firmicutes phylum, respectively, or a decrease of the Bacteroidetes and Actinobacteria phyla. Gut dysbiosis was still present postpartum and can impact the development of the newborn, as shown in several studies. In the evolution of GDM, probiotic supplementation and regular physical activity have the strongest evidence of proper blood glucose control, favoring fetal development and a healthy outcome for the postpartum period. The current review aims to summarize and discuss the most recent findings regarding the correlation between GDM and dysbiosis, and current and future methods for prevention and treatment (lifestyle changes, pre- and probiotics administration). To conclude, by highlighting the role of the gut microbiota, one can change perspectives about the development and progression of GDM and open up new avenues for the development of innovative therapeutic targets in this disease.

A Clinical Update on Gestational Diabetes Mellitus

Gestational diabetes mellitus (GDM) traditionally refers to abnormal glucose tolerance with onset or first recognition during pregnancy. GDM has long been associated with obstetric and neonatal complications primarily relating to higher infant birthweight and is increasingly recognized as a risk factor for future maternal and offspring cardiometabolic disease. The prevalence of GDM continues to rise internationally due to epidemiological factors including the increase in background rates of obesity in women of reproductive age and rising maternal age and the implementation of the revised International Association of the Diabetes and Pregnancy Study Groups' criteria and diagnostic procedures for GDM. The current lack of international consensus for the diagnosis of GDM reflects its complex historical evolution and pragmatic antenatal resource considerations given GDM is now 1 of the most common complications of pregnancy. Regardless, the contemporary clinical approach to GDM should be informed not only by its short-term complications but also by its longer term prognosis. Recent data demonstrate the effect of early in utero exposure to maternal hyperglycemia, with evidence for fetal overgrowth present prior to the traditional diagnosis of GDM from 24 weeks' gestation, as well as the durable adverse impact of maternal hyperglycemia on child and adolescent metabolism. The major contribution of GDM to the global epidemic of intergenerational cardiometabolic disease highlights the importance of identifying GDM as an early risk factor for type 2 diabetes and cardiovascular disease, broadening the prevailing clinical approach to address longer term maternal and offspring complications following a diagnosis of GDM.

Disruption of Fetal Eye Development Caused by Insulin-induced Maternal Hypoglycemia in Rats

We previously revealed that insulin-induced severe and long-lasting maternal hypoglycemia in rats caused anophthalmia and microphthalmia in fetuses; however, it remained unclear whether hypoglycemia-induced eye anomalies were developmental retardation or disruption, and when and how they developed. Hence, we induced hypoglycemia in pregnant Sprague-Dawley rats by injecting insulin from Days 6 to 11 of pregnancy and performed periodical histopathological examination of fetal eyes from embryonic days (E)10 to 20. On E10, optic vesicle had developed normally both in the control and insulin-treated group; however, on E11, optic cup (OC) had developed in the control group but not in the insulin-treated group. On E12, neural retina (NR), retinal pigmented epithelium (RPE), lens, and presumptive cornea had been observed in the control group. In contrast, lens pit and OC with remaining space between RPE and NR had developed in the insulin-treated group. From E13 to E15, developmental disruption characterized by defects, hypoplasia, and degeneration in the retina, lens, and cornea was observed in the insulin-treated group, resulting in anophthalmia or microphthalmia on E20. Moreover, the expression of MITF and chx10, which are essential for early eye development by expressing in the presumptive retina and lens and regulating each other's expression level, was ectopic and suppressed on E11. In conclusion, insulin-induced maternal hypoglycemia caused developmental disruption, but not simple developmental retardation of fetal eyes, and its trigger might be a failure of presumptive retina and lens to interact on E11.

Burden, risk factors and outcomes associated with gestational diabetes in a population-based cohort of pregnant women from North India

Background

The burden of gestational diabetes mellitus (GDM) appears to be increasing in India and may be related to the double burden of malnutrition. The population-based incidence and risk factors of GDM, particularly in lower socio-economic populations, are not known. We conducted analyses on data from a population-based cohort of pregnant women in South Delhi, India, to determine the incidence of GDM, its risk factors and association with adverse pregnancy outcomes (stillbirth, preterm birth, large for gestational age babies) and need for caesarean section.

Methods

We analyzed data from the intervention group of the Women and Infants Integrated Interventions for Growth Study (WINGS), an individually randomized factorial design trial. An oral glucose tolerance test (OGTT) was performed at the time of confirmation of pregnancy, and for those who had a normal test (≤140 mg), it was repeated at 24–28 and at 34–36 weeks. Logistic regression was performed to ascertain risk factors associated with GDM. Risk ratios (RR) were calculated to find association between GDM and adverse pregnancy outcomes and need for caesarean section.

Results

19.2% (95% CI: 17.6 to 20.9) pregnant women who had at least one OGTT were diagnosed to have GDM. Women who had prediabetes at the time of confirmation of pregnancy had a significantly higher risk of developing GDM (RR 2.08, 95%CI 1.45 to 2.97). Other risk factors independently associated with GDM were woman’s age (adjusted OR (AOR) 1.10, 95% CI 1.06 to 1.15) and BMI (AOR 1.04, 95% CI 1.01 to 1.07). Higher maternal height was found to be protective factor for GDM (AOR 0.98, 95% CI 0.96 to 1.00). Women with GDM, received appropriate treatment did not have an increase in adverse outcomes and no increased need for caesarean section

Conclusions

A substantial proportion of pregnant women from a low to mid socio-economic population in Delhi had GDM, with older age, higher BMI and pre-diabetes as important risk factors. These findings highlight the need for interventions for prevention and provision of appropriate management of GDM in antenatal programmes.

Clinical trial registration

Clinical Trial Registry – India, #CTRI/2017/06/008908 (http://ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=19339&EncHid=&userName=society%20for%20applied%20studies).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04389-5.

