Metformin-treated-GDM has lower risk of macrosomia compared to diet-treated GDM- a retrospective cohort study

Metformin in gestational diabetes: physiological actions and clinical applications

Metformin is an effective oral hypoglycaemic agent used in the treatment of type 2 diabetes mellitus; however, its use in pregnancy for the treatment of gestational diabetes mellitus (GDM) remains controversial owing to concerns around safety and efficacy. This comprehensive review outlines the physiological metabolic functions of metformin and synthesizes existing literature and key knowledge gaps pertaining to the use of metformin in pregnancy across various end points in women with GDM. On the basis of current evidence, metformin reduces gestational weight gain, neonatal hypoglycaemia and macrosomia and increases insulin sensitivity. However, considerable heterogeneity between existing studies and the grouping of aggregate and often inharmonious data within meta-analyses has led to disparate findings regarding the efficacy of metformin in treating hyperglycaemia in GDM. Innovative analytical approaches with stratification by individual-level characteristics (for example, obesity, ethnicity, GDM severity and so on) and treatment regimens (diagnostic criteria, treatment timing and follow-up duration) are needed to establish efficacy across a range of end points and to identify which, if any, subgroups might benefit from metformin treatment during pregnancy.

Association between gestational diabetes mellitus diagnostic criteria and adverse pregnancy outcomes-a systematic review and meta-analysis of adjusted effect sizes from studies using current diagnostic criteria

OBJECTIVES

To quantify the association between Gestational Diabetes Mellitus (GDM) and adverse pregnancy outcomes and primarily compare the associations between diagnostic criteria following the International Association of Diabetes and Pregnancy Study Groups (IADPSG) recommendations and non-IADPSG criteria, which use higher blood glucose cut-offs.

DESIGN

Systematic review and meta-analysis of observational studies using contemporary GDM diagnostic criteria.

DATA SOURCES

PubMed, Scopus, Google Scholar, Cochrane Database of Systematic Reviews and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched for articles published between 2010 and 2023. The search was carried out on 15 May 2023.

ELIGIBILITY CRITERIA

Studies were included if they were observational studies that reported adjusted effect sizes for GDM-related adverse outcomes and compared outcomes between women with and without GDM, used contemporary diagnostic criteria and were conducted after 2010.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently extracted data and assessed study quality using the MethodologicAl STandards for Epidemiological Research (MASTER) scale. Bias-adjusted inverse variance heterogeneity meta-analysis models were used to synthesise adjusted effect sizes. The same meta-analytic models were used to synthesise the overall OR and their 95% CIs for comparisons of the criteria which followed the IADPSG recommendations to other criteria, mostly with higher blood glucose cut-offs (non-IADPSG).

RESULTS

We included 30 studies involving 642 355 participants. GDM was associated with higher odds of maternal outcomes, namely; caesarean section (adjusted OR (aOR) 1.24, 95% CI 1.01 to 1.51) and pregnancy-induced hypertension (aOR 1.55, 95% CI 1.03 to 2.34). GDM was associated with higher odds of neonatal outcomes, specifically; macrosomia (aOR 1.38, 95% CI 1.13 to 1.69), large for gestational age (aOR 1.42, 95% CI 1.23 to 1.63), preterm birth (aOR 1.41, 95% CI 1.21 to 1.64), neonatal intensive care unit admission (aOR 1.42, 95% CI 1.12 to 1.78), neonatal hypoglycaemia (aOR 3.08, 95% CI 1.80 to 5.26) and jaundice (aOR 1.47, 95% CI 1.12 to 1.91). Further analyses showed no major differences in adverse pregnancy outcomes between IADPSG and non-IADPSG criteria.

CONCLUSIONS

GDM is consistently associated with adverse pregnancy, maternal and foetal outcomes, regardless of the diagnostic criteria used. These findings suggest no significant difference in risk between lower and higher blood glucose cut-offs used in GDM diagnosis.

