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Meek CL, Simmons D. Timing of gestational diabetes diagnosis: A novel precision approach to hyperglycaemia in pregnancy? Diabet Med 2023; 40:e15191. [PMID: 37528516 DOI: 10.1111/dme.15191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 07/29/2023] [Indexed: 08/03/2023]
Affiliation(s)
- Claire L Meek
- Wolfson Diabetes & Endocrine Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Wellcome-Trust MRC Institute of Metabolic Science Metabolic Research Laboratories, University of Cambridge, Cambridge, UK
| | - David Simmons
- Western Sydney University, Penrith, New South Wales, Australia
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White SL, Koulman A, Ozanne SE, Furse S, Poston L, Meek CL. Towards Precision Medicine in Gestational Diabetes: Pathophysiology and Glycemic Patterns in Pregnant Women With Obesity. J Clin Endocrinol Metab 2023; 108:2643-2652. [PMID: 36950879 PMCID: PMC10807907 DOI: 10.1210/clinem/dgad168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 02/22/2023] [Accepted: 03/17/2023] [Indexed: 03/24/2023]
Abstract
AIMS Precision medicine has revolutionized our understanding of type 1 diabetes and neonatal diabetes but has yet to improve insight into gestational diabetes mellitus (GDM), the most common obstetric complication and strongly linked to obesity. Here we explored if patterns of glycaemia (fasting, 1 hour, 2 hours) during the antenatal oral glucose tolerance test (OGTT), reflect distinct pathophysiological subtypes of GDM as defined by insulin secretion/sensitivity or lipid profiles. METHODS 867 pregnant women with obesity (body mass index ≥ 30 kg/m2) from the UPBEAT trial (ISRCTN 89971375) were assessed for GDM at 28 weeks' gestation (75 g oral glucose tolerance test OGTT; World Health Organization criteria). Lipid profiling of the fasting plasma OGTT sample was undertaken using direct infusion mass spectrometry and analyzed by logistic/linear regression, with and without adjustment for confounders. Insulin secretion and sensitivity were characterized by homeostatic model assessment 2b and 2s, respectively. RESULTS In women who developed GDM (n = 241), patterns of glycaemia were associated with distinct clinical and biochemical characteristics and changes to lipid abundance in the circulation. Severity of glucose derangement, rather than pattern of postload glycaemia, was most strongly related to insulin action and lipid abundance/profile. Unexpectedly, women with isolated postload hyperglycemia had comparable insulin secretion and sensitivity to euglycemic women, potentially indicative of a novel mechanistic pathway. CONCLUSIONS Patterns of glycemia during the OGTT may contribute to a precision approach to GDM as assessed by differences in insulin resistance/secretion. Further research is indicated to determine if isolated postload hyperglycemia reflects a different mechanistic pathway for targeted management.
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Affiliation(s)
- Sara L White
- Department of Women and Children’s Health, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, SE1 7EH, UK
| | - Albert Koulman
- Core Metabolomics and Lipidomics Laboratory, Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Addenbrooke’s Treatment Centre, Cambridge, CB2 0QQ, UK
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Addenbrooke’s Treatment Centre, Cambridge, CB2 0QQ, UK
| | - Susan E Ozanne
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Addenbrooke’s Treatment Centre, Cambridge, CB2 0QQ, UK
| | - Samuel Furse
- Core Metabolomics and Lipidomics Laboratory, Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Addenbrooke’s Treatment Centre, Cambridge, CB2 0QQ, UK
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Addenbrooke’s Treatment Centre, Cambridge, CB2 0QQ, UK
| | - Lucilla Poston
- Department of Women and Children’s Health, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, SE1 7EH, UK
| | - Claire L Meek
- Core Metabolomics and Lipidomics Laboratory, Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Addenbrooke’s Treatment Centre, Cambridge, CB2 0QQ, UK
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Addenbrooke’s Treatment Centre, Cambridge, CB2 0QQ, UK
- Department of Clinical Biochemistry/Wolfson Diabetes & Endocrine Clinic, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
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Coetzee A, Hall DR, Conradie M. Hyperglycemia First Detected in Pregnancy in South Africa: Facts, Gaps, and Opportunities. FRONTIERS IN CLINICAL DIABETES AND HEALTHCARE 2022; 3:895743. [PMID: 36992779 PMCID: PMC10012101 DOI: 10.3389/fcdhc.2022.895743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 04/01/2022] [Indexed: 06/19/2023]