Immunobiology of Gestational Diabetes Mellitus in Post-Medawar Era

Although the concepts related to fetal immune tolerance proposed by Sir Peter Medawar in the 1950s have not withstood the test of time, they revolutionized our current understanding of the immunity at the maternal-fetal interface. An important extension of the original Medawar paradigm is the investigation into the underlying mechanisms for adverse pregnancy outcomes, including recurrent spontaneous abortion, preterm birth, preeclampsia and gestational diabetes mellitus (GDM). Although a common pregnancy complication with systemic symptoms, GDM still lacks understanding of immunological perturbations associated with the pathological processes, particularly at the maternal-fetal interface. GDM has been characterized by low grade systemic inflammation that exacerbates maternal immune responses. In this regard, GDM may also entail mild autoimmune pathology by dysregulating circulating and uterine regulatory T cells (Tregs). The aim of this review article is to focus on maternal-fetal immunological tolerance phenomenon and discuss how local or systemic inflammation has been programmed in GDM. Specifically, this review addresses the following questions: Does the inflammatory or exhausted Treg population affecting the Th17:Treg ratio lead to the propensity of a pro-inflammatory environment? Do glycans and glycan-binding proteins (mainly galectins) contribute to the biology of immune responses in GDM? Our understanding of these important questions is still elementary as there are no well-defined animal models that mimic all the features of GDM or can be used to better understand the mechanistic underpinnings associated with this common pregnancy complication. In this review, we will leverage our preliminary studies and the literature to provide a conceptualized discussion on the immunobiology of GDM.

Pregnancy Complications Can Foreshadow Future Disease—Long-Term Outcomes of a Complicated Pregnancy

During gestation, the maternal body should increase its activity to fulfil the demands of the developing fetus as pregnancy progresses. Each maternal organ adapts in a unique manner and at a different time during pregnancy. In an organ or system that was already vulnerable before pregnancy, the burden of pregnancy can trigger overt clinical manifestations. After delivery, symptoms usually reside; however, in time, because of the age-related metabolic and pro-atherogenic changes, they reappear. Therefore, it is believed that pregnancy acts as a medical stress test for mothers. Pregnancy complications such as gestational hypertension, preeclampsia and gestational diabetes mellitus foreshadow cardiovascular disease and/or diabetes later in life. Affected women are encouraged to modify their lifestyle after birth by adjusting their diet and exercise habits. Blood pressure and plasmatic glucose level checking are recommended so that early therapeutic intervention can reduce long-term morbidity. Currently, the knowledge of the long-term consequences in women who have had pregnancy-related syndromes is still incomplete. A past obstetric history may, however, be useful in determining the risk of diseases later in life and allow timely intervention.

Performance of early risk assessment tools to predict the later development of gestational diabetes

BACKGROUND

Several prognostic models for gestational diabetes mellitus (GDM) are provided in the literature; however, their clinical significance has not been thoroughly evaluated, especially with regard to application at early gestation and in accordance with the most recent diagnostic criteria. This external validation study aimed to assess the predictive accuracy of published risk estimation models for the later development of GDM at early pregnancy.

METHODS

In this cohort study, we prospectively included 1132 pregnant women. Risk evaluation was performed before 16 + 0 weeks of gestation including a routine laboratory examination. Study participants were followed-up until delivery to assess GDM status according to the IADPSG 2010 diagnostic criteria. Fifteen clinical prediction models were calculated according to the published literature.

RESULTS

Gestational diabetes mellitus was diagnosed in 239 women, that is 21.1% of the study participants. Discrimination was assessed by the area under the ROC curve and ranged between 60.7% and 76.9%, corresponding to an acceptable accuracy. With some exceptions, calibration performance was poor as most models were developed based on older diagnostic criteria with lower prevalence and therefore tended to underestimate the risk of GDM. The highest variable importance scores were observed for history of GDM and routine laboratory parameters.

CONCLUSIONS

Most prediction models showed acceptable accuracy in terms of discrimination but lacked in calibration, which was strongly dependent on study settings. Simple biochemical variables such as fasting glucose, HbA1c and triglycerides can improve risk prediction. One model consisting of clinical and laboratory parameters showed satisfactory accuracy and could be used for further investigations.

Inadequate postpartum screening for type 2 diabetes in women with previous gestation diabetes mellitus: A retrospective audit of practice over 17 years

INTRODUCTION

Women with gestational diabetes (GDM) are at greatly increased risk of type 2 diabetes (T2DM). The UK guidance recommends screening for T2DM at around 6-week postpartum and annually thereafter. We evaluated conformity to this guidance in two separate time periods.

METHODS

The proportion of tests performed within guidance was assessed using longitudinal plasma glucose and glycated haemoglobin data in two cohorts (1999-2007, n = 251; 2015-2016, n = 260) from hospital records on women previously diagnosed with GDM.

RESULTS

In the 1999-2007 and 2015-2016 cohorts, 59.8% and 35.0% of women had the recommended postpartum testing, respectively (P < .001); just 13.5% and 14.2%, respectively, underwent the first annual test on time. During long-term follow-up of the 1999-2007 cohort (median follow-up: 12.3 years), the proportion of women tested in any given year averaged 34.2% over a 17-year period; there was a progressive decline in the proportion of women receiving a yearly test with time since delivery (P = .002). Over the follow-up period, 85 women from the 1999-2007 cohort developed blood test results in the diabetic range with a median time to presumed DM diagnosis of 5.2 years (range 0.11-15.95 years). Kaplan-Meier analysis showed that 18.8% of women had blood test results in the diabetes range by 5-year postpartum and 37.8% by 10-year postpartum.

