Controversies in Screening and Diagnostic Criteria for Gestational Diabetes in Early and Late Pregnancy

Comparing the outcomes of rheumatic heart disease in pregnancy complicated with and without atrial fibrillation: A propensity score matched analysis

BACKGROUND

Atrial fibrillation (AF) may increase the risk of adverse maternal and fetal outcomes among pregnant with rheumatic valvular lesions (RHD). We aimed to assess the rate of occurrence of AF in pregnant with RHD and its impact on cardiac and maternal-fetal outcomes compared to those without it.

METHODS

The study group consisted of pregnant women with RHD and AF (cases) and a matched comparison group of pregnant women with RHD but without AF (controls) was derived from the database of pregnant women with RHD receiving care at our center between 2011 and 2021. Incidence of composite adverse outcomes(maternal death, heart failure, or thrombo-embolic events) and pregnancy outcomes were compared between them.

RESULTS

Seventy-one (5.1%; 95%CI 4.1%-6.4%) pregnant women with RHD had AF during pregnancy and childbirth, most occurring in the late second or early third trimester. New-onset AF was diagnosed in 34 (47.9%) of them. After matching, the incidence of composite outcome was higher in women with AF (77.5% (95%CI 66.3%-85.7%) compared to women without AF (17.3%(95%CI 13.3%-22.1%), P < .001), with seven (9.9%) maternal deaths among cases and two (0.7%) in controls. Heart failure was the most common adverse cardiac event (26.7% vs. 4.2%, P < .001, cases vs controls). Those with AF had higher odds (adjusted OR 56.6 (14.1-226.8)) of adverse cardiac outcomes after adjusting for other risk factors. The frequency of most non-cardiac pregnancy complications was similar in both groups. However, there was a trend towards a higher rate of miscarriage (16.9% vs. 9.9%), small-for-gestational-age babies(16.3 vs. 9.0%), and cesarean rates(31.9% vs. 18.3%) women with AF compared to those who did not experience AF.

CONCLUSIONS

Atrial fibrillation in pregnancy among women with RHD was associated with an increased risk of maternal morbidity and mortality, with a trend towards an increase in some non-cardiac pregnancy complications compared to those pregnant women without AF. Our study results provide background data for developing and implementing a pregnancy-specific management strategy tailored to middle-income settings.

Prediction of gestational diabetes mellitus in Asian women using machine learning algorithms

This study developed a machine learning algorithm to predict gestational diabetes mellitus (GDM) using retrospective data from 34,387 pregnancies in multi-centers of South Korea. Variables were collected at baseline, E0 (until 10 weeks' gestation), E1 (11-13 weeks' gestation) and M1 (14-24 weeks' gestation). The data set was randomly divided into training and test sets (7:3 ratio) to compare the performances of light gradient boosting machine (LGBM) and extreme gradient boosting (XGBoost) algorithms, with a full set of variables (original). A prediction model with the whole cohort achieved area under the receiver operating characteristics curve (AUC) and area under the precision-recall curve (AUPR) values of 0.711 and 0.246 at baseline, 0.720 and 0.256 at E0, 0.721 and 0.262 at E1, and 0.804 and 0.442 at M1, respectively. Then comparison of three models with different variable sets were performed: [a] variables from clinical guidelines; [b] selected variables from Shapley additive explanations (SHAP) values; and [c] Boruta algorithms. Based on model [c] with the least variables and similar or better performance than the other models, simple questionnaires were developed. The combined use of maternal factors and laboratory data could effectively predict individual risk of GDM using a machine learning model.

Complications and risk factors of early-onset versus late-onset gestational diabetes mellitus: A cohort study from Saudi Arabia

OBJECTIVES

To contribute to this discussion by comparing the complications associated with early-diagnosed versus (vs.) late-diagnosed gestational diabetes mellitus (GDM) for mothers and infants in order to provide baseline data that might guide future changes in the current recommendations for screening.

METHODS

The study compares the risk factors and complications for early- vs. late-diagnosed GDM in a cohort from Saudi Arabia. Prenatal, perinatal, postpartum, and neonatal variables were compared between the early vs. late-diagnosed GDM groups using information gathered from the patient's hospital records.

RESULTS

Significant predictors of early-diagnosed GDM included pregestational BMI and GDM history. Additionally, early diagnosis of GDM was linked to a higher incidence of pre-eclampsia and intrauterine fetal death. Women with early-diagnosed GDM also required more glycemic control interventions, like administering insulin and metformin and controlling their diet. The fetal birth weight and postpartum BMI were significantly higher in the early onset GDM group. The need for insulin and pre-eclampsia were significant factors linked to an early diagnosis of GDM, according to a logistic regression analysis.

CONCLUSION

Therefore, the current findings emphasize the need for early screening in pregnant women with high pregestational BMI and a history of GDM and show that those with early-onset GDM more likely to need insulin therapy and be at a higher risk of developing pre-eclampsia.

Proteins and metabolites fingerprints of gestational diabetes mellitus forming protein-metabolite interactomes are its potential biomarkers

Gestational diabetes mellitus (GDM) is a consequence of glucose intolerance with an inadequate production of insulin that happens during pregnancy and leads to adverse health consequences for both mother and fetus. GDM patients are at higher risk for preeclampsia, and developing diabetes mellitus type 2 in later life, while the child born to GDM mothers are more prone to macrosomia, and hypoglycemia. The universally accepted diagnostic criteria for GDM are lacking, therefore there is a need for a diagnosis of GDM that can identify GDM at its early stage (first trimester). We have reviewed the literature on proteins and metabolites fingerprints of GDM. Further, we have performed protein-protein, metabolite-metabolite, and protein-metabolite interaction network studies on GDM proteins and metabolites fingerprints. Notably, some proteins and metabolites fingerprints are forming strong interaction networks at high confidence scores. Therefore, we have suggested that those proteins and metabolites that are forming protein-metabolite interactomes are the potential biomarkers of GDM. The protein-metabolite biomarkers interactome may help in a deep understanding of the prognosis, pathogenesis of GDM, and also detection of GDM. The protein-metabolites interactome may be further applied in planning future therapeutic strategies to promote long-term health benefits in GDM mothers and their children.

Prevalence of gestational diabetes mellitus in women with a family history of type 2 diabetes in first- and second-degree relatives

AIMS

A family history of type 2 diabetes mellitus (T2DM) markedly increases an individual's lifetime risk of developing the disease. For gestational diabetes (GDM), this risk factor is less well characterized. This study aimed to investigate the relationship between family history of T2DM in first- and second-degree relatives in women with GDM and the differences in metabolic characteristics at early gestation.

METHODS

This prospective cohort study included 1129 pregnant women. A broad risk evaluation was performed before 16 + 0 weeks of gestation, including a detailed family history of the different types of diabetes and a laboratory examination of glucometabolic parameters. Participants were followed up until delivery and GDM assessed according to the latest diagnosis criteria.

RESULTS

We showed that pregnant women with first- (FHD1, 26.6%, OR 1.91, 95%CI 1.16 to 3.16, p = 0.005), second- (FHD2, 26.3%, OR 1.88, 95%CI 1.16 to 3.05, p = 0.005) or both first- and second-degree relatives with T2DM (FHD1 + D2, 33.3%, OR 2.64, 95%CI 1.41 to 4.94, p < 0.001) had a markedly increased risk of GDM compared to those with negative family history (FHN) (n = 100, 15.9%). The association was strongest if both parents were affected (OR 4.69, 95%CI 1.33 to 16.55, p = 0.009). Women with FHD1 and FHD1 + D2 had adverse glucometabolic profiles already in early pregnancy.

CONCLUSIONS

Family history of T2DM is an important risk factor for GDM, also by applying the current diagnostic criteria. Furthermore, we showed that the degree of kinship plays an essential role in quantifying the risk already at early pregnancy.

Utility of In Vivo Magnetic Resonance Imaging Is Predictive of Gestational Diabetes Mellitus During Early Pregnancy

CONTEXT

Gestational diabetes (GDM) imposes long-term adverse health effects on the mother and fetus. The role of magnetic resonance imaging (MRI) during early gestation in GDM has not been well-studied.