Neonatal Outcomes in Patients with Gestational Diabetes Mellitus Treated with Metformin: A Retrospective Study in Saudi Arabia

BACKGROUND

Gestational diabetes mellitus (GDM) is a common endocrine disease that can occur during pregnancy, increasing the risk of fetal morbidity and mortality. Metformin is a commonly used therapeutic approach for managing GDM. However, there is controversy regarding the effects of metformin on fetal outcomes during pregnancy. This study aimed to evaluate the safety of metformin in relation to neonatal complications, compared to treatment with insulin and/or specialized diets.

METHOD

This was a retrospective study that included pregnant women who were diagnosed with GDM and treated with specialized diets, metformin, or insulin. Data were collected from patients' electronic medical records and analyzed to evaluate the risk of neonatal outcomes in the metformin group compared to the others.

RESULTS

The study included 234 women with GDM. There was no difference between the metformin and insulin groups in terms of the rates of neonatal outcomes, while neonatal hypoglycemia, neonatal hyperbilirubinemia, large for gestational age, and respiratory distress were higher in the metformin group when compared to the diet group. Metformin slightly increased the risk of a lower APGAR score compared to diet alone.

CONCLUSIONS

Metformin was found to be a safe therapy for the fetus when used to manage GDM, compared to insulin therapy. More randomized studies are needed to confirm these findings in the Saudi population.

Differences in neonatal adverse outcomes among women with gestational diabetes mellitus managed by diet or medication: a propensity score matched analysis of a population-based sample

OBJECTIVE

Neonatal outcomes in women with and without medically managed gestational diabetes mellitus (GDM) were compared after accounting for differences in maternal baseline characteristics using a propensity score (PS) analysis.

METHODS

Women without preexisting diabetes, delivering singletons during 2010-2017 in a large hospital, were eligible for inclusion. Using nearest-neighbour PS matching, women with non-pharmacological managed GDM were matched with women whose GDM was medically managed. A conditional logistic regression consequently compared the neonatal adverse outcomes between the groups after adjusting for gestational age, induction of labor, birth type, and number of ultrasounds conducted during the pregnancy.

RESULTS

Of the overall 10028 births, GDM was diagnosed in 930 (9.3%), of whom 710 (76.3%) were successfully matched. The conditional regressions found higher risk of neonatal adverse outcomes in neonates of women with non-pharmacological managed GDM compared to neonates of women with medically managed GDM. These included a higher risk of hypoglycemia (odds ratio (OR) 1.56, 95% confidence interval (CI) 1.03-2.38, p = 0.037), hypothermia (OR 2.29, 95%CI 1.05-5.00, p = 0.037), and birth injuries (OR 3.50, 95%CI 1.62-7.58, p = 0.001), and a higher risk of being small for gestational age (OR 2.06, 95%CI 1.01-4.18, p = 0.046) and being admitted to a special care unit (OR 2.04, 95%CI 1.29-3.21, p = 0.002).

CONCLUSIONS

The increased neonatal morbidity associated with non-medicated GDM identified in our study may indicate that diet and lifestyle changes alone are not sufficient to achieve glycaemic control in some women with GDM. Our findings indicate that gestational diabetes management approach is independently associated with neonatal outcomes.

Effects of insulin aspart and metformin on gestational diabetes mellitus and inflammatory markers

BACKGROUND

Gestational diabetes mellitus (GDM) refers to hyperglycemia caused by insulin resistance or insufficient insulin secretion during pregnancy. Patients with GDM have a high risk of pregnancy complications, which can adversely affect both maternal and fetal health. Therefore, early diagnosis, treatment and monitoring of GDM are essential. In recent years, a new treatment scheme represented by insulin aspart combined with metformin has received increasing attention.

AIM

To explore the effects of insulin aspart combined with metformin on patients with GDM and inflammatory markers.

