Association between maternal glucose and large for gestational outcomes: Real-world evidence to support Hyperglycaemia and Adverse Pregnancy Outcomes (HAPO) study findings

Association between adverse birth outcomes and long-term risk of premature cardiovascular disease and mortality in a contemporary population-based cohort of 502,383 pregnant women

BACKGROUND

Relatively few studies have examined the association between the entire spectrum of adverse birth outcomes [stillbirth, preterm birth (PTB), term births that are low birth weight (LBW) or high birth weight (HBW)] and long-term risk of CVD in the mother. Our objective was to examine the association between birth outcomes and risk of premature CVD or death in a contemporary cohort of pregnant women.

METHODS

We conducted a retrospective population-based cohort study of women in Alberta, Canada, between 01/01/2005 and 01/01/2023. The primary endpoint was a composite of CVD-related hospitalization, CVD-related emergency department visit, or death. Cox proportional hazard modelling was used to examine the independent association between birth outcomes and the risk of CVD or death in the mother, after accounting for other socio-demographic, clinical and pregnancy-related complications.

RESULTS

Among 502,383 mothers, 0.51% had stillbirth, 7.11% had PTB, 86.11% had normal birth weight (NBW), 2.11% had LBW, and 4.15% had HBW. During a median follow-up of 3612 days (∼10 years), compared the NBW group, the adjusted hazard ratio (aHR) and 95% confidence interval (CI) for maternal CVD or death associated with stillbirth was 1.63 (1.33, 1.99); 1.45 (1.36, 1.55) for PTB; 1.22 (1.06, 1.41) for LBW, and 1.13 (1.03, 1.23) for HBW. In addition to birth outcomes, pre-existing diabetes (aHR: 1.61, 95% CI: 1.47, 1.76), gestational hypertension (aHR: 1.47, 95% CI: 1.38, 1.57), and pre-existing hypertension (aHR: 3.28, 95% CI: 2.66, 4.04) carried a higher risk for premature CVD and death in the mother.

CONCLUSIONS

Adverse birth outcomes of stillbirth and preterm birth, and to a lesser degree term births that result in LBW or HBW, are markers of increased risk of premature CVD and death in the mother. Coordinated effort between obstetricians, family physicians, and cardiologists are needed to design and implement effective risk reduction programs tailored for these high-risk women.

Relationship between maternal pre-pregnancy BMI and neonatal birth weight in pregnancies with gestational diabetes mellitus: a retrospective cohort study

Aim

The aim of this study was to explore the association between maternal pre-pregnancy body mass index (BMI) and neonatal birth weight in pregnancies with gestational diabetes mellitus (GDM).

Methods

This was a retrospective cohort study conducted between January 2019 and June 2020 at a university hospital in Fuzhou, China.

Results

Pre-pregnancy BMI was used to categorize 791 pregnant women as underweight (3.03%), normal weight (51.71%), overweight (32.74%), and obese (12.52%). Among the 791 babies, 11.63% were small for gestational age (SGA), 77.37% were normal weight, and 11.00% were large for gestational age (LGA). The rate of the SGA babies increased with higher pre-pregnancy BMI. The percentage of LGA babies was higher in women who were overweight or obese compared to those of normal weight. Neonatal birth weight displayed a significantly increasing trend with increasing maternal pre-pregnancy BMI when maternal pre-pregnancy BMI was less than 27.78 kg/m2 [β = 0.03, 95% CI (0.01, 0.04); p = 0.0052 < 0.05] when maternal pre-pregnancy BMI was greater than 27.78 kg/m2, neonatal birth weight decreased as maternal pre-pregnancy BMI increased [β = -0.01, 95% CI (-0.04, 0.01); p = 0.3555].

Conclusion

The incidence of SGA and LGA babies was higher in the women with GDM who were overweight or obese before pregnancy. The data suggest that different management strategies should be implemented for pregnant women with a pre-pregnancy BMI below 27.78 kg/m2 and above 27.78 kg/m2, particularly in cases of GDM. These findings highlight the importance of providing information, offering preconception counseling, and delivering health education on weight management to ensure healthy pregnancies.

Mindfulness and Cardiometabolic Health During Pregnancy: An Integrative Review

Objectives

Cardiometabolic health during pregnancy has potential to influence long-term chronic disease risk for both mother and offspring. Mindfulness practices have been associated with improved cardiometabolic health in non-pregnant populations. The objective was to evaluate diverse studies that explored relationships between prenatal mindfulness and maternal cardiometabolic health.

Method

An integrative review was conducted in January 2023 across five databases to identify and evaluate studies of diverse methodologies and data types. Quantitative studies that examined mindfulness as an intervention or exposure variable during pregnancy and reported any of the following outcomes were considered: gestational weight gain (GWG), blood glucose, insulin resistance, gestational diabetes, inflammation, blood pressure, hypertensive disorders of pregnancy. Qualitative studies were included if they evaluated knowledge, attitudes, or practices of mindfulness in relation to the above-mentioned outcomes during pregnancy.

