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Crimmins S, Martin L, Solaru O, Desai A, Esteves K, Elsamadicy E, Kopelman JN, Turan OM. Third Trimester Ultrasound Stratifies Risk of Peripartum Complications in Pregnancies Complicated by Impaired Glucose Tolerance. Am J Perinatol 2024; 41:e803-e808. [PMID: 36368651 DOI: 10.1055/s-0042-1758486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The objective of our study was to investigate the effect of impaired glucose metabolism (IGM) and ultrasound (US) findings consistent with hyperglycemia on maternal and neonatal outcomes. STUDY DESIGN This was a retrospective case-control study of singleton, nonanomalous pregnancies with an elevated 1-hour glucose screening test (GST) completed after 23 weeks of gestation. IGM was defined as a 1-hour GST of >130, but less than two abnormal values on 3-hour glucose tolerance test (GTT). Gestational diabetes was defined as two or more abnormal values on 3-hour GTT. Ultrasound evidence of hyperglycemia was defined as abdominal circumference >95th centile and/or polyhydramnios. Individuals with IGM were divided into those with ultrasound evidence of hyperglycemia (impaired glucose metabolism consistent with ultrasound findings [IGM-US]) and those without IGM. Maternal demographics, delivery outcomes (gestational age at delivery, delivery mode, shoulder dystocia, lacerations), postpartum hemorrhage, and neonatal outcome (birth weight centile [BW%], neonatal intensive care unit admission, hypoglycemia, and glucose) were recorded. Composite morbidity was tabulated. Delivery and neonatal outcome variables were compared in individuals with IGM-US, IGM, and gestational diabetes mellitus (GDM). Odds ratios were calculated and adjusted for maternal age, BMI, and gestational weight gain. RESULTS A total of 637 individuals with an abnormal 1-hour GST were included (122 with IGM-US, 280 with IGM, and 235 with GDM). When compared to the IGM group, IGM-US had higher rates of cesarean delivery and BW% > 90th centile at delivery (adjusted odds ratio [aOR]: 1.7 [1.1-2.8] and aOR: 5.9 [2.7-13.0], respectively). Individuals with GDM also demonstrated similar rates with BW% > 90% but not cesarean section(aOR: 3.9 [1.8-8.5] and aOR: 1.4 [0.9-2.1], respectively). The remaining maternal and fetal outcomes were similar. CONCLUSION Women with impaired glucose tolerance should have a third-trimester ultrasound to identify an increased risk of perinatal complications. KEY POINTS · Women with elevated blood glucose screening should be evaluated with third-trimester ultrasound to identify risks for perinatal morbidity.. · The third-trimester ultrasound identifies individuals at risk for cesarean section.. · Counseling should be completed with individuals with polyhydramnios or accelerated growth..
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Affiliation(s)
- Sarah Crimmins
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, Maryland
| | - Lucille Martin
- University of Maryland School of Medicine, Baltimore, Maryland
| | | | - Andrea Desai
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kristyn Esteves
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Emad Elsamadicy
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Jerome N Kopelman
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, Maryland
| | - Ozhan M Turan
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, Maryland
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Hughes AE, Houghton JAL, Bunce B, Chakera AJ, Spyer G, Shepherd MH, Flanagan SE, Hattersley AT. Bringing precision medicine to the management of pregnancy in women with glucokinase-MODY: a study of diagnostic accuracy and feasibility of non-invasive prenatal testing. Diabetologia 2023; 66:1997-2006. [PMID: 37653058 PMCID: PMC10542291 DOI: 10.1007/s00125-023-05982-9] [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: 04/21/2023] [Accepted: 06/08/2023] [Indexed: 09/02/2023]
Abstract
AIMS/HYPOTHESIS In pregnancies where the mother has glucokinase-MODY (GCK-MODY), fetal growth is determined by fetal genotype. When the fetus inherits a maternal pathogenic GCK variant, normal fetal growth is anticipated, and insulin treatment of maternal hyperglycaemia is not recommended. At present, fetal genotype is estimated from measurement of fetal abdominal circumference on ultrasound. Non-invasive prenatal testing of fetal GCK genotype (NIPT-GCK) using cell-free DNA in maternal blood has recently been developed. We aimed to compare the diagnostic accuracy of NIPT-GCK with that of ultrasound, and determine the feasibility of using NIPT-GCK to guide pregnancy management. METHODS We studied an international cohort of pregnant women with hyperglycaemia due to GCK-MODY. We compared the diagnostic accuracy of NIPT-GCK with that of measurement of fetal abdominal circumference at 28 weeks' gestation (n=38) using a directly genotyped offspring sample as the reference standard. In a feasibility study, we assessed the time to result given to clinicians in 43 consecutive pregnancies affected by GCK-MODY between July 2019 and September 2021. RESULTS In terms of diagnostic accuracy, NIPT-GCK was more sensitive and specific than ultrasound in predicting fetal genotype (sensitivity 100% and specificity 96% for NIPT-GCK vs sensitivity 53% and specificity 61% for fetal abdominal circumference 75th percentile). In terms of feasibility, a valid NIPT-GCK fetal genotype (≥95% probability) was reported in all 38 pregnancies with an amenable variant and repeated samples when needed. The median time to report was 5 weeks (IQR 3-8 weeks). For the 25 samples received before 20 weeks' gestation, results were reported at a median gestational age of 20 weeks (IQR 18-24), with 23/25 (92%) reported before 28 weeks. CONCLUSIONS/INTERPRETATION Non-invasive prenatal testing of fetal genotype in GCK-MODY pregnancies is highly accurate and is capable of providing a result before the last trimester for most patients. This means that non-invasive prenatal testing of fetal genotype is the optimal approach to management of GCK-MODY pregnancies.
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Affiliation(s)
- Alice E Hughes
- Faculty of Health and Life Sciences, University of Exeter Medical School, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Jayne A L Houghton
- Exeter Genomics Laboratory, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - Benjamin Bunce
- Exeter Genomics Laboratory, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - Ali J Chakera
- Faculty of Health and Life Sciences, University of Exeter Medical School, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- Department of Diabetes and Endocrinology, Royal Sussex County Hospital, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Gill Spyer
- Faculty of Health and Life Sciences, University of Exeter Medical School, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- Department of Diabetes and Endocrinology, Torbay Hospital, Torbay and South Devon NHS Foundation Trust, Torquay, UK
| | - Maggie H Shepherd
- Faculty of Health and Life Sciences, University of Exeter Medical School, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- National Institute for Health and Care Research, Exeter Clinical Research Facility, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - Sarah E Flanagan
- Faculty of Health and Life Sciences, University of Exeter Medical School, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Andrew T Hattersley
- Faculty of Health and Life Sciences, University of Exeter Medical School, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK.
- National Institute for Health and Care Research, Exeter Clinical Research Facility, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK.
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Drever HJ, Davidson SJ, Callaway LK, Sekar R, DE Jersey SJ. Factors associated with higher risk of small-for-gestational-age infants in women treated for gestational diabetes. Aust N Z J Obstet Gynaecol 2023; 63:714-720. [PMID: 37221081 DOI: 10.1111/ajo.13696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 04/22/2023] [Indexed: 05/25/2023]
Abstract
BACKGROUND Previously, management of gestational diabetes (GDM) has focused largely on glycaemic control, with a view to reduce the occurrence of large-for-gestational-age (LGA) infants. However, tight glycaemic control in GDM is associated with a higher incidence of small-for-gestational-age (SGA) infants, which has been linked to higher rates of adverse outcomes. AIM The aim was to characterise risk factors associated with having an SGA infant in women being treated for GDM. METHODS This was a retrospective observational cohort study of 308 women with GDM. Women were split into groups based on their infant's size at delivery (SGA, appropriate-for-gestational-age (AGA) or LGA). Literature review and expert opinion helped to determine several predictors of women with GDM delivering an SGA infant, and statistical analysis was used to produce odds ratios (OR) for these predictors. RESULTS The sample included primiparous women with a mean pre-pregnancy body mass index (BMI) of 25.72 (standard deviation: 5.75). Metabolic risk factors associated with delivering an SGA infant included a lower pre-pregnancy BMI (adjusted OR 1.13, P = 0.04, 95% confidence interval (CI): 1.01-1.26), a lower fasting blood glucose level (BGL) (adjusted OR: 3.21, P = 0.01, 95% CI: 1.30-7.93) and growth that was high risk for SGA at baseline ultrasound scan (USS) (adjusted OR: 7.43, P < 0.001, 95% CI: 2.93-18.79). CONCLUSIONS The combined clinical picture of lower pre-pregnancy BMI, fasting BGL and baseline USS growth measurements may indicate a need for less aggressive glucose management in women with GDM to prevent SGA infants.
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Affiliation(s)
- Hillarie J Drever
- Perinatal Research Centre, Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Herston
- Department of Obstetrics & Gynaecology, Townsville Hospital and Health Service Research Education, Support and Administration, Townsville University Hospital, Douglas
| | - Sarah J Davidson
- Perinatal Research Centre, Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Herston
- Women's and Newborn Services, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
- Duke University School of Medicine, DUMC 3710, Durham, North Carolina, USA
| | - Leonie K Callaway
- Women's and Newborn Services, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
- Faculty of Medicine, The University of Queensland
| | - Renuka Sekar
- Department of Maternal Fetal Medicine, Maternal and Fetal Medicine Specialist, Royal Brisbane and Women's Hospital
| | - Susan J DE Jersey
- Women's and Newborn Services, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
- Department of Nutrition and Dietetics, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
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Fernández-López M, Blanco-Carnero JE, Guardia-Baena JM, de Paco-Matallana C, Aragón-Alonso A, Hernández-Martínez AM. Flexible treatment of gestational diabetes mellitus adjusted according to intrauterine fetal growth versus treatment according to strict maternal glycemic parameters: a randomized clinical trial. BMJ Open Diabetes Res Care 2022; 10:10/6/e002915. [PMID: 36593648 PMCID: PMC9730386 DOI: 10.1136/bmjdrc-2022-002915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 11/19/2022] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION To compare the conventional treatment of gestational diabetes mellitus (GDM) with flexible treatment according to the measurement of fetal abdominal circumference (AC) in daily clinical practice. RESEARCH DESIGN AND METHODS Two hundred and sixty pregnant women diagnosed with GDM before week 34 were randomly placed in two groups: a control group, treated according to maternal capillary glycemia, and an experimental group, treated according to ultrasound parameters of fetal growth. The glycemic targets in the control group were blood glucose levels when fasting and 1 hour postprandial (<95/140 mg/dL). In the experimental group, glycemic targets depended on the percentile (p) of fetal AC: if AC p <75th, then blood glucose targets when fasting and at 1 hour postprandial were <120/180 mg/dL; and if AC p ≥75th, then the glycemic targets were <80/120 mg/dL. The follow-up of both groups was scheduled according to the GDM protocol of our diabetes and gestation unit. RESULTS The study was completed by 246 pregnant women, 125 in the control group and 121 in the experimental group. In the experimental group, insulin treatment and neonatal hypoglycemia were significantly lower (p=0.018 and p 0.035, respectively). No differences were observed in large and small infants according to gestational age. However, macrosomic infants were less frequent in the experimental group, although this difference did not reach statistical significance. In terms of gestation complications, the type of delivery and its complications and the rest of the neonatal complications analyzed, no significant differences were observed. CONCLUSIONS The treatment of flexible GDM according to the measurement of fetal AC is safe for the mother and the fetus and almost halves the number of pregnant women who require insulin treatment, without increasing the number of ultrasound checks or medical visits.