OBJECTIVE

To investigate the role of quantitative MRI measurements of placental volume and perfusion, with distribution of maternal adiposity, during early gestation in GDM.

METHODS

At UCLA outpatient antenatal obstetrics clinics, ∼200 pregnant women recruited in the first trimester were followed temporally through pregnancy until parturition. Two placental MRI scans were prospectively performed at 14 to 16 weeks and 19 to 24 weeks gestational age (GA). Placental volume and blood flow (PBF) were calculated from placental regions of interest; maternal adiposity distribution was assessed by subcutaneous fat area ratio (SFAR) and visceral fat area ratio (VFAR). Statistical comparisons were performed using the two-tailed t test. Predictive logistic regression modeling was evaluated by area under the curve (AUC).

RESULTS

Of a total 186 subjects, 21 subjects (11.3%) developed GDM. VFAR was higher in GDM vs the control group, at both time points (P < 0.001 each). Placental volume was greater in GDM vs the control group at 19 to 24 weeks GA (P = 0.01). Combining VFAR, placental volume and perfusion, improved the AUC to 0.83 at 14 to 16 weeks (positive predictive value [PPV] = 0.77, negative predictive value [NPV] = 0.83), and 0.81 at 19 to 24 weeks GA (PPV = 0.73, NPV = 0.86).

CONCLUSION

A combination of MRI-based placental volume, perfusion, and visceral adiposity during early pregnancy demonstrates significant changes in GDM and provides a proof of concept for predicting the subsequent development of GDM.

New Developments, Challenges and Open Questions in Diagnosis and Treatment of Gestational Diabetes Mellitus

The prevalence of gestational diabetes mellitus (GDM) is increasing alongside a rising maternal age at conception, an increasing number of people making unhealthy lifestyle choices and, especially, an increasing pregestational body weight [...].

TyGIS: improved triglyceride-glucose index for the assessment of insulin sensitivity during pregnancy

Background

The triglyceride-glucose index (TyG) has been proposed as a surrogate marker of insulin resistance, which is a typical trait of pregnancy. However, very few studies analyzed TyG performance as marker of insulin resistance in pregnancy, and they were limited to insulin resistance assessment at fasting rather than in dynamic conditions, i.e., during an oral glucose tolerance test (OGTT), which allows more reliable assessment of the actual insulin sensitivity impairment. Thus, first aim of the study was exploring in pregnancy the relationships between TyG and OGTT-derived insulin sensitivity. In addition, we developed a new version of TyG, for improved performance as marker of insulin resistance in pregnancy.

Methods

At early pregnancy, a cohort of 109 women underwent assessment of maternal biometry and blood tests at fasting, for measurements of several variables (visit 1). Subsequently (26 weeks of gestation) all visit 1 analyses were repeated (visit 2), and a subgroup of women (84 selected) received a 2 h-75 g OGTT (30, 60, 90, and 120 min sampling) with measurement of blood glucose, insulin and C-peptide for reliable assessment of insulin sensitivity (PREDIM index) and insulin secretion/beta-cell function. The dataset was randomly split into 70% training set and 30% test set, and by machine learning approach we identified the optimal model, with TyG included, showing the best relationship with PREDIM. For inclusion in the model, we considered only fasting variables, in agreement with TyG definition.

Results

The relationship of TyG with PREDIM was weak. Conversely, the improved TyG, called TyGIS, (linear function of TyG, body weight, lean body mass percentage and fasting insulin) resulted much strongly related to PREDIM, in both training and test sets (R² > 0.64, p < 0.0001). Bland–Altman analysis and equivalence test confirmed the good performance of TyGIS in terms of association with PREDIM. Different further analyses confirmed TyGIS superiority over TyG.

Conclusions

We developed an improved version of TyG, as new surrogate marker of insulin sensitivity in pregnancy (TyGIS). Similarly to TyG, TyGIS relies only on fasting variables, but its performances are remarkably improved than those of TyG.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12933-022-01649-8.

Deep Insight of the Pathophysiology of Gestational Diabetes Mellitus

Diabetes mellitus is a severe metabolic disorder, which consistently requires medical care and self-management to restrict complications, such as obesity, kidney damage and cardiovascular diseases. The subtype gestational diabetes mellitus (GDM) occurs during pregnancy, which severely affects both the mother and the growing foetus. Obesity, uncontrolled weight gain and advanced gestational age are the prominent risk factors for GDM, which lead to high rate of perinatal mortality and morbidity. Zn in-depth understanding of the molecular mechanism involved in GDM will help researchers to design drugs for the optimal management of the condition without affecting the mother and foetus. This review article is focused on the molecular mechanism involved in the pathophysiology of GDM and the probable biomarkers, which can be helpful for the early diagnosis of the condition. The early diagnosis of the metabolic disorder, most preferably in first trimester of pregnancy, will lead to its effective long-term management, reducing foetal developmental complications and mortality along with safety measures for the mother.

Study protocol on risk factors for the diagnosis of gestational diabetes mellitus in different trimesters and their relation to maternal and neonatal outcomes (GDM-RIDMAN)

INTRODUCTION

Gestational diabetes mellitus (GDM) is often associated with adverse pregnancy outcomes. However, the association of risk factors with GDM diagnosis, maternal and neonatal health outcomes is less established when compared with women without GDM. We aim to examine the diagnostic accuracy of the conventional and novel risk factors for a GDM diagnosis and their impact on maternal and neonatal health outcomes.

METHODS AND ANALYSIS

This retrospective cohort and nested case-control study at six public health clinics is based on medical records and questionnaire survey of women between 2 and 12 months postpartum. The estimated required sample size is 876 complete records (292 cases, 584 control, at a ratio of 1:2). Oral glucose tolerance test results will be used to identify glucose dysregulation, and maternal and neonatal outcomes include maternal weight gain, pre-eclampsia, polyhydramnios, mode of delivery, preterm or postdate birth, complications in labour, birth weight, gestational age at birth, Apgar score, congenital anomaly, congenital hypothyroidism, neonatal death or stillbirth, hypoglycaemia and hyperbilirubinaemia. Psychosocial measures include the WHO Quality of Life: brief, mother-infant bonding (14-item Postpartum Bonding Questionnaire and 19-item Maternal Postnatal Attachment Scale), anxiety (7-item Generalised Anxiety Disorder), depression (9-item Patient Health Questionnaire) and stress (Perceived Stress Scale symptoms) questionnaires. The comparative incidences of maternal and neonatal health outcomes, the comparative prevalence of the psychosocial outcomes between women with GDM and without GDM, specificity, sensitivity, positive and negative predictive values of the risk factors, separately and combined, will be reported. All GDM risk factors and outcomes will be modelled using multivariable regression analysis and the receiver operating characteristics curve will be reported.

ETHICS AND DISSEMINATION

This study was approved by the Malaysia Research and Ethics Committee, Ministry of Health Malaysia. Informed consent will be obtained from all participants. Findings will be submitted for publications in scientific journals.

Can Thyroid Screening in the First Trimester Improve the Prediction of Gestational Diabetes Mellitus?

This study aimed to evaluate the clinical utility of the subclinical hypothyroidism (SCH) marker, elevated thyroid-stimulating hormone (TSH) and thyroid antibodies in their ability to predict subsequent gestational diabetes mellitus (GDM). In a prospective clinical trial, 230 pregnant women were screened for thyroid function during the first trimester of pregnancy. Increased TSH levels with normal free thyroxine (fT4) were considered SCH. The titers of thyroid peroxidase antibody (anti TPO Ab) at >35 IU/mL and thyroglobulin antibody (anti Tg Ab) at >115 IU/mL were considered as antibodies present. According to the OGTT results, the number of pregnant women with GDM showed the expected growth trend, which was 19%. Two groups of pregnant women were compared, one with GDM and the other without. Increased TSH levels and the presence of thyroid antibodies showed a positive correlation with the risk of GDM. TSH levels were significantly higher in pregnant women with GDM, p = 0.027. In this study, 25.6% of pregnant women met the diagnostic criteria for autoimmune thyroiditis. Hashimoto’s thyroiditis was significantly more common in GDM patients, p < 0.001. Through multivariate logistic regression, it was demonstrated that patient age, TSH 4 IU/mL, and anti TPO Ab > 35 IU/mL are significant predictors of gestational diabetes mellitus that may improve first-trimester pregnancy screening performance, AUC: 0.711; 95% CI: 0.629−0.793.