METHODS

From April 2020 to September 2022, 124 patients with GDM in Sanya Women and Children's Hospital Managed by Shanghai Children's Medical Center were collected and analyzed retrospectively. The control group (CG) comprised 62 patients treated with insulin aspart alone, and 62 patients treated with insulin aspart and metformin formed the observation group (OG). Before and after treatment, improvement of blood-glucose-related indexes [fasting blood glucose (FBG), 2-h postprandial glucose (2h PG) and hemoglobin A1c (HbA1c)], serum related factor [serum homocysteine (Hcy)], serum inflammatory cytokines [tumor necrosis factor (TNF)-α, interleukin (IL)-6 and C-reactive protein (CRP)] were compared between the two groups. The clinical efficacy, adverse pregnancy outcomes and incidence of pregnancy complications were compared between the two groups.

RESULTS

After treatment, the levels of FBG, 2h PG, HbA1c, Hcy, TNF-α, IL-6 and CRP in both groups were significantly decreased (P < 0.05), and the levels of FBG, 2h PG, HbA1c, Hcy, TNF-α, IL-6 and CRP in the OG were lower than in the CG (P < 0.05). The total clinical effectiveness in the OG was higher than that in the CG (P < 0.05). The total incidence of adverse pregnancy outcomes and complications in the OG was significantly lower than in the CG (P < 0.05).

CONCLUSION

Insulin aspart combined with metformin are effective for treatment of GDM, which can reduce blood-glucose-related indexes, Hcy and serum inflammatory cytokines, and risk of adverse pregnancy outcomes and complications.

Precision gestational diabetes treatment: a systematic review and meta-analyses

BACKGROUND

Gestational Diabetes Mellitus (GDM) affects approximately 1 in 7 pregnancies globally. It is associated with short- and long-term risks for both mother and baby. Therefore, optimizing treatment to effectively treat the condition has wide-ranging beneficial effects. However, despite the known heterogeneity in GDM, treatment guidelines and approaches are generally standardized. We hypothesized that a precision medicine approach could be a tool for risk-stratification of women to streamline successful GDM management. With the relatively short timeframe available to treat GDM, commencing effective therapy earlier, with more rapid normalization of hyperglycaemia, could have benefits for both mother and fetus.

METHODS

We conducted two systematic reviews, to identify precision markers that may predict effective lifestyle and pharmacological interventions.

RESULTS

There was a paucity of studies examining precision lifestyle-based interventions for GDM highlighting the pressing need for further research in this area. We found a number of precision markers identified from routine clinical measures that may enable earlier identification of those requiring escalation of pharmacological therapy (to metformin, sulphonylureas or insulin). This included previous history of GDM, Body Mass Index and blood glucose concentrations at diagnosis.

CONCLUSIONS

Clinical measurements at diagnosis could potentially be used as precision markers in the treatment of GDM. Whether there are other sensitive markers that could be identified using more complex individual-level data, such as omics, and if these can feasibly be implemented in clinical practice remains unknown. These will be important to consider in future studies.

Update on gestational diabetes and adverse pregnancy outcomes

PURPOSE OF REVIEW

To explore the recent literature concerning the effect of gestational diabetes (GDM) on adverse pregnancy outcomes (APO).

RECENT FINDINGS

Literature search on PubMed, Medline and British Journal of Obstetrics and Gynaecology was conducted using keywords. Search fields were filtered down to include articles from 2019 onwards. GDM is common during pregnancy and is on the rise because of increasing in obesity rates. GDM tended to show an increased risk of APO compared with non-GDM. Treatment of these pregnancies tended to improve these outcomes, particularly for LGA and macrosomia. Additional factors such as prepregnancy BMI and gestational weight gain (GWG) were shown to influence risk. More studies are needed to determine the true effect on postpartum haemorrhage (PPH) and induction of labour (IOL).

SUMMARY

The review agrees with the findings from previous studies and adds to the current literature. Early intervention to manage glycaemic control and GWG may help improve these outcomes. Public health strategies that tackle obesity rates will help to reduce prepregnancy BMI and, therefore, rates of GDM.

