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Fukuoka M, Yasuhi I, Yamashita H, Ashimoto K, Kurata N, Yamaguchi J, Koga M, Sugimi S, Suga S, Fukuda M. Achievement of Target Glycemic Goal with Simple Basal Insulin Regimen in Women with Gestational Diabetes: A Prospective Cohort Study. J Diabetes Res 2023; 2023:9574563. [PMID: 37283948 PMCID: PMC10241582 DOI: 10.1155/2023/9574563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 05/10/2023] [Accepted: 05/11/2023] [Indexed: 06/08/2023] Open
Abstract
There is little evidence concerning the need to treat gestational diabetes (GDM) in the same way as pregestational diabetes. We evaluated the efficacy of the simple insulin injection (SII) regimen for achieving the target glucose goal without increasing adverse perinatal outcomes in singleton pregnant women with GDM. All subjects underwent self-monitoring of blood glucose (SMBG), and insulin therapy was indicated according to the SMBG profile. Insulin was initially started with the SII regimen, in which one daily injection of NPH insulin before breakfast was used, and another NPH injection was added at bedtime, if necessary. We used the target glucose as <95 mg/dL at fasting and <120 mg/dL postprandial and accepted <130 mg/dL for the latter. If the target glucose did not reach with the regimen, we switched to the multiple daily injection (MDI) with additional prandial insulin aspart. We compared the SMBG profile before delivery as well as the perinatal outcomes between the SII and MDI groups. Among 361 women (age 33.7 years, nullipara 41%, prepregnancy body mass index 23.2 kg/m2) with GDM, 59%, 18%, and 23% were in the diet-alone, SII, and MDI groups, respectively. Consequently, regarding women requiring insulin therapy, 43% were treated with the SII regimen throughout pregnancy. The severity of baseline hyperglycemia according to the SMBG data at baseline was the MDI>the SII>the diet group. The rate of achieving target glucose levels before delivery in the SII group at fasting, postprandial < 120 mg/dL and <130 mg/dL were 93%, 54% and 87%, respectively, which were similar to that in the MDI group (93%, 57%, and 93%, respectively), with no significant differences in perinatal outcomes. In conclusion, more than 40% of women with GDM requiring insulin therapy achieved the target glucose goal with this simple insulin regimen without any increase in adverse effects.
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Affiliation(s)
- Misao Fukuoka
- Department of Obstetrics and Gynecology, National Hospital Organization (NHO) Nagasaki Medical Center, Omura-City, Nagasaki, Japan
| | - Ichiro Yasuhi
- Department of Obstetrics and Gynecology, National Hospital Organization (NHO) Nagasaki Medical Center, Omura-City, Nagasaki, Japan
| | - Hiroshi Yamashita
- Department of Obstetrics and Gynecology, National Hospital Organization (NHO) Nagasaki Medical Center, Omura-City, Nagasaki, Japan
| | - Kensuke Ashimoto
- Department of Obstetrics and Gynecology, National Hospital Organization (NHO) Nagasaki Medical Center, Omura-City, Nagasaki, Japan
- Department of Obstetrics and Gynecology, Kameda General Hospital, Kamogawa, Chiba, Japan
| | - Nao Kurata
- Department of Obstetrics and Gynecology, National Hospital Organization (NHO) Nagasaki Medical Center, Omura-City, Nagasaki, Japan
| | - Junko Yamaguchi
- Department of Obstetrics and Gynecology, National Hospital Organization (NHO) Nagasaki Medical Center, Omura-City, Nagasaki, Japan
| | - Megumi Koga
- Department of Obstetrics and Gynecology, National Hospital Organization (NHO) Nagasaki Medical Center, Omura-City, Nagasaki, Japan
| | - So Sugimi
- Department of Obstetrics and Gynecology, National Hospital Organization (NHO) Nagasaki Medical Center, Omura-City, Nagasaki, Japan
| | - Sachie Suga
- Department of Obstetrics and Gynecology, National Hospital Organization (NHO) Nagasaki Medical Center, Omura-City, Nagasaki, Japan
| | - Masashi Fukuda
- Department of Obstetrics and Gynecology, National Hospital Organization (NHO) Nagasaki Medical Center, Omura-City, Nagasaki, Japan
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Mayne IK, Tyzack-Clark HM, McGovern AP. Studies are needed to support optimal insulin dose titration in gestational diabetes mellitus: A systematic review. Diabetes Metab Syndr 2023; 17:102746. [PMID: 36966543 DOI: 10.1016/j.dsx.2023.102746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 03/11/2023] [Accepted: 03/14/2023] [Indexed: 03/28/2023]
Abstract
BACKGROUND AND AIMS We aimed to summarise the existing literature on insulin dose titration in gestation diabetes. METHODS Databases: Medline, EMBASE, CENTRAL and CINAHL were systematically searched for trials and observational studies comparing insulin titration strategies in gestational diabetes. RESULTS No trials comparing insulin dose titration strategies were identified. Only one small (n = 111) observational study was included. In this study, patient-led daily basal insulin titration was associated with higher insulin doses, tighter glycaemic control, and lower birthweight, vs weekly clinician-led titration. CONCLUSIONS There is a paucity of evidence to support optimal insulin titration in gestational diabetes. Randomized trials are required.
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Affiliation(s)
| | | | - Andrew P McGovern
- University of Exeter Medical School, Exeter, UK; University Hospitals Plymouth NHS Trust, Plymouth, UK
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Lin B, Zhang X. Vitamin E Supplement Protects Against Gestational Diabetes Mellitus in Mice Through nuclear factor-erythroid factor 2-related factor 2/heme oxygenase-1 Signaling Pathway. Diabetes Metab Syndr Obes 2023; 16:565-574. [PMID: 36883138 PMCID: PMC9985888 DOI: 10.2147/dmso.s397255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 02/14/2023] [Indexed: 03/05/2023] Open
Abstract
BACKGROUND Gestational diabetes mellitus (GDM) is the most common pregnant disorder worldwide. In this study, we aimed to explore whether vitamin E (VE) treatment alone could protect against GDM in a mouse model. METHODS 6-week-old C57BL/6J female mice were fed on high-fat diet for two weeks and continued with high-fat diet after pregnancy to induce GDM. The pregnant mice were orally administrated with 2.5, 25 or 250 mg/kg VE twice per day during pregnancy together with high-fat diet. Oral glucose tolerance test, insulin amounts, oxidative stress and inflammation were then measured. RESULTS Only 250 mg/kg VE could improve glucose tolerance and insulin level in pregnant mice. VE (250 mg/kg) effectively inhibited GDM-induced hyperlipidemia, and secretion of inflammatory cytokines such as tumor necrosis factor-α and interleukin-6. VE also significantly ameliorated maternal oxidative stress at the late stage of pregnancy, and also improved reproductive outcomes, including increasing the litter size and birth weight in GDM mice. Moreover, VE also activated GDM-reduced nuclear factor-erythroid factor 2-related factor 2 (Nrf2) / heme oxygenase-1 signaling pathway in the maternal liver tissues of GDM mice. CONCLUSION Our data clearly demonstrated that 250 mg/kg VE twice a day during pregnancy could significantly ameliorate the symptoms of GDM by alleviating oxidative stress, inflammation, hyperglycemia, and hyperlipidemia through Nrf2/HO-1 signaling pathway in GDM mice. Thus, additional VE supplement might be beneficial to GDM.
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Affiliation(s)
- Bozhu Lin
- Gynaecology and Obstetrics Department, Longyan People’s Hospital, Longyan, People’s Republic of China
| | - Xiaorong Zhang
- Neonatal Department, Longyan People’s Hospital, Longyan, People’s Republic of China
- Correspondence: Xiaorong Zhang, Neonatal Department, Longyan People’s Hospital, No. 31, Denggaoxi Road, Xinluo District, Longyan, 364000, People’s Republic of China, Tel +86-13605936060, Email
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Kgosidialwa O, Bogdanet D, Egan A, Newman C, O'Shea PM, Biesty L, McDonagh C, O'Shea C, Devane D, Dunne F. A systematic review on outcome reporting in randomised controlled trials assessing treatment interventions in pregnant women with pregestational diabetes. BJOG 2021; 128:1894-1904. [PMID: 34258852 DOI: 10.1111/1471-0528.16842] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Pregestational diabetes mellitus (PGDM) is associated with adverse pregnancy outcomes. Studies assessing interventions to improve maternal and infant outcomes have increased exponentially over recent years. Several outcomes in this field of maternal diabetes are rare, making it difficult to synthesise evidence. OBJECTIVES To collect outcomes reported in studies assessing treatment interventions in pregnant women with PGDM. SEARCH STRATEGY CENTRAL, Web of Science, Medline, CINAHL, Embase and ClinicalTrials.gov from their inception until 27 January 2020. SELECTION CRITERIA Any randomised controlled trial assessing treatment interventions in pregnant women with PGDM reported in English. DATA COLLECTION AND ANALYSIS Two independent reviewers assessed the suitability of articles and retrieved the data. Outcomes extracted from the literature were broadly categorised into maternal, fetal/infant or other outcomes by the study advisory group. MAIN RESULTS Sixty-seven of the 1475 studies identified fulfilled the inclusion criteria. The median number of outcomes reported per study was 15 (range 1-46). The majority of studies were from North America and Europe. Insulin and metformin were the most commonly investigated pharmacological interventions. Glucose monitoring was the most assessed technological intervention. In all, 131 unique outcomes were extracted: maternal (n = 69), fetal/infant (n = 61) and other (n = 1). CONCLUSIONS Outcome reporting in treatment interventions trials of pregnant women with PGDM is varied, making it difficult to synthesise evidence, especially for rare outcomes. Systems are needed to standardise outcome reporting in future clinical trials and so facilitate evidence synthesis in this area of maternal diabetes. REGISTRATION The systematic review was registered prospectively with the International Prospective Register of Systematic Reviews (PROSPERO) database (Registration number CRD42020173549). TWEETABLE ABSTRACT Outcome reporting is heterogeneous in intervention trials of pregnant women with diabetes existing before pregnancy.