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Affiliation(s)
- Manuela Fernández-López
- Endocrinología y Nutrición, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Spain
| | - José Eliseo Blanco-Carnero
- Obstetricia y Ginecología, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Spain
- Biotecnología. Aplicaciones Sanitarias de Biociencias, Instituto Murciano de Investigación Biosanitaria, IMIB-Arrixaca, Murcia, Spain
| | | | - Catalina de Paco-Matallana
- Obstetricia y Ginecología, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Spain
- Biotecnología. Aplicaciones Sanitarias de Biociencias, Instituto Murciano de Investigación Biosanitaria, IMIB-Arrixaca, Murcia, Spain
| | - Aurora Aragón-Alonso
- Endocrinología y Nutrición, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Spain
- Medicina Interna: Endocrinología, Universidad de Murcia, Murcia, Spain
| | - Antonio Miguel Hernández-Martínez
- Endocrinología y Nutrición, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Spain
- Medicina Interna: Endocrinología, Universidad de Murcia, Murcia, Spain
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Kim HS, Oh SY, Cho GJ, Choi SJ, Hong SC, Kwon JY, Kwon HS. A Predictive Model for Large-for-Gestational-Age Infants among Korean Women with Gestational Diabetes Mellitus Using Maternal Characteristics and Fetal Biometric Parameters. J Clin Med 2022; 11:jcm11174951. [PMID: 36078881 PMCID: PMC9456704 DOI: 10.3390/jcm11174951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 08/09/2022] [Accepted: 08/18/2022] [Indexed: 11/16/2022] Open
Abstract
Background: With increasing incidence of gestational diabetes mellitus (GDM), newborn infants with perinatal morbidity, including large-for-gestational-age (LGA) or macrosomia, are also increasing. The purpose of this study was to develop a prediction model for LGA infants with GDM mothers. Methods: This was a retrospective case-control study of 660 women with GDM and singleton pregnancies in four tertiary care hospitals from 2006 to 2013 in Korea. Biometric parameters were obtained at diagnoses of GDM and within two weeks before delivery. These biometric data were all transformed retrospectively into Z-scores calculated using a reference. Interval changes of values between the two periods were obtained. Multivariable logistic and stepwise backwards regression analyses were performed to develop the most parsimonious predictive model. The prediction model included pre-pregnancy body mass index (BMI), head circumference (HC), Z-score at 24 + 0 to 30 + 6 weeks’ gestation, and abdominal circumference (AC) Z-score at 34 + 0 to 41 + 6 weeks within 2 weeks before delivery. The developed model was then internally validated. Results: Our model’s predictive performance (area under the curve (AUC): 0.925) was higher than estimated fetal weight (EFW) within two weeks before delivery (AUC: 0.744) and the interval change of EFW Z-score between the two periods (AUC: 0.874). It was internally validated (AUC: 0.916). Conclusions: A clinical model was developed and internally validated to predict fetal overgrowth in Korean women with GDM, which showed a relatively good performance.
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Affiliation(s)
- Hee-Sun Kim
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Dongguk University Ilsan Hospital, Goyang 10326, Korea
| | - Soo-Young Oh
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Geum Joon Cho
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Korea University College of Medicine, Seoul 02841, Korea
| | - Suk-Joo Choi
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Soon Cheol Hong
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Korea University College of Medicine, Seoul 02841, Korea
| | - Ja-Young Kwon
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Yonsei University College of Medicine, Yonsei University Health System, Seoul 03722, Korea
| | - Han Sung Kwon
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Konkuk University School of Medicine 120-1, Neungdongno, Gwangjin-gu, Seoul 05030, Korea
- Correspondence: ; Tel.: +82-2-2030-7645; Fax: +82-2-2030-7748
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Timsit J, Ciangura C, Dubois-Laforgue D, Saint-Martin C, Bellanne-Chantelot C. Pregnancy in Women With Monogenic Diabetes due to Pathogenic Variants of the Glucokinase Gene: Lessons and Challenges. Front Endocrinol (Lausanne) 2022; 12:802423. [PMID: 35069449 PMCID: PMC8766338 DOI: 10.3389/fendo.2021.802423] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 12/13/2021] [Indexed: 12/12/2022] Open
Abstract
Heterozygous loss-of-function variants of the glucokinase (GCK) gene are responsible for a subtype of maturity-onset diabetes of the young (MODY). GCK-MODY is characterized by a mild hyperglycemia, mainly due to a higher blood glucose threshold for insulin secretion, and an up-regulated glucose counterregulation. GCK-MODY patients are asymptomatic, are not exposed to diabetes long-term complications, and do not require treatment. The diagnosis of GCK-MODY is made on the discovery of hyperglycemia by systematic screening, or by family screening. The situation is peculiar in GCK-MODY women during pregnancy for three reasons: 1. the degree of maternal hyperglycemia is sufficient to induce pregnancy adverse outcomes, as in pregestational or gestational diabetes; 2. the probability that a fetus inherits the maternal mutation is 50% and; 3. fetal insulin secretion is a major stimulus of fetal growth. Consequently, when the fetus has not inherited the maternal mutation, maternal hyperglycemia will trigger increased fetal insulin secretion and growth, with a high risk of macrosomia. By contrast, when the fetus has inherited the maternal mutation, its insulin secretion is set at the same threshold as the mother's, and no fetal growth excess will occur. Thus, treatment of maternal hyperglycemia is necessary only in the former situation, and will lead to a risk of fetal growth restriction in the latter. It has been recommended that the management of diabetes in GCK-MODY pregnant women should be guided by assessment of fetal growth by serial ultrasounds, and institution of insulin therapy when the abdominal circumference is ≥ 75th percentile, considered as a surrogate for the fetal genotype. This strategy has not been validated in women with in GCK-MODY. Recently, the feasibility of non-invasive fetal genotyping has been demonstrated, that will improve the care of these women. Several challenges persist, including the identification of women with GCK-MODY before or early in pregnancy, and the modalities of insulin therapy. Yet, retrospective observational studies have shown that fetal genotype, not maternal treatment with insulin, is the main determinant of fetal growth and of the risk of macrosomia. Thus, further studies are needed to specify the management of GCK-MODY pregnant women during pregnancy.
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Affiliation(s)
- José Timsit
- Department of Diabetology, Université de Paris, AP-HP, Cochin-Port-Royal Hospital, DMU ENDROMED, Paris, France
- PRISIS National Reference Center for Rare Diseases of Insulin Secretion and Insulin Sensitivity, Department of Endocrinology, Diabetology and Reproductive Endocrinology, Assistance Publique-Hôpitaux de Paris, Saint-Antoine University Hospital, Paris, France
- Monogenic Diabetes Study Group of the Société Francophone du Diabète, Paris, France
| | - Cécile Ciangura
- PRISIS National Reference Center for Rare Diseases of Insulin Secretion and Insulin Sensitivity, Department of Endocrinology, Diabetology and Reproductive Endocrinology, Assistance Publique-Hôpitaux de Paris, Saint-Antoine University Hospital, Paris, France
- Monogenic Diabetes Study Group of the Société Francophone du Diabète, Paris, France
- Department of Diabetology, Sorbonne Université, AP-HP, Pitié-Salpêtrière Hospital, Paris, France
| | - Danièle Dubois-Laforgue
- Department of Diabetology, Université de Paris, AP-HP, Cochin-Port-Royal Hospital, DMU ENDROMED, Paris, France
- PRISIS National Reference Center for Rare Diseases of Insulin Secretion and Insulin Sensitivity, Department of Endocrinology, Diabetology and Reproductive Endocrinology, Assistance Publique-Hôpitaux de Paris, Saint-Antoine University Hospital, Paris, France
- Monogenic Diabetes Study Group of the Société Francophone du Diabète, Paris, France
- INSERM U1016, Cochin Hospital, Paris, France
| | - Cécile Saint-Martin
- PRISIS National Reference Center for Rare Diseases of Insulin Secretion and Insulin Sensitivity, Department of Endocrinology, Diabetology and Reproductive Endocrinology, Assistance Publique-Hôpitaux de Paris, Saint-Antoine University Hospital, Paris, France
- Department of Medical Genetics, Sorbonne Université, AP-HP, Pitié-Salpêtrière Hospital, DMU BioGeM, Paris, France
| | - Christine Bellanne-Chantelot
- PRISIS National Reference Center for Rare Diseases of Insulin Secretion and Insulin Sensitivity, Department of Endocrinology, Diabetology and Reproductive Endocrinology, Assistance Publique-Hôpitaux de Paris, Saint-Antoine University Hospital, Paris, France
- Monogenic Diabetes Study Group of the Société Francophone du Diabète, Paris, France
- Department of Medical Genetics, Sorbonne Université, AP-HP, Pitié-Salpêtrière Hospital, DMU BioGeM, Paris, France
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Davidson SJ, de Jersey SJ, Britten FL, Wolski P, Sekar R, Callaway LK. Fetal ultrasound scans to guide management of gestational diabetes: Improved neonatal outcomes in routine clinical practice. Diabetes Res Clin Pract 2021; 173:108696. [PMID: 33592211 DOI: 10.1016/j.diabres.2021.108696] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 12/30/2020] [Accepted: 01/28/2021] [Indexed: 11/16/2022]
Abstract
AIMS Some guidelines recommend altering glycemic targets in gestational diabetes mellitus (GDM) based on ultrasound measurements of fetal growth, but the impact on outcomes in clinical practice is unknown. The aim of this study was to compare the effects of ultrasound-guided and non-ultrasound-guided management on neonatal outcomes. METHODS This was a retrospective, observational study of a random sample of women with GDM and their infants. Outcomes were compared between those who had GDM management tailored according to fetal growth and those who did not. RESULTS In the sample of 221 women, 134 had documentation of ultrasound-guided management while 87 did not. There was no significant difference in size-for-gestational age between groups. Fewer neonates in the ultrasound-guided management group were admitted to the Special Care or Intensive Care Nursery (29.1% vs. 48.3%, P = 0.004), had a prolonged hospital stay (3.7% vs. 13.8%, P = 0.006), or had hypoglycemia after birth (42.5% vs. 56.3%, P = 0.045). The reduction in admission rates and prolonged hospital stays remained significant after controlling for confounding variables. CONCLUSIONS Ultrasound-guided management was independently associated with improvements in some neonatal outcomes.