Fatty liver indices and their association with glucose metabolism in pregnancy - An observational cohort study

AIMS

Non-invasive hepatic steatosis indices can be used to assess the risk for metabolic (dysfunction) associated fatty liver disease (MAFLD). This may be helpful to detect metabolic disorders in pregnancy, specifically gestational diabetes (GDM). We aimto examine the association of these indices with parameters of glucose metabolism.

METHODS

109 women underwent a metabolic characterization at 16 weeks of gestation andwere classified according to the fatty-liver index (FLI) andhepatic-steatosis index (HSI) into low (G1), intermediate (G2) and high risk (G3). At 26 weeks, participants received an oral glucose tolerance test (OGTT) to assess insulin action, β-cell function and GDM status.

RESULTS

Both MAFLD indices wereassociated with impaired insulin sensitivityand compensatory increase of insulin release. G3 groups showedimpaired insulin action. The higher circulating insulin concentrations were not able to compensate for insulin resistance in women with higher MAFLD scores, resulting in an increased risk of GDM(OR: 1.05, 95% CI 1.03 to 1.08, p < 0.001 for FLI). MAFLD scores were associated with fetal overgrowth.

CONCLUSIONS

Maternal MAFLD represents a high-risk obstetric condition. Hepatic steatosis indices are associated with impaired glucose regulation and may provide a useful tool for early risk assessment for impaired glucose metabolism.

Changed definition of disease and broader screening criteria had little impact on prevalence of gestational diabetes mellitus

INTRODUCTION

There are major controversies in screening for gestational diabetes mellitus (GDM). The present study evaluates the impact of the 2017 revised guidelines for GDM screening and a changed definition of GDM in Norway.

MATERIAL AND METHODS

We used a case-series design and included women with no pre-pregnancy diabetes mellitus, who gave birth after gestational week 29 to a singleton fetus at the University Hospital of North Norway, Tromsø, or at a local maternity ward in Troms county, during the first 6 months of 2013 (before group, n = 676) and 2018 (after group, n = 673). Data were collected from antenatal records, maternal health information sheets, and electronic medical records (Partus). We assessed the screening criteria age, parity, pre-pregnancy BMI, and ethnicity. Primary outcomes were change in size of the population eligible for GDM screening, screening adherence, and prevalence of GDM, and follow up of GDM (treatment and obstetric risk assessment at gestational week 36). Statistical analyses were done using IBM SPSS with chi-squared test. A p value less than 0.05 was considered statistically significant.

RESULTS

The proportion of women eligible for GDM screening increased from 46.4% in the before group to 67.6% in the after group (+45%) (p < 0.01). However, screening adherence among eligible women was only 28.3% and 49.2% in the before and after groups, respectively (p < 0.01). Among screened women, 16.9% (15/89) and 10.7% (24/224), respectively, were diagnosed with GDM, resulting in an overall estimated prevalence of 2.2% (15/676) and 3.6% (24/673). Among women diagnosed with GDM, 13.3% received no follow up in 2013 and this proportion was 20.8% in 2018. The remaining women underwent obstetric risk assessment at gestational week 36 as advised in the guidelines.

CONCLUSIONS

The introduction of broader screening criteria and a more liberal case definition increased the population eligible for GDM screening by 45%. The higher proportion of women screened resulted in an insignificant higher prevalence of GDM. Screening adherence was poor in both study groups. Stakeholders for obstetric care need to consolidate quality measures and revisit the screening algorithm.

Circulating extracellular vesicles exhibit a differential miRNA profile in gestational diabetes mellitus pregnancies

We undertook a prospective temporal study collecting blood samples from consenting pregnant women, to test the hypothesis that circulating extracellular vesicles (EVs) carrying specific non-coding microRNA signatures can underlie gestational diabetes mellitus (GDM). To test this hypothesis, miRNA cargo of isolated and characterized EVs revealed contributions from the placenta and differential expression at all three trimesters and at delivery between pregnant and non-pregnant states. Many miRNAs originate from the placental-specific chromosome 19 microRNA cluster (19MC) and chromosome 14 microRNA cluster (14MC). Further a positive correlation emerged between third trimester and at delivery EVs containing miRNAs and those expressed by the corresponding post-parturient placentas (R value = 0.63 to 0.69, p value = 2.2X10-16), in normal and GDM. In addition, distinct differences at all trimesters emerged between women who subsequently developed GDM. Analysis by logistic regression with leave-one-out-cross validation revealed the optimal combination of miRNAs using all the circulating miRNAs (miR-92a-3p, miR-192-5p, miR-451a, miR-122-5p), or using only the differentially expressed miRNAs (has-miR-92a-3p, hsa-miR-92b-3p, hsa-miR-100-5p and hsa-miR-125a-3p) in GDM during the first trimester. As an initial step, both sets of miRNAs demonstrated a predictive probability with an area under the curve of 0.95 to 0.96. These miRNAs targeted genes involved in cell metabolism, proliferation and immune tolerance. In particular genes of the P-I-3-Kinase, FOXO, insulin signaling and glucogenic pathways were targeted, suggestive of placental connectivity with various maternal organs/cells, altering physiology along with pathogenic mechanisms underlying the subsequent development of GDM. We conclude that circulating EVs originating from the placenta with their miRNA cargo communicate and regulate signaling pathways in maternal organs, thereby predetermining development of GDM.

Gestational Diabetes Mellitus in Pregnant Women with Beta-Thalassemia Minor: A Matched Case-Control Study

Pregnancy in women with thalassemia minor is considered safe. However, a higher incidence of maternal and neonatal complications in women with the disorder has been reported in the literature. This study aimed to determine whether there is an increased risk of gestational diabetes mellitus (GDM) in pregnant women with beta-thalassemia minor. We conducted a retrospective matched case-control study of 230 pregnant women who delivered at the Department of Obstetrics and Feto-Maternal Medicine at the Medical University of Vienna between the years 2008 and 2020, whereof 115 women had beta-thalassemia minor. We found no significant difference in the occurrence of GDM between the case group and control group of age and BMI-matched healthy women. However, we observed a significantly lower hemoglobin (Hb) and hematocrit (Ht) level during the first, the second, and the third trimesters of pregnancy, and postpartum (all: p < 0.001) among women with beta-thalassemia minor compared to the healthy controls. Neonates of women with beta-thalassemia were more likely to experience post-natal jaundice and excessive weight loss (p < 0.001). We conclude that GDM is not more likely to occur in pregnant women with beta-thalassemia minor. However, clinicians should be made aware of the risk of adverse maternal and neonatal outcomes. Furthermore, women with beta-thalassemia minor should undergo regular laboratory screening and multidisciplinary pregnancy care.

Overt Diabetes in Pregnancy

AIMS

Overt diabetes in pregnancy is defined as hyperglycemia first recognized during pregnancy which meets the diagnostic threshold of diabetes in non-pregnant adults. This case-based narrative review aims to describe this unique condition and discuss the potential implications for its accurate diagnosis and management.

METHODS AND RESULTS

We conducted a literature search in PubMed for relevant articles published in English language up to January 2022. Women with overt diabetes have a higher risk for adverse pregnancy outcomes and postpartum diabetes, compared to their counterparts with gestational diabetes mellitus (GDM). Such women often need aggressive management, including early and prompt initiation of insulin therapy, and a close follow-up during pregnancy and in the postpartum period. Not all pregnant women with overt diabetes have persistent diabetes in the postpartum period. Early diagnosis, especially during the first trimester, and fasting plasma glucose elevation (≥ 126 mg/dl or 7 mmol/L) at the time of initial diagnosis are predictors of postpartum diabetes.