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Affiliation(s)
- O Kgosidialwa
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - D Bogdanet
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - A Egan
- Department of Endocrinology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - C Newman
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - P M O'Shea
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - L Biesty
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland.,Ireland HRB-Trials Methodology Research Network, National University of Ireland Galway, Galway, Ireland
| | - C McDonagh
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - C O'Shea
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - D Devane
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland.,Ireland HRB-Trials Methodology Research Network, National University of Ireland Galway, Galway, Ireland
| | - F Dunne
- School of Medicine, National University of Ireland Galway, Galway, Ireland
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Kgosidialwa O, Bogdanet D, Egan AM, O'Shea PM, Newman C, Griffin TP, McDonagh C, O'Shea C, Carmody L, Cooray SD, Anastasiou E, Wender-Ozegowska E, Clarson C, Spadola A, Alvarado F, Noctor E, Dempsey E, Napoli A, Crowther C, Galjaard S, Loeken MR, Maresh M, Gillespie P, de Valk H, Agostini A, Biesty L, Devane D, Dunne F. A core outcome set for the treatment of pregnant women with pregestational diabetes: an international consensus study. BJOG 2021; 128:1855-1868. [PMID: 34218508 PMCID: PMC9311326 DOI: 10.1111/1471-0528.16825] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2021] [Indexed: 12/21/2022]
Abstract
Objective To develop a core outcome set (COS) for randomised controlled trials (RCTs) evaluating the effectiveness of interventions for the treatment of pregnant women with pregestational diabetes mellitus (PGDM). Design A consensus developmental study. Setting International. Population Two hundred and five stakeholders completed the first round. Methods The study consisted of three components. (1) A systematic review of the literature to produce a list of outcomes reported in RCTs assessing the effectiveness of interventions for the treatment of pregnant women with PGDM. (2) A three-round, online eDelphi survey to prioritise these outcomes by international stakeholders (including healthcare professionals, researchers and women with PGDM). (3) A consensus meeting where stakeholders from each group decided on the final COS. Main outcome measures All outcomes were extracted from the literature. Results We extracted 131 unique outcomes from 67 records meeting the full inclusion criteria. Of the 205 stakeholders who completed the first round, 174/205 (85%) and 165/174 (95%) completed rounds 2 and 3, respectively. Participants at the subsequent consensus meeting chose 19 outcomes for inclusion into the COS: trimester-specific haemoglobin A1c, maternal weight gain during pregnancy, severe maternal hypoglycaemia, diabetic ketoacidosis, miscarriage, pregnancy-induced hypertension, pre-eclampsia, maternal death, birthweight, large for gestational age, small for gestational age, gestational age at birth, preterm birth, mode of birth, shoulder dystocia, neonatal hypoglycaemia, congenital malformations, stillbirth and neonatal death. Conclusions This COS will enable better comparison between RCTs to produce robust evidence synthesis, improve trial reporting and optimise research efficiency in studies assessing treatment of pregnant women with PGDM. 165 key stakeholders have developed #Treatment #CoreOutcomes in pregnant women with #diabetes existing before pregnancy.
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Affiliation(s)
- O Kgosidialwa
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
| | - D Bogdanet
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
| | - A M Egan
- Division of Endocrinology, Mayo Clinic, Rochester, MN, USA
| | - P M O'Shea
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
| | - C Newman
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
| | - T P Griffin
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
| | - C McDonagh
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
| | - C O'Shea
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
| | - L Carmody
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
| | - S D Cooray
- Diabetes and Endocrinology Units, Monash Health, Clayton, Vic., Australia.,Monash Centre for Health Research and Implementation, Monash University, Clayton, Vic., Australia
| | - E Anastasiou
- Department Diabetes & Pregnancy Outpatients, Mitera Hospital, Athens, Greece
| | - E Wender-Ozegowska
- Department of Reproduction, Poznan University of Medical Sciences, Poznan, Poland
| | - C Clarson
- Department of Paediatrics, University of Western Ontario, London, ON, Canada.,Lawson Health Research Institute, London, ON, Canada
| | - A Spadola
- Mother Infant Research Institute, Tufts Medical Center, Boston, MA, USA
| | - F Alvarado
- Mother Infant Research Institute, Tufts Medical Center, Boston, MA, USA
| | - E Noctor
- Division of Endocrinology, University Hospital Limerick, Limerick, Ireland
| | - E Dempsey
- INFANT Centre and Department of Paediatrics & Child Health, University College Cork, Cork, Ireland
| | - A Napoli
- Department of Clinical and Molecular Medicine, Sant'Andrea University Hospital, Sapienza, University of Rome, Rome, Italy
| | - C Crowther
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - S Galjaard
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Prenatal Medicine, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - M R Loeken
- Section of Islet Cell and Regenerative Biology, Joslin Diabetes Center, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Mja Maresh
- Department of Obstetrics, St Mary's Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - P Gillespie
- Health Economics and Policy Analysis Centre (HEPAC), National University of Ireland, Galway, Ireland
| | - H de Valk
- Department of Internal Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - A Agostini
- A.S.LViterbo Distretto A, Consultorio Montefiascone, Rome, Italy
| | - L Biesty
- School of Nursing & Midwifery, National University of Ireland Galway, Galway, Ireland
| | - D Devane
- School of Nursing & Midwifery, National University of Ireland Galway, Galway, Ireland.,HRB-Trials Methodology Research Network, National University of Ireland Galway, Galway, Ireland
| | - F Dunne
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
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Meng X, Zhu B, Liu Y, Fang L, Yin B, Sun Y, Ma M, Huang Y, Zhu Y, Zhang Y. Unique Biomarker Characteristics in Gestational Diabetes Mellitus Identified by LC-MS-Based Metabolic Profiling. J Diabetes Res 2021; 2021:6689414. [PMID: 34212051 PMCID: PMC8211500 DOI: 10.1155/2021/6689414] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 02/18/2021] [Accepted: 05/15/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Gestational diabetes mellitus (GDM) is a type of glucose intolerance disorder that first occurs during women's pregnancy. The main diagnostic method for GDM is based on the midpregnancy oral glucose tolerance test. The rise of metabolomics has expanded the opportunity to better identify early diagnostic biomarkers and explore possible pathogenesis. METHODS We collected blood serum from 34 GDM patients and 34 normal controls for a LC-MS-based metabolomics study. RESULTS 184 metabolites were increased and 86 metabolites were decreased in the positive ion mode, and 65 metabolites were increased and 71 were decreased in the negative ion mode. Also, it was found that the unsaturated fatty acid metabolism was disordered in GDM. Ten metabolites with the most significant differences were selected for follow-up studies. Since the diagnostic specificity and sensitivity of a single differential metabolite are not definitive, we combined these metabolites to prepare a ROC curve. We found a set of metabolite combination with the highest sensitivity and specificity, which included eicosapentaenoic acid, docosahexaenoic acid, docosapentaenoic acid, arachidonic acid, citric acid, α-ketoglutaric acid, and genistein. The area under the curves (AUC) value of those metabolites was 0.984 between the GDM and control group. CONCLUSIONS Our results provide a direction for the mechanism of GDM research and demonstrate the feasibility of developing a diagnostic test that can distinguish between GDM and normal controls clearly. Our findings were helpful to develop novel biomarkers for precision or personalized diagnosis for GDM. In addition, we provide a critical insight into the pathological and biological mechanisms for GDM.
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Affiliation(s)
- Xingjun Meng
- Department of Clinical Laboratory, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou 310006, China
- Institute of Laboratory Medicine, Zhejiang University, Hangzhou 310006, China
| | - Bo Zhu
- Department of Clinical Laboratory, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou 310006, China
- Institute of Laboratory Medicine, Zhejiang University, Hangzhou 310006, China
| | - Yan Liu
- School of Traditional Chinese Medicine, Jinan University, Guangzhou 510632, China
| | - Lei Fang
- Department of Clinical Laboratory, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou 310006, China
- Institute of Laboratory Medicine, Zhejiang University, Hangzhou 310006, China
| | - Binbin Yin
- Department of Clinical Laboratory, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou 310006, China
- Institute of Laboratory Medicine, Zhejiang University, Hangzhou 310006, China
| | - Yanni Sun
- Department of Clinical Laboratory, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou 310006, China
- Institute of Laboratory Medicine, Zhejiang University, Hangzhou 310006, China
| | - Mengni Ma
- Department of Clinical Laboratory, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou 310006, China
- Institute of Laboratory Medicine, Zhejiang University, Hangzhou 310006, China
| | - Yuli Huang
- Department of Cardiology, Shunde Hospital, Southern Medical University (The First People's Hospital of Shunde Foshan), Foshan 528300, China
| | - Yuning Zhu
- Department of Clinical Laboratory, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou 310006, China
- Institute of Laboratory Medicine, Zhejiang University, Hangzhou 310006, China
| | - Yunlong Zhang
- Key Laboratory of Neuroscience, School of Basic Medical Sciences, Guangzhou Medical University, Guangzhou 511436, China
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Musa OAH, Syed A, Mohamed AM, Chivese T, Clark J, Furuya-Kanamori L, Xu C, Toft E, Bashir M, Abou-Samra AB, Thalib L, Doi SA. Metformin is comparable to insulin for pharmacotherapy in gestational diabetes mellitus: A network meta-analysis evaluating 6046 women. Pharmacol Res 2021; 167:105546. [PMID: 33716167 DOI: 10.1016/j.phrs.2021.105546] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 03/07/2021] [Accepted: 03/09/2021] [Indexed: 12/13/2022]
Abstract
CONTEXT The comparative efficacy of gestational diabetes (GDM) treatments lack conclusive evidence for choice of first-line treatment. OBJECTIVES The aim of this study was to compare the efficacy of metformin and glibenclamide to insulin using a core outcome set (COS) to unify outcomes across trials investigating the treatment of gestational diabetes mellitus. STUDY DESIGN A network meta-analysis (NMA) was conducted. DATA-SOURCE PubMed, Embase, and Cochrane Controlled Register of Trials were searched from inception to January 2020. STUDY SELECTION RCTs that enrolled pregnant women who were diagnosed with GDM and that compared the efficacy of different pharmacological interventions for the treatment of GDM were included. META-ANALYSIS A generalized pairwise modelling framework was employed. RESULTS A total of 38 RCTs with 6046 participants were included in the network meta-analysis. Compared to insulin, the estimated effect of metformin indicated improvements for weight gain (WMD -2·39 kg; 95% CI -3·31 to -1·46), maternal hypoglycemia (OR 0.34; 95% CI 0.12 to 0·97) and LGA (OR 0.61; 95% CI 0.38 to 0·98). There were also improvements in estimated effects for neonatal hypoglycemia (OR 0.48; 95% CI 0.19 to 1·25), pregnancy induced hypertension (OR 0.63; 95% CI 0.37 to 1·06), and preeclampsia (OR 0.74; 95% CI 0.538 to 1·04), though with limited evidence against our model hypothesis of equivalence with insulin for these outcomes. CONCLUSION Metformin is, at least, comparable to insulin for the treatment of GDM. Glibenclamide appears less favorable, in comparison to insulin, than metformin.
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Affiliation(s)
- Omran A H Musa
- Department of Population Medicine, College of Medicine, QU Health, Qatar University, Doha, Qatar
| | - Asma Syed
- Department of Population Medicine, College of Medicine, QU Health, Qatar University, Doha, Qatar
| | - Aisha M Mohamed
- Department of Population Medicine, College of Medicine, QU Health, Qatar University, Doha, Qatar
| | - Tawanda Chivese
- Department of Population Medicine, College of Medicine, QU Health, Qatar University, Doha, Qatar
| | - Justin Clark
- The Center for Research into Evidence Based Practice, Bond University, Gold Coast, Australia
| | - Luis Furuya-Kanamori
- Research School of Population Health, Australian National University, Canberra, Australia
| | - Chang Xu
- Department of Population Medicine, College of Medicine, QU Health, Qatar University, Doha, Qatar
| | - Egon Toft
- Deans Office, College of Medicine, QU Health, Qatar University, Doha, Qatar
| | - Mohammed Bashir
- Division of Endocrinology, Hamad General Hospital, Doha, Qatar
| | - Abdul Badi Abou-Samra
- Division of Endocrinology, Hamad General Hospital, Doha, Qatar; Qatar Metabolic Institute, Hamad General Hospital, Doha, Qatar
| | - Lukman Thalib
- Department of Public Health, College of Health Sciences, QU Health, Qatar University, Doha, Qatar
| | - Suhail A Doi
- Department of Population Medicine, College of Medicine, QU Health, Qatar University, Doha, Qatar.