The function, mechanisms, and clinical applications of metformin: potential drug, unlimited potentials

Metformin has been used clinically for more than 60 years. As time goes by, more and more miraculous effects of metformin beyond the clinic have been discovered and discussed. In addition to the clinically approved hypoglycemic effect, it also has a positive metabolic regulation effect on the human body that cannot be ignored. Such as anti-cancer, anti-aging, brain repair, cardiovascular protection, gastrointestinal regulation, hair growth and inhibition of thyroid nodules, and other nonclinical effects. Metformin affects almost the entire body in the situation taking it over a long period, and the preventive effects of metformin in addition to treating diabetes are also beginning to be recommended in some guidelines. This review is mainly composed of four parts: the development history of metformin, the progress of clinical efficacy, the nonclinical efficacy of metformin, and the consideration and prospect of its application.

Observational assessments of the relationship of dietary and pharmacological treatment on continuous measures of dysglycemia over 24 hours in women with gestational diabetes

Objectives

Studies that use continuous glucose monitoring (CGM) to monitor women with gestational diabetes (GDM), highlight the importance of managing dysglycemia over a 24-hour period. However, the effect of current treatment methods on dysglycemia over 24-hrs are currently unknown. This study aimed to characterise CGM metrics over 24-hrs in women with GDM and the moderating effect of treatment strategy.

Methods

Retrospective analysis of CGM data from 128 women with GDM in antenatal diabetes clinics. CGM was measured for 7-days between 30-32 weeks gestation. Non-parametric tests were used to evaluate differences of CGM between periods of day (morning, afternoon, evening, and overnight) and between treatment methods (i.e., diet alone or diet+metformin). Exploratory analysis in a subgroup of 34 of participants was performed to investigate the association between self-reported macronutrient intake and glycaemic control.

Results

Glucose levels significantly differed during the day (i.e., morning to evening; P<0.001) and were significantly higher (i.e., mean blood glucose and area under the curve [AUC]) and more variable (i.e., SD and CV) than overnight glucose levels. Morning showed the highest amount of variability (CV; 8.4% vs 6.5%, P<0.001 and SD; 0.49 mmol/L vs 0.38 mmol/L, P<0.001). When comparing treatment methods, mean glucose (6.09 vs 5.65 mmol/L; P<0.001) and AUC (8760.8 vs 8115.1 mmol/L.hr; P<0.001) were significantly higher in diet+metformin compared to diet alone. Finally, the exploratory analysis revealed a favourable association between higher protein intake (+1SD or +92 kcal/day) and lower mean glucose (-0.91 mmol/L p, P=0.02) and total AUC (1209.6 mmol/L.h, P=0.021).

Conclusions

Glycemia varies considerably across a day, with morning glycemia demonstrating greatest variability. Additionally, our work supports that individuals assigned to diet+metformin have greater difficulty managing glycemia and results suggest that increased dietary protein may assist with management of dysglycemia. Future work is needed to investigate the benefit of increased protein intake on management of dysglycemia.

Metformin in pregnancy and risk of abnormal growth outcomes at birth: a register-based cohort study

We previously reported an increased risk of being small for gestational age (SGA) and a decreased risk of being large for gestational age (LGA) after in utero exposure to metformin compared with insulin exposure. This follow-up study investigated if these observations remain when metformin exposure (henceforth, metformin cohort) is compared with non-pharmacological antidiabetic treatment of gestational diabetes mellitus (GDM; naïve cohort), instead of insulin. RESEARCH DESIGN AND METHODS : This was a Finnish population register-based cohort study from singleton children born during 2004-2016. Birth outcomes from metformin cohort (n=3964) and the naïve cohort (n=82 675) were used in the main analyses. Additional analyses were conducted in a subcohort, restricting the metformin cohort to children of mothers with GDM only (n=2361). Results were reported as inverse probability of treatment weighted OR (wOR), with the naïve cohort as reference. RESULTS  : No difference was found for the outcome of SGA between the cohorts in the main analyses (wOR 0.97, 95% CI 0.73 to 1.27) or in the additional analyses (wOR 1.01, 95% CI 0.75 to 1.37). No difference between the cohorts was found for the risk of LGA (wOR 0.91, 95% CI 0.75 to 1.11) in the main analyses but a decreased risk was observed in the additional analyses (wOR 0.72, 95% CI 0.56 to 0.92). CONCLUSIONS : This follow-up study found no increase in the risk of SGA or LGA after in utero exposure to metformin, compared with drug-naïve GDM. The decreased risk of LGA in mothers with GDM may suggest residual confounding. The lack of increased SGA risk aligns with findings from studies using metformin in non-diabetic pregnancies. In contrast, lower birth weight and increased SGA birth risk were observed in GDM pregnancies for metformin versus insulin. Metformin should be avoided with emerging growth restriction in utero. The interplay of intrauterine hyperglycemia and pharmacological treatments needs further assessment.