Results

Fifteen eligible studies were identified, and 4 received a "Good" quality rating (1/7 interventional, 1/5 observational, 2/2 qualitative). Qualitative studies revealed interest among pregnant women in mindfulness-based practices for managing GWG. Some beneficial effects of mindfulness interventions on maternal glucose tolerance and blood pressure were identified, but not for other cardiometabolic outcomes. Observational studies revealed null direct associations between maternal trait mindfulness and cardiometabolic parameters, but one study suggests potential for mindful eating to mitigate excess GWG and insulin resistance.

Conclusions

There currently exists limited quality evidence for mindfulness practices to support prenatal cardiometabolic health. Further rigorous studies are required to understand whether prenatal mindfulness-based interventions, either alone or in combination with other lifestyle modalities, can benefit cardiometabolic health.

Preregistration

This study is not preregistered.

Gestational diabetes: One size does not fit all-an observational study of maternal and neonatal outcomes by maternal glucose profile

OBJECTIVES

To examine obstetrical and neonatal outcomes across maternal glucose profiles at the population level and to explore insulin sensitivity and beta-cell function across profiles in an independent, well-phenotyped cohort for potential pathophysiologic explanation.

RESEARCH DESIGN AND METHODS

Observational cohort study of all pregnancies with gestational diabetes screening between October 2008 and December 2018 resulting in live singleton birth in Alberta, Canada (n = 436,773) were categorized into seven maternal glucose profiles: (1) normal 50 g-glucose challenge test (nGCT), (2) normal 75-g OGTT (nOGTT), (3) isolated elevated 1 h post-load glucose (ePLPG1), (4) isolated elevated 2 h post-load glucose (ePLPG2), (5) elevated 1 and 2 h post-load glucose (ePLPG12), (6) isolated elevated FPG (eFPG), and (7) elevated FPG + elevated 1-h and/or 2-h PLG (Combined). Primary outcomes were large for gestational age (LGA) and neonatal intensive care unit (NICU) admission rates. An independent observational cohort of 1451 women was examined for measures of beta-cell function (ISSI-2, insulinogenic index/HOMA-IR) and insulin sensitivity/resistance (Matsuda index, HOMA-IR) by similar maternal glucose profiles.

RESULTS

Pregnancies with elevated FPG, either isolated or combined, had higher adverse events and lower insulin sensitivity. The combination of elevated FPG + elevated 1-h and/or 2-h PLG had the highest rates of LGA(20.9%), NICU admissions (14.7%), and lowest insulin sensitivity as measured by Matsuda index and HOMA-IR, and beta-cell function as measured by ISSI-2 and Insulinogenic index/HOMA-IR.

CONCLUSIONS

Elevated fasting plasma glucose, either alone or combined with post-load glucose elevation is associated with worse outcomes than isolated post-load glucose elevation, possibly due to higher degrees of insulin resistance. Future work is needed to better understand these differences, and explore whether tailored treatment of GDM can improve neonatal outcomes.

Glycemic status during pregnancy according to fasting and post-load glucose values: The association with adverse pregnancy outcomes. An observational study

AIM

Prognosis of treated hyperglycemia in pregnancy (HIP) may differ according to whether diagnosis following an oral glucose tolerance test (OGTT) is based on high fasting and/or high post-load glucose values.

METHODS

From a multiethnic prospective study, we included 8,339 women screened for HIP after 22 weeks of gestation. We evaluated the risk of large-for-gestational-age (LGA) infant (primary endpoint) and other adverse pregnancy outcomes according to HIP status in four groups defined as follows: no HIP (n = 6,832, reference); isolated fasting HIP (n = 465), isolated post-load HIP (n = 646), and fasting and post-load HIP (n = 396).

RESULTS

After adjusting for age, body mass index, ethnicity, smoking during pregnancy and parity, compared with no HIP, the adjusted odds ratios [95% confidence interval] for LGA infant were higher in the isolated fasting HIP (1.47 [1.11-1.96]) and fasting and post-load HIP (1.65 [1.23-2.21]) groups, but not in the isolated post-load HIP (1.13 [0.86-1.48]) group. The adjusted odds ratios for preterm delivery and neonatal intensive care unit were higher in the post-load HIP group (1.44 [1.03-2.03] and 1.28 [1.04-1.57], respectively), the fasting and post-load HIP group (1.81 [1.23-2.68] and 1.42 [1.10-1.81], respectively) but not in the isolated fasting HIP group (1.34 [0.90-2.00] and 1.20 [0.94-1.52], respectively).

CONCLUSION

Despite glucose-lowering care and adjustment for confounders, compared with no HIP, fasting HIP was associated with a higher rate of LGA infant, whereas post-load HIP was associated with higher preterm delivery and neonatal intensive care unit admission rates.

Is There a Relationship between Adverse Pregnancy Outcomes and Future Development of Atherosclerosis?