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Walton JC, Walker WH, Bumgarner JR, Meléndez-Fernández OH, Liu JA, Hughes HL, Kaper AL, Nelson RJ. Circadian Variation in Efficacy of Medications. Clin Pharmacol Ther 2020; 109:1457-1488. [PMID: 33025623 DOI: 10.1002/cpt.2073] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 09/13/2020] [Indexed: 12/22/2022]
Abstract
Although much has been learned about circadian clocks and rhythms over the past few decades, translation of this foundational science underlying the temporal regulation of physiology and behavior to clinical applications has been slow. Indeed, acceptance of the modern study of circadian rhythms has been blunted because the phenomenology of cyclic changes had to counteract the 20th century dogma of homeostasis in the biological sciences and medicine. We are providing this review of clinical data to highlight the emerging awareness of circadian variation in efficacy of medications for physicians, clinicians, and pharmacists. We are suggesting that gold-standard double-blind clinical studies should be conducted to determine the best time of day for optimal effectiveness of medications; also, we suggest that time of day should be tracked and reported as an important biological variable in ongoing clinical studies hereafter. Furthermore, we emphasize that time of day is, and should be considered, a key biological variable in research design similar to sex. In common with biomedical research data that have been historically strongly skewed toward the male sex, most pharmaceutical data have been skewed toward morning dosing without strong evidence that this is the optimal time of efficacy.
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Affiliation(s)
- James C Walton
- Department of Neuroscience, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, West Virginia, USA
| | - William H Walker
- Department of Neuroscience, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, West Virginia, USA
| | - Jacob R Bumgarner
- Department of Neuroscience, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, West Virginia, USA
| | - O Hecmarie Meléndez-Fernández
- Department of Neuroscience, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, West Virginia, USA
| | - Jennifer A Liu
- Department of Neuroscience, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, West Virginia, USA
| | - Heather L Hughes
- Department of Neuroscience, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, West Virginia, USA
| | - Alexis L Kaper
- Department of Neuroscience, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, West Virginia, USA
| | - Randy J Nelson
- Department of Neuroscience, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, West Virginia, USA
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9
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Bozkaya VÖ, Oskovi-Kaplan ZA, Erel O, Keskin LH. Anemia in pregnancy: it's effect on oxidative stress and cardiac parameters. J Matern Fetal Neonatal Med 2020; 34:105-111. [PMID: 32907417 DOI: 10.1080/14767058.2020.1813709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE We aimed to evaluate the changes in cardiac functions by echocardiography and oxidative stress markers in pregnant women with iron deficiency anemia. METHOD A total of 100 patients (pregnant women with IDA n = 34, healthy pregnant women n = 33, non-pregnant control group n = 33) were enrolled. Demographic data, serum thiol-disulfide and ischemia modified albumin levels, and echocardiographic parameters were compared. RESULTS Native thiol (NT) (p < .001) and Total Thiol (TT) (p < .001) levels as antioxidant markers; left ventricular ejection fraction (LVEF) (p < .001), tricuspid annular plane systolic excursion (TAPSE) (p < .001) were significantly decreased in the IDA group compared to healthy pregnant women and non-pregnant controls. Adjusted IMA ratios were significantly increased in the IDA group (p =.001). A significant negative correlation was determined between adjusted IMA and LVEF (r = -0,4226; p =.016), a significant positive correlation was determined between thiol levels and TAPSE (r = 0.361; p =.041) in IDA group, no correlation was observed in healthy pregnant women and healthy non-pregnant control group. CONCLUSION Anemia in pregnanc may trigger oxidative stress and increased OS may be related to changes in cardiac functions. The possible cardiovascular impact should be considered in pregnant women with anemia and clinicians should not neglect to refer these patients to cardiology in clinical practise.
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Affiliation(s)
- Veciha Özlem Bozkaya
- Department of Cardiology, Keçiören Education and Research Hospital, Ankara, Turkey
| | - Z Aslı Oskovi-Kaplan
- Department of Obstetrics and Gynecology, Ministry of Health Ankara City Hospital, Ankara, Turkey
| | - Ozcan Erel
- Department Biochemistry, Faculty of Medicine, Yıldırım Beyazıt University, Ankara, Turkey
| | - Levent H Keskin
- Department of Obstetrics and Gynecology, Ministry of Health Ankara City Hospital, Ankara, Turkey
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Araki E, Goto A, Kondo T, Noda M, Noto H, Origasa H, Osawa H, Taguchi A, Tanizawa Y, Tobe K, Yoshioka N. Japanese Clinical Practice Guideline for Diabetes 2019. Diabetol Int 2020; 11:165-223. [PMID: 32802702 PMCID: PMC7387396 DOI: 10.1007/s13340-020-00439-5] [Citation(s) in RCA: 197] [Impact Index Per Article: 49.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Indexed: 01/09/2023]
Affiliation(s)
- Eiichi Araki
- Department of Metabolic Medicine, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Atsushi Goto
- Department of Health Data Science, Graduate School of Data Science, Yokohama City University, Yokohama, Japan
| | - Tatsuya Kondo
- Department of Diabetes, Metabolism and Endocrinology, Kumamoto University Hospital, Kumamoto, Japan
| | - Mitsuhiko Noda
- Department of Diabetes, Metabolism and Endocrinology, Ichikawa Hospital, International University of Health and Welfare, Ichikawa, Japan
| | - Hiroshi Noto
- Division of Endocrinology and Metabolism, St. Luke’s International Hospital, Tokyo, Japan
| | - Hideki Origasa
- Department of Biostatistics and Clinical Epidemiology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan
| | - Haruhiko Osawa
- Department of Diabetes and Molecular Genetics, Ehime University Graduate School of Medicine, Toon, Japan
| | - Akihiko Taguchi
- Department of Endocrinology, Metabolism, Hematological Science and Therapeutics, Graduate School of Medicine, Yamaguchi University, Ube, Japan
| | - Yukio Tanizawa
- Department of Endocrinology, Metabolism, Hematological Science and Therapeutics, Graduate School of Medicine, Yamaguchi University, Ube, Japan
| | - Kazuyuki Tobe
- First Department of Internal Medicine, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan
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11
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Araki E, Goto A, Kondo T, Noda M, Noto H, Origasa H, Osawa H, Taguchi A, Tanizawa Y, Tobe K, Yoshioka N. Japanese Clinical Practice Guideline for Diabetes 2019. J Diabetes Investig 2020; 11:1020-1076. [PMID: 33021749 PMCID: PMC7378414 DOI: 10.1111/jdi.13306] [Citation(s) in RCA: 140] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 05/24/2020] [Indexed: 01/09/2023] Open
Affiliation(s)
- Eiichi Araki
- Department of Metabolic MedicineFaculty of Life SciencesKumamoto UniversityKumamotoJapan
| | - Atsushi Goto
- Department of Health Data ScienceGraduate School of Data ScienceYokohama City UniversityYokohamaJapan
| | - Tatsuya Kondo
- Department of Diabetes, Metabolism and EndocrinologyKumamoto University HospitalKumamotoJapan
| | - Mitsuhiko Noda
- Department of Diabetes, Metabolism and EndocrinologyIchikawa HospitalInternational University of Health and WelfareIchikawaJapan
| | - Hiroshi Noto
- Division of Endocrinology and MetabolismSt. Luke's International HospitalTokyoJapan
| | - Hideki Origasa
- Department of Biostatistics and Clinical EpidemiologyGraduate School of Medicine and Pharmaceutical SciencesUniversity of ToyamaToyamaJapan
| | - Haruhiko Osawa
- Department of Diabetes and Molecular GeneticsEhime University Graduate School of MedicineToonJapan
| | - Akihiko Taguchi
- Department of Endocrinology, Metabolism, Hematological Science and TherapeuticsGraduate School of MedicineYamaguchi UniversityUbeJapan
| | - Yukio Tanizawa
- Department of Endocrinology, Metabolism, Hematological Science and TherapeuticsGraduate School of MedicineYamaguchi UniversityUbeJapan
| | - Kazuyuki Tobe
- First Department of Internal MedicineGraduate School of Medicine and Pharmaceutical SciencesUniversity of ToyamaToyamaJapan
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12
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Management of Gestational Diabetes Mellitus. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1307:257-272. [PMID: 32548833 DOI: 10.1007/5584_2020_552] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Once a woman is diagnosed with gestational diabetes mellitus (GDM), two strategies are considered for management; life-style modifications and pharmacological therapy. The management of GDM aims to maintain a normoglycemic state and to prevent excessive weight gain in order to reduce maternal and fetal complications. Lifestyle modifications include nutritional therapy and exercise. Calorie restriction with a low glycemic index diet is recommended to avoid postprandial hyperglycemia and to reduce insulin resistance. Blood glucose levels, HbA1c levels, and ketonuria are monitored to analyze the efficacy of conservative management. Pharmacological treatment is initiated if conservative strategies fail to provide expected glucose levels during follow-ups.Insulin has been the first choice for the treatment of diabetes during pregnancy. Recently, metformin has been used more commonly in diabetic pregnant women in cases when insulin cannot be prescribed, after its safety has been proven. However, a high percentage of women, which may be up to 46% may require additional insulin to maintain expected blood glucose levels. The evidence on the long-term safety of other oral anti-diabetics has been lacking yet.Women with diet-controlled GDM can wait for spontaneous labor expectantly in case there are no obstetric indications for birth. However, in women with GDM under insulin therapy or with poor glycemic control, elective induction at term is recommended by authorities.The women who have GDM during pregnancy should be counseled about their increased risks of impaired glucose tolerance, type 2 diabetes mellitus, hypertensive disorders, cardiovascular diseases, and metabolic syndrome.