Abstract
This review contextualizes hyperglycemia in pregnancy from a South-African perspective. It aims to create awareness of the importance of hyperglycemia in pregnancy in low-middle-income countries. We address unanswered questions to guide future research on sub-Saharan African women with hyperglycemia first detected in pregnancy (HFDP). South African women of childbearing age have the highest prevalence of obesity in sub-Saharan Africa. They are predisposed to Type 2 diabetes (T2DM), the leading cause of death in South African women. T2DM remains undiagnosed in many African countries, with two-thirds of people living with diabetes unaware. With the South African health policy's increased focus on improving antenatal care, women often gain access to screening for non-communicable diseases for the first time in pregnancy. While screening practices and diagnostic criteria for gestational diabetes mellitus (GDM) differ amongst geographical areas in South Africa (SA), hyperglycemia of varying degrees is often first detected in pregnancy. This is often erroneously ascribed to GDM, irrespective of the degree of hyperglycemia and not overt diabetes. T2DM and GDM convey a graded increased risk for the mother and fetus during and after pregnancy, with cardiometabolic risk accumulating across the lifespan. Resource limitations and high patient burden have hampered the opportunity to implement accessible preventative care in young women at increased risk of developing T2DM in the broader public health system in SA. All women with HFDP, including those with true GDM, should be followed and undergo glucose assessment postpartum. In SA, studies conducted early postpartum have noted persistent hyperglycemia in a third of women after GDM. Interpregnancy care is advantageous and may attain a favourable metabolic legacy in these young women, but the yield of return following delivery is suboptimal. We review the current best evidence regarding HFDP and contextualize the applicability in SA and other African or low-middle-income countries. The review identifies gaps and shares pragmatic solutions regarding clinical factors that may improve awareness, identification, diagnosis, and management of women with HFDP.
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Affiliation(s)
- Ankia Coetzee
- Department of Medicine, Division of Endocrinology Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - David R. Hall
- Department of Obstetrics and Gynecology, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Magda Conradie
- Department of Medicine, Division of Endocrinology Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
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Fox RA, Patient CJ, Aiken AR, Meek CL, Aiken CE. Temporal variations in maternal treatment requirements and early neonatal outcomes in patients with gestational diabetes. Diabet Med 2021; 38:e14596. [PMID: 33963609 PMCID: PMC10782837 DOI: 10.1111/dme.14596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 04/05/2021] [Indexed: 11/28/2022]
Abstract
AIMS There is seasonal variation in the incidence of gestational diabetes (GDM) and delivery outcomes of affected patients. We assessed whether there was also evidence of temporal variation in maternal treatment requirements and early neonatal outcomes. METHODS We performed a retrospective analysis of women diagnosed with GDM (75 g oral glucose tolerance test, 0 h ≥ 5.1; 1 h ≥ 10.0; 2 h ≥ 8.5 mmol/L) in a UK tertiary obstetric centre (2015-2019) with a singleton infant. Data regarding demographic characteristics, total insulin requirements and neonatal outcomes were extracted from contemporaneous electronic medical records. Linear/logistic regression models using month of the year as a predictor of outcomes were used to assess annual variation. RESULTS In all, 791 women (50.6% receiving pharmacological treatment) and 790 neonates were included. The likelihood of requiring insulin treatment was highest in November (p < 0.05). The average total daily insulin dose was higher at peak (January) compared to average by 19 units/day (p < 0.05). There was no temporal variation in neonatal intensive care admission, or neonatal capillary blood glucose. However, rates of neonatal hypoglycaemia (defined as <2.6 mmol/L) were highest in December (40% above average; p < 0.05). CONCLUSIONS Women with GDM diagnosed in winter are more likely to require insulin treatment and to require higher insulin doses. Neonates born to winter-diagnosed mothers had a corresponding increased risk of neonatal hypoglycaemia. Maternal treatment requirements and neonatal outcomes of GDM vary significantly throughout the year, even in a relatively temperate climate.
