Gestational diabetes mellitus prevalence in Maela refugee camp on the Thai-Myanmar border: a clinical report

Factors influencing maternal death in Cambodia, Laos, Myanmar, and Vietnam countries: A systematic review

BACKGROUND

A maternal mortality ratio is a sensitive indicator when comparing the overall maternal health between countries and its very high figure indicates the failure of maternal healthcare efforts. Cambodia, Laos, Myanmar, and Vietnam-CLMV countries are the low-income countries of the South-East Asia region where their maternal mortality ratios are disproportionately high. This systematic review aimed to summarize all possible factors influencing maternal mortality in CLMV countries.

METHODS

This systematic review applied "The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Checklist (2020)", Three key phrases: "Maternal Mortality and Health Outcome", "Maternal Healthcare Interventions" and "CLMV Countries" were used for the literature search. 75 full-text papers were systematically selected from three databases (PubMed, Google Scholar and Hinari). Two stages of data analysis were descriptive analysis of the general information of the included papers and qualitative analysis of key findings.

RESULTS

Poor family income, illiteracy, low education levels, living in poor households, and agricultural and unskilled manual job types of mothers contributed to insufficient antenatal care. Maternal factors like non-marital status and sex-associated work were highly associated with induced abortions while being rural women, ethnic minorities, poor maternal knowledge and attitudes, certain social and cultural beliefs and husbands' influences directly contributed to the limitations of maternal healthcare services. Maternal factors that made more contributions to poor maternal healthcare outcomes included lower quintiles of wealth index, maternal smoking and drinking behaviours, early and elderly age at marriage, over 35 years pregnancies, unfavourable birth history, gender-based violence experiences, multigravida and higher parity. Higher unmet needs and lower demands for maternal healthcare services occurred among women living far from healthcare facilities. Regarding the maternal healthcare workforce, the quality and number of healthcare providers, the development of healthcare infrastructures and human resource management policy appeared to be arguable. Concerning maternal healthcare service use, the provisions of mobile and outreach maternal healthcare services were inconvenient and limited.

CONCLUSION

Low utilization rates were due to several supply-side constraints. The results will advance knowledge about maternal healthcare and mortality and provide a valuable summary to policymakers for developing policies and strategies promoting high-quality maternal healthcare.

Born too soon in a resource-limited setting: A 10-year mixed methods review of a special care baby unit for refugees and migrants on the Myanmar-Thailand border

Background

Preterm birth is a major public health concern with the largest burden of morbidity and mortality falling within low- and middle-income countries (LMIC).

Materials and methods

This sequential explanatory mixed methods study was conducted in special care baby units (SCBUs) serving migrants and refugees along the Myanmar-Thailand border. It included a retrospective medical records review, qualitative interviews with mothers receiving care within SCBUs, and focus group discussions with health workers. Changes in neonatal mortality and four clinical outcomes were described. A mix of ethnographic phenomenology and implementation frameworks focused on cultural aspects, the lived experience of participants, and implementation outcomes related to SCBU care.

Results

From 2008-2017, mortality was reduced by 68% and 53% in very (EGA 28-32 weeks) and moderate (EGA 33-36 weeks) preterm neonates, respectively. Median SCBU stay was longer in very compared to moderate preterm neonates: 35 (IQR 22, 48 days) vs. 10 days (IQR 5, 16). Duration of treatments was also longer in very preterm neonates: nasogastric feeding lasted 82% (IQR 74, 89) vs. 61% (IQR 40, 76) of the stay, and oxygen therapy was used a median of 14 (IQR 7, 27) vs. 2 (IQR 1, 6) days respectively. Nine interviews were conducted with mothers currently receiving care in the SCBU and four focus group discussions with a total of 27 local SCBU staff. Analysis corroborated quantitative analysis of newborn care services in this setting and incorporated pertinent implementation constructs including coverage, acceptability, appropriateness, feasibility, and fidelity. Coverage, acceptability, and appropriateness were often overlapping outcomes of interest highlighting financial issues prior to or while admitted to the SCBU and social issues and support systems adversely impacting SCBU stays. Interview and FGD findings highlight the barriers in this resource-limited setting as they impact the feasibility and fidelity of providing evidence-based SCBU care that often required adaptation to fit the financial and environmental constraints imposed by this setting.

Discussion

This study provides an in-depth look at the nature of providing preterm neonatal interventions in a SCBU for a vulnerable population in a resource-limited setting. These findings support implementation of basic evidence-based interventions for preterm and newborn care globally, particularly in LMICs.

Incidence of gestational diabetes mellitus in the United Arab Emirates; comparison of six diagnostic criteria: The Mutaba'ah Study

Background

For more than half a century, there has been much research and controversies on how to accurately screen for and diagnose gestational diabetes mellitus (GDM). There is a paucity of updated research among the Emirati population in the United Arab Emirates (UAE). The lack of a uniform GDM diagnostic criteria results in the inability to accurately combine or compare the disease burden worldwide and locally. This study aimed to compare the incidence of GDM in the Emirati population using six diagnostic criteria for GDM.