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Yefet E, Schwartz N, Sliman B, Ishay A, Nachum Z. Good glycemic control of gestational diabetes mellitus is associated with the attenuation of future maternal cardiovascular risk: a retrospective cohort study. Cardiovasc Diabetol 2019; 18:75. [PMID: 31167664 PMCID: PMC6549350 DOI: 10.1186/s12933-019-0881-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 05/30/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND To examine whether glycemic control of gestational diabetes mellitus (GDM) could modify the risk for future maternal metabolic and cardiovascular morbidities. METHODS A retrospective cohort study of women with a first diagnosis of GDM who delivered between 1991 and 2011. Women were divided into groups of good and poor glycemic control, defined as a mean daily glucose of up to 95 mg/dL (N = 230) and more than 95 mg/dL (N = 216), respectively. In addition, a control group of women without GDM (N = 352) was also analyzed. The primary outcomes were the development of type 2 diabetes mellitus (T2DM), obesity, hypertension, or dyslipidemia. RESULTS Mean follow-up time was 15.8 ± 5.1 years. Assessment was performed at a maternal age of 45 ± 7 years. The rates of the study outcomes in the control, GDM with good glycemic control and GDM with poor glycemic control were as follows: T2DM [19 (5.4%), 87 (38%), 127 (57%)]; hypertension [44 (13%), 42 (18%), 44 (20%)]; obesity [111 (32%), 112 (48%), 129 (58%)]; and dyslipidemia [49 (14%), 67 (29%), 106 (48%)]. Glycemic control was an independent risk factor for T2DM in multivariate Cox regression analysis (hazard ratio (HR) for poor glycemic control vs. controls 10.7 95% CI [6.0-19.0], good glycemic control vs. control HR 6.0 [3.3-10.8], and poor glycemic control vs. good glycemic control HR 1.8 [1.3-2.4]). Glycemic control was also an independent risk factor for dyslipidemia (poor glycemic control vs. controls HR 3.7 [2.3-5.8], good glycemic control vs. controls HR 2.0 [1.2-3.2], and poor glycemic control vs. good glycemic control HR 1.8 1.8 [1.3-2.6]). The fasting glucose level during oral glucose tolerance test (OGTT) was also an independent risk factor for these complications. The interaction term between glycemic control and the fasting value of the OGTT was not statistically significant, suggesting that the effect of glycemic control on the rate of future T2DM and dyslipidemia was not modified by the baseline severity of GDM. CONCLUSION GDM and especially poor glycemic control are associated with T2DM and dyslipidemia. Strict glycemic control for reducing that risk should be evaluated in prospective trials.
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Affiliation(s)
- Enav Yefet
- Department of Obstetrics & Gynecology, Emek Medical Center, Afula, Israel.
| | | | - Basma Sliman
- Department of Obstetrics & Gynecology, Emek Medical Center, Afula, Israel
| | - Avraham Ishay
- Endocrine & Diabetes Unit, Emek Medical Center, Afula, Israel.,Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Zohar Nachum
- Department of Obstetrics & Gynecology, Emek Medical Center, Afula, Israel.,Rappaport Faculty of Medicine, Technion, Haifa, Israel
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14
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Martis R, Crowther CA, Shepherd E, Alsweiler J, Downie MR, Brown J. Treatments for women with gestational diabetes mellitus: an overview of Cochrane systematic reviews. Cochrane Database Syst Rev 2018; 8:CD012327. [PMID: 30103263 PMCID: PMC6513179 DOI: 10.1002/14651858.cd012327.pub2] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Successful treatments for gestational diabetes mellitus (GDM) have the potential to improve health outcomes for women with GDM and their babies. OBJECTIVES To provide a comprehensive synthesis of evidence from Cochrane systematic reviews of the benefits and harms associated with interventions for treating GDM on women and their babies. METHODS We searched the Cochrane Database of Systematic Reviews (5 January 2018) for reviews of treatment/management for women with GDM. Reviews of pregnant women with pre-existing diabetes were excluded.Two overview authors independently assessed reviews for inclusion, quality (AMSTAR; ROBIS), quality of evidence (GRADE), and extracted data. MAIN RESULTS We included 14 reviews. Of these, 10 provided relevant high-quality and low-risk of bias data (AMSTAR and ROBIS) from 128 randomised controlled trials (RCTs), 27 comparisons, 17,984 women, 16,305 babies, and 1441 children. Evidence ranged from high- to very low-quality (GRADE). Only one effective intervention was found for treating women with GDM.EffectiveLifestyle versus usual careLifestyle intervention versus usual care probably reduces large-for-gestational age (risk ratio (RR) 0.60, 95% confidence interval (CI) 0.50 to 0.71; 6 RCTs, N = 2994; GRADE moderate-quality).PromisingNo evidence for any outcome for any comparison could be classified to this category.Ineffective or possibly harmful Lifestyle versus usual careLifestyle intervention versus usual care probably increases the risk of induction of labour (IOL) suggesting possible harm (average RR 1.20, 95% CI 0.99 to 1.46; 4 RCTs, N = 2699; GRADE moderate-quality).Exercise versus controlExercise intervention versus control for return to pre-pregnancy weight suggested ineffectiveness (body mass index, BMI) MD 0.11 kg/m², 95% CI -1.04 to 1.26; 3 RCTs, N = 254; GRADE moderate-quality).Insulin versus oral therapyInsulin intervention versus oral therapy probably increases the risk of IOL suggesting possible harm (RR 1.3, 95% CI 0.96 to 1.75; 3 RCTs, N = 348; GRADE moderate-quality).Probably ineffective or harmful interventionsInsulin versus oral therapyFor insulin compared to oral therapy there is probably an increased risk of the hypertensive disorders of pregnancy (RR 1.89, 95% CI 1.14 to 3.12; 4 RCTs, N = 1214; GRADE moderate-quality).InconclusiveLifestyle versus usual careThe evidence for childhood adiposity kg/m² (RR 0.91, 95% CI 0.75 to 1.11; 3 RCTs, N = 767; GRADE moderate-quality) and hypoglycaemia was inconclusive (average RR 0.99, 95% CI 0.65 to 1.52; 6 RCTs, N = 3000; GRADE moderate-quality).Exercise versus controlThe evidence for caesarean section (RR 0.86, 95% CI 0.63 to 1.16; 5 RCTs, N = 316; GRADE moderate quality) and perinatal death or serious morbidity composite was inconclusive (RR 0.56, 95% CI 0.12 to 2.61; 2 RCTs, N = 169; GRADE moderate-quality).Insulin versus oral therapyThe evidence for the following outcomes was inconclusive: pre-eclampsia (RR 1.14, 95% CI 0.86 to 1.52; 10 RCTs, N = 2060), caesarean section (RR 1.03, 95% CI 0.93 to 1.14; 17 RCTs, N = 1988), large-for-gestational age (average RR 1.01, 95% CI 0.76 to 1.35; 13 RCTs, N = 2352), and perinatal death or serious morbidity composite (RR 1.03; 95% CI 0.84 to 1.26; 2 RCTs, N = 760). GRADE assessment was moderate-quality for these outcomes.Insulin versus dietThe evidence for perinatal mortality was inconclusive (RR 0.74, 95% CI 0.41 to 1.33; 4 RCTs, N = 1137; GRADE moderate-quality).Insulin versus insulinThe evidence for insulin aspart versus lispro for risk of caesarean section was inconclusive (RR 1.00, 95% CI 0.91 to 1.09; 3 RCTs, N = 410; GRADE moderate quality).No conclusions possibleNo conclusions were possible for: lifestyle versus usual care (perineal trauma, postnatal depression, neonatal adiposity, number of antenatal visits/admissions); diet versus control (pre-eclampsia, caesarean section); myo-inositol versus placebo (hypoglycaemia); metformin versus glibenclamide (hypertensive disorders of pregnancy, pregnancy-induced hypertension, death or serious morbidity composite, insulin versus oral therapy (development of type 2 diabetes); intensive management versus routine care (IOL, large-for-gestational age); post- versus pre-prandial glucose monitoring (large-for-gestational age). The evidence ranged from moderate-, low- and very low-quality. AUTHORS' CONCLUSIONS Currently there is insufficient high-quality evidence about the effects on health outcomes of relevance for women with GDM and their babies for many of the comparisons in this overview comparing treatment interventions for women with GDM. Lifestyle changes (including as a minimum healthy eating, physical activity and self-monitoring of blood sugar levels) was the only intervention that showed possible health improvements for women and their babies. Lifestyle interventions may result in fewer babies being large. Conversely, in terms of harms, lifestyle interventions may also increase the number of inductions. Taking insulin was also associated with an increase in hypertensive disorders, when compared to oral therapy. There was very limited information on long-term health and health services costs. Further high-quality research is needed.
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Affiliation(s)
- Ruth Martis
- The University of AucklandLiggins InstitutePark RoadGraftonAucklandNew Zealand1142
| | - Caroline A Crowther
- The University of AucklandLiggins InstitutePark RoadGraftonAucklandNew Zealand1142
- The University of AdelaideARCH: Australian Research Centre for Health of Women and Babies, Robinson Research Institute, Discipline of Obstetrics and GynaecologyWomen's and Children's Hospital72 King William RoadAdelaideSouth AustraliaAustralia5006
| | - Emily Shepherd
- The University of AdelaideARCH: Australian Research Centre for Health of Women and Babies, Robinson Research Institute, Discipline of Obstetrics and GynaecologyWomen's and Children's Hospital72 King William RoadAdelaideSouth AustraliaAustralia5006
| | - Jane Alsweiler
- Auckland HospitalNeonatal Intensive Care UnitPark Rd.AucklandNew Zealand
| | - Michelle R Downie
- Southland HospitalDepartment of MedicineKew RoadInvercargillSouthlandNew Zealand9840
| | - Julie Brown
- The University of AucklandDepartment of Obstetrics and GynaecologyPark RdGraftonAucklandNew Zealand1142
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15
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Abstract
Women with diabetic nephropathy have challenging pregnancies, with pregnancy outcomes far worse than expected for the stage of chronic kidney disease. The underlying mechanisms that cause the adverse events remain poorly understood, but it is a widely held belief that substantial endothelial injury in these women likely contributes. Maternal hypertension, preeclampsia, and cesarean section rates are high, and offspring are often preterm and of low birth weight, with additional neonatal complications associated with glycemic control. This review will present the current evidence for maternal and fetal outcomes of women with diabetic nephropathy and describe prepregnancy, antenatal, and peripartum optimization strategies.
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Affiliation(s)
- Kate Bramham
- Division of Transplantation and Mucosal Biology, King's College London, London, UK.