CONCLUSIONS

Both GDM and overt diabetes in pregnancy are hyperglycemic conditions first recognized during pregnancy, but the two conditions differ in severity; the latter is a more severe form of hyperglycemia associated with worse maternal and fetal outcomes, and a higher risk of postpartum diabetes.

Early pregnancy hyperglycaemia as a significant predictor of large for gestational age neonates

AIMS

We aimed to determine the effect of early pregnancy hyperglycaemia on having a large for gestational age (LGA) neonate.

METHODS

A prospective cohort study was conducted among pregnant women in their first trimester. One-step plasma glucose (PG) evaluation procedure was performed to assess gestational diabetes mellitus (GDM) and diabetes mellitus (DM) in pregnancy as defined by the World Health Organization (WHO) criteria with International Association of Diabetes in Pregnancy Study Group (IADPSG) thresholds. The main outcome studied was large for gestational age neonates (LGA).

RESULTS

A total of 2,709 participants were recruited with a mean age of 28 years (SD = 5.4) and a median gestational age (GA) of eight weeks (interquartile range [IQR] = 2). The prevalence of GDM in first trimester (T1) was 15.0% (95% confidence interval [CI] = 13.7-16.4). Previously undiagnosed DM was detected among 2.5% of the participants. Out of 2,285 live births with a median delivery GA of 38 weeks (IQR = 3), 7.0% were LGA neonates. The cumulative incidence of LGA neonates in women with GDM and DM was 11.1 and 15.5 per 100 women, respectively. The relative risk of having an LGA neonate among women with DM and GDM was 2.30 (95% CI = 1.23-4.28) and 1.80 (95% CI = 1.27-2.53), respectively. The attributable risk percentage of a LGA neonate for hyperglycaemia was 15.01%. T1 fasting PG was significantly correlated with both neonatal birth weight and birth weight centile.

CONCLUSIONS

The proposed WHO criteria for hyperglycaemia in pregnancy are valid, even in T1, for predicting LGA neonates. The use of IADPSG threshold for Fasting PG, for risk assessment in early pregnancy in high-risk populations is recommended.

Impact Of Prepregnancy Overweight And Obesity On Treatment Modality And Pregnancy Outcome In Women With Gestational Diabetes Mellitus

BACKGROUND

We aim to evaluate the impact of prepregnancy overweight on treatment modalities of Gestational Diabetes Mellitus (GDM). We assessed the association of increased pregravid Body Mass Index (BMI) with dosing of basal and rapid acting insulin as well as pregnancy outcome.

METHODS

We included 509 gestational diabetic women (normal weight: 200, overweight: 157, obese: 152), attending the pregnancy outpatient clinic at the Department of Obstetrics and Gynecology, Medical University of Vienna, in this retrospective study. We used a prospectively compiled database to assess patient characteristics, treatment approaches - particularly maximum doses of basal and rapid acting insulin or metformin - and pregnancy outcome.

RESULTS

Increased BMI was associated with the need of glucose lowering medication (odds ratio (OR): 1.08 for the increase of 1 kg/m² BMI, 95%CI 1.05-1.11, p<0.001). Mothers with pregestational obesity received the highest amount of insulin. Metformin was more often used in patients with obesity who also required higher daily doses. Maternal BMI was associated with increased risk of cesarean section (OR 1.04, 95%CI 1.01-1.07, p<0.001) and delivering large for gestational age offspring (OR 1.09, 95%CI 1.04-1.13, p<0.001). Birthweight percentiles were highest in patients with obesity who required glucose lowering therapy.

CONCLUSIONS

Treatment modalities and outcome in GDM pregnancies are closely related to the extent of maternal BMI. Patients with obesity required glucose lowering medication more often and were at higher risk of adverse pregnancy outcomes. It is crucial to further explore the underlying pathophysiologic mechanisms to optimize clinical management and individual treatment approaches.

Detection of gestational diabetes mellitus by circulating plasma and serum microRNAs: A systematic review and meta-analysis

BACKGROUND AND AIMS

The diagnostic performance of microRNAs (miRNAs), which have recently emerged as a potential early diagnostic tool capable of detecting gestational diabetes mellitus (GDM) in its early stages, has yet to be systematically investigated. This meta-analysis aims to investigate the diagnostic utility of circulating plasma or serum miRNAs in detecting GDM patients.

METHODS

Eligible studies were included and assessed for risk of bias with the Quality Assessment of Diagnostic Accuracy Studies 2 tool. A bivariate meta-analysis using the hierarchical summary receiver operating characteristic model was performed to estimate the pooled diagnostic value of miRNAs.

RESULTS

Twelve studies (32 index tests) cumulating a total of 1768 patients were included in the present study. The pooled sensitivity of miRNAs was 74.5% (95% confidence interval [CI]: 63.7-82.9) and the pooled specificity was 84.1% (95% CI: 76.8-89.3). The overall area under the curve was 0.869 (95% CI: 0.818-0.907) with a relatively narrow 95% confidence region and a wide 95% prediction region.

CONCLUSION

miRNAs may emerge as a promising diagnostic tool in detecting GDM. Further cross-sectional cohort studies with larger sample sizes and more heterogeneous populations, and studies evaluating the accuracy of multiple miRNAs in diagnosing GDM are required to confirm our findings.

Diagnostic Accuracy of Capillary Blood Glucometer Testing for Gestational Diabetes

PURPOSE

Few pregnant women in low-resource settings are screened for gestational diabetes mellitus (GDM) using the gold standard oral glucose tolerance test (OGTT). This study compared capillary blood glucose testing with 2-h plasma glucose measurements obtained using the 75-g OGTT to screen for GDM at primary healthcare clinics in Mexico.

PATIENTS AND METHODS

Pregnant women who participated in a previous prospective multicenter longitudinal cohort study and who had not been previously diagnosed with diabetes were included. Participants were evaluated using the plasmatic 2-h 75-g OGTT with simultaneous capillary blood glucose measurements using a glucometer. The study endpoint was the comparability of the glucometer results to the gold standard OGTT when collected simultaneously. Sensitivity, specificity, and area under the curve of the glucose measurements obtained for capillary blood compared with venous plasma (gold standard) were calculated to determine diagnostic accuracy.

RESULTS

The study included 947 pregnant women who had simultaneous glucose measurements available (blood capillary [glucometer] and venous blood OGTT). Overall, capillary blood glucose testing was very sensitive (89.47%); the specificity was 66.58% and the area under the curve (95% confidence interval) was 0.78 (0.74-0.81). The sensitivity, specificity and area under the curve of each capillary measurement were: 89.47%, 66.58% and 0.78 (0.74-0.82) for the fasting measurement, 91.53%, 93.24% and 0.92 (0.88-0.96) for the one-hour measurement, and 89.80%, 93.32%, 0.91 (0.87-0.95) for the second-hour measurement, respectively. No adverse events were reported.

CONCLUSION

Capillary OGTT is a valid alternative to the gold standard OGTT for screening of GDM in low-resource situations or in situations where there are other limitations to performing the OGTT as part of primary healthcare services.

Early Identification of the Maternal, Placental and Fetal Dialog in Gestational Diabetes and Its Prevention

Gestational diabetes mellitus (GDM) complicates between 5 and 12% of pregnancies, with associated maternal, fetal, and neonatal complications. The ideal screening and diagnostic criteria to diagnose and treat GDM have not been established and, currently, diagnostic use with an oral glucose tolerance test occurs late in pregnancy and produces poor reproducibility. Therefore, in recent years, significant research has been undertaken to identify a first-trimester biomarker that can predict GDM later in pregnancy, enable early intervention, and reduce GDM-related adverse pregnancy outcomes. Possible biomarkers include glycemic markers (fasting glucose and hemoglobin A1c), adipocyte-derived markers (adiponectin and leptin), pregnancy-related markers (pregnancy-associated plasma protein-A and the placental growth factor), inflammatory markers (C-reactive protein and tumor necrosis factor-α), insulin resistance markers (sex hormone-binding globulin), and others. This review summarizes current data on first-trimester biomarkers, the advantages, and the limitations. Large multi-ethnic clinical trials and cost-effectiveness analyses are needed not only to build effective prediction models but also to validate their clinical use.