CONCLUSIONS

Despite high profile guidelines and a clear clinical rationale to screen women with a past diagnosis of GDM, many women did not receive adequate screening for T2DM both in the short term and long term. This suggests that alternative approaches are needed to ensure effective follow-up of this high-risk group. To have an impact, interventions need to be tailored to a young, generally healthy group in which traditional approaches to follow-up may not be best suited.

Relationships between gut microbiota, plasma glucose and gestational diabetes mellitus

AIMS/INTRODUCTION

To investigate the changes in the gut microbiome in the second trimester of pregnancy associated with later-diagnosed gestational diabetes mellitus (GDM) and their relationship with fasting serum levels of metabolites, especially glucose.

MATERIALS AND METHODS

We carried out a case-control study with 110 GDM patients and 220 healthy pregnant women who provided fecal samples for 16S ribosomal ribonucleic acid sequencing in the second trimester of pregnancy.

RESULTS

Our results showed that GDM patients had lower α-diversity that was significantly associated with glycemic traits. Principal coordinates analysis showed significantly different microbial communities, as within GDM patients, seven genera within the phylum Firmicutes and two within the phylum Actinobacteria were significantly decreased, and four genera within phylum Bacteroidetes were increased. In addition, microbiota co-occurrence network analysis was carried out, and decreased genera within the phylum Firmicutes in GDM patients showed a significant negative correlation with oral glucose tolerance test values. Finally, microbial gene functions related to glycan biosynthesis and metabolism were found to be enriched in GDM patients.

CONCLUSIONS

Our results show the relationship between changed gut microbiota composition in the second trimester of pregnancy before the diagnosis of GDM and fasting serum levels of metabolites, which might inform the diagnosis, prevention and treatment of GDM.

Growth factors in the fetus and pre-adolescent offspring of hyperglycemic rats

BACKGROUND

Maternal hyperglycemia influences childhood metabolic syndrome, including obesity and hyperglycemia. We tested the hypothesis that the maternal hyperglycemia influences growth factors in the fetal and pre-adolescent offspring.

METHODS

Hyperglycemia was induced in pregnant rats on embryonic day (E)16 using streptozocin followed by implantation with insulin or placebo pellets at embryonic day 18 (E18). Fetuses at E20 and pre-adolescent pups at postnatal day 14 (P14) were studied: (1) normal untreated controls (CTL) at E20; (2) hyperglycemic placebo-treated (HPT) at E20; (3) hyperglycemic insulin-treated (HIT) at E20; (4) CTL at P14; and (5) HIT at P14. Fetal and pre-adolescent growth factors were determined.

RESULTS

Biomarkers of hypoxia were elevated in the HPT group at E20. This group did not survive to term. Maternal insulin improved fetal survival despite lower fetal body weight at E20, however, at normal birth (postnatal day 0 (P0)) and at P14, body weights and blood glucose were higher than CTL. These high levels correlated with aberrant growth factors. Maternal hyperglycemia influenced glucose-6-phosphate dehydrogenase, glucagon, insulin, interleukin-10, and leptin genes.

CONCLUSIONS

The impact of maternal hyperglycemia on pre-adolescent glucose and body weight was not a consequence of maternal overnutrition. This suggests an independent link which may affect offspring metabolic health in later life.

Health Behaviors and Prenatal Health Conditions in Repeat Vs First-time Teenage Mothers in the United States: 2015-2018

STUDY OBJECTIVE

Repeat teenage mothers, those who give birth to a second or higher-order infant before age 20 years, are at elevated risk for adverse perinatal outcomes compared with first-time teenage mothers. The objective of the current study was to compare the prevalence of negative pregnancy-related behaviors and gestational health conditions in the national United States population of first-time and repeat teenage mothers.

DESIGN, SETTING, AND PARTICIPANTS

We conducted a retrospective, population-based cohort study using annual US birth data files from 2015 to 2018, N = 799,756 (673,394 [84.2%] first, 126,362 [15.8%] repeat) births to women ages 15-19 years.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Pregnancy-related behaviors (including adequacy of prenatal care and weight gain, sexually transmitted infection, smoking, and breastfeeding) and gestational health conditions (gestational hypertension and gestational diabetes).

RESULTS

Repeat (vs first-time) mothers had higher prevalence of negative pregnancy-related behaviors: inadequate prenatal care, smoking, inadequate weight gain, and sexually transmitted infection during pregnancy; they were also less likely to breastfeed. Conversely, repeat teenage mothers experienced lower prevalence of gestational hypertension and gestational diabetes.

CONCLUSION

Repeat teenage mothers experienced lower prevalence of physical health complications during pregnancy but engaged in more negative pregnancy-related health behaviors. Negative health behavior in pregnancy can lead directly to poor perinatal outcomes for infants. To prevent adverse outcomes from repeat teenage childbearing, we must ensure access to quality, timely, prenatal and postpartum care so teenage mothers can receive support for healthy pregnancy-related behaviors as well as linkage to highly effective contraception to prevent unintended repeat births.

Longitudinal Changes of High Molecular Weight Adiponectin are Associated with Postpartum Development of Type 2 Diabetes Mellitus in Patients with Gestational Diabetes Mellitus

BACKGROUND

The influence of serial changes of adipokines on maternal glucose metabolism from pregnancy to postpartum periods in women with previous gestational diabetes mellitus (pGDM) has not been thoroughly explored. We tried to examine the relationship between the serial changes of adipokines and the development of diabetes mellitus (DM) in women with pGDM.

METHODS

We longitudinally measured following adipokines: high molecular weight (HMW) adiponectin, retinol-binding protein-4 (RBP-4), lipocalin-2, and chemerin, during pregnancy, and at 2 months and 3 years after delivery. Based on glucose status at postpartum 3 years, we divided into three groups: normal glucose tolerance (GDM-NGT, n=20), impaired glucose tolerance (GDM-IGT, n=23), and GDM-DM (n=22). We analyzed the correlations between adipokines and various metabolic parameters.