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16
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Feig DS, Berger H, Donovan L, Godbout A, Kader T, Keely E, Sanghera R. Diabetes and Pregnancy. Can J Diabetes 2018; 42 Suppl 1:S255-S282. [DOI: 10.1016/j.jcjd.2017.10.038] [Citation(s) in RCA: 108] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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17
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Caissutti C, Saccone G, Khalifeh A, Mackeen AD, Lott M, Berghella V. Which criteria should be used for starting pharmacologic therapy for management of gestational diabetes in pregnancy? Evidence from randomized controlled trials. J Matern Fetal Neonatal Med 2018; 32:2905-2914. [DOI: 10.1080/14767058.2018.1449203] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- Claudia Caissutti
- Department of Experimental Clinical and Medical Science, DISM, Clinic of Obstetrics and Gynecology, University of Udine, Udine, Italy
| | - Gabriele Saccone
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples “Federico II”, Naples, Italy
| | - Adeeb Khalifeh
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - A. Dhanya Mackeen
- Division of Maternal-Fetal Medicine, Women’s and Children’s Institute, Geisinger Health System, Danville, PA, USA
| | - Melisa Lott
- Division of Maternal-Fetal Medicine, Women’s and Children’s Institute, Geisinger Health System, Danville, PA, USA
| | - Vincenzo Berghella
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
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18
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Farrar D, Simmonds M, Griffin S, Duarte A, Lawlor DA, Sculpher M, Fairley L, Golder S, Tuffnell D, Bland M, Dunne F, Whitelaw D, Wright J, Sheldon TA. The identification and treatment of women with hyperglycaemia in pregnancy: an analysis of individual participant data, systematic reviews, meta-analyses and an economic evaluation. Health Technol Assess 2018; 20:1-348. [PMID: 27917777 DOI: 10.3310/hta20860] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Gestational diabetes mellitus (GDM) is associated with a higher risk of important adverse outcomes. Practice varies and the best strategy for identifying and treating GDM is unclear. AIM To estimate the clinical effectiveness and cost-effectiveness of strategies for identifying and treating women with GDM. METHODS We analysed individual participant data (IPD) from birth cohorts and conducted systematic reviews to estimate the association of maternal glucose levels with adverse perinatal outcomes; GDM prevalence; maternal characteristics/risk factors for GDM; and the effectiveness and costs of treatments. The cost-effectiveness of various strategies was estimated using a decision tree model, along with a value of information analysis to assess where future research might be worthwhile. Detailed systematic searches of MEDLINE® and MEDLINE In-Process & Other Non-Indexed Citations®, EMBASE, Cumulative Index to Nursing and Allied Health Literature Plus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Health Technology Assessment database, NHS Economic Evaluation Database, Maternity and Infant Care database and the Cochrane Methodology Register were undertaken from inception up to October 2014. RESULTS We identified 58 studies examining maternal glucose levels and outcome associations. Analyses using IPD alone and the systematic review demonstrated continuous linear associations of fasting and post-load glucose levels with adverse perinatal outcomes, with no clear threshold below which there is no increased risk. Using IPD, we estimated glucose thresholds to identify infants at high risk of being born large for gestational age or with high adiposity; for South Asian (SA) women these thresholds were fasting and post-load glucose levels of 5.2 mmol/l and 7.2 mmol/l, respectively and for white British (WB) women they were 5.4 and 7.5 mmol/l, respectively. Prevalence using IPD and published data varied from 1.2% to 24.2% (depending on criteria and population) and was consistently two to three times higher in SA women than in WB women. Lowering thresholds to identify GDM, particularly in women of SA origin, identifies more women at risk, but increases costs. Maternal characteristics did not accurately identify women with GDM; there was limited evidence that in some populations risk factors may be useful for identifying low-risk women. Dietary modification additional to routine care reduced the risk of most adverse perinatal outcomes. Metformin (Glucophage,® Teva UK Ltd, Eastbourne, UK) and insulin were more effective than glibenclamide (Aurobindo Pharma - Milpharm Ltd, South Ruislip, Middlesex, UK). For all strategies to identify and treat GDM, the costs exceeded the health benefits. A policy of no screening/testing or treatment offered the maximum expected net monetary benefit (NMB) of £1184 at a cost-effectiveness threshold of £20,000 per quality-adjusted life-year (QALY). The NMB for the three best-performing strategies in each category (screen only, then treat; screen, test, then treat; and test all, then treat) ranged between -£1197 and -£1210. Further research to reduce uncertainty around potential longer-term benefits for the mothers and offspring, find ways of improving the accuracy of identifying women with GDM, and reduce costs of identification and treatment would be worthwhile. LIMITATIONS We did not have access to IPD from populations in the UK outside of England. Few observational studies reported longer-term associations, and treatment trials have generally reported only perinatal outcomes. CONCLUSIONS Using the national standard cost-effectiveness threshold of £20,000 per QALY it is not cost-effective to routinely identify pregnant women for treatment of hyperglycaemia. Further research to provide evidence on longer-term outcomes, and more cost-effective ways to detect and treat GDM, would be valuable. STUDY REGISTRATION This study is registered as PROSPERO CRD42013004608. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Diane Farrar
- Bradford Institute for Health Research, Bradford Teaching Hospitals, Bradford, UK.,Department of Health Sciences, University of York, York, UK
| | - Mark Simmonds
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Susan Griffin
- Centre for Health Economics, University of York, York, UK
| | - Ana Duarte
- Centre for Health Economics, University of York, York, UK
| | - Debbie A Lawlor
- MRC Integrative Epidemiology Unit at the University of Bristol, Bristol, UK.,School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Mark Sculpher
- Centre for Health Economics, University of York, York, UK
| | - Lesley Fairley
- Bradford Institute for Health Research, Bradford Teaching Hospitals, Bradford, UK
| | - Su Golder
- Department of Health Sciences, University of York, York, UK
| | - Derek Tuffnell
- Bradford Women's and Newborn Unit, Bradford Teaching Hospitals, Bradford, UK
| | - Martin Bland
- Department of Health Sciences, University of York, York, UK
| | - Fidelma Dunne
- Galway Diabetes Research Centre (GDRC) and School of Medicine, National University of Ireland, Galway, Republic of Ireland
| | - Donald Whitelaw
- Department of Diabetes & Endocrinology, Bradford Teaching Hospitals, Bradford, UK
| | - John Wright
- Bradford Institute for Health Research, Bradford Teaching Hospitals, Bradford, UK
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19
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Caissutti C, Saccone G, Ciardulli A, Berghella V. Very tight vs. tight control: what should be the criteria for pharmacologic therapy dose adjustment in diabetes in pregnancy? Evidence from randomized controlled trials. Acta Obstet Gynecol Scand 2017; 97:235-247. [DOI: 10.1111/aogs.13257] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 11/06/2017] [Indexed: 12/11/2022]
Affiliation(s)
- Claudia Caissutti
- Department of Experimental Clinical and Medical Science (DISM); Clinic of Obstetrics and Gynecology; University of Udine; Udine Italy
| | - Gabriele Saccone
- Department of Neuroscience, Reproductive Sciences and Dentistry; School of Medicine; University of Naples Federico II; Naples Italy
| | - Andrea Ciardulli
- Department of Obstetrics and Gynecology; Catholic University of Sacred Heart; Rome Italy
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine; Department of Obstetrics and Gynecology; Sidney Kimmel Medical College of Thomas Jefferson University; Philadelphia PA USA
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20
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Brown J, Grzeskowiak L, Williamson K, Downie MR, Crowther CA. Insulin for the treatment of women with gestational diabetes. Cochrane Database Syst Rev 2017; 11:CD012037. [PMID: 29103210 PMCID: PMC6486160 DOI: 10.1002/14651858.cd012037.pub2] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Gestational diabetes mellitus (GDM) is associated with short- and long-term complications for the mother and her infant. Women who are unable to maintain their blood glucose concentration within pre-specified treatment targets with diet and lifestyle interventions will require anti-diabetic pharmacological therapies. This review explores the safety and effectiveness of insulin compared with oral anti-diabetic pharmacological therapies, non-pharmacological interventions and insulin regimens. OBJECTIVES To evaluate the effects of insulin in treating women with gestational diabetes. SEARCH METHODS We searched Pregnancy and Childbirth's Trials Register (1 May 2017), ClinicalTrials.gov, WHO International Clinical Trials Registry Platform (ICTRP) (1 May 2017) and reference lists of retrieved studies. SELECTION CRITERIA We included randomised controlled trials (including those published in abstract form) comparing:a) insulin with an oral anti-diabetic pharmacological therapy;b) with a non-pharmacological intervention;c) different insulin analogues;d) different insulin regimens for treating women with diagnosed with GDM.We excluded quasi-randomised and trials including women with pre-existing type 1 or type 2 diabetes. Cross-over trials were not eligible for inclusion. DATA COLLECTION AND ANALYSIS Two review authors independently assessed study eligibility, risk of bias, and extracted data. Data were checked for accuracy. MAIN RESULTS We included 53 relevant studies (103 publications), reporting data for 7381 women. Forty-six of these studies reported data for 6435 infants but our analyses were based on fewer number of studies/participants.Overall, the risk of bias was unclear; 40 of the 53 included trials were not blinded. Overall, the quality of the evidence ranged from moderate to very low quality. The primary reasons for downgrading evidence were imprecision, risk of bias and inconsistency. We report the results for our maternal and infant GRADE outcomes for the main comparison. Insulin versus oral anti-diabetic pharmacological therapyFor the mother, insulin was associated with an increased risk for hypertensive disorders of pregnancy (not defined) compared to oral anti-diabetic pharmacological therapy (risk ratio (RR) 1.89, 95% confidence interval (CI) 1.14 to 3.12; four studies, 1214 women; moderate-quality evidence). There was no clear evidence of a difference between those who had been treated with insulin and those who had been treated with an oral anti-diabetic pharmacological therapy for the risk of pre-eclampsia (RR 1.14, 95% CI 0.86 to 1.52; 10 studies, 2060 women; moderate-quality evidence); the risk of birth by caesarean section (RR 1.03, 95% CI 0.93 to 1.14; 17 studies, 1988 women; moderate-quality evidence); or the risk of developing type 2 diabetes (metformin only) (RR 1.39, 95% CI 0.80 to 2.44; two studies, 754 women; moderate-quality evidence). The risk of undergoing induction of labour for those treated with insulin compared with oral anti-diabetic pharmacological therapy may possibly be increased, although the evidence was not clear (average RR 1.30, 95% CI 0.96 to 1.75; three studies, 348 women; I² = 32%; moderate-quality of evidence). There was no clear evidence of difference in postnatal weight retention between women treated with insulin and those treated with oral anti-diabetic pharmacological therapy (metformin) at six to eight weeks postpartum (MD -1.60 kg, 95% CI -6.34 to 3.14; one study, 167 women; low-quality evidence) or one year postpartum (MD -3.70, 95% CI -8.50 to 1.10; one study, 176 women; low-quality evidence). The outcomes of perineal trauma/tearing or postnatal depression were not reported in the included studies.For the infant, there was no evidence of a clear difference between those whose mothers had been treated with insulin and those treated with oral anti-diabetic pharmacological therapies for the risk of being born large-for-gestational age (average RR 1.01, 95% CI 0.76 to 1.35; 13 studies, 2352 infants; moderate-quality evidence); the risk of perinatal (fetal and neonatal death) mortality (RR 0.85; 95% CI 0.29 to 2.49; 10 studies, 1463 infants; low-quality evidence);, for the risk of death or serious morbidity composite (RR 1.03, 95% CI 0.84 to 1.26; two studies, 760 infants; moderate-quality evidence); the risk of neonatal hypoglycaemia (average RR 1.14, 95% CI 0.85 to 1.52; 24 studies, 3892 infants; low-quality evidence); neonatal adiposity at birth (% fat mass) (mean difference (MD) 1.6%, 95% CI -3.77 to 0.57; one study, 82 infants; moderate-quality evidence); neonatal adiposity at birth (skinfold sum/mm) (MD 0.8 mm, 95% CI -2.33 to 0.73; random-effects; one study, 82 infants; very low-quality evidence); or childhood adiposity (total percentage fat mass) (MD 0.5%; 95% CI -0.49 to 1.49; one study, 318 children; low-quality evidence). Low-quality evidence also found no clear differences between groups for rates of neurosensory disabilities in later childhood: hearing impairment (RR 0.31, 95% CI 0.01 to 7.49; one study, 93 children), visual impairment (RR 0.31, 95% CI 0.03 to 2.90; one study, 93 children), or any mild developmental delay (RR 1.07, 95% CI 0.33 to 3.44; one study, 93 children). Later infant mortality, and childhood diabetes were not reported as outcomes in the included studies.We also looked at comparisons for regular human insulin versus other insulin analogues, insulin versus diet/standard care, insulin versus exercise and comparisons of insulin regimens, however there was insufficient evidence to determine any differences for many of the key health outcomes. Please refer to the main results for more information about these comparisons. AUTHORS' CONCLUSIONS The main comparison in this review is insulin versus oral anti-diabetic pharmacological therapies. Insulin and oral anti-diabetic pharmacological therapies have similar effects on key health outcomes. The quality of the evidence ranged from very low to moderate, with downgrading decisions due to imprecision, risk of bias and inconsistency.For the other comparisons of this review (insulin compared with non-pharmacological interventions, different insulin analogies or different insulin regimens), there is insufficient volume of high-quality evidence to determine differences for key health outcomes.Long-term maternal and neonatal outcomes were poorly reported for all comparisons.The evidence suggests that there are minimal harms associated with the effects of treatment with either insulin or oral anti-diabetic pharmacological therapies. The choice to use one or the other may be down to physician or maternal preference, availability or severity of GDM. Further research is needed to explore optimal insulin regimens. Further research could aim to report data for standardised GDM outcomes.