Placental DNA methylation changes in gestational diabetes mellitus

In this study, we investigated the association between altered methylation in the maternal placenta and hyperglycaemia and explored the epigenetic mechanisms underlying gestational diabetes mellitus (GDM). Reduced representation bisulphite sequencing (RRBS) and RNA sequencing (RNA-seq) were performed on placental tissues obtained from women with GDM and healthy controls. Further, pyrosequencing, correlation analyses, and linear regression analyses were performed to valuate relationships between aberrantly methylated-differentially expressed genes and clinical parameters. The EMBOSS and JASPAR databases were used for a computational analysis of CpG islands and transcription factor-binding sites in the TRIM67 promoter region. A CpG island with a length of 264 bp in the placental TRIM67 promoter region in the GDM group exhibited significant hypermethylation at four CpG sites. The hypermethylation of the TRIM67 promoter region in the maternal placenta showed a significant, positive correlation with the 1 h and 2 h oral glucose tolerance test (OGTT) values and a negative correlation with lipoprotein(a). Placental DNA methylation levels in the TRIM67 promoter region were markedly elevated in GDM and were associated with blood glucose and lipid levels during healthy pregnancy.

Establishing the Optimal Time for Induction of Labor in Women with Diet-Controlled Gestational Diabetes Mellitus: A Single-Center Observational Study

To determine the optimal week for labor induction in women with diet-controlled gestational diabetes mellitus by comparing differences in perinatal and neonatal outcomes of labor induction to expectant management at different gestational weeks. Methods: This was a retrospective analysis of a prospectively recruited cohort of 797 singleton pregnancies complicated by diet-controlled gestational diabetes mellitus that were diagnosed, treated, and delivered after 37 weeks in a tertiary, university-affiliated perinatal center between January 2016 and December 2021. Results: The incidence of neonatal complications was highest when delivery occurred at 37 weeks, whereas fetal macrosomia occurred mostly at 41 weeks (20.7%); the frequency of large for gestational age infants did not differ between the groups. Conversely, the best neonatal outcomes were observed at 40 weeks due to the lowest number of neonates requiring phototherapy for neonatal jaundice (1.7%) and the smallest proportion of neonates experiencing composite adverse neonatal outcomes defined as neonatal hypoglycemia, phototherapy, clavicle fracture, or umbilical artery pH < 7.15 (10.4%). Compared with expectant management, the risk for neonatal hypoglycemia was increased for induction at 39 weeks (adjusted odds ratio 12.29, 95% confidence interval 1.35−111.75, p = 0.026) and that for fetal macrosomia was decreased for induction at 40 weeks (adjusted odds ratio 0.11, 95% confidence interval 0.01−0.92, p = 0.041), after adjusting for maternal pre-pregnancy body mass index, nulliparity, and mean pregnancy A1c. Conclusions: The lowest rate of neonatal complications was observed at 40 weeks. Labor induction at 40 weeks prevented fetal macrosomia.

The association between gestational diabetes and stillbirth: a systematic review and meta-analysis

AIMS/HYPOTHESIS

Controversy exists over whether gestational diabetes increases the risk of stillbirth. The aim of this review was to examine the association between gestational diabetes and stillbirth.

METHODS

We performed searches of the published literature to May 2021. Study selection and data extraction were performed in duplicate by independent reviewers. Meta-analyses of summary measures were conducted using random-effect models for cohort and case-control studies separately. The study protocol was registered in PROSPERO (registration ID CRD42020166939).