RESULTS

Plasma HMW adiponectin levels were not different among the three groups during pregnancy. However, HMW adiponectin levels increased at 3 years after the delivery in women with GDM-NGT compared with women with GDM-DM. In the GDM-IGT group, HMW adiponectin levels increased at 2 months postpartum compared to pregnancy period. In contrast, HMW adiponectin levels showed no alternation after parturition in women with GDM-DM. HMW adiponectin was negatively correlated with body mass index and a homeostasis model assessment of insulin resistance. Other adipokines such as RBP-4, lipocalin-2, and chemerin neither showed any differences among the groups nor any significant correlations with 3 years postpartum status of glucose intolerance.

CONCLUSION

Serial changes of HMW adiponectin are associated with the maintenance of glucose metabolism in women with pGDM after delivery.

The Role of Lifestyle Intervention in the Prevention and Treatment of Gestational Diabetes

Obesity during pregnancy is associated with the development of adverse outcomes, including gestational diabetes mellitus (GDM). GDM is highly associated with obesity and independently increases the risk of both complications during pregnancy and future impaired glycemic control and risk factors for cardiovascular disease for both the mother and child. Despite extensive research evaluating the effectiveness of lifestyle interventions incorporating diet and/or exercise, there remains a lack of definitive consensus on their overall efficacy alone or in combination for both the prevention and treatment of GDM. Combination of diet and physical activity/exercise interventions for GDM prevention demonstrates limited success, whereas exercise-only interventions report of risk reductions ranging from 3 to 49%. Similarly, combination therapy of diet and exercise is the first-line treatment of GDM, with positive effects on maternal weight gain and the prevalence of infants born large-for-gestational age. Yet, there is inconclusive evidence on the effects of diet or exercise as standalone therapies for GDM treatment. In clinical care, women with GDM should be treated with a multidisciplinary approach, starting with lifestyle modification and escalating to pharmacotherapy if needed. Several key knowledge gaps remain, including how lifestyle interventions can be optimized during pregnancy, and whether intervention during preconception is effective for preventing the rising prevalence of GDM.

Prevalence of Gestational Diabetes Mellitus and Its Associated Risk Factors in Boo-Ali Hospital, Tehran

BACKGROUND

Gestational diabetes mellitus (GDM) represents the most common metabolic complication during pregnancy. GDM is associated with maternal and fetal complications. Approximately 7% of all pregnancies are affected by GDM, resulting in more than 200,000 cases worldwide annually, and the prevalence may vary from 1% to 14% among all pregnancies. Accordingly, this study attempted to determine the prevalence and some risk factors of GDM.

MATERIALS AND METHODS

This hospital-based cross-sectional study was carried out at Boo-Ali hospital in Tehran, the capital of Iran. Four hundred non-diabetics pregnant women with a gestational age of 24-28 weeks who attended the Boo-Ali hospital outpatient department were included in our study. Demographic and anthropometric data including age, gravida, para, gestational age, family history of diabetes, history of GDM, weight, height, and body mass index (BMI) were collected. Blood samples were collected from the women at 24-28 weeks to diagnose GDM by oral glucose tolerance test (OGTT). We measured the 25-OH-D level in participants at 24-28 weeks.

RESULTS

Among the 400 pregnant women, 46 (11.5%) had GDM based on OGTT, and the mean age of GDM women were 30.78± 5.96 years. Among selected variables, BMI ≥25kg/m2, family history, and GDM history were associated with increased risks of GDM (odds ratio=2.49, 95% confidence interval [CI] 1.22-5.07;3.52, 95% CI 1.84-6.70; 19.57, and 95% CI 6.16-62.17, respectively). The association was more robust in the positive GDM history of women.

CONCLUSION

High prevalence of GDM highlights more attention of health-care givers in screening pregnant women with risk factors. BMI as a modifiable risk factor for GDM needs more attention, and positive family history and previous GDM history should be considered in the core activities of pregnant women.

Diabetes Risk and Control in Multi-ethnic US Immigrant Populations

PURPOSE OF REVIEW

The goal of this review is to assess current evidence on diabetes risk and control among adult immigrants in the USA.

RECENT FINDINGS

Patterns of diabetes risk in US immigrants may reflect global diabetes trends. Asian, Black, and Latinx immigrants all see a diabetes disadvantage relative to US-born Whites. Diabetes risk in Asian immigrants also surpasses US-born Asians. Relative diabetes risk among all groups increases with time in the USA. Research to explain patterns in diabetes risk and control among immigrants has broadened from lifestyle factors to include multi-level, life course influences on trajectories of risk. Some determinants are shared across groups, such as structural racism, healthcare access, and migration stress, whereas others such as diet are embedded in sending country culture. Current literature on diabetes in immigrant populations suggests a need to shift towards a transnational lens and macro-level social determinants of health framework to understand diabetes risk and potential prevention factors.

Altered gut bacterial and metabolic signatures and their interaction in gestational diabetes mellitus

Emerging evidence indicates that the gut microbiome can modulate metabolic homeostasis, and thus may influence the development of gestational diabetes mellitus (GDM). However, whether and how the gut microbiome and its correlated metabolites change in GDM is uncertain. Herein we compare the gut microbial compositions, and fecal and urine metabolomes, of 59 patients with GDM versus 48 pregnant healthy controls (HCs). We showed that the microbial and metabolic signatures of GDM patients were significantly different from those of HCs. Compared to HCs, the GDM subjects were characterized by enriched bacterial operational taxonomic units (OTUs) of the family Lachnospiraceae, and depleted OTUs of the families Enterobacteriaceae and Ruminococcaceae. Some altered gut microbes were significantly correlated with glucose values and fetal ultrasonography indexes. Moreover, we identified four fecal and 15 urine metabolites that discriminate GDM from HC. These differential metabolites are mainly involved in carbohydrate and amino acid metabolism. Significantly, co-occurrence network analysis revealed that Lachnospiraceae and Enterobacteriaceae bacterial OTUs formed strong co-occurring relationships with metabolites involved in carbohydrate and amino acid metabolism, suggesting that disturbed gut microbiome may mediate GDM. Furthermore, we identified a novel combinatorial marker panel that could distinguish GDM from HC subjects with high accuracy. Together our findings demonstrate that altered microbial composition and metabolic function may be relevant to the pathogenesis and pathophysiology of GDM.