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Affiliation(s)
- Julie Brown
- The University of AucklandLiggins InstitutePark RdGraftonAucklandNew Zealand1142
| | - Luke Grzeskowiak
- University of AdelaideAdelaide Medical School, Robinson Research InstituteAdelaideAustralia
| | | | - Michelle R Downie
- Southland HospitalDepartment of MedicineKew RoadInvercargillSouthlandNew Zealand9840
| | - Caroline A Crowther
- The University of AucklandLiggins InstitutePark RdGraftonAucklandNew Zealand1142
- The University of AdelaideARCH: Australian Research Centre for Health of Women and Babies, Robinson Research Institute, Discipline of Obstetrics and GynaecologyWomen's and Children's Hospital72 King William RoadAdelaideSouth AustraliaAustralia5006
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O'Neill SM, Kenny LC, Khashan AS, West HM, Smyth RMD, Kearney PM. Different insulin types and regimens for pregnant women with pre-existing diabetes. Cochrane Database Syst Rev 2017; 2:CD011880. [PMID: 28156005 PMCID: PMC6464609 DOI: 10.1002/14651858.cd011880.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Insulin requirements may change during pregnancy, and the optimal treatment for pre-existing diabetes is unclear. There are several insulin regimens (e.g. via syringe, pen) and types of insulin (e.g. fast-acting insulin, human insulin). OBJECTIVES To assess the effects of different insulin types and different insulin regimens in pregnant women with pre-existing type 1 or type 2 diabetes. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 October 2016), ClinicalTrials.gov (17 October 2016), the WHO International Clinical Trials Registry Platform (ICTRP; 17 October 2016), and the reference lists of retrieved studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared different insulin types and regimens in pregnant women with pre-existing diabetes.We had planned to include cluster-RCTs, but none were identified. We excluded quasi-randomised controlled trials and cross-over trials. We included studies published in abstract form and contacted the authors for further details when applicable. Conference abstracts were superseded by full publications. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion, conducted data extraction, assessed risk of bias, and checked for accuracy. We assessed the quality of the evidence using the GRADE approach. MAIN RESULTS The findings in this review were based on very low-quality evidence, from single, small sample sized trial estimates, with wide confidence intervals (CI), some of which crossed the line of no effect; many of the prespecified outcomes were not reported. Therefore, they should be interpreted with caution. We included five trials that included 554 women and babies (four open-label, multi-centre, two-arm trials; one single centre, four-arm RCT). All five trials were at a high or unclear risk of bias due to lack of blinding, unclear methods of randomisation, and selective reporting of outcomes. Pooling of data from the trials was not possible, as each trial looked at a different comparison.1. One trial (N = 33 women) compared Lispro insulin with regular insulin and provided very low-quality evidence for the outcomes. There were seven episodes of pre-eclampsia in the Lispro group and nine in the regular insulin group, with no clear difference between the two groups (risk ratio (RR) 0.68, 95% CI 0.35 to 1.30). There were five caesarean sections in the Lispro group and nine in the regular insulin group, with no clear difference between the two groups (RR 0.59, 95% CI 0.25 to 1.39). There were no cases of fetal anomaly in the Lispro group and one in the regular insulin group, with no clear difference between the groups (RR 0.35, 95% CI 0.02 to 8.08). Macrosomia, perinatal deaths, episodes of birth trauma including shoulder dystocia, nerve palsy, and fracture, and the composite outcome measure of neonatal morbidity were not reported.2. One trial (N = 42 women) compared human insulin to animal insulin, and provided very low-quality evidence for the outcomes. There were no cases of macrosomia in the human insulin group and two in the animal insulin group, with no clear difference between the groups (RR 0.22, 95% CI 0.01 to 4.30). Perinatal death, pre-eclampsia, caesarean section, fetal anomaly, birth trauma including shoulder dystocia, nerve palsy and fracture and the composite outcome measure of neonatal morbidity were not reported.3. One trial (N = 93 women) compared pre-mixed insulin (70 NPH/30 REG) to self-mixed, split-dose insulin and provided very low-quality evidence to support the outcomes. Two cases of macrosomia were reported in the pre-mixed insulin group and four in the self-mixed insulin group, with no clear difference between the two groups (RR 0.49, 95% CI 0.09 to 2.54). There were seven cases of caesarean section (for cephalo-pelvic disproportion) in the pre-mixed insulin group and 12 in the self-mixed insulin group, with no clear difference between groups (RR 0.57, 95% CI 0.25 to 1.32). Perinatal death, pre-eclampsia, fetal anomaly, birth trauma including shoulder dystocia, nerve palsy, or fracture and the composite outcome measure of neonatal morbidity were not reported.4. In the same trial (N = 93 women), insulin injected with a Novolin pen was compared to insulin injected with a conventional needle (syringe), which provided very low-quality evidence to support the outcomes. There was one case of macrosomia in the pen group and five in the needle group, with no clear difference between the different insulin regimens (RR 0.21, 95% CI 0.03 to 1.76). There were five deliveries by caesarean section in the pen group compared with 14 in the needle group; women were less likely to deliver via caesarean section when insulin was injected with a pen compared to a conventional needle (RR 0.38, 95% CI 0.15 to 0.97). Perinatal death, pre-eclampsia, fetal anomaly, birth trauma including shoulder dystocia, nerve palsy, or fracture, and the composite outcome measure of neonatal morbidity were not reported.5. One trial (N = 223 women) comparing insulin Aspart with human insulin reported none of the review's primary outcomes: macrosomia, perinatal death, pre-eclampsia, caesarean section, fetal anomaly, birth trauma including shoulder dystocia. nerve palsy, or fracture, or the composite outcome measure of neonatal morbidity.6. One trial (N = 162 women) compared insulin Detemir with NPH insulin, and supported the outcomes with very low-quality evidence. There were three cases of major fetal anomalies in the insulin Detemir group and one in the NPH insulin group, with no clear difference between the groups (RR 3.15, 95% CI 0.33 to 29.67). Macrosomia, perinatal death, pre-eclampsia, caesarean section, birth trauma including shoulder dystocia, nerve palsy, or fracture and the composite outcome of neonatal morbidity were not reported. AUTHORS' CONCLUSIONS With limited evidence and no meta-analyses, as each trial looked at a different comparison, no firm conclusions could be made about different insulin types and regimens in pregnant women with pre-existing type 1 or 2 diabetes. Further research is warranted to determine who has an increased risk of adverse pregnancy outcome. This would include larger trials, incorporating adequate randomisation and blinding, and key outcomes that include macrosomia, pregnancy loss, pre-eclampsia, caesarean section, fetal anomalies, and birth trauma.
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Affiliation(s)
- Sinéad M O'Neill
- University College CorkIrish Centre for Fetal and Neonatal Translational Research (INFANT)5th Floor, Cork University Maternity HospitalWiltonCorkMunsterIreland
| | - Louise C Kenny
- University College CorkIrish Centre for Fetal and Neonatal Translational Research (INFANT)5th Floor, Cork University Maternity HospitalWiltonCorkMunsterIreland
| | - Ali S Khashan
- University College CorkIrish Centre for Fetal and Neonatal Translational Research (INFANT)5th Floor, Cork University Maternity HospitalWiltonCorkMunsterIreland
- University College CorkDepartment of Epidemiology and Public HealthCorkIreland
| | - Helen M West
- The University of LiverpoolInstitute of Psychology, Health and SocietyLiverpoolUK
| | - Rebecca MD Smyth
- The University of ManchesterSchool of Nursing, Midwifery and Social WorkJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
| | - Patricia M Kearney
- University College CorkDepartment of Epidemiology and Public HealthCorkIreland
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Martis R, Brown J, Alsweiler J, Downie MR, Crowther CA. Treatments for women with gestational diabetes mellitus: an overview of Cochrane systematic reviews. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2016. [DOI: 10.1002/14651858.cd012327] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Ruth Martis
- The University of Auckland; Liggins Institute; Park Road Grafton Auckland New Zealand 1142
| | - Julie Brown
- The University of Auckland; Liggins Institute; Park Road Grafton Auckland New Zealand 1142
| | - Jane Alsweiler
- Auckland Hospital; Neonatal Intensive Care Unit; Park Rd. Auckland New Zealand
| | - Michelle R Downie
- Southland Hospital; Department of Medicine; Kew Road Invercargill Southland New Zealand 9840
| | - Caroline A Crowther
- The University of Auckland; Liggins Institute; Park Road Grafton Auckland New Zealand 1142
- The University of Adelaide; ARCH: Australian Research Centre for Health of Women and Babies, Robinson Research Institute, Discipline of Obstetrics and Gynaecology; Women's and Children's Hospital 72 King William Road Adelaide South Australia Australia 5006
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Saleem N, Godman B, Hussain S. Comparing twice- versus four-times daily insulin in mothers with gestational diabetes in Pakistan and its implications. J Comp Eff Res 2016; 5:453-9. [PMID: 27417703 DOI: 10.2217/cer-2016-0022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Gestational diabetes mellitus is a common medical problem associated with maternal and fetal complications. Good glycemic control is the cornerstone of treatment. OBJECTIVE Compare outcomes between four times (q.i.d) and twice daily (b.i.d) regimens. The morning dose of the b.i.d regimen contained two-thirds of the total insulin, comprising a third human regular insulin and two-thirds human intermediate insulin; equal amounts in the evening. METHODS 480 women at >30 weeks with gestational diabetes mellitus with failure to control blood glucose were randomly assigned to either regimen. RESULTS Mean time to the control of blood glucose was significantly less and glycemic control significantly increased with the q.i.d regimen. Operative deliveries, extent of neonatal hypoglycemia, babies with low Agpar scores and those with hyperbilirubinemia were significantly higher with the b.i.d daily regimen. CONCLUSION The q.i.d daily regime was associated with improved fetal and maternal outcomes. Consequently should increasingly be used in Pakistan, assisted by lower acquisition costs.