RESULTS

From 9981 citations, 419 were identified for full-text review and 73 met inclusion criteria (n = 70,292,090). There was no significant association between gestational diabetes and stillbirth in cohort studies (pooled OR 1.04 [95% CI 0.90, 1.21]; I2 86.1%) or in case-control studies (pooled OR 1.57 [95% CI 0.83, 2.98]; I2 94.8%). Gestational diabetes was associated with lower odds of stillbirth among cohort studies presenting with an adjusted OR (pooled OR 0.78 [95% CI 0.68, 0.88]; I2 42.7%). Stratified analyses by stillbirth ≥28 weeks' gestation, studies published prior to 2013 and studies identified as low quality demonstrated a significantly higher odds of stillbirth in meta-regression (p = 0.016, 0.023 and 0.005, respectively). Egger's test for all included cohort studies (p = 0.018) suggests publication bias for the main meta-analysis.

CONCLUSIONS/INTERPRETATION

Given the substantial heterogeneity across studies, there are insufficient data to define the relationship between stillbirth and gestational diabetes adequately. In the main analyes, gestational diabetes was not associated with an increased risk of stillbirth. However, heterogeneity across studies means this finding should be interpreted cautiously.

High glucose increases IGF-2/H19 expression by changing DNA methylation in HTR8/SVneo trophoblast cells

INTRODUCTION

Gestational diabetes mellitus (GDM) is associated with many adverse outcomes of pregnancy, especially macrosomia. The aim of our study was to verify whether high glucose concentrations change the methylation levels of the insulin-like growth factor-2 (IGF-2)/H19 gene promoters to increase the expression of IGF-2, a key gene in fetal growth regulation.

METHODS

HTR8/SVneo cells were used to establish a cell model of intrauterine hyperglycemia in pregnant women with GDM. The RNA expression levels of the IGF-2/H19 genes and the methylation levels of the IGF-2/H19 gene promoter regions were measured. Methylated and unmethylated IGF-2/H19 gene promoter plasmids were transfected into HTR8/SVneo cells.

RESULTS

Among the five groups of cells, the RNA levels of IGF-2 and H19 were lowest in the 5-mM (physiological blood glucose level) group, which was statistically significant (all P < 0.05). Compared with those in the 5-mM group, two cytosine-phosphate-guanine (CpG) sites in the promoter region of the IGF-2 gene and twelve CpG sites in the promoter region of the H19 gene had statistically significant changes in methylation levels (all P < 0.05). Additionally, luciferase activity was significantly higher in cells transfected with the methylated H19 gene promoter plasmid than in control cells transfected with the unmethylated plasmid (P < 0.01), while the methylated IGF-2 gene promoter plasmid produced lower luciferase activity than the unmethylated plasmid (P < 0.01).

DISCUSSION

High glucose concentrations may increase IGF-2/H19 expression by changing the methylation levels of the IGF-2 and H19 gene promoters.

Screening pregnant women in a high-risk population with WHO-2013 or NICE diagnostic criteria does not affect the prevalence of gestational diabetes

There are currently several diagnostic criteria for gestational diabetes (GDM). Both the WHO -2013 and NICE diagnose GDM based on a single step 75 g OGT; however; each uses different glucose thresholds. Previous studies have shown that the prevalence of GDM using the NICE criteria (GDM-N) is lower than that using the WHO-2013 criteria (GDM-W). Qatar has national diabetes in pregnancy program in which all pregnant women undergo OGTT screening using the WHO-2013 criteria. This study aims to define the prevalence of GDM using both criteria in a high-risk population. This retrospective study included 2000 women who underwent a 75 g (OGTT) between Jan 2016 and Apr 2016 and excluded patients with known pre-conception diabetes, multiple pregnancy, and those who did not complete the OGTT. We then classified the women into GDM-W positive, GDM-N positive but GDM-W negative, and normal glucose tolerance (NGT) population. A total of 1481 women (74%) had NGT using the NICE or the WHO-2013 criteria. The number of patients who met both criteria was 279 subjects (14%) with a good agreement (Kappa coefficient 0.67, p < 0.001). The NICE and the WHO-2013 criteria were discordant in 240 subjects (12% of the cohort); 6.7% met the WHO -2013 criteria only and only 5.3% met the NICE criteria. The frequency of pre-eclampsia, pre-term delivery, Caesarean-section, LGA and neonatal ICU admissions were significantly increased in the GDM-W group. However, the GDM-N positive but GDM-W negative had no increased risk of maternal or fetal complications apart from pregnancy-induced hypertension. The WHO-2013 and the NICE criteria classified a similar proportion of pregnant women, 21.5% and 20.1%, respectively, as having GDM; however, they were concordant in only 14% of the cases. Women who are GDM-N positive but GDM-W negative are not at increased risk of maternal and fetal pregnancy complications, except for pregnancy-induced hypertension. As the NICE criteria are more specific to the UK population, we would recommend the use of the WHO-2013 criteria to diagnose GDM in the MENA region and possibly other regions that do not have the same set-up as the UK.