Developmental Effects of (Pre-)Gestational Diabetes on Offspring: Systematic Screening Using Omics Approaches

Worldwide, gestational diabetes affects 2-25% of pregnancies. Due to related disturbances of the maternal metabolism during the periconceptional period and pregnancy, children bear an increased risk for future diseases. It is well known that an aberrant intrauterine environment caused by elevated maternal glucose levels is related to elevated risks for increased birth weights and metabolic disorders in later life, such as obesity or type 2 diabetes. The complexity of disturbances induced by maternal diabetes, with multiple underlying mechanisms, makes early diagnosis or prevention a challenging task. Omics technologies allowing holistic quantification of several classes of molecules from biological fluids, cells, or tissues are powerful tools to systematically investigate the effects of maternal diabetes on the offspring in an unbiased manner. Differentially abundant molecules or distinct molecular profiles may serve as diagnostic biomarkers, which may also support the development of preventive and therapeutic strategies. In this review, we summarize key findings from state-of-the-art Omics studies addressing the impact of maternal diabetes on offspring health.

Performance of early risk assessment tools to predict the later development of gestational diabetes

BACKGROUND

Several prognostic models for gestational diabetes mellitus (GDM) are provided in the literature; however, their clinical significance has not been thoroughly evaluated, especially with regard to application at early gestation and in accordance with the most recent diagnostic criteria. This external validation study aimed to assess the predictive accuracy of published risk estimation models for the later development of GDM at early pregnancy.

METHODS

In this cohort study, we prospectively included 1132 pregnant women. Risk evaluation was performed before 16 + 0 weeks of gestation including a routine laboratory examination. Study participants were followed-up until delivery to assess GDM status according to the IADPSG 2010 diagnostic criteria. Fifteen clinical prediction models were calculated according to the published literature.

RESULTS

Gestational diabetes mellitus was diagnosed in 239 women, that is 21.1% of the study participants. Discrimination was assessed by the area under the ROC curve and ranged between 60.7% and 76.9%, corresponding to an acceptable accuracy. With some exceptions, calibration performance was poor as most models were developed based on older diagnostic criteria with lower prevalence and therefore tended to underestimate the risk of GDM. The highest variable importance scores were observed for history of GDM and routine laboratory parameters.

CONCLUSIONS

Most prediction models showed acceptable accuracy in terms of discrimination but lacked in calibration, which was strongly dependent on study settings. Simple biochemical variables such as fasting glucose, HbA1c and triglycerides can improve risk prediction. One model consisting of clinical and laboratory parameters showed satisfactory accuracy and could be used for further investigations.

Recurrence of Gestational Diabetes Mellitus: To Assess Glucose Metabolism and Clinical Risk Factors at the Beginning of a Subsequent Pregnancy

Women with a history of gestational diabetes mellitus (GDM) are at high risk of developing hyperglycemia in a subsequent pregnancy. This study aimed to assess parameters of glucose metabolism at the beginning of a subsequent pregnancy in women with a history of GDM. This prospective cohort study included 706 women who had at least one previous pregnancy (120 with prior GDM and 586 without GDM history). All study participants received a broad risk evaluation and laboratory testing at the beginning of a subsequent pregnancy and were followed up until delivery to assess GDM status, risk factors for GDM recurrence, and pregnancy outcomes. Women with a history of GDM exhibited lower insulin sensitivity and subtle impairments in β-cell function associated with subclinical hyperglycemia already at the beginning of a subsequent pregnancy compared to women without GDM history. This was associated with a markedly increased risk for the later development of GDM (OR: 6.59, 95% CI 4.34 to 10.09, p < 0.001). Early gestational fasting glucose and HbA1c were identified as the most important predictors. Mothers with a history of GDM showed marked alterations in glucose metabolism at the beginning of a subsequent pregnancy, which explains the high prevalence of GDM recurrence in these women.

Early markers of gestational diabetes mellitus: what we know and which way forward?

Women’s metabolism during pregnancy undergoes numerous changes that can lead to gestational diabetes mellitus (GDM). The cause and pathogenesis of GDM, a heterogeneous disease, are not completely clear, but GDM is increasing in prevalence and is associated with the modern lifestyle. Most diagnoses of GDM are made via the guidelines from the International Association of Diabetes and Pregnancy Study Groups (IADSPG), which involve an oral glucose tolerance test (OGTT) between 24 and 28 weeks of pregnancy. Diagnosis in this stage of pregnancy can lead to short- and long-term implications for the mother and child. Therefore, there is an urgent need for earlier GDM markers in order to enable prevention and earlier treatment. Routine GDM biomarkers (plasma glucose, insulin, C-peptide, homeostatic model assessment of insulin resistance, and sex hormone-binding globulin) can differentiate between healthy pregnant women and those with GDM but are not suitable for early GDM diagnosis. In this article, we present an overview of the potential early biomarkers for GDM that have been investigated recently. We also present our view of future developments in the laboratory diagnosis of GDM.

The diagnostic indicators of gestational diabetes mellitus from second trimester to birth: a systematic review

BACKGROUND

Gestational diabetes mellitus (GDM) is glucose intolerance first recognised during pregnancy. Both modalities and thresholds of the GDM diagnostic test, the Oral Glucose Tolerance Test (OGTT), have varied widely over time and among countries. Additionally, OGTT limitations include inconsistency, poor patient tolerability, and questionable diagnostic reliability. Many biological parameters have been reported to be modified by GDM and could potentially be used as diagnostic indicators. This study aimed to 1) systematically explore biomarkers reported in the literature as differentiating GDM from healthy pregnancies 2) screen those indicators assessed against OGTT to propose OGTT alternatives.

MAIN BODY

A systematic review of GDM diagnostic indicators was performed according to PRISMA guidelines (PROSPERO registration CRD42020145499). Inclusion criteria were full-text, comprehensible English-language articles published January 2009-January 2021, where a biomarker (from blood, ultrasound, amniotic fluid, placenta) was compared between GDM and normal glucose tolerance (NGT) women from the second trimester onward to immediately postpartum. GDM diagnostic method had to be clearly specified, and the number of patients per study higher than 30 in total or 15 per group. Results were synthesised by biomarkers.

RESULTS

Of 13,133 studies identified in initial screening, 174 studies (135,801 participants) were included. One hundred and twenty-nine studies described blood analytes, one amniotic fluid analytes, 27 ultrasound features, 17 post-natal features. Among the biomarkers evaluated in exploratory studies, Adiponectin, AFABP, Betatrophin, CRP, Cystatin-C, Delta-Neutrophil Index, GGT, TNF-A were those demonstrating statistically and clinically significant differences in substantial cohorts of patients (> 500). Regarding biomarkers assessed versus OGTT (i.e. potential OGTT alternatives) most promising were Leptin > 48.5 ng/ml, Ficolin3/adiponectin ratio ≥ 1.06, Chemerin/FABP > 0.71, and Ultrasound Gestational Diabetes Score > 4. These all demonstrated sensitivity and specificity > 80% in adequate sample sizes (> / = 100).

CONCLUSIONS

Numerous biomarkers may differentiate GDM from normoglycaemic pregnancy. Given the limitations of the OGTT and the lack of a gold standard for GDM diagnosis, advanced phase studies are needed to triangulate the most promising biomarkers. Further studies are also recommended to assess the sensitivity and specificity of promising biomarkers not yet assessed against OGTT.

TRIAL REGISTRATION

PROSPERO registration number CRD42020145499.