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Affiliation(s)
| | - Brian Godman
- Department of Laboratory Medicine, Division of Clinical Pharmacology, Karolinska Institute, Karolinska University Hospital Huddinge, SE-141 86, Stockholm, Sweden.,Strathclyde Institute of Pharmacy & Biomedical Sciences, Strathclyde University, Glasgow G4 ORE, UK
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Ashwal E, Hod M. Gestational diabetes mellitus: Where are we now? Clin Chim Acta 2015; 451:14-20. [DOI: 10.1016/j.cca.2015.01.021] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2014] [Revised: 01/24/2015] [Accepted: 01/24/2015] [Indexed: 01/17/2023]
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Hod M, Kapur A, Sacks DA, Hadar E, Agarwal M, Di Renzo GC, Roura LC, McIntyre HD, Morris JL, Divakar H. The International Federation of Gynecology and Obstetrics (FIGO) Initiative on gestational diabetes mellitus: A pragmatic guide for diagnosis, management, and care . Int J Gynaecol Obstet 2015; 131 Suppl 3:S173-S211. [PMID: 29644654 DOI: 10.1016/s0020-7292(15)30033-3] [Citation(s) in RCA: 507] [Impact Index Per Article: 56.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Moshe Hod
- Division of Maternal Fetal Medicine, Rabin Medical Center, Tel Aviv University, Petah Tikva, Israel
| | - Anil Kapur
- World Diabetes Foundation, Gentofte, Denmark
| | - David A Sacks
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Eran Hadar
- Helen Schneider Hospital for Women, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mukesh Agarwal
- Department of Pathology, UAE University, Al Ain, United Arab Emirates
| | - Gian Carlo Di Renzo
- Centre of Perinatal and Reproductive Medicine, Department of Obstetrics and Gynecology, University of Perugia, Perugia, Italy
| | - Luis Cabero Roura
- Maternal Fetal Medicine Unit, Vall d'Hebron University Hospital, Barcelona, Spain
| | | | - Jessica L Morris
- International Federation of Gynecology and Obstetrics, London, UK
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Simmons D. Safety considerations with pharmacological treatment of gestational diabetes mellitus. Drug Saf 2015; 38:65-78. [PMID: 25542297 DOI: 10.1007/s40264-014-0253-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The number of women with gestational diabetes mellitus (GDM: diabetes first diagnosed in pregnancy) continues to grow, as do the associated risks of antenatal and postnatal complications and the chance of future diabetes and obesity in both mother and offspring. Recent randomised controlled trials have demonstrated clear benefits for intensive management of GDM using lifestyle modification, self blood glucose monitoring, close clinical supervision and, where glycaemia remains inadequately controlled, insulin therapy. More recently, metformin and glibenclamide have been shown to adequately reduce hyperglycaemia as part of a stepped approach to GDM management, with a switch to insulin therapy where necessary. Other oral medications have not been shown to be safe in pregnancy. Human insulin therapy is safe within the limits of hypoglycaemia and weight gain. Most insulin analogues are also now considered safe for use in pregnancy (insulin lispro, aspart and detemir). Metformin therapy is oral, and therefore preferred to insulin, but is associated with more gastrointestinal adverse effects, although not hypoglycaemia or weight gain. Conversely, glibenclamide is also an oral therapy but is associated with hypoglycaemia and weight gain. However, metformin crosses the placenta and it remains unclear whether glibenclamide crosses the placenta or not: long-term risks have not been shown, and are thought to be minimal, but further studies are needed. Metformin is seen by some as the treatment of choice where weight gain is an issue, providing that the unanswered questions over the long-term safety of oral agents have been discussed.
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Affiliation(s)
- David Simmons
- Wolfson Diabetes and Endocrinology Clinic, Institute of Metabolic Science, Cambridge University Hospitals NHS Foundation Trust, Addenbrookes Hospital, Cambridge, CB2 2QQ, UK,
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Korkmazer E, Solak N, Tokgöz VY. Gestational Diabetes: Screening, Management, Timing of Delivery. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2015. [DOI: 10.1007/s13669-015-0113-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Diabète et grossesse. Can J Diabetes 2013. [DOI: 10.1016/j.jcjd.2013.03.437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Diabetes and Pregnancy. Can J Diabetes 2013. [DOI: 10.1016/j.jcjd.2013.02.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Thompson D, Berger H, Feig D, Gagnon R, Kader T, Keely E, Kozak S, Ryan E, Sermer M, Vinokuroff C. Diabetes and pregnancy. Can J Diabetes 2013; 37 Suppl 1:S168-83. [PMID: 24070943 DOI: 10.1016/j.jcjd.2013.01.044] [Citation(s) in RCA: 131] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Abstract
With appropriate multi-disciplinary team care, most women with diabetic nephropathy will have successful pregnancy outcomes; however, pregnancy complications are increased compared to non-diabetic individuals, particularly in those with poor glycaemic control. Women with more severe renal impairment, especially those with hypertension and proteinuria at are highest risk of worse pregnancy outcomes and deterioration in pre-existing renal function. Pre-pregnancy counselling should be offered to all women with diabetes in order to optimise diabetic care, and inform women of potential complications. Pregnancy is an indicator of long-term health, and may indicate important issues for the future management of women with diabetic nephropathy.
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Affiliation(s)
- Kate Bramham
- Maternal and Fetal Research Unit, King's College London, London, UK
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Bhat M, Ramesha KN, Sarma SP, Menon S, Ganesh Kumar S. Outcome of gestational diabetes mellitus from a tertiary referral center in South India: a case-control study. J Obstet Gynaecol India 2012; 62:644-9. [PMID: 24293841 DOI: 10.1007/s13224-012-0226-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2010] [Accepted: 06/14/2012] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND Carbohydrate intolerance is the most common metabolic complication of pregnancy. Gestational diabetes mellitus (GDM) poses numerous problems for both mother and fetus. The objective of this study was to compare the maternal and perinatal outcome between women with gestational diabetes mellitus and non-diabetic women. STUDY DESIGN A case-control study with 286 cases and 292 age-matched controls was conducted for a period of 11 months (August 2007-June 2008) in Sree Avittom Thirunal Hospital, Thiruvananthapuram, India. MATERIALS AND METHODS Universal screening was applied by means of glucose challenge test (GCT) using 50 g of glucose. If GCT >130 mg%, the patients were subjected to oral glucose tolerance test with 100 g of glucose. National Diabetes Data Group criteria was taken to assign patients to study group. These women were further followed up and the maternal and perinatal outcomes were assessed. STATISTICAL ANALYSIS Univariate analysis was done by means of t test, Odd's ratio, Chi-square test, and Fisher Exact test. P < 0.05 was taken as significant. RESULTS The frequency of induction of labor was significantly higher than spontaneous labor (OR = 1.84, P = 0.001). 40.1 % GDM mothers and 35.8 % of non-diabetic mothers were delivered by Cesarean section. Premature rupture of membranes (PROM) was the most common complication of labor (OR = 1.66, P = 0.04). Babies of diabetic mothers had a positive trend toward prematurity (OR = 2.3, P = 0.007). Hypoglycemia was the most common neonatal complication (OR = 11.97, P < 0.001) and nine babies of diabetic mothers were macrosomic (OR = 5.2, P = 0.02). CONCLUSIONS Maternal morbidities and neonatal complications such as neonatal hypoglycemia, macrosomia, and prematurity were significantly higher in GDM.
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Affiliation(s)
- Mamta Bhat
- Department of Obstetrics and Gynecology, Medical College, Thiruvananthapuram, 695011 India
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Abstract
Insulin therapy is essential for optimal glycemic control during pregnancy in women with type 1 diabetes and is frequently required to optimize control in women with type 2 diabetes. Less commonly, women with gestational diabetes mellitus (GDM) require insulin for glycemic control. However, because of its greater prevalence, GDM is the most common reason for insulin use in pregnancy. The most frequently used insulin regimen in pregnancy is a basal/bolus combination of long- and short-acting insulin preparations. There is no evidence base to support one treatment regimen over another. Therapy should be individualized and based on local expertise.
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Affiliation(s)
- Aidan McElduff
- Discipline of Medicine, Sydney University, Sydney, NSW, Australia.
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Abstract
PURPOSE OF REVIEW To understand all of the current options available to treat glucose intolerance in pregnancy. RECENT FINDINGS Recent attention to the use of oral agents in the treatment of gestational diabetes remains controversial. This review will outline the advantages and disadvantages, as well as safety profiles of two classes of oral mediations. SUMMARY There are many effective treatments for gestational diabetes. Oral medications appear to be well tolerated and effective for treatment of gestational diabetes, and may offer a greater patient compliance. The literature supports use of oral medications as first-line treatment for patients with gestational diabetes that cannot achieve glycemic goals with diet and exercise.
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Affiliation(s)
- Aviva Lee-Parritz
- Boston Medical Center, 85 East Concord Street, Boston, Massachusetts 02118, USA.
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Weinert LS, Silveiro SP, Oppermann ML, Salazar CC, Simionato BM, Siebeneichler A, Reichelt AJ. Diabetes gestacional: um algoritmo de tratamento multidisciplinar. ACTA ACUST UNITED AC 2011; 55:435-45. [DOI: 10.1590/s0004-27302011000700002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2010] [Accepted: 09/29/2011] [Indexed: 11/22/2022]
Abstract
O tratamento do diabetes gestacional é importante para evitar a morbimortalidade materno-fetal. O objetivo deste artigo é descrever o tratamento atualmente disponível para o manejo otimizado da hiperglicemia na gestação e sugerir um algoritmo de tratamento multidisciplinar. A terapia nutricional é a primeira opção de tratamento para as gestantes, e a prática de exercício físico leve a moderado deve ser estimulada na ausência de contraindicações obstétricas. O tratamento medicamentoso está recomendado quando os alvos glicêmicos não são atingidos ou na presença de crescimento fetal excessivo à ultrassonografia. O tratamento tradicional do diabetes gestacional é a insulinoterapia, embora mais recentemente a metformina venha sendo considerada uma opção segura e eficaz. A monitorização do tratamento é realizada com aferição da glicemia capilar e com avaliação da circunferência abdominal fetal por meio de ultrassonografia obstétrica a partir da 28ª semana de gestação.