Prevalence of Gestational Diabetes in India by Individual Socioeconomic, Demographic, and Clinical Factors

IMPORTANCE

Gestational diabetes is common in pregnancy and is associated with adverse pregnancy and fetal outcomes. Currently, population-based data on the prevalence of gestational diabetes are limited in India.

OBJECTIVE

To provide a comprehensive national assessment of gestational diabetes in India and its socioeconomic, demographic, and geographic associations, using elevated random blood glucose data as a proxy for a gestational diabetes diagnosis.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study analyzed the fourth National Family Health Survey, conducted in India between January 2015 and December 2016. This nationally representative sample comprised 699 686 women 15 to 49 years of age, of whom 32 428 (4.6%) were pregnant. Data were analyzed between July and December 2019 and between July and August 2020.

EXPOSURES

Age, body mass index, hypertension, wealth, and social caste were factors potentially associated with gestational diabetes.

MAIN OUTCOMES AND MEASURES

Gestational diabetes, defined as elevated random blood glucose according to predetermined thresholds (≥200 mg/dL for nonfasting, ≥92 mg/dL for fasting).

RESULTS

Of the 31 746 pregnant women with complete data in the study, the mean (SD) age was 24.3 (4.7) years, and the mean (SD) gestational age was 5.1 (2.3) months. The weighted age-adjusted prevalence of gestational diabetes was 1.3% (95% CI, 1.1%-1.5%). The prevalence of gestational diabetes increased with age, from 1.0% (95% CI, 0.5%-1.5%) at age 15 to 19 years to 2.4% (95% CI, 1.0%-3.8%) at age 35 years or older. The age-adjusted prevalence of gestational diabetes was higher among women with a body mass index of 27.5 or greater (1.8%; 95% CI, 1.0%-2.5%) compared with women with a body mass index of less than 18.5 (0.8%; 95% CI, 0.5%-1.1%), among women in the highest wealth quartile (1.7%; 95% CI, 1.1%-2.5%) compared with those in the lowest (0.9%; 95% CI, 0.7%-1.2%), and women in the south (eg, Kerala: 4.5%; 95% CI, 2.4%-6.7%; Telangana: 5.4%; 95% CI, 0.0%-11.0%) compared with the northeast (eg, Assam: 0.23%; 95% CI, 0.0%-0.48%; Mizoram: 0.16%; 95% CI, 0.0%-0.49%).

CONCLUSIONS AND RELEVANCE

In this study, considerable variation was found in the prevalence of gestational diabetes by state, socioeconomic status, and demographic factors. This finding has implications for the method of gestational diabetes screening in low-resource settings in India, especially in areas or among demographic groups with lower prevalence.

Prevalence of gestational diabetes mellitus in Argentina according to the Latin American Diabetes Association (ALAD) and International Association of Diabetes and Pregnancy Study Groups (IADPSG) diagnostic criteria and the associated maternal-neonatal complications

In Argentina, gestational diabetes mellitus (GDM) is diagnosed by the Latin American Diabetes Association (ALAD) diagnostic criterion. In this work, we investigated GDM prevalence according to the ALAD and IADPSG diagnostic criteria, evaluated maternal and fetal outcomes and assessed whether fasting glycemia between 92-99 mg/dL was associated with increased risk of macrosomia and maternal obesity/overweight in an Argentine cohort of pregnant women. GDM prevalence was 9.8% with the ALAD diagnostic criterion and 25% considering the IADPSG criterion. Increased prevalence of maternal obesity/overweight was observed in patients with fasting glycemia over 99 mg/dL. A population of high metabolic risk is identified by the ALAD criterion.

Pregnancy complications in women of Russian, Somali, and Kurdish origin and women in the general population in Finland

Objective:

We compared the prevalence of gestational diabetes and hypertensive disorders in the most recent pregnancy among women of Russian, Somali, and Kurdish origin and women in the general population in Finland.

Methods:

The study groups were selected from population-based samples of 18- to 64-year-old women. The women were of Russian (n = 318), Somali (n = 583), and Kurdish (n = 373) origin or from the general population (n = 243), and had given birth in Finland between 2004 and 2014. The data were obtained from the National Medical Birth Register and the Hospital Discharge Register. Data on gestational diabetes and hypertensive disorders were extracted based on relevant International Classification of Diseases, Tenth Revision codes. The main statistical methods were logistic regression analyses adjusted for age, parity, body mass index, socioeconomic status, and smoking.

Results:

The prevalence of gestational diabetes was 19.1% in Kurdish, 14.4% in Somali, 9.3% in Russian, and 11.8% in the general population. The prevalence of hypertensive disorders was 5.4% in the general population, 3.8% in Somali, 3.1% in Kurdish, and 1.7% in Russian. When adjusted for confounders, Kurdish women had two-fold odds for gestational diabetes (odds ratio = 1.98; 95% confidence interval = 1.20–3.32) compared with the general population, but the odds for hypertensive disorders did not differ between groups.

Conclusion:

Women of Kurdish origin were more likely to develop gestational diabetes. Studies with larger samples are required to confirm these findings to develop prevention strategies for later development of type 2 diabetes. Future research including other migrant groups is recommended to identify differences in pregnancy complications among the women in migrant and general population.