Commentary: Implications of SARS-Cov-2 infection for pregnancy with diabetes: achievements and open questions for feto-maternal medicine

SARS-Cov-2 (Severe Acute Respiratory Coronavirus 2) infection confers a non-negligible risk for younger pregnant women with diabetes, which is still less well investigated. This topic was recently addressed by a systematic scoping review in BMC Pregnancy and Childbirth, aiming to summarize the complex interaction between SARS-Cov-2 infection, pregnancy and diabetes. This commentary will summarize and discuss the main findings of this article and its implications for future research.

The relationship between fasting plasma glucose in the first trimester of pregnancy and the incidence of gestational diabetes in Iran

AIMS

This study aimed to investigate the relationship between fasting plasma glucose in the first trimester of pregnancy and the incidence of gestational diabetes.

METHODS

This descriptive-analytical study was conducted using the merging data from two prospective cohort studies that were carried out from 2015 to 2018 in Ahvaz, southwest of Iran. Logistic regression and ROC curves were used to evaluate the predictive power of risk factors.

RESULTS

Of all 1270 pregnant women studied, 454 (35.75%) had gestational diabetes who were compared with the other 816 (64.25%) healthy women. The area under the curve (AUC) of fasting glucose for the first pregnancy visit was 0.80 (95% CI: 0.76-83), and the optimum fasting glucose cut-off point was 85.5 mg/dL with a sensitivity of 71% and a specificity of 69%. AUC of the combination of fasting glucose at the first visit with body mass index ≥25 kg/m² and family history of diabetes was calculated to be 0.85 (CI, 0.82-0.88) and 0.84 (CI, 0.79-0.89) respectively.

CONCLUSION

Fasting plasma glucose in the first trimester of pregnancy is a relatively good predictor of gestational diabetes. If this factor is combined with other risks, its diagnostic value will increase.

Association between early oxidative DNA damage and iron status in women with gestational diabetes mellitus

This study aims to assess the relationship between oxidative DNA damage and iron status in women with gestational diabetes mellitus (GDM) compared to those with normal glucose tolerance in the first and the second trimesters of pregnancy. Maternal serum and urine samples were collected in the 11th-14th weeks and the 24th-28th weeks of gestation. In addition to oral glucose tolerance test in the second trimester, fasting blood glucose, HbA1c, ferritin and hemoglobin levels were measured in blood samples. Urinary levels of oxidative DNA damage products 8-hydroxy-2'-deoxyguanosine (8-OH-dG) and 8,5'-cyclo-2'-deoxyadenosines (S-cdA, R-cdA) were determined using liquid chromatography-tandem mass spectrometry with isotope-dilution. In the first trimester, urinary 8-OH-dG levels were found higher in the GDM group (n = 33) than in the control group (n = 84) (p = 0.006). R-cdA and S-cdA levels were not significantly different between the two groups (p = 0.794 and p = 0.792 respectively). When the cases were stratified according to their first trimester ferritin levels, women with ≥50th centile (≥130 ng/mL) demonstrated higher levels of 8-OH-dG and R-cdA than those under <50th centile (p = 0.034, p = 0.009). In the GDM group, there was a positive correlation between the second trimester 8-OH-dG and ferritin and 1st-hour glucose levels (p = 0.014, p = 0.020). This is the first study where oxidative DNA damage is evaluated in both early and late periods of pregnancy. Our findings reveal an association between GDM and iron status and oxidative DNA damage.

Using space-time cube to analyze trends in adverse birth outcomes and maternal characteristics in Massachusetts, USA

Rates of preterm births (< 37 gestational weeks) and low birthweight (≤  2500 g) are rising throughout the United States. This study uses singleton live birth data, Empirical Bayes approach, space-time cube and Mann-Kendall statistic to evaluate temporal trends in these adverse birth outcomes (ABO) and maternal characteristics over 15 years (2000-2014) at the census tract level for non-Hispanic white and black women in Massachusetts. In addition to analyzing trends for each variable individually, the study analyzes spatial coincidence of trends to determine which maternal characteristics exhibited trends that most strongly correlated with the ABO trends. The 15-year average rate of ABO was 7.34% for white women, and 12.05% for black women. Results show that more census tracts exhibited an increasing trend than decreasing trend in birth outcomes and in several maternal characteristics for both races (gestational and chronic hypertension, gestational diabetes, and previous preterm birth). Study identified 52 census tracts concurrently experiencing an increasing trend in ABO and in four maternal characteristics for black women, indicating that multiple negative trends in health outcomes are concentrated at the same location creating a potential for even more adverse outcomes in the future. This study provides a novel, spatially explicit analytical framework based on Empirical Bayes rates and space-time cube, which could be extended to analyze trends in other health outcomes at various spatial scales.

SUPPLEMENTARY INFORMATION

The online version supplementary material available at 10.1007/s10708-021-10382-w.

Putrescine as a Novel Biomarker of Maternal Serum in First Trimester for the Prediction of Gestational Diabetes Mellitus: A Nested Case-Control Study

AIMS

Early identification of gestational diabetes mellitus (GDM) aims to reduce the risk of adverse maternal and perinatal outcomes. Currently, no acknowledged biomarker has proven clinically useful for the accurate prediction of GDM. In this study, we tested whether serum putrescine level changed in the first trimester and could improve the prediction of GDM.

METHODS

This study is a nested case-control study conducted in Beijing Obstetrics and Gynecology Hospital. We examined serum putrescine at 8-12 weeks pregnancy in 47 women with GDM and 47 age- and body mass index (BMI)-matched normoglycaemic women. Anthropometric, clinical and laboratory variables were obtained during the same period. The receiver operating characteristic (ROC) curve and area under the curve (AUC) were used to assess the discrimination and calibration of the prediction models.

RESULTS

Serum putrescine in the first trimester was significantly higher in women who later developed GDM. When using putrescine alone to predict the risk of GDM, the AUC of the nomogram was 0.904 (sensitivity of 100% and specificity of 83%, 95% CI=0.832-0.976, P<0.001). When combined with traditional risk factors (prepregnant BMI and fasting blood glucose), the AUC was 0.951 (sensitivity of 89.4% and specificity of 91.5%, 95% CI=0.906-0.995, P<0.001).

CONCLUSION

This study revealed that GDM women had an elevated level of serum putrescine in the first trimester. Circulating putrescine may serve as a valuable predictive biomarker for GDM.

Relationship between environmental temperature and the diagnosis and treatment of gestational diabetes mellitus: An observational retrospective study

INTRODUCTION

Environmental temperature has been described to affect plasma glucose levels after oral glucose tolerance testing (OGTT).

AIMS

We evaluated the relationship between seasons and environmental temperature and gestational diabetes mellitus (GDM) diagnosis and treatment.

METHODS

We analyzed data from 2374 women retrospectively. GDM was diagnosed in 473 patients by a 100-g OGTT. OGTT results and needing of insulin therapy were evaluated in relation to seasons and environmental temperature (mean temperature and temperature change) the day of the OGTT and the preceding 14 and 28 days.

RESULTS

We found significant seasonal differences in the percentage of GDM: 24.4% in summer vs. 15.6% in autumn (p < 0.01). The odds ratio (OR) for being diagnosed with GDM was 1.78 in summer relative to autumn, after controlling for age. A higher mean temperature the day of the OGTT and the preceding 14 and 28 days increased the risk of being diagnosed with GDM the months in which temperature was rising (March-August) but not the months in which temperature was decreasing (September-February). We observed a negative correlation between temperature and fasting glucose and a positive correlation with post-load glucose. Neither the season nor the environmental temperature affected the risk of requiring insulin therapy.

CONCLUSIONS

There is a higher prevalence of GDM diagnosis at warmer seasons and at rising temperatures the 2-4 weeks prior to the OGTT. The impact of temperature is different between fasting and post-load glucose.