Methods

The Mutaba'ah study is the largest multi-center mother and child cohort study in the UAE with an 18-year follow-up. We included singleton pregnancies from the Mutaba'ah cohort screened with the oral glucose tolerance test (OGTT) at 24-32 weeks from May 2017 to March 2021. We excluded patients with known diabetes and with newly diagnosed diabetes. GDM cumulative incidence was determined using the six specified criteria. GDM risk factors were compared using chi-square and t-tests. Agreements among the six criteria were assessed using kappa statistics.

Results

A total of 2,546 women were included with a mean age of 30.5 ± 6.0 years. Mean gravidity was 3.5 ± 2.1, and mean body mass index (BMI) at booking was 27.7 ± 5.6 kg/m2. GDM incidence as diagnosed by any of the six criteria collectively was 27.1%. It ranged from 8.4% according to the EASD 1996 criteria to 21.5% according to the NICE 2015 criteria. The two most inclusive criteria were the NICE 2015 and the IADPSG criteria with GDM incidence rates of 21.5% (95% CI: 19.9, 23.1) and 21.3% (95% CI: 19.8, 23.0), respectively. Agreement between the two criteria was moderate (k = 0.66; p < 0.001). The least inclusive was the EASD 1996 criteria [8.4% (95% CI: 7.3, 9.6)]. The locally recommended IADPSG/WHO 2013 criteria had weak to moderate agreement with the other criteria, with Cohen's kappa coefficient ranging from (k = 0.51; p < 0.001) to (k = 0.71; p < 0.001). Most of the GDM risk factors assessed were significantly higher among those with GDM (p < 0.005) identified by all criteria.

Conclusions

The findings indicate discrepancies among the diagnostic criteria in identifying GDM cases. This emphasizes the need to unify GDM diagnostic criteria in this population to provide accurate and reliable incidence estimates for healthcare planning, especially because the agreement with the recommended criteria was not optimal.

Systematic review on chronic non-communicable disease in disaster settings

BACKGROUND

Non-communicable diseases (NCDs) constitute the leading cause of mortality globally. Low and middle-income countries (LMICs) not only experience the largest burden of humanitarian emergencies but are also disproportionately affected by NCDs, yet primary focus on the topic is lagging. We conducted a systematic review on the effect of humanitarian disasters on NCDs in LMICs assessing epidemiology, interventions, and treatment.

METHODS

A systematic search in MEDLINE, MEDLINE (PubMed, for in-process and non-indexed citations), Social Science Citation Index, and Global Health (EBSCO) for indexed articles published before December 11, 2017 was conducted, and publications reporting on NCDs and humanitarian emergencies in LMICs were included. We extracted and synthesized results using a thematic analysis approach and present the results by disease type. The study is registered at PROSPERO (CRD42018088769).

RESULTS

Of the 85 included publications, most reported on observational research studies and almost half (48.9%) reported on studies in the Eastern Mediterranean Region (EMRO), with scant studies reporting on the African and Americas regions. NCDs represented a significant burden for populations affected by humanitarian crises in our findings, despite a dearth of data from particular regions and disease categories. The majority of studies included in our review presented epidemiologic evidence for the burden of disease, while few studies addressed clinical management or intervention delivery. Commonly cited barriers to healthcare access in all phases of disaster and major disease diagnoses studied included: low levels of education, financial difficulties, displacement, illiteracy, lack of access to medications, affordability of treatment and monitoring devices, and centralized healthcare infrastructure for NCDs. Screening and prevention for NCDs in disaster-prone settings was supported. Refugee status was independently identified both as a risk factor for diagnosis with an NCD and conferring worse morbidity.

CONCLUSIONS

An increased focus on the effects of, and mitigating factors for, NCDs occurring in disaster-afflicted LMICs is needed. While the majority of studies included in our review presented epidemiologic evidence for the burden of disease, research is needed to address contributing factors, interventions, and means of managing disease during humanitarian emergencies in LMICs.

Risk factor-based screening compared to universal screening for gestational diabetes mellitus in marginalized Burman and Karen populations on the Thailand-Myanmar border: An observational cohort