Associations of exposure to fine particulate matter during pregnancy with maternal blood glucose levels and gestational diabetes mellitus: Potential effect modification by ABO blood group

BACKGROUND

Previous studies have examined the relationships between prenatal fine particulate matter (PM_2.5) exposure and gestational diabetes mellitus (GDM), but the results were inconsistent. Furthermore, the possible effect modification by ABO blood group has not been explored.

OBJECTIVES

To assess the associations of PM_2.5 exposures during pregnancy with maternal glucose levels as well as GDM, and further to evaluate the potential effect modification by ABO blood group.

METHODS

Between January 2013 and January 2015, 4783 pregnant women were enrolled in our study based on a birth cohort in Wuhan. Daily PM_2.5 exposure levels for each woman during pregnancy were estimated using a spatial-temporal land-use regression model. Linear regressions with general estimating equations (GEE) were performed to assess the associations between trimester-specific PM_2.5 exposures and maternal glucose levels. Modified Poisson regressions with GEE analyses were used to evaluate the impacts of PM_2.5 exposures during each trimester on the risk of GDM. The associations of PM_2.5 exposure during the whole study period with glucose levels and GDM were estimated using multiple linear regression model and modified Poisson regression model, respectively. We conducted a stratified analysis to explore the potential effect modification by ABO blood group.

RESULTS

Among all the 4783 participants, 394 (8.24%) had GDM. Exposure to PM_2.5 was found to be positively associated with elevated fasting glucose level during the whole study period [0.382 mg/dL, 95% confidence interval (CI): 0.179-0.586, per 10 μg/m³ increase in PM_2.5], the first trimester (0.154 mg/dL ,95% CI: 0.017-0.291) and the second trimester (0.541 mg/dL, 95% CI: 0.390-0.692). No statistically significant results were observed between PM_2.5 and 1-h and 2-h glucose levels during any study period. Increased risks of GDM for each 10 μg/m³ increase in PM_2.5 levels were observed during the whole study period [relative risk (RR): 1.120, 95% CI: 1.021-1.228] and the first trimester (RR: 1.074, 95% CI: 1.012-1.141), but not the second trimester (RR: 1.035, 95% CI: 0.969-1.106). Stratified analysis indicated that the associations of PM_2.5 exposures with GDM were more pronounced among pregnant women with blood group A, but no significant effect modifications were observed.

CONCLUSION

Our study enriched epidemiological evidence linking PM_2.5 exposures during pregnancy to elevated maternal glucose levels and increased risk of GDM. More importantly, we first highlighted that the impact of PM_2.5 on GDM might be greater among pregnant women with blood group A.

The risk for childhood malignancies in the offspring of mothers with previous gestational diabetes mellitus: a population-based cohort study

The hyperglycemic intrauterine environment has been shown to have long-term effects on offspring. We aimed to evaluate its effect on the long-term risk of childhood malignancies. This was a population-based cohort analysis comparing the risk for long-term childhood malignancies (≤18 years) in children born to mothers with and without gestational diabetes mellitus (GDM). Childhood malignancies were diagnosed by physicians and recorded in hospital medical files according to predefined codes based on ICD-9. Deliveries occurred between the years 1991 and 2014 in a tertiary medical center. Children to mothers with pre-GDM, with fetal congenital malformations, and with benign tumors were excluded from the analysis. Kaplan-Meier survival curve was constructed to compare cumulative oncological morbidity in both groups over time. Cox proportional hazards model was used to control for confounders. During the study period, 236 893 infants met the inclusion criteria; 10 294 (4.3%) of whom were born to mothers with GDM. Hospitalizations involving malignancy diagnoses were comparable between the groups (0.11 vs. 0.12%; P=0.424), as were the cumulative incidences of total oncological morbidity using a Kaplan-Meier survival curve (log-rank P=0.820). In the Cox regression model, maternal GDM was not associated with increased childhood oncological hospitalizations while controlling for maternal age, gestational age, and hypertensive disorders (adjusted hazard ratio: 1.02, 95% confidence interval: 0.58-1.82, P=0.932). Exposure to intrauterine hyperglycemic environment due to maternal GDM does not increase the risk for childhood malignancies.

Fetal macrosomia in a Hispanic/Latinx predominant cohort and altered expressions of genes related to placental lipid transport and metabolism

Fetal overgrowth, termed fetal macrosomia when birth weight is greater than 4000 grams, is the major concern in the treatment of gestational diabetes mellitus (GDM). However, to date, the underlying mechanisms of fetal macrosomia have not been understood completely. Placental lipid metabolism is emerging as a critical player in fetal growth. In this study, we hypothesized that fatty acid transport and metabolism in the placental tissue was impaired in GDM women, dependent on fetal sex. To test this hypothesis, we analyzed the incidence of GDM, fetal macrosomia, and obesity in a large cohort consisting of 17995 pregnant subjects and majority of subjects being Hispanic/Latinx, and investigated expression of genes related to lipid transport and metabolism in placenta from obese women with or without GDM, and with or without fetal macrosomia. The main findings include: 1) There is a higher incidence of GDM and obesity in Hispanic subjects compared to non-Hispanic subjects, but not fetal macrosomia; 2) Expressions of most of genes related to placental lipid transport and metabolism are not altered by the presence of GDM, fetal macrosomia, or fetal sex; 3) Expression of FABP4 is increased in obese women with GDM and fetal macrosomia, and this occurred in male placentas; 4) Expression of LPL is decreased in obese women with GDM despite fetal macrosomia, and this occurred in male placentas; 5) Expression of ANGPTL3 is decreased in obese women with GDM and fetal macrosomia, but is not altered when fetal sex is included in the analysis. This study indicates that there is race disparity in GDM with higher incidence of GDM in obese Hispanic women, although fetal macrosomia disparity is not present. Moreover, altered placental lipid transport may contribute to fetal overgrowth in obese women with GDM.