Dysglycemia in Pregnancy and Maternal/Fetal Outcomes

Maternal dysglycemia-including diabetes, impaired glucose tolerance, and impaired fasting glucose-affects one in six pregnancies worldwide and represents a significant health risk to the mother and the fetus. Maternal dysglycemia is an independent risk factor for perinatal mortality, major congenital anomalies, and miscarriages. Furthermore, it increases the longer-term risk of type 2 diabetes mellitus, metabolic syndrome, cardiovascular morbidity, malignancies, and ophthalmic, psychiatric, and renal diseases in the mother. The most commonly encountered form of maternal dysglycemia is gestational diabetes. Currently, international consensus does not exist for diagnostic criteria defining gestational diabetes at 24-28 weeks gestation, and potential diagnostic glucose thresholds earlier in gestation require further investigation. Likewise, recommendations regarding the timing and modality (e.g., lifestyle or pharmacological) of treatment vary greatly. Because a precise diagnosis determines the appropriate treatment and outcome of the pregnancy, it is imperative that a better definition of maternal dysglycemia and its treatment be achieved. This article will address some of the controversies related to diagnosing and managing maternal dysglycemia. In addition, the article will discuss the impact of maternal dysglycemia on complications experienced by the mother and infant, both at birth and in later life.

Early Screening for Gestational Diabetes Using IADPSG Criteria May Be a Useful Predictor for Congenital Anomalies: Preliminary Data from a High-Risk Population

Background: Our aim was to investigate whether the International Association of the Diabetes and Pregnancy Study Groups (IADPSG) glycemic thresholds used for detecting hyperglycemia in pregnancy can be predictive for malformations in women with hyperglycemia detected in early pregnancy. Methods: a single-center, retrospective observational trial of 125 mother-infant pairs from singleton pregnancies with hyperglycemia according to the IADPSG criteria diagnosed at the gestational age below 16 weeks. Glucose values obtained from 75-g OGTT (oral glucose tolerance test) were investigated as predictors for congenital malformations in newborns. Results: Characteristics of the cohort: maternal age: 31.5 ± 5.2, pre-pregnancy body mass index (BMI) ≥ 30 kg/m²: 42.0%, gestational age at diagnosis (weeks): 12.0 ± 4.0, and newborns with congenital malformations: 8.8%. Fasting blood glycemia (FBG) and HbA1c (Haemoglobin A1c) at baseline significantly predicted the outcome (expB: 1.06 (1.02–1.1), p = 0.007 and expB: 2.05 (1.24–3.38), p = 0.005, respectively). Both the fasting blood glucose (FBG) value of 5.1 mmol/dL (diagnostic for gestational diabetes mellitus (GDM)) and 5.5 mmol/dL (upper limit for normoglycemia in the general population) significantly increased the likelihood ratio (LR) for fetal malformations: 1.3 (1.1; 1.4) and 1.5 (1.0; 2.4), respectively. Conclusions: (1) Fasting glycemia diagnostic for GDM measured in early pregnancy is associated with a significantly elevated risk for congenital malformations. (2) Our data suggest that women at elevated risks of GDM/diabetes in pregnancy (DiP) should have their fasting blood glucose assessed before becoming pregnant, and the optimization of glycemic control should be considered if the FBG exceeds 5.1 mmol/dL.

HbA1c during early pregnancy reflects beta-cell dysfunction in women developing GDM

INTRODUCTION

It is of current interest to assess eligibility of hemoglobin A1c (HbA1c) as a screening tool for earlier identification of women with risk for more severe hyperglycemia in pregnancy but data regarding accuracy are controversial. We aimed to evaluate if HbA1c mirrors pathophysiological precursors of glucose intolerance in early pregnancy that characterize women who develop gestational diabetes mellitus (GDM).

RESEARCH DESIGN AND METHODS

220 pregnant women underwent an HbA1c measurement as well as an oral glucose tolerance test (OGTT) with multiple measurements of glucose, insulin and C-peptide for evaluation of insulin sensitivity and beta-cell function at 16th gestational week (IQR: 14-18). Clinical follow-ups were performed until end of pregnancy.

RESULTS

Increased maternal HbA1c ≥5.7% (39 mmol/mol) corresponding to pre-diabetes outside of pregnancy was associated with altered glucose dynamics during the OGTT. Pregnancies with early HbA1c ≥5.7% showed higher fasting (90.4±13.2 vs 79.7±7.2 mg/dL, p<0.001), mean (145.6±31.4 vs 116.2±21.4 mg/dL, p<0.001) as well as maximum glucose concentrations and tended to a delay in reaching the maximum glucose level compared with those with normal-range HbA1c (186.5±42.6 vs 147.8±30.1 mg/dL, p<0.001). Women with increased HbA1c showed impaired beta-cell function and differences in disposition index independent of body mass index status. We observed a high specificity for the HbA1c cut-off of 5.7% for GDM manifestation (0.96, 95% CI 0.91 to 0.98) or need of glucose-lowering medication (0.95, 95% CI 0.90 to 0.98) although overall predictive accuracy was moderate to fair. Further, elevated HbA1c was associated with higher risk for delivering large-for-gestational-age infants, also after adjustment for GDM status (OR 4.4, 95% CI 1.2 to 15.0, p=0.018).

CONCLUSIONS

HbA1c measured before recommended routine screening period reflects early pathophysiological derangements in beta-cell function and glucose disposal that are characteristic of GDM development and may be useful in early risk stratification.

Obstructive sleep apnea is associated with adverse maternal outcomes using a United States multistate database cohort, 2007-2014

BACKGROUND

Obstructive sleep apnea affects approximately 11% of women of reproductive age, although it is often undetected and untreated. Previous studies suggest an association between obstructive sleep apnea and adverse maternal outcomes. Herein, we aim to better characterize the relationship between obstructive sleep apnea and maternal outcomes.

METHODS

Using the State Inpatient Databases, we performed a retrospective analysis of parturients ≥18 years old having inpatient deliveries in Florida, New York, California, Maryland, and Kentucky from 2007 to 2014. Outcomes included maternal pre-existing conditions, in-hospital mortality, maternal-fetal conditions and complications, and hospital length of stay >5 days.

RESULTS

Our cohort consisted of 6 911 916 parturients of whom 4326 (0.06%) had obstructive sleep apnea. Women with obstructive sleep apnea were more likely to present with pre-existing conditions, such as obesity and pre-pregnancy diabetes. After adjusting for patient- and hospital-level confounders in our multivariate analysis, obstructive sleep apnea status was associated with an increased odds of maternal-fetal conditions and complications, including pre-eclampsia (aOR 2.05, 95% CI 1.87 to 2.26), pulmonary edema (aOR 4.73, 95% CI 2.84 to 7.89), cesarean delivery (aOR 1.96, 95% CI 1.81 to 2.11), early onset delivery (aOR 1.28, 95% CI 1.17 to 1.40), and length of stay >5 days (aOR 2.42, 95% CI 2.21 to 2.65). Obstructive sleep apnea was not significantly associated with a higher risk of in-hospital mortality.

CONCLUSIONS

Pregnant women with obstructive sleep apnea have a significantly higher adjusted risk of adverse maternal outcomes compared with women without obstructive sleep apnea.

Temporary changes in clinical guidelines of gestational diabetes screening and management during COVID-19 outbreak: A narrative review

BACKGROUND AND AIMS

New clinical approaches are needed to minimize complications of gestational diabetes during the COVID-19 outbreak with timely screening and proper management. The present study aims to highlight changes in the clinical guideline for gestational diabetes during the pandemic.

METHODS

In a narrative review, multiple databases were searched. Furthermore, online searches were conducted to identify guidelines or support documents provided by NGOs, local health authorities, and societies and organizations in the field of diabetes and obstetrics.

RESULTS

We included five national guidelines that were published in English from Canada, the United Kingdom, Australia, New Zealand, and Australia health agencies. FBG, A1C, RPG were recommended as alternative tests instead of a 2-h oral glucose tolerance test (OGGT) for GDM screening at 24-28 weeks of gestation. Recommendations also included a deferral of postpartum screening till the end of the pandemic, or postponement of testing to 6-12 months after delivery, use telemedicine and telecare.

CONCLUSIONS

Updated temporary changes in clinical guidelines are sensible and accommodates social distancing and minimizes risk of exposure to COVID-19. Despite many unsolved controversies in screening, treatment, and follow-up of gestational diabetes, it seems involvement with novel coronavirus have made a reach to a global agreement simpler.