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Affiliation(s)
- Sarah J Davidson
- Women's & Newborn Services, Royal Brisbane & Women's Hospital, Cnr Butterfield St and Bowen Bridge Rd, Herston, Queensland 4029, Australia; Duke University School of Medicine, DUMC 3710, Durham, NC 27710, USA; Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Building 71/918, Royal Brisbane & Women's Hospital Campus, Herston, Queensland 4029, Australia.
| | - Susan J de Jersey
- Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Building 71/918, Royal Brisbane & Women's Hospital Campus, Herston, Queensland 4029, Australia; Department of Nutrition & Dietetics, Royal Brisbane & Women's Hospital, Cnr Butterfield St and Bowen Bridge Rd, Herston, Queensland 4029, Australia
| | - Fiona L Britten
- Women's & Newborn Services, Royal Brisbane & Women's Hospital, Cnr Butterfield St and Bowen Bridge Rd, Herston, Queensland 4029, Australia; Faculty of Medicine, The University of Queensland, Mayne Medical Building, 288 Herston Road, Herston, Queensland 4006, Australia
| | - Penny Wolski
- Women's & Newborn Services, Royal Brisbane & Women's Hospital, Cnr Butterfield St and Bowen Bridge Rd, Herston, Queensland 4029, Australia
| | - Renuka Sekar
- Maternal and Fetal Medicine Specialist, Royal Brisbane & Women's Hospital, Cnr Butterfield St and Bowen Bridge Rd, Herston, Queensland 4029, Australia
| | - Leonie K Callaway
- Women's & Newborn Services, Royal Brisbane & Women's Hospital, Cnr Butterfield St and Bowen Bridge Rd, Herston, Queensland 4029, Australia; Faculty of Medicine, The University of Queensland, Mayne Medical Building, 288 Herston Road, Herston, Queensland 4006, Australia
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Hulín J, Škopková M, Valkovičová T, Mikulajová S, Rosoľanková M, Papcun P, Gašperíková D, Staník J. Clinical implications of the glucokinase impaired function - GCK MODY today. Physiol Res 2020; 69:995-1011. [PMID: 33129248 DOI: 10.33549/physiolres.934487] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Heterozygous inactivating mutations of the glucokinase (GCK) gene are causing GCK-MODY, one of the most common forms of the Maturity Onset Diabetes of the Young (MODY). GCK-MODY is characterized by fasting hyperglycemia without apparent worsening with aging and low risk for chronic vascular complications. Despite the mild clinical course, GCK-MODY could be misdiagnosed as type 1 or type 2 diabetes. In the diagnostic process, the clinical suspicion is often based on the clinical diagnostic criteria for GCK-MODY and should be confirmed by DNA analysis. However, there are several issues in the clinical and also in genetic part that could complicate the diagnostic process. Most of the people with GCK-MODY do not require any pharmacotherapy. The exception are pregnant women with a fetus which did not inherit GCK mutation from the mother. Such a child has accelerated growth, and has increased risk for diabetic foetopathy. In this situation the mother should be treated with substitutional doses of insulin. Therefore, distinguishing GCK-MODY from gestational diabetes in pregnancy is very important. For this purpose, special clinical diagnostic criteria for clinical identification of GCK-MODY in pregnancy are used. This review updates information on GCK-MODY and discusses several currently not solved problems in the clinical diagnostic process, genetics, and treatment of this type of monogenic diabetes.
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Affiliation(s)
- J Hulín
- Department of Pediatrics, Medical Faculty of the Comenius University, Bratislava, Slovakia.
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Affiliation(s)
- Miriam S Udler
- From the Departments of Medicine (M.S.U., C.E.P.) and Pathology (C.A.A.-T.), Massachusetts General Hospital, and the Departments of Medicine (M.S.U., C.E.P.) and Pathology (C.A.A.-T.), Harvard Medical School - both in Boston
| | - Camille E Powe
- From the Departments of Medicine (M.S.U., C.E.P.) and Pathology (C.A.A.-T.), Massachusetts General Hospital, and the Departments of Medicine (M.S.U., C.E.P.) and Pathology (C.A.A.-T.), Harvard Medical School - both in Boston
| | - Christina A Austin-Tse
- From the Departments of Medicine (M.S.U., C.E.P.) and Pathology (C.A.A.-T.), Massachusetts General Hospital, and the Departments of Medicine (M.S.U., C.E.P.) and Pathology (C.A.A.-T.), Harvard Medical School - both in Boston
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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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Salihu HM, Dongarwar D, King LM, Yusuf KK, Ibrahimi S, Salinas-Miranda AA. Trends in the incidence of fetal macrosomia and its phenotypes in the United States, 1971-2017. Arch Gynecol Obstet 2019; 301:415-426. [PMID: 31811414 DOI: 10.1007/s00404-019-05400-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Accepted: 11/21/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE Studies have reported a surge in the prevalence of obesity among various demographic groups including pregnant women in the U.S. Given the association between maternal obesity and risk of fetal macrosomia, we hypothesized that the incidence of fetal macrosomia will be on the rise in the U.S. We examined trends in fetal macrosomia and macrosomia phenotypes in the U.S. among singleton live births within the gestational age of 28-42 weeks inclusive. METHODS This was a retrospective cohort study covering the period 1971-2017 using U.S. Natality Data files. We applied Joinpoint regression models to derive the average annual percentage change in the outcome. We measured incidence and trends of fetal macrosomia which was defined as birth weight ≥ 4000 g. We further subdivided macrosomia into its phenotypes as previously recommended: Grade 1 (4000-4499 g), Grade 2 (4500-4999 g) and Grade 3 (≥ 5000 g). RESULTS A total of 147,331,305 singleton births over the entire study period of 47 years were analyzed. From a baseline incidence of 8.84%, the rate of fetal macrosomia declined to 8.07% by the end of the study representing a drop of 8.70% in relative terms. The greatest drop was among infants with Grade 3 macrosomia, the most severe and lethal phenotype. The most impactful factors were maternal age and gestational weight gain. CONCLUSION This study is the largest population-based study conducted regarding fetal macrosomia. The rate of fetal macrosomia declined over the previous 5 decades with the most substantial drop observed in the phenotype with the worst prognosis.
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Affiliation(s)
- Hamisu M Salihu
- Center of Excellence in Health Equity, Training and Research, Baylor College of Medicine, 3701 Kirby Drive, Suite 600, Houston, TX, 77098, USA. .,Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA.
| | - Deepa Dongarwar
- Center of Excellence in Health Equity, Training and Research, Baylor College of Medicine, 3701 Kirby Drive, Suite 600, Houston, TX, 77098, USA.,Office of the Provost, Baylor College of Medicine, Houston, TX, USA
| | - Lindsey M King
- Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA.,Department of Health Services Research, Management and Policy, College of Public Health and Health Professions, University of Florida, Gainesville, FL, USA.,College of Public Health, University of South Florida, Tampa, FL, USA
| | - Korede K Yusuf
- College of Nursing and Public Health, Adelphi University, Garden City, NY, USA
| | - Sahra Ibrahimi
- College of Nursing and Public Health, Adelphi University, Garden City, NY, USA
| | - Abraham A Salinas-Miranda
- Center of Excellence in Maternal and Child Health Education, Science, and Practice, College of Public Health, University of South Florida, Tampa, FL, USA
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Hosokawa Y, Higuchi S, Kawakita R, Hata I, Urakami T, Isojima T, Takasawa K, Matsubara Y, Mizuno H, Maruo Y, Matsui K, Aizu K, Jinno K, Araki S, Fujisawa Y, Osugi K, Tono C, Takeshima Y, Yorifuji T. Pregnancy outcome of Japanese patients with glucokinase-maturity-onset diabetes of the young. J Diabetes Investig 2019; 10:1586-1589. [PMID: 30897270 PMCID: PMC6825925 DOI: 10.1111/jdi.13046] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 03/04/2019] [Accepted: 03/17/2019] [Indexed: 12/12/2022] Open
Abstract
AIMS/INTRODUCTION Glucokinase-maturity-onset diabetes of the young (GCK-MODY; also known as MODY2) is a benign hyperglycemic condition, which generally does not require medical interventions. The only known exception is increased birthweight and related perinatal complications in unaffected offspring of affected women. As previous data were obtained mostly from white Europeans, the present study analyzed the pregnancy outcomes of Japanese women with GCK-MODY to better formulate the management plan for this population. MATERIALS AND METHODS The study participants were 34 GCK-MODY families whose members were diagnosed at Osaka City General Hospital during 2010-2017. A total of 53 pregnancies (40 from 23 affected women, 13 from 11 unaffected women) were retrospectively analyzed by chart review. RESULTS Birthweights of unaffected offspring born to affected women were significantly greater as compared with those of affected offspring (P = 0.003). The risk of >4,000 g birthweight (16%), however, was lower as compared with that previously reported for white Europeans, and none of the offspring had complications related to large birthweight. Insulin treatment of the affected women resulted in a significant reduction in the birthweights of unaffected offspring. Perinatal complications including small-for-gestational age birthweight were found only in affected offspring born to insulin-treated women. CONCLUSIONS In Japanese GCK-MODY families, unaffected offspring born to affected women were heavier than affected offspring. However, insulin treatment of affected women might not be advisable because of the lower risk of macrosomic birth injury, and an increased risk of perinatal complications in affected offspring.