Effect of metformin on biomarkers of placental- mediated disease: A systematic review and meta-analysis

Metformin reduces the incidence of placental-mediated disease (PMD) in pregnancies with and without diabetes, but the mechanism through which it exerts these effects is not yet fully understood. We performed a systematic review and meta-analysis to examine the effect of metformin on biomarkers implicated in the pathogenesis of PMD. We searched Medline, Embase and the Cochrane Library for studies of metformin and biomarkers of PMD in pregnancy. Meta-analysis was undertaken where comparable data were obtained from two or more studies. 12 studies were included in the final review. Meta-analysis of 2 studies including 323 pregnant women showed significantly reduced CRP levels following treatment with metformin compared to placebo [mean difference = -1.72, 95% CI (-2.97; -0.48); p = 0.007]. Metformin exposure was also associated with decreased levels of the inflammatory cytokines TNFα, IL-1a, IL-1b and IL-6 in serum, placenta and omental tissue taken from pregnant women. Metformin significantly decreased the release of anti-angiogenic factors sFlt-1 and sEng from ex-vivo placental and umbilical vein tissue, and increased maternal serum levels of non-phosphorylated IGFBP-1. Overall, our findings show that metformin mediates several molecular pathways implicated in the pathogenesis of pre-eclampsia and intrauterine growth retardation. Metformin therefore has exciting potential as a therapeutic, as well as preventative, agent in the treatment of PMD, which warrants further investigation.

apoA2 correlates to gestational age with decreased apolipoproteins A2, C1, C3 and E in gestational diabetes

INTRODUCTION

Pregnant women with gestational diabetes mellitus (GDM) are at risk of adverse outcomes, including gestational hypertension, pre-eclampsia, and preterm delivery. This study was undertaken to determine if apolipoprotein (apo) levels differed between pregnant women with and without GDM and if they were associated with adverse pregnancy outcome.

RESEARCH DESIGN AND METHODS

Pregnant women (46 women with GDM and 26 women without diabetes (ND)) in their second trimester were enrolled in the study. Plasma apos were measured and correlated to demographic, biochemical, and pregnancy outcome data.

RESULTS

apoA2, apoC1, apoC3 and apoE were lower in women with GDM compared with control women (p=0.0019, p=0.0031, p=0.0002 and p=0.015, respectively). apoA1, apoB, apoD, apoH, and apoJ levels did not differ between control women and women with GDM. Pearson bivariate analysis revealed significant correlations between gestational age at delivery and apoA2 for women with GDM and control women, and between apoA2 and apoC3 concentrations and C reactive protein (CRP) as a measure of inflammation for the whole group.

CONCLUSIONS

Apoproteins apoA2, apoC1, apoC3 and apoE are decreased in women with GDM and may have a role in inflammation, as apoA2 and C3 correlated with CRP. The fact that apoA2 correlated with gestational age at delivery in both control women and women with GDM raises the hypothesis that apoA2 may be used as a biomarker of premature delivery, and this warrants further investigation.