Role of interleukin-6 (IL-6) in predicting gestational diabetes mellitus

Gestational diabetes mellitus (GDM) is the most common pregnancy-associated metabolic disorder that is steadily increasing worldwide. Early diagnosis of pregnant women susceptible to GDM is the first step for deploying effective preventive treatment to reduce maternal, fetal, and neonatal complications. The diagnostic process of GDM is still controversial and interleukin-6 (IL-6) is one of the most recent markers used for the diagnosis of GDM. In this study, we aimed to systematically review the role of IL-6 in the diagnosis of GDM. In this systematic review, Google Scholar, Scopus, PubMed, ISI Web of Science, ProQuest, and MEDLINE databases were searched using the following keywords: GDM, screening, and IL-6, with the time interval 2009–2020. The quality of articles was assessed using the Strengthening the Reporting of Observational Studies in Epidemiology checklist. Twenty-four articles with desired quality that met the inclusion criteria were selected and reviewed further. Sixteen studies showed a statistically significant association, while 8 studies did not report any relationship between IL-6 levels and GDM. Based on the results of these studies, assessing the serum IL-6 levels can be investigated a newly established diagnostic biomarker for GDM. Therefore, through early diagnosis of susceptible women, effective measures can be implemented to reduce its complications.

The effects of n-3 fatty acids from flaxseed oil on genetic and metabolic profiles in patients with gestational diabetes mellitus: a randomised, double-blind, placebo-controlled trial

The present study was performed to evaluate the effects of n-3 fatty acids from flaxseed oil on genetic and metabolic profiles in patients with gestational diabetes mellitus (GDM). This randomised, double-blind, placebo-controlled clinical trial was performed in sixty women with GDM. Participants were randomly divided into two groups to intake either 2 × 1000 mg/d n-3 fatty acids from flaxseed oil containing 400 mg α-linolenic acid in each capsule (n 30) or placebo (n 30) for 6 weeks. n-3 Fatty acid intake up-regulated PPAR-γ (P < 0·001) and LDL receptor (P = 0·004) and down-regulated gene expression of IL-1 (P = 0·002) and TNF-α (P = 0·001) in peripheral blood mononuclear cells of subjects with GDM. In addition, n-3 fatty acid supplementation reduced fasting plasma glucose (P = 0·001), insulin levels (P = 0·001) and insulin resistance (P < 0·001) and increased insulin sensitivity (P = 0·005) when compared with the placebo. Additionally, n-3 fatty acid supplementation was associated with a decrease in TAG (P < 0·001), VLDL-cholesterol (P < 0·001), total cholesterol (P = 0·01) and total cholesterol:HDL-cholesterol ratio (P = 0·01) when compared with placebo. n-3 Fatty acid administration was also associated with a significant reduction in high-sensitivity C-reactive protein (P = 0·006) and malondialdehyde (P < 0·001), and an increase in total nitrite (P < 0·001) and total glutathione levels (P = 0·006) when compared with the placebo. n-3 Fatty acid supplementation for 6 weeks to women with GDM had beneficial effects on gene expression related to insulin, lipid and inflammation, glycaemic control, lipids, inflammatory markers and oxidative stress.

Gestational Diabetes Mellitus Screening and Diagnosis

An ideal screening test for gestational diabetes should be capable of identifying not only women with the disease but also the women with a high risk of developing gestational diabetes mellitus (GDM). Screening and diagnosis are the main steps leading to the way of management. There is a lack of consensus among healthcare professionals regarding the screening methods worldwide. Different study groups advocate a variety of screening methods with the support of evidence-based comprehensive data. Some of the organizations suggest screening for high risk or all pregnant women, while others prefer to offer definitive testing without screening. Glycemic thresholds are also not standardized to decide GDM among different guidelines. Prevalence rates of GDM vary between populations and with the choice of glucose thresholds for both screening and definitive tests. One-step or two-step methods have been used for GDM diagnosis. However, screening includes selecting patients with historical risk factors, 50 g 1-h glucose challenge test, fasting plasma glucose, random plasma glucose, and hemoglobin A1c with different cutoffs. In this chapter, screening and diagnosis methods of GDM accepted by different study groups will be discussed which will be followed by the evaluation of different glycemic thresholds. Then the advantages and disadvantages of used methods will be explained and the chapter will finish with an evaluation of the current international guidelines.

Pregnancy-associated plasma protein-A2 levels are increased in early-pregnancy gestational diabetes: a novel biomarker for early risk estimation

AIM

To determine whether pregnancy-associated plasma protein-A2 levels are increased in early pregnancies complicated by gestational diabetes and whether gestation age influences levels. The possible use of pregnancy-associated plasma protein-A2 as a pre-screening biomarker to reduce the need for performing oral glucose tolerance tests in pregnant women was also investigated.

METHODS

Pregnant women were diagnosed with gestational diabetes in early pregnancy after a 2-hour 75 g oral glucose tolerance test in the catchment area of Skåne University Hospital, Lund, Sweden during 2011-2015 (n = 99). Age- and BMI-matched pregnant women without diabetes were recruited at similar gestational ages from maternal healthcare centres in the same geographical area during 2014-2015 to act as controls (n = 100). Circulating pregnancy-associated plasma protein-A2 was analysed in participant serum using commercially available enzyme-linked immunosorbent assay kits.

RESULTS

Circulating pregnancy-associated plasma protein-A2 was increased in women diagnosed with gestational diabetes [13.5 (9.58-18.8) ng/ml] compared with controls [8.11 (5.74-11.3) ng/ml; P < 0.001]. Pregnancy-associated plasma protein-A2 was associated with gestational diabetes independent of age, BMI, C-peptide and adiponectin (P < 0.001). Pregnancy-associated plasma protein-A2 as a pre-screening biomarker to identify women at a decreased risk of gestational diabetes resulted in a negative predictive value of 99.7%, with a sensitivity of 96% and a specificity of 30% at a cut-off level of 6 ng/ml.

CONCLUSIONS

This is the first study to show increased pregnancy-associated plasma protein-A2 levels in gestational diabetes. Pregnancy-associated plasma protein-A2 also shows promise as a pre-screening biomarker with the potential to reduce the need for performing oral glucose tolerance tests in early pregnancy. Future prospective cohort studies in a larger group of both high- and low-risk women are, however, needed to further confirm this observation.

Importance of early elevated maternal HbA1c levels in identifying adverse fetal and neonatal events

AIMS

The aims of this study were to explore factors that associated with gestational diabetes mellitus (GDM), and to determine the relationship between early maternal HbA1c levels and adverse fetal or neonatal events, and to determine an optimal maternal glucose testing method in order to decrease the potential health risk for their offspring.

METHODS

From December 2015 to May 2016, a total of 6744 pregnant women were enrolled from Shanghai First Maternal and Infant Hospital affiliated to Tongji University prospectively in the nested case-control study. Each GDM case was matched with a healthy pregnant woman and followed up. Outcome analyses were conducted between GDM case and control groups, as well as elevated and normal maternal HbA1c levels, respectively.

RESULTS

A total of 1836 women were included in the adverse fetal and neonatal events examination. For pregnant women with early HbA1c ≥ 5.2%, the adjusted risk ratios (RR) of respiratory distress syndrome (RDS), pneumonia and jaundice were 4.37 (95%CI 1.54-12.35), 2.03 (95%CI 1.24-3.33) and 1.49 (95%CI 1.01-2.20), respectively. After treatments, the frequency for the majority of events in GDM group was similar to that of healthy pregnant women. Moreover, the area under the curve (AUC) of early maternal HbA1c in predicting potential RDS is 0.734. HbA1c ≤ 4.9% excluded for RDS.

CONCLUSIONS

Compared with women with normal HbA1c, those with an early elevated HbA1c level were more likely to develop adverse events, including RDS, pneumonia and jaundice. Early HbA1c testing can be used as an auxiliary method identifying potential RDS.