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Affiliation(s)
- Yuki Hosokawa
- Division of Pediatric Endocrinology and MetabolismChildren's Medical CenterOsakaJapan
- Present address:
Department of PediatricsKurashiki Central HospitalKurashikiOkayamaJapan
| | - Shinji Higuchi
- Division of Pediatric Endocrinology and MetabolismChildren's Medical CenterOsakaJapan
| | - Rie Kawakita
- Division of Pediatric Endocrinology and MetabolismChildren's Medical CenterOsakaJapan
- Department of Genetic MedicineOsaka City General HospitalOsakaJapan
| | - Ikue Hata
- Faculty of Medical SciencesDepartment of PediatricsUniversity of FukuiFukuiJapan
| | - Tatsuhiko Urakami
- Department of PediatricsNihon University School of MedicineTokyoJapan
| | - Tsuyoshi Isojima
- Department of PediatricsTeikyo University School of MedicineTokyoJapan
| | - Kei Takasawa
- Department of Pediatrics and Developmental BiologyTokyo Medical and Dental UniversityTokyoJapan
| | - Yohei Matsubara
- Department of Pediatrics and Developmental BiologyTokyo Medical and Dental UniversityTokyoJapan
| | - Haruo Mizuno
- Department of PediatricsInternational University of Health and Welfare School of MedicineChibaJapan
| | - Yoshihiro Maruo
- Department of PediatricsShiga University of Medical ScienceShigaJapan
| | - Katsuyuki Matsui
- Department of PediatricsShiga University of Medical ScienceShigaJapan
| | - Katsuya Aizu
- Division of Endocrinology and MetabolismSaitama Children's Medical CenterSaitamaJapan
| | - Kazuhiko Jinno
- Department of PediatricsHiroshima Prefectural HospitalHiroshimaJapan
| | - Shunsuke Araki
- Department of PediatricsSchool of MedicineUniversity of Occupational and Environmental HealthFukuokaJapan
| | - Yasuko Fujisawa
- Department of PediatricsHamamatsu University School of MedicineShizuokaJapan
| | - Koji Osugi
- Department of PediatricsYokohama City University Medical CenterKanagawaJapan
| | - Chikako Tono
- Department of PediatricsIwate Prefectural Chubu HospitalIwateJapan
| | | | - Tohru Yorifuji
- Division of Pediatric Endocrinology and MetabolismChildren's Medical CenterOsakaJapan
- Department of Genetic MedicineOsaka City General HospitalOsakaJapan
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Wexler DJ, Powe CE, Barbour LA, Buchanan T, Coustan DR, Corcoy R, Damm P, Dunne F, Feig DS, Ferrara A, Harper LM, Landon MB, Meltzer SJ, Metzger BE, Roeder H, Rowan JA, Sacks DA, Simmons D, Umans JG, Catalano PM. Research Gaps in Gestational Diabetes Mellitus: Executive Summary of a National Institute of Diabetes and Digestive and Kidney Diseases Workshop. Obstet Gynecol 2019; 132:496-505. [PMID: 29995731 DOI: 10.1097/aog.0000000000002726] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The National Institute of Diabetes and Digestive and Kidney Diseases convened a workshop on research gaps in gestational diabetes mellitus (GDM) with a focus on 1) early pregnancy diagnosis and treatment and 2) pharmacologic treatment strategies. This article summarizes the proceedings of the workshop. In early pregnancy, the appropriate diagnostic criteria for the diagnosis of GDM remain poorly defined, and an effect of early diagnosis and treatment on the risk of adverse outcomes has not been demonstrated. Despite many small randomized controlled trials of glucose-lowering medication treatment in GDM, our understanding of medication management of GDM is incomplete as evidenced by discrepancies among professional society treatment guidelines. The comparative effectiveness of insulin, metformin, and glyburide remains uncertain, particularly with respect to long-term outcomes. Additional topics in need of further research identified by workshop participants included phenotypic heterogeneity in GDM and novel and individualized treatment approaches. Further research on these topics is likely to improve our understanding of the pathophysiology and treatment of GDM to improve both short- and long-term outcomes for mothers and their children.
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Affiliation(s)
- Deborah J Wexler
- Diabetes Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; the Divisions of Endocrinology, Metabolism, and Diabetes and Maternal-Fetal Medicine, University of Colorado School of Medicine and Anschutz Medical Campus, Aurora, Colorado; the Division of Endocrinology and Diabetes, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California; Women & Infants Hospital of Rhode Island and Warren Alpert Medical School of Brown University, Providence, Rhode Island; the Diabetes Unit, Hospital de la Santa Creu I Sant Pau, Universitat Autonoma de Barcelona, Bellaterra, Barcelona, CIBER-BBN, Spain; the Center for Pregnant Women with Diabetes, Department of Obstetrics, Rigshospitalet, Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; College Medicine Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland; the Diabetes & Endocrine in Pregnancy Program, Mount Sinai Hospital and University of Toronto, Toronto, Canada; the Division of Research, Kaiser Permanente Northern California, Oakland, California; the Department of Maternal-Fetal Medicine, Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, Alabama; the Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio; the Departments of Medicine and Obstetrics and Gynecology, McGill University Health Centre, Montreal, Quebec, Canada; Northwestern University Feinberg School of Medicine, Chicago, Illinois; Kaiser Permanente Southern California, San Diego, California; National Women's Health, Auckland, New Zealand; the Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California; Campbelltown Hospital and Western Sydney University, Sydney, Australia; MedStar Health Research Institute, Hyattsville, Maryland; Georgetown-Howard Universities Center for Clinical and Translational Science, Washington, DC; and the Center for Reproductive Health, Case Western Reserve University at MetroHealth Medical Center, Cleveland, Ohio
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Rao U, de Vries B, Ross GP, Gordon A. Fetal biometry for guiding the medical management of women with gestational diabetes mellitus for improving maternal and perinatal health. Cochrane Database Syst Rev 2019; 9:CD012544. [PMID: 31476798 PMCID: PMC6718273 DOI: 10.1002/14651858.cd012544.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Gestational diabetes mellitus (GDM) is a common medical condition that complicates pregnancy and causes adverse maternal and fetal outcomes. At present, most treatment strategies focus on normalisation of maternal blood glucose values with use of diet, lifestyle modification, exercise, oral anti-hyperglycaemics and insulin. This has been shown to reduce the incidence of adverse outcomes, such as birth trauma and macrosomia. However, this involves intensive monitoring and treatment of all women with GDM. We propose that using medical imaging to identify pregnancies displaying signs of being affected by GDM could help to target management, allowing low-risk women to be spared excessive intervention, and facilitating better resource allocation. OBJECTIVES We wanted to address the following question: in women with gestational diabetes, does the use of fetal imaging plus maternal blood glucose concentration to indicate the need for medical management compared with glucose concentration alone reduce the risk of adverse perinatal outcomes? SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register (29 January 2019), ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (ICTRP) (both on 29 January 2019), and reference lists of retrieved studies. SELECTION CRITERIA Randomised controlled trials, including those published in abstract form only. Studies using a cluster-randomised design and quasi-randomised controlled trials were both eligible for inclusion, but we didn't identify any. Cross-over trials were not eligible for inclusion in our review.We included women carrying singleton pregnancies who were diagnosed with GDM, as defined by the trials' authors. The intervention of interest was the use of fetal biometry on imaging methods in addition to maternal glycaemic values for indicating the use of medical therapy for GDM. The control group was the use of maternal glycaemic values alone for indicating the use of such therapy. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and assessed risk of bias. Two review authors extracted data and checked them for accuracy. MAIN RESULTS Three randomised controlled trials met the inclusion criteria for our systematic review - the studies randomised a total of 524 women.We assessed the three included studies as being at a low to moderate risk of bias; the nature of the intervention made it difficult to achieve blinding of participants and personnel and none of the trial reports contained information about methods of allocation concealment (and were therefore assessed as being at an unclear risk of selection bias).In all studies, the intervention was the use of fetal biometry on ultrasound to identify fetuses displaying signs of fetal macrosomia, and the use of this information to indicate the use of medical anti-hyperglycaemic treatments. Those pregnancies were subject to more stringent blood glucose targets than those without signs of fetal macrosomia.Maternal outcomesThe use of fetal biometry in addition to maternal blood glucose concentration (compared with maternal blood glucose concentration alone) may make little or no difference to the incidence of caesarean delivery (risk ratio (RR) 0.81, 95% confidence interval (CI) 0.59 to 1.10; 2 trials, 428 women; low-certainty evidence). We are unclear about the results for hypertensive disorders of pregnancy (RR 0.80, 95% CI 0.34 to 1.89; 2 trials, 325 women) due to very low-certainty evidence. The included trials did not report on development of type 2 diabetes in the mother or maternal hypoglycaemia.Fetal and neonatal outcomesThe use of fetal biometry may make little or no difference to the incidence of neonatal hypoglycaemia (RR 0.90, 95% CI 0.57 to 1.42; 3 trials, 524 women; low-certainty evidence). Very low-certainty evidence means that we are unclear about the results for large-for-gestational age (RR 0.81, 95% CI 0.38 to 1.74; 3 trials, 524 women); shoulder dystocia (RR 0.33, 95% CI 0.01 to 7.98; 1 trial, 96 women); a composite measure of perinatal morbidity or mortality (RR 1.00, 95% CI 0.21 to 4.71; 1 study, 96 women); or perinatal mortality (RR 0.33, 95% CI 0.01 to 7.98; 1 trial, 96 women). AUTHORS' CONCLUSIONS This review is based on evidence from three trials involving 524 women. The trials did not report some important outcomes of interest to this review, and the majority of our secondary outcomes were also unreported. The available evidence ranged from low- to very low-certainty, with downgrading decisions based on limitations in study design, imprecision and inconsistency.There is insufficient evidence to evaluate the use of fetal biometry (in addition to maternal blood glucose concentration values) to assist in guiding the medical management of GDM, on either maternal or perinatal health outcomes, or the associated costs.More research is required, ideally larger randomised studies which report the maternal and infant short- and long-term outcomes listed in this review, as well as those outcomes relating to financial and resource implications.
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Affiliation(s)
- Ujvala Rao
- Royal Prince Alfred HospitalDepartment of Women and BabiesMissenden RdSydneyNSWAustralia2050
| | - Bradley de Vries
- Royal Prince Alfred HospitalDepartment of High Risk ObstetricsSydneyAustralia
| | - Glynis P Ross
- Royal Prince Alfred HospitalDepartment of EndocrinologyMissenden RoadSydneyNSWAustralia2050
| | - Adrienne Gordon
- Royal Prince Alfred HospitalNeonatologyMissenden RoadCamperdownSydneyNSWAustralia2050
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Hagen G, Brown C, Dietrich J, Gibbs C, Lee GT. The Utility of Lower Glycemic Targets for Treating Gestational Diabetes: A Retrospective Study. J Diabetes Res 2019; 2019:6372474. [PMID: 31886283 PMCID: PMC6915122 DOI: 10.1155/2019/6372474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 11/16/2019] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE In vivo study of glucose homeostasis in pregnancy suggests normal glucose levels are lower than current glycemic targets used in gestational diabetes. After the HAPO study results, our institution began using glycemic targets of fasting 85 mg/dL and 2-hour postprandial of 110 mg/dL. We reviewed our results. METHODS A retrospective cohort of GDM patients that delivered at KUMC from January 2007 to May 2017 was reviewed. All patients were diagnosed with the 2-step Carpenter-Coustan thresholds. High targets were compared with low targets. The primary outcome investigated was birthweight > 90% (large for gestational age, LGA). RESULTS 604 patients were studied, and 34% were treated with low glycemic targets. Our unadjusted results showed that the low-target group had a lower incidence of LGA infants (24.0 vs. 31.8%), higher incidence of neonatal hypoglycemia (20.7 vs. 11.6%), and inductions (39.4 vs. 20.5%). After adjustment for demographic variables, only a higher risk of inductions remained (aOR 2.54 (1.44, 4.49)). CONCLUSION Lower glycemic targets did not produce large reductions in fetal overgrowth, but they were associated with a higher rate of inductions. As there were no observed differences in maternal or neonatal outcomes otherwise, aiming for lower glycemic targets in GDM is likely not cost-effective.