Improvement Effect of Metformin on Female and Male Reproduction in Endocrine Pathologies and Its Mechanisms

Metformin (MF), a first-line drug to treat type 2 diabetes mellitus (T2DM), alone and in combination with other drugs, restores the ovarian function in women with polycystic ovary syndrome (PCOS) and improves fetal development, pregnancy outcomes and offspring health in gestational diabetes mellitus (GDM) and T2DM. MF treatment is demonstrated to improve the efficiency of in vitro fertilization and is considered a supplementary drug in assisted reproductive technologies. MF administration shows positive effect on steroidogenesis and spermatogenesis in men with metabolic disorders, thus MF treatment indicates prospective use for improvement of male reproductive functions and fertility. MF lacks teratogenic effects and has positive health effect in newborns. The review is focused on use of MF therapy for restoration of female and male reproductive functions and improvement of pregnancy outcomes in metabolic and endocrine disorders. The mechanisms of MF action are discussed, including normalization of metabolic and hormonal status in PCOS, GDM, T2DM and metabolic syndrome and restoration of functional activity and hormonal regulation of the gonadal axis.

Prevalence of Gestational Diabetes Mellitus in the Middle East and North Africa, 2000-2019: A Systematic Review, Meta-Analysis, and Meta-Regression

Women in the Middle East and North Africa (MENA) region are burdened with several risk factors related to gestational diabetes mellitus (GDM) including overweight and high parity. We systematically reviewed the literature and quantified the weighted prevalence of GDM in MENA at the regional, subregional, and national levels. Studies published from 2000 to 2019 reporting the prevalence of GDM in the MENA region were retrieved and were assessed for their eligibility. Overall and subgroup pooled prevalence of GDM was quantified by random-effects meta-analysis. Sources of heterogeneity were investigated by meta-regression. The risk of bias (RoB) was assessed by the National Heart, Lung, and Blood Institute's tool. One hundred and two research articles with 279,202 tested pregnant women for GDM from 16 MENA countries were included. Most of the research reports sourced from Iran (36.3%) and Saudi Arabia (21.6%), with an overall low RoB. In the 16 countries, the pooled prevalence of GDM was 13.0% (95% confidence interval [CI], 11.5-14.6%, I² , 99.3%). Nationally, GDM was highest in Qatar (20.7%, 95% CI, 15.2-26.7% I² , 99.0%), whereas subregionally, GDM was highest in Gulf Cooperation Council (GCC) countries (14.7%, 95% CI, 13.0-16.5%, I² , 99.0%). The prevalence of GDM was high in pregnant women aged ≥30 years (21.9%, 95% CI, 18.5-25.5%, I² , 97.1%), in their third trimester (20.0%, 95% CI, 13.1-27.9%, I² , 98.8%), and who were obese (17.2%, 95% CI, 12.8-22.0%, I² , 93.8%). The prevalence of GDM was 10.6% (95% CI, 8.1-13.4%, I² , 98.9%) in studies conducted before 2009, whereas it was 14.0% (95% CI, 12.1-16.0%, I² , 99.3%) in studies conducted in or after 2010. Pregnant women in the MENA region are burdened with a substantial prevalence of GDM, particularly in GCC and North African countries. Findings have implications for maternal health in the MENA region and call for advocacy to unify GDM diagnostic criteria.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018100629.

Metformin during Pregnancy: Effects on Offspring Development and Metabolic Function

Maternal obesity during pregnancy and gestational diabetes mellitus (GDM) are both associated with of several postnatal diseases in the offspring, including obesity, early onset hypertension, diabetes mellitus, and reproductive alterations. Metformin is an oral drug that is being evaluated to treat GDM, obesity-associated insulin resistance, and polycystic ovary syndrome (PCOS) during pregnancy. The beneficial effects of metformin on glycemia and pregnancy outcomes place it as a good alternative for its use during pregnancy. In this line of thought, improving the metabolic status of the pregnant mother by using metformin should avoid the consequences of insulin resistance on the offspring's fetal and postnatal development. However, some human and animal studies have shown that metformin during pregnancy could amplify these alterations and be associated with excessive postnatal weight gain and obesity. In this minireview, we discuss not only the clinical and experimental evidence that supports the benefits of using metformin during pregnancy but also the evidence showing a possible negative impact of this drug on the offspring's development.