Placensin is a glucogenic hormone secreted by human placenta

FBN1 encodes asprosin, a glucogenic hormone, following furin cleavage of the C-terminus of profibrillin 1. Based on evolutionary conservation between FBN1 and FBN2, together with conserved furin cleavage sites, we identified a peptide hormone placensin encoded by FBN2 based on its high expression in trophoblasts of human placenta. In primary and immortalized murine hepatocytes, placensin stimulates cAMP production, protein kinase A (PKA) activity, and glucose secretion, accompanied by increased expression of gluconeogenesis enzymes. In situ perfusion of liver and in vivo injection with placensin also stimulate glucose secretion. Placensin is secreted by immortalized human trophoblastic HTR-8/SVneo cells, whereas placensin treatment stimulates cAMP-PKA signaling in these cells, accompanied by increases in MMP9 transcripts and activities, thereby promoting cell invasion. In pregnant women, levels of serum placensin increase in a stage-dependent manner. During third trimester, serum placensin levels of patients with gestational diabetes mellitus are increased to a bigger extent compared to healthy pregnant women. Thus, placensin represents a placenta-derived hormone, capable of stimulating glucose secretion and trophoblast invasion.

Serum miR-195-5p is upregulated in gestational diabetes mellitus

BACKGROUND

Gestational diabetes mellitus (GDM) is defined as varying degrees of glucose intolerance with an onset or first recognition during pregnancy in women without previously diagnosed diabetes. Accumulating evidence indicates that miRNAs exert crucial roles in the pathogenesis and development of diabetes, including GDM. In the present study, we aimed to determine the clinical performance of miR-195-5p in GDM.

METHODS

First, the miR-195-5p expressions in serum samples from healthy pregnant women and women with GDM at 25 weeks pregnancy were detected using real-time polymerase chain reaction (RT-qPCR). Then, receive characteristic (ROC) curve was used to determine the diagnostic value of miR-195-5p in GDM. Finally, the correlation analysis of miR-195-5p expression with related clinicopathological factors was carried out to determine the clinical value of miR-195-5p in GDM.

RESULTS

In this study, we found that miR-195-5p expression was significantly increased in serum samples from GDM patients as compared with that in healthy pregnancies. Furthermore, miR-195-5p might be a putative biomarker for GDM diagnosis with an area under the curve (AUC) of 0.8451; the cutoff value was 1.598, sensitivity was 73.69%, specificity was 96.85%, accuracy was 81.26%, and Youden index was 70.54%. Expression of miR-195-5p was positively associated with fasting plasma glucose, one-hour plasma glucose, and two-hour plasma glucose.

CONCLUSION

miR-195-5p might function as a putative diagnostic biomarker for GDM and contribute to identifying at-risk mothers in pregnancy.

Effects of gum chewing on glycaemic control in women with gestational diabetes mellitus: A randomized controlled trial. Impact of chewing on hyperglycaemia in women with GDM

BACKGROUND

The amount of chewing might be relevant in reducing hyperglycaemia in diabetic patients. The study assessed the impact of enhanced chewing on glycaemic control in women with gestational diabetes mellitus (GDM).

METHODS

As an open-label, mono-centre randomized controlled trial, 59 women with recent diagnosis of GDM were included. They received either routine care or additional chewing gum intervention. SMBG was performed for five days.

RESULTS

No significant impact on mean values of postprandial glucose levels were observed. The estimated mean differences (intervention vs. control group) were: 4.9 mg/dl, 98.4 %CI -7.2-17.1 (breakfast); -4.5 mg/dl, 98.4 %CI -15.1-6.0 (lunch); -3.8 mg/dl, 98.4 %CI -15.9 to 8.4 (dinner). OGTT levels at 60 and 120 min. were associated with glucose levels after breakfast.

CONCLUSION

In conclusion, no significant differences in blood glucose levels were observed between the groups and therefore major effects of chewing on hyperglycaemia in women with GDM could be excluded.

TRIAL REGISTRATION

ClinicalTrials.gov; NCT03961542, Date of registration: 20.01.2019. Retrospectively registered.

Gestational Diabetes Mellitus Treatment Schemes Modify Maternal Plasma Cholesterol Levels Dependent to Women´s Weight: Possible Impact on Feto-Placental Vascular Function

: Gestational diabetes mellitus (GDM) associates with fetal endothelial dysfunction (ED), which occurs independently of adequate glycemic control. Scarce information exists about the impact of different GDM therapeutic schemes on maternal dyslipidemia and obesity and their contribution to the development of fetal-ED. The aim of this study was to evaluate the effect of GDM-treatments on lipid levels in nonobese (N) and obese (O) pregnant women and the effect of maternal cholesterol levels in GDM-associated ED in the umbilical vein (UV). O-GDM women treated with diet showed decreased total cholesterol (TC) and low-density lipoproteins (LDL) levels with respect to N-GDM ones. Moreover, O-GDM women treated with diet in addition to insulin showed higher TC and LDL levels than N-GDM women. The maximum relaxation to calcitonin gene-related peptide of the UV rings was lower in the N-GDM group compared to the N one, and increased maternal levels of TC were associated with even lower dilation in the N-GDM group. We conclude that GDM-treatments modulate the TC and LDL levels depending on maternal weight. Additionally, increased TC levels worsen the GDM-associated ED of UV rings. This study suggests that it could be relevant to consider a specific GDM-treatment according to weight in order to prevent fetal-ED, as well as to consider the possible effects of maternal lipids during pregnancy.

Nomogram for prediction of gestational diabetes mellitus in urban, Chinese, pregnant women

Background

This study sought to develop and validate a nomogram for prediction of gestational diabetes mellitus (GDM) in an urban, Chinese, antenatal population.