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Affiliation(s)
- Rachel A. Fox
- School of Clinical Medicine, Addenbrooke’s Hospital, Cambridge, UK
| | - Charlotte J. Patient
- School of Clinical Medicine, Addenbrooke’s Hospital, Cambridge, UK
- Department of Obstetrics and Gynaecology, Rosie Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Abigail R. Aiken
- LBJ School of Public Affairs, University of Texas at Austin, Austin, TX, USA
| | - Claire L. Meek
- Institute of Metabolic Science, Addenbrooke’s Hospital, Cambridge, UK
- Department of Clinical Biochemistry, Cambridge University Hospitals, Addenbrooke’s Hospital, Cambridge, UK
- Wolfson Diabetes and Endocrinology Clinic, Cambridge University Hospitals, Addenbrooke’s Hospital, Cambridge, UK
| | - Catherine E. Aiken
- School of Clinical Medicine, Addenbrooke’s Hospital, Cambridge, UK
- Institute of Metabolic Science, Addenbrooke’s Hospital, Cambridge, UK
- University Department of Obstetrics and Gynaecology, University of Cambridge, NIHR Cambridge Comprehensive Biomedical Research Centre, Cambridge, UK
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Meek CL. Swings and roundabouts: Time to rethink our approach to gestational diabetes diagnosis? Diabet Med 2021; 38:e14597. [PMID: 33966291 DOI: 10.1111/dme.14597] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 05/05/2021] [Indexed: 12/12/2022]
Affiliation(s)
- Claire L Meek
- Institute of Metabolic Science, University of Cambridge, Cambridge, UK
- Cambridge Universities NHS Foundation Trust, Cambridge, UK
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Yong HEJ, Chan SY. Current approaches and developments in transcript profiling of the human placenta. Hum Reprod Update 2021; 26:799-840. [PMID: 33043357 PMCID: PMC7600289 DOI: 10.1093/humupd/dmaa028] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 06/05/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The placenta is the active interface between mother and foetus, bearing the molecular marks of rapid development and exposures in utero. The placenta is routinely discarded at delivery, providing a valuable resource to explore maternal-offspring health and disease in pregnancy. Genome-wide profiling of the human placental transcriptome provides an unbiased approach to study normal maternal–placental–foetal physiology and pathologies. OBJECTIVE AND RATIONALE To date, many studies have examined the human placental transcriptome, but often within a narrow focus. This review aims to provide a comprehensive overview of human placental transcriptome studies, encompassing those from the cellular to tissue levels and contextualize current findings from a broader perspective. We have consolidated studies into overarching themes, summarized key research findings and addressed important considerations in study design, as a means to promote wider data sharing and support larger meta-analysis of already available data and greater collaboration between researchers in order to fully capitalize on the potential of transcript profiling in future studies. SEARCH METHODS The PubMed database, National Center for Biotechnology Information and European Bioinformatics Institute dataset repositories were searched, to identify all relevant human studies using ‘placenta’, ‘decidua’, ‘trophoblast’, ‘transcriptome’, ‘microarray’ and ‘RNA sequencing’ as search terms until May 2019. Additional studies were found from bibliographies of identified studies. OUTCOMES The 179 identified studies were classifiable into four broad themes: healthy placental development, pregnancy complications, exposures during pregnancy and in vitro placental cultures. The median sample size was 13 (interquartile range 8–29). Transcriptome studies prior to 2015 were predominantly performed using microarrays, while RNA sequencing became the preferred choice in more recent studies. Development of fluidics technology, combined with RNA sequencing, has enabled transcript profiles to be generated of single cells throughout pregnancy, in contrast to previous studies relying on isolated cells. There are several key study aspects, such as sample selection criteria, sample processing and data analysis methods that may represent pitfalls and limitations, which need to be carefully considered as they influence interpretation of findings and conclusions. Furthermore, several areas of growing importance, such as maternal mental health and maternal obesity are understudied and the profiling of placentas from these conditions should be prioritized. WIDER IMPLICATIONS Integrative analysis of placental transcriptomics with other ‘omics’ (methylome, proteome and metabolome) and linkage with future outcomes from longitudinal studies is crucial in enhancing knowledge of healthy placental development and function, and in enabling the underlying causal mechanisms of pregnancy complications to be identified. Such understanding could help in predicting risk of future adversity and in designing interventions that can improve the health outcomes of both mothers and their offspring. Wider collaboration and sharing of placental transcriptome data, overcoming the challenges in obtaining sufficient numbers of quality samples with well-defined clinical characteristics, and dedication of resources to understudied areas of pregnancy will undoubtedly help drive the field forward.