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Affiliation(s)
- Grace Hagen
- Department of OBGYN, University of Kansas Medical Center, Kansas City, KS, USA
| | - Crystal Brown
- Department of OBGYN, University of Kansas Medical Center, Kansas City, KS, USA
| | - Jordan Dietrich
- Department of OBGYN, University of Kansas Medical Center, Kansas City, KS, USA
| | - Charles Gibbs
- Department of OBGYN, University of Kansas Medical Center, Kansas City, KS, USA
| | - Gene T. Lee
- Department of OBGYN, University of Kansas Medical Center, Kansas City, KS, USA
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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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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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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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Simpson KJ, Pavicic M, Lee GT. What is the accuracy of an early third trimester sonogram for identifying LGA infants born to GDM patients diagnosed with the one-step approach? J Matern Fetal Neonatal Med 2017; 31:2628-2633. [DOI: 10.1080/14767058.2017.1350643] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Kelsey J. Simpson
- Department of OBGYN, University of Kansas Medical Center, Kansas City, KS, USA
| | - Meredith Pavicic
- Department of OBGYN, University of Kansas Medical Center, Kansas City, KS, USA
| | - Gene T. Lee
- Department of OBGYN, University of Washington Medicine-Valley Medical Center, Renton, WA, USA
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Abstract
Suspected fetal macrosomia is encountered commonly in obstetric practice. As birth weight increases, the likelihood of labor abnormalities, shoulder dystocia, birth trauma, and permanent injury to the neonate increases. The purpose of this document is to quantify those risks, address the accuracy and limitations of methods for estimating fetal weight, and suggest clinical management for a pregnancy with suspected fetal macrosomia.
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Uma R, Bhavadharini B, Ranjani H, Mahalakshmi MM, Anjana RM, Unnikrishnan R, Kayal A, Malanda B, Belton A, Mohan V. Pregnancy outcome of gestational diabetes mellitus using a structured model of care : WINGS project (WINGS-10). J Obstet Gynaecol Res 2016; 43:468-475. [PMID: 28026897 DOI: 10.1111/jog.13249] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 10/05/2016] [Accepted: 11/04/2016] [Indexed: 12/16/2022]
Abstract
AIM To evaluate the impact of a structured model of care (MOC) prepared for resource-constrained settings, on the pregnancy outcomes of Asian Indian women with gestational diabetes mellitus (GDM). METHODS Pregnant women were screened under the Women in India with GDM Strategy (WINGS) MOC for GDM using the International Association of Diabetes and Pregnancy Study Groups criteria. Women with GDM went through a structured MOC that included medical nutrition therapy (MNT), regular physical activity (PA); and insulin when indicated. Fasting blood glucose and post-prandial blood sugar were monitored every 2 weeks. The pregnancy outcomes of women with GDM who underwent the MOC were compared with those without GDM. RESULTS Under the MOC, 212 women with GDM were followed through pregnancy, of whom 33 (15.6%) required insulin and 179 (84.4%) were managed with MNT and PA. The maternal and neonatal outcomes of women with GDM were similar to the non-GDM women: there were no significant differences in pregnancy complications such as cesarean section, macrosomia, pre-eclampsia, oligo/polyhydramnios, preterm delivery, neonatal death, fetal distress, hyperbilirubinemia and low birthweight. CONCLUSION Implementation of a structured MOC for women with GDM helped achieve pregnancy outcomes similar to those without GDM.
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Affiliation(s)
- Ram Uma
- Seethapathy Clinic and Hospital, Chennai, India
| | | | | | | | | | | | | | - Belma Malanda
- International Diabetes Federation, Brussels, Belgium
| | - Anne Belton
- International Diabetes Federation, Brussels, Belgium
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Quevedo SF, Bovbjerg ML, Kington RL. Translation of fetal abdominal circumference-guided therapy of gestational diabetes complicated by maternal obesity to a clinical outpatient setting. J Matern Fetal Neonatal Med 2016; 30:1450-1455. [PMID: 27554188 DOI: 10.1080/14767058.2016.1219987] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To evaluate the effectiveness of fetal abdominal circumference-guided therapy for gestational diabetes (GDM) in an outpatient population characterized by highly-prevalent maternal obesity. METHODS Data for this translational retrospective cohort study come from medical records. Fetal abdominal circumference was assessed by ultrasound in late second trimester, and sex- and gestational age-specific percentiles assigned. Taking fetal abdominal circumference percentile as a marker for adequacy of fetal growth, maternal glucose targets were set accordingly: loose, moderate or tight. Associations between mother's targets and neonatal outcomes (small for gestational age (SGA), large for gestational age (LGA), macrosomia, neonatal intensive care unit (NICU) admission, and neonatal hypoglycemia) were assessed using unconditional logistic regression, controlling for pre-gravid body mass index (BMI) and gestational weight gain. RESULTS In 419 consecutive pregnancies complicated by GDM, neonatal outcomes compared favorably with previous randomized trials of intensive GDM management. Importantly, adverse outcomes were observed less often than might be expected in an obese GDM population. BMI did not have an independent effect on neonatal outcomes. CONCLUSIONS Ultrasound-guided therapy of GDM, in general clinic use, can limit excess macrosomia and LGA, even in a population with significant maternal obesity.
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Affiliation(s)
- Stephen F Quevedo
- a Joslin Diabetes Center Affiliate , Lawrence & Memorial Hospital , New London, CT , USA and
| | - Marit L Bovbjerg
- b Epidemiology Program, College of Public Health and Human Sciences , Oregon State University , Corvallis , OR , USA
| | - Randi L Kington
- a Joslin Diabetes Center Affiliate , Lawrence & Memorial Hospital , New London, CT , USA and
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Lavery JA, Friedman AM, Keyes KM, Wright JD, Ananth CV. Gestational diabetes in the United States: temporal changes in prevalence rates between 1979 and 2010. BJOG 2016; 124:804-813. [PMID: 27510598 DOI: 10.1111/1471-0528.14236] [Citation(s) in RCA: 195] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2016] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To examine age-period-cohort effects on trends in gestational diabetes mellitus (GDM) prevalence in the US, and to evaluate how these trends have affected the rates of stillbirth and large for gestational age (LGA)/macrosomia. DESIGN Retrospective cohort study. SETTING USA, 1979-2010. POPULATION Over 125 million pregnancies (3 337 284 GDM cases) associated with hospitalisations. METHODS Trends in GDM prevalence were examined via weighted Poisson models to parse out the extent to which GDM trends can be attributed to maternal age, period of delivery, and maternal birth cohort. Multilevel models were used to assess the contribution of population effects to the rate of GDM. Log-linear Poisson regression models were used to estimate the contributions of the increasing GDM rates to changes in the rates of LGA and stillbirth between 1979-81 and 2008-10. MAIN OUTCOME MEASURES Rates and rate ratios (RRs). RESULTS Compared with 1979-1980 (0.3%), the rate of GDM has increased to 5.8% in 2008-10, indicating a strong period effect. Substantial age and modest cohort effects were evident. The period effect is partly explained by period trends in body mass index (BMI), race, and maternal smoking. The increasing prevalence of GDM is associated with a 184% (95% CI 180-188%) decline in the rate of LGA/macrosomia and a 0.75% (95% CI 0.74-0.76) increase in the rate of stillbirths for 2008-10, compared with 1979-81. CONCLUSIONS The temporal increase in GDM can be attributed to period of pregnancy and age. Increasing BMI appears to partially contribute to the GDM increase in the US. TWEETABLE ABSTRACT The increasing prevalence of GDM can be attributed to period of delivery and increasing maternal age.
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Affiliation(s)
- J A Lavery
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY, USA.,Biostatistics Coordinating Center, Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - A M Friedman
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - K M Keyes
- Department of Epidemiology, Joseph L. Mailman School of Public Health, Columbia University, New York, NY, USA
| | - J D Wright
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - C V Ananth
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY, USA.,Biostatistics Coordinating Center, Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY, USA.,Department of Epidemiology, Joseph L. Mailman School of Public Health, Columbia University, New York, NY, USA
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Mahalakshmi MM, Bhavadharini B, Maheswari K, Kalaiyarasi G, Anjana RM, Ranjit U, Mohan V, Joseph K, Rekha K, Nallaperumal S, Malanda B, Kayal A, Belton A, Uma R. Comparison of maternal and fetal outcomes among Asian Indian pregnant women with or without gestational diabetes mellitus: A situational analysis study (WINGS-3). Indian J Endocrinol Metab 2016; 20:491-496. [PMID: 27366715 PMCID: PMC4911838 DOI: 10.4103/2230-8210.183469] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
AIM To compare the existing maternal and fetal outcomes in Asian Indian women with or without gestational diabetes mellitus (GDM) before the development of the Women in India with GDM Strategy (WINGS) GDM model of care (MOC). MATERIALS AND METHODS Records of pregnant women were extracted retrospectively from three maternity centers in Chennai. GDM was diagnosed using the International Association for Pregnancy Study Groups criteria or the Carpenter and Coustan criteria. Demographic details, obstetric history, antenatal follow-up, treatment for GDM, and outcomes of delivery were collected from the electronic medical records. RESULTS Of the 3642 records analyzed, 799 (21.9%) had GDM, of whom 456 (57.1%) were treated with insulin and medical nutrition therapy (MNT), 339 (42.4%) with MNT alone, and 4 (0.5%) with metformin. Women with GDM were older than those without (28.5 ± 4.5 vs. 27.1 ± 4.5 years; P < 0.001) and had higher mean body mass index at first booking (26.4 ± 5.2 kg/m(2) vs. 25.2 ± 5.1 kg/m(2); P < 0.001). Rates of cesarean section (26.2% vs. 18.7%; P < 0.001), preeclampsia (1.8% vs. 0.8%; P = 0.04), and macrosomia (13.9% vs. 10.8%; P = 0.02) were significantly higher among women with GDM. In women with GDM treated with insulin and MNT, emergency cesarean section (16.2% vs. 36.6%; P < 0.0001), preeclampsia (0.7% vs. 3.2%; P = 0.015), and macrosomia (9.9% vs. 18.6%; P = 0.0006) were significantly lesser compared to those treated with MNT alone. CONCLUSION Pregnancy outcomes were in general worse in GDM women. Treatment with insulin was associated with a significantly lower risk of complications. However, in countries with limited access to insulin and other medicines may lead to poor follow-up and management of GDM. Data from this retrospective study will form the basis for the development of the WINGS GDM MOC, which will address these gaps in GDM care in low-resource settings.