Methods

Age, pre-pregnancy body mass index (BMI), fasting plasma glucose (FPG) in the first trimester and diabetes in first degree relatives were incorporated as validated risk factors. A prediction model (nomogram) for GDM was developed using multiple logistic regression analysis, from a retrospective study conducted on 3956 women who underwent their first antenatal visit during 2015 in Shanghai. Performance of the nomogram was assessed through discrimination and calibration. We refined the predicting model with t-distributed stochastic neighbor embedding (t-SNE) to distinguish GDM from non-GDM. The results were validated using bootstrap resampling and a prospective cohort of 6572 women during 2016 at the same institution.

Results

Advanced age, pre-pregnancy BMI, high first-trimester, fasting, plasma glucose, and, a family history of diabetes were positively correlated with the development of GDM. This model had an area under the receiver operating characteristic (ROC) curve of 0.69 [95% CI:0.67–0.72, p < 0.0001]. The calibration curve for probability of GDM showed good consistency between nomogram prediction and actual observation. In the validation cohort, the ROC curve was 0.70 [95% CI: 0.68–0.72, p < 0.0001] and the calibration plot was well calibrated. In exploratory and validation cohorts, the distinct regions of GDM and non-GDM were distinctly separated in the t-SNE, generating transitional boundaries in the image by color difference. Decision curve analysis showed that the model had a positive net benefit at threshold between 0.05 and 0.78.

Conclusions

This study demonstrates the ability of our model to predict the development of GDM in women, during early stage of pregnancy.

Blood pressure in pregnancy-A stress test for hypertension? Five-year, prospective, follow-up of the ROLO study

OBJECTIVE

To investigate whether maternal blood pressure (BP) below the diagnostic criteria of hypertensive disorders of pregnancy (HDP) is associated with maternal BP 5 years later.

DESIGN

Prospective, observational study.

SETTING

Dublin, Ireland (2007-2011).

SAMPLE

Three hundred twenty-nine women from the ROLO study (Randomized cOntrol trial of LOw glycaemic index diet to prevent the recurrence of macrosomia).

METHODS

Maternal BP measurements were taken during pregnancy (13, 28 and 34 weeks' gestation and day 1 postpartum) and at the 5-year follow-up. Systolic BP (SBP) and diastolic BP (DBP) were categorized as normal (SBP < 120 and DBP < 80 mm Hg), elevated (SBP 120-129 and DBP < 80 mm Hg), HTN stage 1 (SBP 130-139 or DBP 80-89 mm Hg) or HTN stage 2 (SBP ≥ 140 or DBP ≥ 90 mm Hg) at each timepoint.

MAIN OUTCOME MEASURES

Maternal blood pressure at the 5-year follow-up.

RESULTS

Women with elevated BP at 28 and 34 weeks' gestation had 2.68 (95% CI: 1.36-5.26) and 2.45-fold (95% CI: 1.22-4.95) increased odds of HTN stage 1 respectively, at the 5-year follow-up, compared to those with normal BP in pregnancy.

CONCLUSION

Elevated BP at 28 and 34 weeks' gestation was associated with an increased risk of HTN stage 1 at 5 years later. Thus, raised BP, below the diagnostic criteria of HDP, could be flagged for follow-up postpartum.

Neonatal outcomes and its association among gestational diabetes mellitus with and without depression, anxiety and stress symptoms in Malaysia: A cross-sectional study

OBJECTIVE

Prevalence of depression, anxiety and stress symptoms in gestational diabetes mellitus ranges from 10.2% to 39.9% based on previous studies in Malaysia. Presence of depression, anxiety or stress in pregnancy may increase the risk of neonatal morbidity and mortality. The aim of this study was to determine the prevalence of neonatal outcomes and its association among mothers with gestational diabetes mellitus with and without the presence of depression, anxiety and stress symptoms in Malaysia.

DESIGN

This was a cross-sectional study.

SETTING

Tertiary hospitals in Malaysia.

PARTICIPANTS

Mothers with gestational diabetes mellitus (n = 418) who deliver their neonates at two major tertiary hospitals in Malaysia.

MEASUREMENTS

Neonatal outcomes, such as low birth weight, preterm birth, macrosomia, metabolic and electrolyte disorders, neonatal respiratory distress and congenital anomalies were determined.

FINDINGS

Prevalence of low birth weight in neonates born to mothers with gestational diabetes mellitus was 14.6%, followed by metabolic and electrolyte disorders 10.5%, preterm birth 9.1%, macrosomia 4.8%, neonatal respiratory distress 5.8% and congenital anomalies (2.4%). Among the adverse neonatal outcomes, neonatal respiratory distress was significantly associated with the presence of depression symptoms in mothers with gestational diabetes mellitus using univariate analysis (p = 0.010). After controlling for confounding factors, predictors for neonatal respiratory distress at delivery were the presence of depression symptoms in mothers with gestational diabetes mellitus (Adjusted OR = 3.87, 95% CI = 1.32-11.35), living without a husband (Adjusted OR = 9.74, 95% CI = 2.04-46.51), preterm delivery (Adjusted OR = 7.20, 95% CI = 2.23-23.30), caesarean section (Adjusted OR = 3.33, 95% CI = 1.09-10.15), being nulliparous and primiparous (Adjusted OR = 3.62, 95% CI = 1.17-11.17) and having family history of diabetes (Adjusted OR = 3.20, 95% CI = 1.11-9.21).

KEY CONCLUSIONS

The findings of this study demonstrate the positive association of neonatal respiratory distress with the presence of depression symptoms in mothers with gestational diabetes mellitus.

IMPLICATIONS FOR PRACTICE

It is therefore important to identify depression symptoms after a diagnosis of gestational diabetes mellitus in pregnant mothers is made to enable early referral and interventions.