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Affiliation(s)
- Hannah E J Yong
- Singapore Institute for Clinical Sciences, Agency for Science, Technology and Research, Singapore, Singapore
| | - Shiao-Yng Chan
- Singapore Institute for Clinical Sciences, Agency for Science, Technology and Research, Singapore, Singapore.,Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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de Wit L, Bos DM, van Rossum AP, van Rijn BB, Boers KE. Repeated oral glucose tolerance tests in women at risk for gestational diabetes mellitus. Eur J Obstet Gynecol Reprod Biol 2019; 242:79-85. [PMID: 31569028 DOI: 10.1016/j.ejogrb.2019.09.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 09/16/2019] [Accepted: 09/20/2019] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Pregnant women with a negative oral glucose tolerance test (OGTT) between 24-28 weeks as part of risk-based screening for gestational diabetes mellitus (GDM) may develop clinical signs or symptoms suggestive for GDM in the third trimester. We aimed to determine the additional yield of repeating an OGTT to detect missed GDM in this group and assess patient characteristics and indications associated with a positive second OGTT. STUDY DESIGN We conducted a retrospective cohort study of women with a negative OGTT between 24-28 weeks of pregnancy in two hospitals in the Netherlands. Patient characteristics, pregnancy outcomes, OGTT results and indications were compared between women with normal (non-GDM) and abnormal (GDM) results of the second OGTT, using the WHO 1999 criteria (fasting glucose ≥7.0 mmol/L or 2 -h post load ≥7.8 mmol/L). We used receiver operating characteristic (ROC) curve analysis to determine cut-offs for fasting and 2 -h glucose values of the index OGTT that were associated with a positive OGTT in the third trimester. RESULTS Of 3147 women at risk for GDM, 183 underwent a second OGTT in the third trimester following their regular OGTT at 24-28 weeks. In 43 women (23.5%) GDM was diagnosed based on the second OGTT. A history of GDM was associated with subsequent GDM diagnosis, with an odds ratio of 2.6 (95% CI 1.0-6.3). Both fasting and 2 -h post load glucose values of the index OGTT were significantly higher in women with abnormal OGTT results later in pregnancy. Index OGTT glucose value cut-offs of 4.8 mmol/L (fasting) and 6.5 mmol/L (2 -h) had positive predictive values of 0.32 and 0.47 for a positive OGTT in the third trimester, and negative predictive values of 0.83 and 0.90, respectively. Fetal growth as a clinical symptom for GDM was the most frequent indication for repeating the OGTT, resulting in the diagnosis of GDM in 22.7% of women tested for this indication. CONCLUSION Repeating an OGTT after initial negative screening results in additional GDM diagnoses. In case of clinical signs, especially in women with additional risk factors such as a history of GDM or higher index OGTT glucose values, repeating an OGTT could be considered.
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Affiliation(s)
- L de Wit
- Department of Obstetrics & Gynecology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
| | - D M Bos
- Department of Obstetrics & Gynecology, University Medical Center Leiden, Leiden University, Leiden, the Netherlands.
| | - A P van Rossum
- Department of Clinical Chemistry and Hematology, Haaglanden Medical Center Bronovo, the Hague, the Netherlands.
| | - B B van Rijn
- Department of Obstetrics & Gynecology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Department of Obstetrics and Prenatal Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands.
| | - K E Boers
- Department of Obstetrics & Gynecology, Haaglanden Medical Center Bronovo, the Hague, the Netherlands.
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