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Affiliation(s)
- Manni Mohanraj Mahalakshmi
- Department of Epidemiology and Diabetology, Madras Diabetes Research Foundation, Chennai, Tamil Nadu, India
| | - Balaji Bhavadharini
- Department of Epidemiology and Diabetology, Madras Diabetes Research Foundation, Chennai, Tamil Nadu, India
| | - Kumar Maheswari
- Department of Epidemiology and Diabetology, Madras Diabetes Research Foundation, Chennai, Tamil Nadu, India
| | - Gunasekaran Kalaiyarasi
- Department of Epidemiology and Diabetology, Madras Diabetes Research Foundation, Chennai, Tamil Nadu, India
| | - Ranjit Mohan Anjana
- Department of Epidemiology and Diabetology, Madras Diabetes Research Foundation, Chennai, Tamil Nadu, India
| | - Unnikrishnan Ranjit
- Department of Epidemiology and Diabetology, Madras Diabetes Research Foundation, Chennai, Tamil Nadu, India
| | - Viswanathan Mohan
- Department of Epidemiology and Diabetology, Madras Diabetes Research Foundation, Chennai, Tamil Nadu, India
| | - Kurian Joseph
- Department of Obstetrics and Gynecology, Joseph Nursing Home, Chennai, Tamil Nadu, India
| | - Kurian Rekha
- Department of Obstetrics and Gynecology, Joseph Nursing Home, Chennai, Tamil Nadu, India
| | - Sivagnanam Nallaperumal
- Department of Diabetology, Prashanth Infertility Research Centre, Chennai, Tamil Nadu, India
| | - Belma Malanda
- Department of Policy and Programmes, International Diabetes Federation, Brussels, Belgium
| | - Arivudainambi Kayal
- Department of Policy and Programmes, International Diabetes Federation, Brussels, Belgium
| | - Anne Belton
- Department of Policy and Programmes, International Diabetes Federation, Brussels, Belgium
| | - Ram Uma
- Department of Obstetrics and Gynecology, Seethapathy Clinic and Hospital, Chennai, Tamil Nadu, India
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26
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Moses RG, Wong VCK, Lambert K, Morris GJ, San Gil F. The prevalence of hyperglycaemia in pregnancy in Australia. Aust N Z J Obstet Gynaecol 2016; 56:341-5. [PMID: 26914693 DOI: 10.1111/ajo.12447] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 01/09/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND The Australasian Diabetes in Pregnancy Society (ADIPS) has recently endorsed the World Health Organization (WHO) terminology and classification of hyperglycaemia in pregnancy. The prevalence is likely to increase, but no prospective data are available for a representative Australian population. AIMS To determine the prevalence of hyperglycaemia in pregnancy (HIP) using results from both the public and private sectors in a population that has a similar ethnicity to the overall Australian population. MATERIAL AND METHODS The results of all pregnancy oral glucose tolerance tests (POGTT) in the public sector and by a dominant private pathology provider in a major city have been prospectively collected for a three-year period and analysed using the ADIPS (WHO) criteria. RESULTS The prevalence of hyperglycaemia in pregnancy (HIP) was 13.1% with diabetes mellitus in pregnancy (DIP) being 0.4% and gestational diabetes mellitus (GDM) being 12.7%. CONCLUSION The new criteria will diagnose about one-third more women with GDM than the previous ADIPS criteria. This will have resource and health implications. Focussed local health economic data will be important.
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Nesbitt-Hawes EM, Tetstall E, Gee K, Welsh AW. Ultrasound (in)accuracy: it's in the formulae not in the technique - assessment of accuracy of abdominal circumference measurement in term pregnancies. Australas J Ultrasound Med 2015; 17:38-44. [PMID: 28191205 PMCID: PMC5024923 DOI: 10.1002/j.2205-0140.2014.tb00083.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Introduction: Fetal abdominal circumference (AC) is utilised in calculations for the estimation of fetal weight (EFW) and has been proposed as a method of monitoring diabetic pregnancies. We evaluated true ultrasound accuracy by comparing fetal AC biometry with neonatal anthropometry and compared this with standard ultrasound estimations of fetal weight. Methods: A prospective observational study was performed at a tertiary referral centre. Women who were having their confinement of a term, singleton gestation either by induction of labour or elective caesarean section from 2009–2011 were approached to participate. An ultrasound was performed within 24 hours of delivery measuring the biometric parameters of AC, head circumference (HC), biparietal diameter and femur length. Following delivery the AC, HC and birthweight were measured on the neonate. Results: Fifty‐two patients were enrolled in the study with data collected from 50. Mean AC measurement was 35.1 ± 2.1 cm and birth weight was 3596 ± 517 g. A Bland‐Altman plot was used to compare the two AC measurements with the 95% limits of agreement ranging from −2.33–4.69 cm around a mean difference of 1.2 cm. Mean percentage error was 5.0% and 6.2% for the AC and HC measurements respectively, in comparison with percentage errors of 7.0–13.8% for estimation of fetal weight (EFW) from 27 formulae. Conclusions: Sonographic AC measurement is accurate in term pregnancies, with a percentage error less than HC or EFW. Perceptions of ultrasound inaccuracy may relate to the application of formulae rather than the ultrasound technique itself. Fetal surveillance using serial AC measurement has been proposed, in particular monitoring of diabetic pregnancies and in such a group AC may be easier and faster to obtain and more meaningful than EFW.
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Affiliation(s)
- Erin M Nesbitt-Hawes
- Division of Women's and Children's HealthUniversity of New South WalesRandwickNew South WalesAustralia; Department of Obstetrics and GynaecologyRoyal Hospital for WomenRandwickNew South WalesAustralia; Australian Centre for Perinatal ScienceUniversity of New South WalesRandwickNew South WalesAustralia
| | - Emma Tetstall
- Division of Women's and Children's HealthUniversity of New South WalesRandwickNew South WalesAustralia; Department of Obstetrics and GynaecologyRoyal Hospital for WomenRandwickNew South WalesAustralia
| | - Kiera Gee
- Faculty of Medicine University of New South Wales Randwick New South Wales Australia
| | - Alec W Welsh
- Division of Women's and Children's HealthUniversity of New South WalesRandwickNew South WalesAustralia; Department of Maternal-Fetal MedicineRoyal Hospital for WomenRandwickNew South WalesAustralia; Australian Centre for Perinatal ScienceUniversity of New South WalesRandwickNew South WalesAustralia
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Schmitz T. Modalités de l’accouchement dans la prévention de la dystocie des épaules en cas de facteurs de risque identifiés. ACTA ACUST UNITED AC 2015; 44:1261-71. [DOI: 10.1016/j.jgyn.2015.09.051] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 09/18/2015] [Indexed: 10/22/2022]
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Bacon S, Schmid J, McCarthy A, Edwards J, Fleming A, Kinsley B, Firth R, Byrne B, Gavin C, Byrne MM. The clinical management of hyperglycemia in pregnancy complicated by maturity-onset diabetes of the young. Am J Obstet Gynecol 2015; 213:236.e1-7. [PMID: 25935773 DOI: 10.1016/j.ajog.2015.04.037] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Revised: 02/01/2015] [Accepted: 04/27/2015] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Women with maturity-onset diabetes of the young (MODY) are often first identified and diagnosed with diabetes during pregnancy. Genetics and hyperglycemia play an important role in determining fetal size in MODY pregnancies. The principal objective of the current study is to determine the outcomes and clinical management of hyperglycemia in pregnancies complicated by glucokinase gene (GCK) and hepatocyte nuclear factor (HNF)-1α MODY mutations. STUDY DESIGN A retrospective chart review of 37 women with a GCK/HNF-1α mutation was conducted. Data on variables such as birthweight, mode of delivery, and the treatment of hyperglycemia were available on 89 pregnancies. RESULTS The birthweight in unaffected GCK offspring was significantly higher than in the affected GCK offspring (4.8 [4.1-5.2] kg vs 3.2 [3.1-3.7] kg; P = .01). Seven-point home blood glucose monitoring over a 7-day period in each trimester demonstrated higher fasting and postprandial glycemic excursions in the first trimester of GCK pregnancies when compared to HNF-1α pregnancies (fasting 104 [90-115] mg/dL vs 84 [77-88] mg/dL; P = .01 and postprandial 154 [135-196] mg/dL vs 111 [100-131] mg/dL; P = .04) despite insulin treatment. There was a higher percentage of miscarriages in the GCK group when compared to the HNF-1α MODY group (33.3% vs 14%; P = .07), which was similar to the background population. Insulin initiated at an early gestation appeared to lower the incidence of macrosomia in GCK unaffected offspring. CONCLUSION Hyperglycemia in HNF-1α pregnancies is easily managed with current insulin protocols; in contrast, glycemic excursions are difficult to manage in GCK pregnancies. There was an increased percentage of miscarriages in GCK pregnancies highlighting the importance of a diagnosis of GCK-MODY in women prior to conception and the necessity for preconception care.
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Affiliation(s)
- Siobhan Bacon
- Diabetes Day Center, Mater Misericordiae University Hospital, Dublin, Ireland; Rotunda Maternity Hospital, Dublin, Ireland
| | - Jasmin Schmid
- Center for Systems Medicine and Department of Physiology and Medical Physics, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ailbhe McCarthy
- Diabetes Day Center, Mater Misericordiae University Hospital, Dublin, Ireland
| | | | | | - Brendan Kinsley
- Diabetes Day Center, Mater Misericordiae University Hospital, Dublin, Ireland; Coombe Women and Infants University Hospital, Dublin, Ireland
| | | | - Bridgette Byrne
- Coombe Women and Infants University Hospital, Dublin, Ireland
| | - Claire Gavin
- Diabetes Day Center, Mater Misericordiae University Hospital, Dublin, Ireland; National Maternity Hospital, Dublin, Ireland
| | - Maria M Byrne
- Diabetes Day Center, Mater Misericordiae University Hospital, Dublin, Ireland; Rotunda Maternity Hospital, Dublin, Ireland.
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Chakera AJ, Steele AM, Gloyn AL, Shepherd MH, Shields B, Ellard S, Hattersley AT. Recognition and Management of Individuals With Hyperglycemia Because of a Heterozygous Glucokinase Mutation. Diabetes Care 2015; 38:1383-92. [PMID: 26106223 DOI: 10.2337/dc14-2769] [Citation(s) in RCA: 166] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Glucokinase-maturity-onset diabetes of the young (GCK-MODY), also known as MODY2, is caused by heterozygous inactivating mutations in the GCK gene. GCK gene mutations are present in ∼1 in 1,000 of the population, but most are not diagnosed. They are common causes of MODY (10-60%): persistent incidental childhood hyperglycemia (10-60%) and gestational diabetes mellitus (1-2%). GCK-MODY has a unique pathophysiology and clinical characteristics, so it is best considered as a discrete genetic subgroup. People with GCK-MODY have a defect in glucose sensing; hence, glucose homeostasis is maintained at a higher set point resulting in mild, asymptomatic fasting hyperglycemia (5.4-8.3 mmol/L, HbA1c range 5.8-7.6% [40-60 mmol/mol]), which is present from birth and shows slight deterioration with age. Even after 50 years of mild hyperglycemia, people with GCK-MODY do not develop significant microvascular complications, and the prevalence of macrovascular complications is probably similar to that in the general population. Treatment is not recommended outside pregnancy because glucose-lowering therapy is ineffective in people with GCK-MODY and there is a lack of long-term complications. In pregnancy, fetal growth is primarily determined by whether the fetus inherits the GCK gene mutation from their mother. Insulin treatment of the mother is only appropriate when increased fetal abdominal growth on scanning suggests the fetus is unaffected. The impact on outcome of maternal insulin treatment is limited owing to the difficulty in altering maternal glycemia in these patients. Making the diagnosis of GCK-MODY through genetic testing is essential to avoid unnecessary treatment and investigations, especially when patients are misdiagnosed with type 1 or type 2 diabetes.