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Affiliation(s)
| | - Sandra Pinho Silveiro
- Universidade Federal do Rio Grande do Sul, Brasil; Hospital de Clínicas de Porto Alegre, Brasil
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Montaner P, Ripollés J, Pamies C, Corcoy R. Measurement of fasting ketonuria and capillary blood glucose after main meals in women with gestational diabetes mellitus: How well is the metabolic picture captured? J Obstet Gynaecol Res 2011; 37:722-8. [PMID: 21375677 DOI: 10.1111/j.1447-0756.2010.01415.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIM Metabolic monitoring of women with gestational diabetes mellitus (GDM) usually consists of measuring fasting ketonuria and postprandial capillary blood glucose (CBG) after main meals. We aimed to evaluate how this monitoring system captures the metabolic picture as compared to a scheme with a greater number of time points. METHODS Thirty-five women with GDM were recommended to follow a fractionated diet and trained in CBG and ketonuria monitoring. They were asked to monitor ketonuria before a main meal, and to monitor CBG at fasting and 1 h postprandial after any two of the six daily meals. Participants were requested to monitor different meals each day. The goal for 1 h postprandial CBG was <135 mg/dL (7.5 mmol/L). Ketonuria was defined as significant before a certain meal when ≥30% of measurements at that point were positive. Similarly, postprandial CBG was defined as abnormal after a meal when ≥30% measurements exceeded the goal. RESULTS Ketonuria was significant in 22.5% of the time points and 41.2% of women had significant ketonuria at one or more time points; 61% of the time points and 35.7% of the women with significant ketonuria would have been undetected with monitoring restricted to breakfast. Postprandial CBG was abnormal in 17.6% of meals and 57% of women had abnormal postprandial CBG at one or more meals; 37.8% of points and 15% of women with abnormal postprandial CBG would have been undetected with monitoring restricted to main meals. CONCLUSION A substantial proportion of metabolic abnormalities in GDM women are not detected with a monitoring program that measures only fasting ketonuria and postprandial CBG after main meals.
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Affiliation(s)
- Paquita Montaner
- Department of Internal Medicine, Hospital Sant Joan de Déu, Martorell, Spain.
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Jacqueminet S, Jannot-Lamotte MF. Therapeutic management of gestational diabetes. DIABETES & METABOLISM 2010; 36:658-71. [DOI: 10.1016/j.diabet.2010.11.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Gestational diabetes mellitus (GDM) is commonly defined as glucose intolerance first recognized during pregnancy. Diagnostic criteria for GDM have changed over the decades, and several definitions are currently used; recent recommendations may increase the prevalence of GDM to as high as one of five pregnancies. Perinatal complications associated with GDM include hypertensive disorders, preterm delivery, shoulder dystocia, stillbirths, clinical neonatal hypoglycemia, hyperbilirubinemia, and cesarean deliveries. Postpartum complications include obesity and impaired glucose tolerance in the offspring and diabetes and cardiovascular disease in the mothers. Management strategies increasingly emphasize optimal management of fetal growth and weight. Monitoring of glucose, fetal stress, and fetal weight through ultrasound combined with maternal weight management, medical nutritional therapy, physical activity, and pharmacotherapy can decrease comorbidities associated with GDM. Consensus is lacking on ideal glucose targets, degree of caloric restriction and content, algorithms for pharmacotherapy, and in particular, the use of oral medications and insulin analogs in lieu of human insulin. Postpartum glucose screening and initiation of healthy lifestyle behaviors, including exercise, adequate fruit and vegetable intake, breastfeeding, and contraception, are encouraged to decrease rates of future glucose intolerance in mothers and offspring.
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Affiliation(s)
- Catherine Kim
- Departments of Medicine and Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA.
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Abstract
The prevalence of both obesity and gestational diabetes mellitus (GDM) is increasing worldwide. GDM affects about 7% of all pregnancies and is defined as any degree of impaired glucose tolerance during gestation. The presence of obesity has a significant impact on both maternal and fetal complications associated with GDM. These complications can be addressed, at least in part, by good glycaemic control during pregnancy. The significance and impact of obesity in women with GDM are discussed in this article, together with treatment options, the need for long-term risk modification and postpartum follow-up.
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Affiliation(s)
- T Sathyapalan
- Department of Diabetes, Endocrinology and Metabolism, Hull York Medical School, Hull, UK
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Horvath K, Koch K, Jeitler K, Matyas E, Bender R, Bastian H, Lange S, Siebenhofer A. Effects of treatment in women with gestational diabetes mellitus: systematic review and meta-analysis. BMJ 2010; 340:c1395. [PMID: 20360215 PMCID: PMC2848718 DOI: 10.1136/bmj.c1395] [Citation(s) in RCA: 188] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/22/2010] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To summarise the benefits and harms of treatments for women with gestational diabetes mellitus. DESIGN Systematic review and meta-analysis of randomised controlled trials. DATA SOURCES Embase, Medline, AMED, BIOSIS, CCMed, CDMS, CDSR, CENTRAL, CINAHL, DARE, HTA, NHS EED, Heclinet, SciSearch, several publishers' databases, and reference lists of relevant secondary literature up to October 2009. Review methods Included studies were randomised controlled trials of specific treatment for gestational diabetes compared with usual care or "intensified" compared with "less intensified" specific treatment. RESULTS Five randomised controlled trials matched the inclusion criteria for specific versus usual treatment. All studies used a two step approach with a 50 g glucose challenge test or screening for risk factors, or both, and a subsequent 75 g or 100 g oral glucose tolerance test. Meta-analyses did not show significant differences for most single end points judged to be of direct clinical importance. In women specifically treated for gestational diabetes, shoulder dystocia was significantly less common (odds ratio 0.40, 95% confidence interval 0.21 to 0.75), and one randomised controlled trial reported a significant reduction of pre-eclampsia (2.5 v 5.5%, P=0.02). For the surrogate end point of large for gestational age infants, the odds ratio was 0.48 (0.38 to 0.62). In the 13 randomised controlled trials of different intensities of specific treatments, meta-analysis showed a significant reduction of shoulder dystocia in women with more intensive treatment (0.31, 0.14 to 0.70). CONCLUSIONS Treatment for gestational diabetes, consisting of treatment to lower blood glucose concentration alone or with special obstetric care, seems to lower the risk for some perinatal complications. Decisions regarding treatment should take into account that the evidence of benefit is derived from trials for which women were selected with a two step strategy (glucose challenge test/screening for risk factors and oral glucose tolerance test).
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Affiliation(s)
- Karl Horvath
- EBM Review Center, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria.
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Abstract
A wide range of physiological and hormonal changes occur during pregnancy. Most begin early in the first trimester and increase by the last trimester. These changes can significantly affect pharmacokinetics and pharmacodynamics of drugs and thus may alter their safety and efficacy. Approximately 5% of pregnant women are affected by some form of diabetes, with gestational diabetes being the most prevalent. Several classes of antidiabetic drugs are currently available for the treatment of diabetes, including human insulin, its short and long analogues, and oral hypoglycemic agents. Maternal and fetal responses to these drugs can be affected by changes in absorption, distribution, and elimination in both the mother and the placental-fetal unit. This can dictate the amount of drug that can cross and the amount that is metabolized or eliminated by the placenta. Further studies are needed on the safety of antidiabetic drugs in pregnancy to clarify the extent of their transplacental passage. Specifically, in vitro placental perfusion studies in combination with controlled trials and cord blood measurements can provide insight in to the pharmacokinetics of drug transport across the placenta. This article reviews common types of antidiabetic drugs, focusing on pharmacokinetic considerations that need to be incorporated into the decision on treatment in pregnancy.
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Vargas R, Repke JT, Ural SH. Type 1 diabetes mellitus and pregnancy. REVIEWS IN OBSTETRICS & GYNECOLOGY 2010; 3:92-100. [PMID: 21364860 PMCID: PMC3046748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Diabetes complicates up to 10% of all pregnancies in the United States. Of these, 0.2% to 0.5% are patients with type 1 diabetes mellitus (T1DM). Pregnancies affected by T1DM are at increased risk for preterm delivery, preeclampsia, macrosomia, shoulder dystocia, intrauterine fetal demise, fetal growth restriction, cardiac and renal malformations, in addition to rare neural conditions such as sacral agenesis. Intensive glycemic control and preconception planning have been shown to decrease the rate of fetal demise and malformations seen in pregnancies complicated by T1DM. Recent advances in insulin formulations and delivery methods have increased the number of options available to the obstetric team. Insulin regimens should be tailored to each individual patient to maximize compliance and ensure proper glycemic control. Intensive preconception counseling with frequent follow-up visits emphasizing tight glucose control is recommended for adequate management.
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Affiliation(s)
- Roberto Vargas
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Penn State University College of Medicine Hershey, PA
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Abstract
The incidence of gestational diabetes is increasing. As gestational diabetes is associated with adverse pregnancy outcomes, and has long-term implications for both mother and child, it is important that it is recognized and appropriately managed. This review will examine the pharmacological options for the management of gestational diabetes, as well as the evidence for blood glucose monitoring, dietary and exercise therapy. The medical management of gestational diabetes is still evolving, and recent randomized controlled trials have added considerably to our knowledge in this area. As insulin therapy is effective and safe, it is considered the gold standard of pharmacotherapy for gestational diabetes, against which other treatments have been compared. The current experience is that the short acting insulin analogs lispro and aspart are safe, but there are only limited data to support the use of long acting insulin analogs. There are randomized controlled trials which have demonstrated efficacy of the oral agents glyburide and metformin. Whilst short-term data have not demonstrated adverse effects of glyburide and metformin on the fetus, and they are increasingly being used in pregnancy, there remain long-term concerns regarding their potential for harm.
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Affiliation(s)
- N Wah Cheung
- Centre for Diabetes and Endocrinology Research, Westmead Hospital, and University of Sydney, NSW, Australia.
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48
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Abstract
Gestational diabetes mellitus (GDM) is a form of diabetes first diagnosed during pregnancy, usually between 24 and 28 weeks. Currently, management for women with GDM consists of medical nutrition therapy with adjunctive exercise for at least 30 minutes/day. Patients who fail to maintain glycemic goals through diet and exercise therapy are given insulin injections. Several epidemiological studies have suggested a robust link between physical activity and reduced risk of GDM; however, researchers have been unable to suggest a cost-effective, easily accessible, evidence-based program with guidelines for frequency, intensity, duration, and type of activity to prevent the incidence of GDM in sedentary, at-risk populations. True effectiveness of specific structured exercise programs remains untapped in GDM prevention and treatment, and many well-controlled exercise studies are warranted.
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Affiliation(s)
- Michelle F Mottola
- The R. Samuel McLaughlin Foundation, Exercise & Pregnancy Laboratory, The University of Western Ontario, London, Ontario, Canada, N6A 3K7.
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