Cardiovascular disease is one of the main death causes globally. Effective cardiovascular risk management requires a thorough understanding of the mechanisms underlying the disorder. Establishing early markers of the disease allows a timely intervention and prevention of further atherosclerosis development. Multiple studies confirm the correlation between pregnancy disorders and cardiovascular disease in the postpartum period. Moreover, over 30% of women experience adverse pregnancy outcomes. Thus, the examination of the links between these conditions and atherosclerotic cardiovascular disease may help to identify gender-specific risk factors. In this review, we will explore the association between several adverse pregnancy outcome conditions and atherosclerosis. The current analysis is based on the data from several recent studies on the mechanisms behind gestational diabetes, hypertensive disorders of pregnancy, miscarriages, and stillbirths and their implications for the female cardiovascular system.

Is there a residual risk of large-for-gestational-age infant related to gestational diabetes mellitus when it is treated?

OBJECTIVE

The hyperglycaemia and adverse pregnancy outcomes (HAPO) study, where hyperglycaemia was untreated, showed a continuous association between large-for-gestational-age (LGA) infant and seven increasing categories of fasting plasma glucose (PG), 1-hour and 2-hour PG values after a 75 g oral glucose tolerance test at 24-32 gestational weeks. We evaluated whether the excess risk persisted in the 6th and 7th glucose categories - corresponding to women treated for gestational diabetes mellitus (GDM).

PATIENTS AND METHODS

We included 7,190 women meeting the HAPO criteria, of whom 655 (9.2%) were treated for GDM (dietary education in all; insulin therapy in 150 (20.3%)). We evaluated the adjusted odds ratio (aOR) for each glucose category (reference 1st category) for LGA infant.

RESULTS

The aOR for LGA linearly increased from the 1st to 5th categories of fasting, 1-hour and 2-hour PG. Specifically, the aORs for the 5th category were 2.20 (95% confidence interval 1.41-3.44), 2.25 (1.11-4.59), and 2.51 (1.63-3.85), respectively. The aORs for the 6th category were globally stable at 2.52 (1.46-4.36), 2.87 (1.48-5.54), and 2.47 (1.46-4.16), respectively. The same was true for the 7th category: 1.41 (0.56-3.55), 2.84 (1.03-7.86), and 3.53 (1.77-7.06), respectively.

CONCLUSION

We confirmed the association between increasing PG category and LGA infant in women without GDM. We did not observe a residual risk of LGA infant in women treated for GDM in our hospital, irrespective of elevated fasting, 1-hour, or 2-hour PG diagnosis. The risk of LGA infant was globally similar to that in women with high normal glucose values.

Diabetes und Schwangerschaft – Update 2022

Gestationsdiabetes mellitus (GDM) ist mit einem Anteil von 80 % die häufigste Form der Hyperglykämie in der Schwangerschaft. Stillen reduziert das Risiko für Typ-2-Diabetes, je länger die Stilldauer, umso größer ist der Effekt. Bei Frauen, die eine Früh- oder eine Totgeburt durchgemacht haben, besteht ein erhöhtes Risiko, selbst frühzeitig zu versterben. Das Potenzial einer Präeklampsieprävention durch niedrig dosierte Azetylsalizylsäuregabe bei Frauen mit Diabetes mellitus wird bei weitem nicht ausgeschöpft. Schwangere reduzieren durch eine COVID-19-Impfung (COVID-19: „coronavirus disease 2019“) ihr Risiko für einen schweren Krankheitsverlauf. Die nach wie vor hohe Rate an perinataler Mortalität bei Schwangerschaften mit Typ-1- und Typ-2-Diabetes kann in erster Linie durch eine Verbesserung von Basisfaktoren bei der perikonzeptionellen Betreuung reduziert werden. Zweizeitiges Screening auf GDM reduziert im Vergleich zum einzeitigen Screening die GDM-Prävalenz und die Medikalisierung ohne Nachteile für die Mütter und ihre Neugeborenen. Die Zulassung von Metformin für Schwangere seit Februar 2022 bedeutet nicht, dass dieses Arzneimittel als primäre Pharmakotherapie für schwangere Frauen empfohlen wird.

Epigenetic and Transcriptomic Programming of HSC Quiescence Signaling in Large for Gestational Age Neonates

Excessive fetal growth is associated with DNA methylation alterations in human hematopoietic stem and progenitor cells (HSPC), but their functional impact remains elusive. We implemented an integrative analysis combining single-cell epigenomics, single-cell transcriptomics, and in vitro analyses to functionally link DNA methylation changes to putative alterations of HSPC functions. We showed in hematopoietic stem cells (HSC) from large for gestational age neonates that both DNA hypermethylation and chromatin rearrangements target a specific network of transcription factors known to sustain stem cell quiescence. In parallel, we found a decreased expression of key genes regulating HSC differentiation including EGR1, KLF2, SOCS3, and JUNB. Our functional analyses showed that this epigenetic programming was associated with a decreased ability for HSCs to remain quiescent. Taken together, our multimodal approach using single-cell (epi)genomics showed that human fetal overgrowth affects hematopoietic stem cells' quiescence signaling via epigenetic programming.