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Affiliation(s)
- Ali J Chakera
- Institute of Biomedical & Clinical Science, University of Exeter Medical School, Exeter, U.K. MacLeod Diabetes and Endocrine Centre, Royal Devon and Exeter National Health Service Foundation Trust, Exeter, U.K.
| | - Anna M Steele
- Institute of Biomedical & Clinical Science, University of Exeter Medical School, Exeter, U.K. National Institute for Health Research Exeter Clinical Research Facility, Royal Devon and Exeter National Health Service Foundation Trust, and University of Exeter Medical School, Exeter, U.K
| | - Anna L Gloyn
- Oxford Centre for Diabetes Endocrinology and Metabolism, University of Oxford, Oxford, U.K. National Institute for Health Research Oxford Biomedical Research Centre, The Churchill Hospital, Oxford, U.K
| | - Maggie H Shepherd
- Institute of Biomedical & Clinical Science, University of Exeter Medical School, Exeter, U.K. National Institute for Health Research Exeter Clinical Research Facility, Royal Devon and Exeter National Health Service Foundation Trust, and University of Exeter Medical School, Exeter, U.K
| | - Beverley Shields
- Institute of Biomedical & Clinical Science, University of Exeter Medical School, Exeter, U.K
| | - Sian Ellard
- Institute of Biomedical & Clinical Science, University of Exeter Medical School, Exeter, U.K. Department of Molecular Genetics, Royal Devon and Exeter National Health Service Foundation Trust, and University of Exeter Medical School, Exeter, U.K
| | - Andrew T Hattersley
- Institute of Biomedical & Clinical Science, University of Exeter Medical School, Exeter, U.K. MacLeod Diabetes and Endocrine Centre, Royal Devon and Exeter National Health Service Foundation Trust, Exeter, U.K. National Institute for Health Research Exeter Clinical Research Facility, Royal Devon and Exeter National Health Service Foundation Trust, and University of Exeter Medical School, Exeter, U.K.
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Abstract
The definition of optimal glycemic control in pregnancies affected by diabetes remains enigmatic. Diabetes phenotypes are heterogeneous. Moreover, fetal macrosomia insidiously occurs even with excellent glycemic control. Current blood glucose (BG) targets (FBG ≤95, 1-h post-prandial <140, 2 h <120 mg/dL) have improved perinatal outcomes, but arguably they have not normalized. The conventional management approach has been to replicate a pattern of glycemia in normal pregnancy. Although these patterns are lower than previously appreciated, a randomized controlled trial (RCT) has never compared current vs. lower glucose targets powered on maternal/fetal outcomes. This paper provides historical context to the current targets by reviewing evidence supporting their evolution. Using lower targets (FBG <90, 1 h <122, 2 h <110, mean BG ≤95 mg/dL) may help normalize outcomes, but phenotypic differences (type 1 vs. type 2 vs. gestational diabetes) might require different glycemic goals. There remains a critical need for well-designed RCTs to confirm optimal glycemic control that minimizes both small for and large for gestational age across pregnancies affected by diabetes.
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MESH Headings
- Adult
- Birth Weight
- Body Mass Index
- Diabetes Mellitus, Type 1/blood
- Diabetes Mellitus, Type 1/complications
- Diabetes Mellitus, Type 1/history
- Diabetes Mellitus, Type 2/blood
- Diabetes Mellitus, Type 2/complications
- Diabetes Mellitus, Type 2/history
- Diabetes, Gestational/blood
- Diabetes, Gestational/history
- Female
- Fetal Macrosomia/history
- Fetal Macrosomia/prevention & control
- Glycated Hemoglobin/metabolism
- Glycemic Index
- History, 19th Century
- History, 20th Century
- History, 21st Century
- Humans
- Infant, Newborn
- Meta-Analysis as Topic
- Postprandial Period
- Pregnancy
- Pregnancy in Diabetics/blood
- Pregnancy in Diabetics/history
- Randomized Controlled Trials as Topic
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Affiliation(s)
- Teri L Hernandez
- Department of Medicine, Division of Endocrinology, Metabolism, and Diabetes, University of Colorado, Anschutz Medical Campus, 12801 E. 17th Avenue, MS8106, Aurora, CO, 80045, USA,
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Menato G, Bo S, Signorile A, Gallo ML, Cotrino I, Poala CB, Massobrio M. Current management of gestational diabetes mellitus. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/17474108.3.1.73] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Balsells M, García-Patterson A, Gich I, Corcoy R. Ultrasound-guided compared to conventional treatment in gestational diabetes leads to improved birthweight but more insulin treatment: systematic review and meta-analysis. Acta Obstet Gynecol Scand 2013; 93:144-51. [PMID: 24372329 DOI: 10.1111/aogs.12291] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Accepted: 10/20/2013] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To perform a systematic review and meta-analysis of randomized controlled trials assessing ultrasound-guided versus conventional management in women with a broad severity-spectrum of gestational diabetes mellitus. DESIGN Systematic review and meta-analysis of trials published until August 2012. SETTING PubMed and Web of Science databases. STUDY SELECTION AND METHODS Eighteen studies were reviewed in full text. Eligibility criteria were (i) randomized controlled trials comparing metabolic management in women with gestational diabetes mellitus and ultrasound-based vs. the conventional management to assess fetal growth, (ii) representative of the whole spectrum of hyperglycemia and fetal growth, (iii) data on perinatal outcomes. Review Manager 5.0 was used to summarize the results. RESULTS Two studies fulfilled inclusion criteria. The ultrasound-guided group had a lower rate of large-for-gestational age newborns (relative risk 0.58, 95% confidence interval 0.34-0.99), macrosomia (relative risk 0.32, 95% confidence interval 0.11-0.95) and abnormal birthweight (small/large-for-gestational age, relative risk 0.64, 95% confidence interval 0.45-0.93) and a higher rate of insulin treatment (relative risk 1.58, 95% confidence interval 1.14-2.20). The number of women with gestational diabetes with a need to treat to prevent an additional newborn with abnormal birthweight was 10. CONCLUSIONS In women with a broad severity-spectrum of gestational diabetes mellitus, ultrasound-guided management improves birthweight distribution, but increases the need for insulin treatment. More research is needed in this area because results are derived from a limited number of patients.
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Affiliation(s)
- Montserrat Balsells
- Department of Endocrinology and Nutrition, Mútua de Terrassa Hospital, Barcelona, Spain
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Blumer I, Hadar E, Hadden DR, Jovanovič L, Mestman JH, Murad MH, Yogev Y. Diabetes and pregnancy: an endocrine society clinical practice guideline. J Clin Endocrinol Metab 2013; 98:4227-49. [PMID: 24194617 PMCID: PMC8998095 DOI: 10.1210/jc.2013-2465] [Citation(s) in RCA: 313] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Our objective was to formulate a clinical practice guideline for the management of the pregnant woman with diabetes. PARTICIPANTS The Task Force was composed of a chair, selected by the Clinical Guidelines Subcommittee of The Endocrine Society, 5 additional experts, a methodologist, and a medical writer. EVIDENCE This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe both the strength of recommendations and the quality of evidence. CONSENSUS PROCESS One group meeting, several conference calls, and innumerable e-mail communications enabled consensus for all recommendations save one with a majority decision being employed for this single exception. CONCLUSIONS Using an evidence-based approach, this Diabetes and Pregnancy Clinical Practice Guideline addresses important clinical issues in the contemporary management of women with type 1 or type 2 diabetes preconceptionally, during pregnancy, and in the postpartum setting and in the diagnosis and management of women with gestational diabetes during and after pregnancy.
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Affiliation(s)
- Ian Blumer
- 8401 Connecticut Avenue, Suite 900, Chevy Chase, Maryland 20815.
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Neff KJ, Walsh C, Kinsley B, Daly S. Serial fetal abdominal circumference measurements in predicting normal birth weight in gestational diabetes mellitus. Eur J Obstet Gynecol Reprod Biol 2013; 170:106-10. [DOI: 10.1016/j.ejogrb.2013.05.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2012] [Revised: 03/28/2013] [Accepted: 05/30/2013] [Indexed: 11/24/2022]
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Abstract
BACKGROUND Gestational diabetes mellitus, defined as diabetes diagnosed during pregnancy that is not clearly overt diabetes, is becoming more common as the epidemic of obesity and type 2 diabetes continues. Newly proposed diagnostic criteria will, if adopted universally, further increase the prevalence of this condition. Much controversy surrounds the diagnosis and management of gestational diabetes. CONTENT This review provides information regarding various approaches to the diagnosis of gestational diabetes and the recommendations of a number of professional organizations. The implications of gestational diabetes for both the mother and the offspring are described. Approaches to self-monitoring of blood glucose concentrations and treatment with diet, oral medications, and insulin injections are covered. Management of glucose metabolism during labor and the postpartum period are discussed, and an approach to determining the timing of delivery and the mode of delivery is outlined. SUMMARY This review provides an overview of current controversies as well as current recommendations for gestational diabetes care.
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Affiliation(s)
- Donald R Coustan
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Providence, RI 02905, USA.
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Chakera AJ, Carleton VL, Shields B, Ross GP, Hattersley AT. Response to Comment on: Chakera et al. Antenatal diagnosis of fetal genotype determines if maternal hyperglycemia due to a glucokinase mutation requires treatment. Diabetes Care 2012;35:1832-1834. Diabetes Care 2013; 36:e15. [PMID: 23264298 PMCID: PMC3526246 DOI: 10.2337/dc12-1497] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Ali J. Chakera
- From the Peninsula College of Medicine and Dentistry, University of Exeter, Exeter, U.K.; the
- Department of Diabetes and Endocrinology, Royal Devon and Exeter Hospital, Exeter, U.K.; the
| | - Victoria L. Carleton
- Department of Endocrinology, Royal Prince Alfred Hospital, Sydney, Australia; and
- The University of Sydney, Sydney, Australia
| | - Beverley Shields
- From the Peninsula College of Medicine and Dentistry, University of Exeter, Exeter, U.K.; the
| | - Glynis P. Ross
- Department of Endocrinology, Royal Prince Alfred Hospital, Sydney, Australia; and
| | - Andrew T. Hattersley
- From the Peninsula College of Medicine and Dentistry, University of Exeter, Exeter, U.K.; the
- Department of Diabetes and Endocrinology, Royal Devon and Exeter Hospital, Exeter, U.K.; the
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Diabetologisches und geburtshilfliches Management des Gestationsdiabetes. DIABETOLOGE 2012. [DOI: 10.1007/s11428-012-0931-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Abstract
Gestational diabetes mellitus (GDM) carries a small but potentially important risk of adverse perinatal outcomes and a long-term risk of obesity and glucose intolerance in offspring. Mothers with GDM have an excess of hypertensive disorders during pregnancy and a high risk of developing diabetes mellitus thereafter. Diagnosing and treating GDM can reduce perinatal complications, but only a small fraction of pregnancies benefit. Nutritional management is the cornerstone of treatment; insulin, glyburide and metformin can be used to intensify treatment. Fetal measurements complement maternal glucose monitoring in the identification of pregnancies that require such intensification. Glucose testing shortly after delivery can stratify the short-term diabetes risk in mothers. Thereafter, annual glucose and HbA(1c) testing can detect deteriorating glycaemic control, a harbinger of future diabetes mellitus, usually type 2 diabetes mellitus. Interventions that mitigate obesity or its metabolic effects are most potent in preventing or delaying diabetes mellitus. Lifestyle modification is the primary approach; use of medications for diabetes prevention after GDM remains controversial. Family planning enables optimization of health in subsequent pregnancies. Breastfeeding may reduce obesity in children and is recommended. Families should be encouraged to help children adopt lifestyles that reduce the risk of obesity.
