Hyperglycemia recognised in early pregnancy is phenotypically type 2 diabetes mellitus not gestational diabetes mellitus: a case control study

Hypertensive disorders in a gestational diabetes cohort from Cape Town, South Africa

INTRODUCTION AND OBJECTIVE

As thresholds for the diagnosis of gestational diabetes mellitus (GDM) become lower, and the prevalence of obesity in society rises, more pregnant women will be diagnosed with GDM and hypertension. Both conditions hold dangers for mother and baby. Our objective was to properly describe this association.

STUDY DESIGN AND OUTCOME MEASURES

This retrospective audit was conducted at the Obstetric High-Risk Clinic at Tygerberg Academic Hospital, Cape Town, South Africa. All patients diagnosed with GDM from 01/01/19 - 31/12/19 were included. The primary aim was to determine the incidence, and different classes of hypertensive disease associated with GDM in this population. The secondary aims were to evaluate associations with the development of hypertensive disorders in women with GDM and to include descriptions of the management, course and complications during the pregnancies, including the early neonatal period. The research was approved by the Ethics Committee of Stellenbosch University.

RESULTS

Of the 274 women with GDM, included in the analysis, 204 (75 %) had concomitant hypertension. Classes of hypertension were chronic hypertension 21 % (58/274), gestational hypertension 26 % (71/274), and pre-eclampsia (de novo and super-imposed) 27 % (75/275). Those without hypertension had significantly lower BMIs: 35 [29-42] vs 41 [34-45] kg/m2 (median [IQR]; p < 0.001). Using ROC curves, BMI at booking had strong associations with chronic and gestational hypertension (p = 0,002; p = 0,001), and pre-eclampsia (p = 0,002). All three intra-uterine deaths (two spontaneous and one iatrogenic) occurred in the GDM + hypertension group.

CONCLUSION

Hypertensive conditions of pregnancy were common amongst a referral-based population with GDM, with BMI being the strongest predictor.

Use of oral glucose tolerance testing and HbA1c at 6-14 gestational weeks to predict gestational diabetes mellitus in high-risk women

PURPOSE

To study the prediction of gestational diabetes mellitus (GDM) in high-risk pregnant women by testing fasting blood glucose, 1-h(1hPG) and 2-h plasma glucose (2hPG) after an oral glucose tolerance test, and glycated hemoglobin (HbA1c) in early pregnancy (6-14 weeks).

METHODS

We recruited 1311 pregnant women at high risk for diabetes from the Obstetrics Clinic of Daxing District People's Hospital between June 2017 and December 2019. The tests performed during the first trimester included fasting blood glucose (FPG), HbA1c, and 75-g oral glucose tolerance test (OGTT) with 1hPG and 2hPG. Seventy-three pregnant women diagnosed with pregestational diabetes mellitus (PGDM) early in pregnancy and 36 who were missed in the second trimester were excluded. A total of 1202 women were followed up until 24-28 weeks for GDM. The receiver operating characteristic (ROC) and area under the ROC curve (AUC) were calculated to determine the predictive values of FPG, 1hPG, 2hPG, and HbA1c for GDM in early pregnancy in high-risk pregnant women.

RESULTS

The AUC for 1hPG for the prediction of GDM in high-risk pregnant women was greater than those for FPG, 2hPG, and HbA1c. All differences were significant. The AUCs for the predictive values of FPG, 1hPG, 2hPG, and HbA1c in high-risk pregnant women were 0.63, 0.76, 0.71, and 0.67, respectively. The prevalence of PGDM among pregnant women at high risk of diabetes was 5.6%.

CONCLUSION

First-trimester levels of FPG, 1hPG, 2hPG, and HbA1c in high-risk women are significant predictors of GDM, with 1hPG having the most significant predictive value.

Markers of Maternal Insulin Resistance and Lipid Ratios Measured in Early Pregnancy Are Related to Adverse Fetomaternal Outcomes in Women Treated for Hyperglycemia Detected in Early Pregnancy-Data from a Retrospective Cohort Study

Background: Hyperglycemia detected in early pregnancy is still inadequately studied as a risk factor for adverse maternal and neonatal outcomes. Methods: a retrospective study of a cohort of N = 193 women in singleton pregnancies with hyperglycemia diagnosed before the 20th gestational week (GW). Results: characteristics of the study group: GW at the diagnosis: 12.0 (9.0; 15.0), diabetes diagnosed in early pregnancy (eDiP): 21%, insulin-therapy required: 61.8%, gestational hypertension/preeclampsia: 7.7%, premature delivery: 9.2%, composite adverse neonatal outcome: 59.2%, high (LGA) birth weight/low (SGA) birth weight according to the WHO growth charts: 24.2%/9.2%, respectively. Women with eDiP have lower eGDR, a higher TAG/HDL ratio, and a higher atherogenic index of plasma (AIP) compared to women with gestational diabetes diagnosed in early pregnancy—eGDM (9.33 ± 1.56 vs. 7.92 ± 2.54, p = 0.007, 1.06 ± 0.78, vs. 1.25 ± 0.68, p = 0.020, and −0.06 ± 0.25 vs. 0.04 ± 0.23 p = 0.021, respectively). NonHDL/HDL cholesterol ratio > 2.6, and AIP > 0.24 total/HDL cholesterol ratio > 4.5 significantly predicted metabolic adverse neonatal outcome (hypoglycemia and/or hyperbilirubinemia)—OR (95% CI): 4.62 (1.35; 15.79), 3.60 (1.04; 12.48), 8.75 (1.02; 74.83), respectively. Conclusions: 1, Hyperglycemia diagnosed in early pregnancy coexists with a lipid profile suggestive of insulin resistance. 2, Lipid-related markers of cardiometabolic risk measured in early pregnancy can be useful tools in assessment of fetomaternal risk in high-risk populations. 3, Women with eDiP present a more severe insulin resistance phenotype than those with eGDM.

Global burden of early pregnancy gestational diabetes mellitus (eGDM): A systematic review

AIMS

Gestational diabetes mellitus (GDM) diagnosed during the first trimester of pregnancy is called 'early pregnancy Gestational Diabetes Mellitus' (eGDM). The burden of eGDM has only been studied sporadically. This review aims to understand the global burden of eGDM in terms of prevalence, risk factors, pregnancy outcomes, treatment and postpartum dysglycemia.  METHODS: A review of epidemiologic studies reporting on early GDM screening as per Joanna Briggs Institute (JBI) methodology for prevalence reviews was conducted. A customized search strategy was used to search electronic databases namely, PubMed, CINAHL, EMBASE, Cochrane Library, Scopus, MEDLINE, Ovid, ScienceDirect, and Google Scholar. Three independent reviewers reviewed studies using Covidence software. Observational studies irrespective of study design and regardless of diagnostic criteria were included. Quality of evidence was appraised, and findings were synthesized.

RESULTS

Of 58 included studies, 41 reported a prevalence of eGDM, ranging from 0.7 to 36.8%. Body mass index (BMI), previous history of GDM, family history of diabetes and multiparity were reported as eGDM risk factors. Adverse pregnancy outcomes associated with eGDM were macrosomia, caesarean delivery, induction of labour, hypertension, preterm delivery, and shoulder dystocia. The incidence of postpartum dysglycemia and the need for insulin was higher in women with eGDM. The risk of bias was moderate. Heterogeneity of studies is a limitation. Meta-analysis was not performed.

CONCLUSIONS

There is heterogeneity in the prevalence of eGDM and intrapartum and postpartum ill effects for the mother and the offspring. There is a need to develop a universal screening protocol for eGDM.