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Affiliation(s)
- Thomas A Buchanan
- Division of Endocrinology and Diabetes, Department of Medicine, Keck School of Medicine of the University of Southern California, 2250 Alcazar Street, CSC 205, Los Angeles, CA 90033, USA.
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Gestationsdiabetes. GYNAKOLOGISCHE ENDOKRINOLOGIE 2012. [DOI: 10.1007/s10304-012-0488-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Badakhsh MH, Khamseh ME, Malek M, Shafiee G, Aghili R, Moghimi S, Baradaran HR, Seifoddin M. A thirty-year analysis of cesarean section rate in gestational diabetes and normal pregnant population in Tehran, Iran: a concerning trend. Gynecol Endocrinol 2012; 28:436-9. [PMID: 22114863 DOI: 10.3109/09513590.2011.633654] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The aims of this study were to analyze the trend of cesarean section (CS), determining possible risk factors and also comparing the rate of CS in mothers with gestational diabetes (GDM) and normal pregnant population. MATERIALS AND METHODS A hospital-based midwives data collection including 37,997 pregnancies in Tehran was used for this study. The study population included all women giving birth between 1 January 1980 and 31 December 2009. RESULTS The global rate for CS was 37.8 and 85.9% in normal pregnant population and GDM subjects, respectively. An increase in the rate of CS was observed in normal population from 16.97% during 1980-1989 to 71.08% during 2000-2009. There was a similar upward trend for GDM subjects from 79.17 to 93.55%. The most frequent indications for CS in GDM subjects were unsuccessful induction (31%) and repeat CS (22.76%). CONCLUSION The rate of CS is surprisingly very high in normal pregnant population as well as subjects with GDM. This should be an alarming issue for healthcare policy-makers and a trigger for monitoring situation in the country.
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Affiliation(s)
- Mohammad H Badakhsh
- Department of Obstetrics and Gynecology, Faculty of Medicine, Tehran University of Medical Sciences (TUMS), Tehran, Iran
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Buhling KJ, Doll I, Siebert G, Catalano PM. Relationship between sonographically estimated fetal subcutaneous adipose tissue measurements and neonatal skinfold measurements. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2012; 39:558-562. [PMID: 21898636 DOI: 10.1002/uog.10092] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVE Increased subcutaneous adipose tissue is a well known characteristic of diabetic fetopathy. Prenatal estimation of adipose tissue can be performed by ultrasound, while postnatally skinfold measurements are performed using a Holtain caliper. The aim of this study was to compare these methods in the same patients. METHODS This was a prospective study of 172 pregnant patients (142 controls and 30 with gestational diabetes) at ≥ 37 gestational weeks. In addition to fetal weight estimation, fetal subcutaneous tissue was measured at the anterior abdomen lateral to the umbilicus (SonoSfAbd) and at the middle of the femur (SonoSfFem). Within 72 h after delivery, a Holtain caliper was used to measure neonatal skinfold thickness at the left anterior iliac spine (SfAbd), at the lower angle of the left scapula (SfSca), at the middle of the femur, above the left quadriceps femoris (SfFem) and at the middle of the left triceps (SfHum). Ultrasound and mechanical measurements were correlated. RESULTS The sonographic and mechanical methods showed good correlation with each other. Linear regression analysis gave the following equations: SfAbd (mm) = SonoSfAbd (mm) × 0.489 + 1.988 (r(2) = 0.34, P < 0.001); SfSca (mm) = SonoSfAbd (mm) 0.457 + 2.043 (r(2) = 0.40, P < 0.001); SfFem (mm) = SonoSfFem (mm) × 0.714 + 1.763 (r(2) = 0.41, P < 0.001); SfHum (mm) = SonoSfFem (mm) 0.564 + 2.09 (r(2) = 0.39, P < 0.001). CONCLUSIONS Ultrasound examination is a reliable method for non-invasive intrauterine measurement of fetal subcutaneous tissue and can be used to predict mechanical neonatal skinfold thickness measurements.
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Affiliation(s)
- K J Buhling
- Department of Gynaecological Endocrinology, Clinic of Gynaecology, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany.
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Sacks DA. The use of pharmacotherapy in pregnancies with suspected diabetic fetopathy. J Matern Fetal Neonatal Med 2011; 25:45-9. [DOI: 10.3109/14767058.2012.626929] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Nelson L, Wharton B, Grobman WA. Prediction of large for gestational age birth weights in diabetic mothers based on early third-trimester sonography. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2011; 30:1625-1628. [PMID: 22123996 DOI: 10.7863/jum.2011.30.12.1625] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVES The purpose of this study was to evaluate the ability of early third-trimester sonography to predict large for gestational age (LGA) birth weights in women with diabetes mellitus. METHODS We identified women with nonanomalous singleton gestations and pregestational and gestational diabetes mellitus who underwent sonographic examinations between gestational ages of 28 weeks and 32 weeks 6 days and subsequently delivered at 37 weeks or later. Using a cohort study design, we compared data from women with an estimated fetal weight at or above the 75th percentile (exposed group) with data from those with an estimated fetal weight below the 75th percentile (unexposed group). The primary outcome variable was LGA birth weight, defined as a birth weight of greater than 90% for gestational age. RESULTS Eighty-six women met inclusion criteria over a 3-year period: 40 were in the exposed group, and 46 were in the unexposed group. The mean body mass indices ± SD at delivery were similar for both groups: 35.4 ± 8.2 kg/m(2) exposed versus 35.0 ± 8.2 kg/m(2) unexposed (P = .80). There was no difference in the number of women with gestational diabetes mellitus: 40% exposed versus 39% unexposed (P = .90). Neonates whose early third-trimester estimated fetal weight was at or above the 75th percentile were significantly more likely to be LGA at birth compared with neonates whose early third-trimester estimated fetal weight was below the 75th percentile: 65% exposed versus 15% unexposed (P < .001; odds ratio, 10.3; 95% confidence interval, 3.7-29.1). There was no significant difference in cesarean delivery rates: 60% exposed versus 44% unexposed (P = .13) CONCLUSIONS Measurements obtained by early third-trimester sonographic fetal biometry are reasonably predictive of fetal LGA birth weights at term.
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Affiliation(s)
- Latasha Nelson
- Department of Obstetrics and Gynecology, Northwestern University, Feinberg School of Medicine, Chicago, IL 60611, USA.
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Schaefer-Graf UM, Wendt L, Sacks DA, Kilavuz Ö, Gaber B, Metzner S, Vetter K, Abou-Dakn M. How many sonograms are needed to reliably predict the absence of fetal overgrowth in gestational diabetes mellitus pregnancies? Diabetes Care 2011; 34:39-43. [PMID: 20864517 PMCID: PMC3005443 DOI: 10.2337/dc10-0415] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Serial measurements of the fetal abdominal circumference have been used to guide metabolic management of pregnancies complicated by gestational diabetes mellitus (GDM). A reduction in the number of repeat ultrasound examinations would save resources. Our purpose was to determine the number of serial abdominal circumference measurements per patient necessary to reliably predict the absence of fetal overgrowth. RESEARCH DESIGN AND METHODS Women who had GDM were asked to return for repeat ultrasound at 3- to 4-week intervals starting at initiation of care (mean 26.9 ± 5.7 weeks). Maternal risk factors associated with fetal overgrowth were determined. RESULTS A total of 4,478 ultrasound examinations were performed on 1,914 subjects (2.3 ± 1.2 per pregnancy). Of the 518 women with fetal abdominal circumference >90th percentile, it was diagnosed in 73.9% with the first ultrasound examination at entry and in 13.1% with the second ultrasound examination. Of the fetuses, 85.9 and 86.9% of the fetuses were born non-large for gestational age (LGA) when abdominal circumference was <90th percentile at 24-27 weeks and 28-32 weeks, respectively, and 88.0% were born non-LGA when both scans showed normal growth. For those women who had no risk factors for fetal overgrowth (risk factors: BMI >30 kg/m², history of macrosomia, and fasting glucose > 100 mg/dl), the accuracy of prediction of a non-LGA neonate was 90.0, 89.5, and 95.2%. The predictive ability did not increase with more than two normal scans. CONCLUSIONS The yield of sonographic diagnosis of a large fetus drops markedly after the finding of a fetal abdominal circumference <90th percentile on two sonograms, which excludes with high reliability the risk of a LGA newborn. The ability was enhanced in women who had no risk factors for neonatal macrosomia.
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Affiliation(s)
- Ute M Schaefer-Graf
- Department of Obstetrics and Gynecology, Berlin Center for Diabetes and Pregnancy, St. Joseph Hospital, Berlin, Germany.
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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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Thiebaugeorges O, Guyard-Boileau B. [Obstetrical care in gestational diabetes and management of preterm labor]. J Gynecol Obstet Hum Reprod 2010; 39:S264-S273. [PMID: 21185476 DOI: 10.1016/s0368-2315(10)70052-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
OBJECTIVES Search for data necessary to elaborate recommendations for obstetrical care in gestational diabetes and management of preterm labor. METHODS Systematic review of the literature and levels of evidence. RESULTS In case of gestational diabetes and in the absence of disease or other risk factor associated, there is no evidence to support a systematic rate of clinical follow up different from other pregnancy. The relevance of ultrasound estimates of fetal weight is limited. No formula is superior to others or to the simple measurement of abdominal circumference for the prediction of macrosomia (EL3). The usefulness of the research septal hypertrophy is not demonstrated (EL4). The systematic application of umbilical Doppler has no proven benefits in the absence of growth restriction or hypertension associated (EL4). Monthly ultrasound monitoring of the fetus can be proposed for diabetics on insulin or poorly controlled. In cases of gestational diabetes controlled by diet, cardiotocography of fetal heart rate has not proven useful. In poorly controlled diabetes and/or on insulin, the registration may be discussed taking into account other risk factors associated (EL4). A weekly recording of fetal heart rate is often recommended in case of type 2 diabetes discovered during pregnancy. In case of preterm labor, calcium channel blockers and oxytocin antagonists can be used without specific precautions. The risk of using beta-adrenergic outweighs the benefit. Administration of corticosteroid can be done under glycemic control, with insulin therapy if necessary. Screening test for gestational diabetes should not be performed within few days after last steroid injection.
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Affiliation(s)
- O Thiebaugeorges
- Service obstétrique, maternité régionale universitaire de Nancy, 10 rue du Dr Heydenreich, 54000 Nancy, France.
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Thiebaugeorges O, Guyard-Boileau B. Obstetrical care in gestational diabetes and management of preterm labour. DIABETES & METABOLISM 2010; 36:672-81. [DOI: 10.1016/j.diabet.2010.11.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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