Background: Gestational diabetes mellitus (GDM) contributes to maternal and neonatal morbidity. As data from marginalized populations remains scarce, this study compares risk-factor-based to universal GDM screening in a low resource setting. Methods: This is a secondary analysis of data from a prospective preterm birth cohort. Pregnant women were enrolled in the first trimester and completed a 75g oral glucose tolerance test (OGTT) at 24-32 weeks' gestation. To define GDM cases, Hyperglycaemia and Adverse Pregnancy Outcomes (HAPO trial) criteria were used. All GDM positive cases were treated. Sensitivity and specificity of risk-factor-based selection for screening (criteria: age ≥30y, obesity (Body mass index (BMI) ≥27.5kg/m ²), previous GDM, 1 ^st degree relative with diabetes, previous macrosomia (≥4kg), previous stillbirth, or symphysis-fundal height ≥90th percentile) was compared to universal screening using the OGTT as the gold standard. Adverse maternal and neonatal outcomes were compared by GDM status. Results: GDM prevalence was 13.4% (50/374) (95% CI: 10.3-17.2). Three quarters of women had at least one risk factor (n=271 women), with 37/50 OGTT positive cases correctly identified: sensitivity 74.0% (59.7-85.4) and specificity 27.8% (3.0-33.0). Burman women (self-identified) accounted for 29.1% of the cohort population, but 38.0% of GDM cases. Percentiles for birthweight (p=0.004), head circumference (p=0.002), and weight-length ratio (p=0.030) were higher in newborns of GDM positive compared with non-GDM mothers. 21.7% (75/346) of newborns in the cohort were small-for-gestational age (≤10 ^th percentile). In Burman women, overweight/obese BMI was associated with a significantly increased adjusted odds ratio 5.03 (95% CI: 1.43-17.64) for GDM compared with normal weight, whereas in Karen women, the trend in association was similar but not significant (OR 2.36; 95% CI 0.95-5.89). Conclusions: Risk-factor-based screening missed one in four GDM positive women. Considering the benefits of early detection of GDM and the limited additional cost of universal screening, a two-step screening program was implemented.

Risk factor-based screening compared to universal screening for gestational diabetes mellitus in marginalized Burman and Karen populations on the Thailand-Myanmar border: An observational cohort

Background: Gestational diabetes mellitus (GDM) contributes significantly to maternal and neonatal morbidity, but data from marginalized populations remains scarce. This study aims to compare risk-factor-based screening to universal testing for GDM among migrants along the Thailand-Myanmar border. Methods: From the prospective cohort (September 2016, February 2019), 374 healthy pregnant women completed a 75g oral glucose tolerance test (OGTT) at 24-32 weeks gestation. Fasting, one hour and two hour cut-offs were based on Hyperglycaemia and Adverse Pregnancy Outcomes (HAPO trial) criteria and cases were treated. The sensitivity and specificity of risk-factor-based screening criteria was calculated using OGTT as the gold standard. Risk factors included at least one positive finding among 10 criteria, e.g., obesity (body mass index (BMI) ≥27.5kg/m ²), 1 ^st degree relative with diabetes etc. Adverse maternal and neonatal outcomes were compared by GDM status, and risk factors for GDM were explored. Results: GDM prevalence was 13.4% (50/374) (95% CI: 10.3-17.2). Risk-factors alone correctly identified 74.0% (37/50) OGTT positive cases: sensitivity 74.0% (59.7-85.4) and specificity 27.8% (3.0-33.0). Burman women accounted for 29.1% of the cohort population, but 38.0% of GDM cases. Percentiles for birthweight (p=0.004), head circumference (p=0.005), and weight-length ratio (p=0.010) were higher in newborns of GDM mothers compared with non-GDM, yet 21.7% (75/346) of newborns in the cohort were small-for-gestational age. In Burman women, overweight/obese BMI was associated with a significantly increased adjusted odds ratio 5.03 (95% CI: 1.43-17.64) for GDM compared to normal weight, whereas underweight and overweight/obese in Karen women were both associated with similarly elevated adjusted odds, approximately 2.4-fold (non-significant) for GDM. GDM diagnosis by OGTT was highest prior to peak rainfall. Conclusions: Risk-factor-based screening was not sufficiently sensitive or specific to be useful to diagnose GDM in this setting among a cohort of low-risk pregnant women. A two-step universal screening program has thus been implemented.

Research trends in gestational diabetes mellitus in Southeast Asia: A bibliometric analysis (1975-2020)

AIMS

To determine the characteristics and trends of published articles in the field of gestational diabetes mellitus (GDM) in Southeast Asia (SEA) through a bibliometric analysis.

METHODS

Systematic review of literature on GDM in SEA countries was performed using the Ovid MEDLINE®, Scopus, and WPRIM databases between 1975 and 2020. All published studies on GDM conducted in or published by authors from any SEA country were included in our analysis. Bibliometric information was obtained from Scopus and bibliometrics diagrams were created using VOSviewer software.

RESULTS

A total of 322 articles were obtained in this study. The number of publications showed an upward trend starting 2011. The country with the greatest number of publications was Malaysia while The National University of Singapore was the most productive institution in GDM research in SEA. The focus of GDM research in SEA were on the prevalence, prevention, diagnosis, and pregnancy outcomes. GDP, research expenditure, and researchers per million people were positively correlated with research productivity and impact in GDM research in SEA.

CONCLUSIONS

This is the first bibliometric analysis on GDM in SEA countries. GDM research in SEA continued to increase in the past years but still lagged behind that of other regions. The SEA countries should consider increasing support for research to produce substantial research that can serve as basis for evidence-based and locally applicable GDM interventions.

Short maternal stature and gestational weight gain among refugee and migrant women birthing appropriate for gestational age term newborns: a retrospective cohort on the Myanmar-Thailand border, 2004-2016

Introduction

To examine the interactions between short maternal stature, body mass index (BMI) and gestational weight gain (GWG) among appropriate for gestational age (AGA) term newborns in a population of refugees and migrants in Southeast Asia.

Methods

This is a retrospective cohort study from 2004 to 2016, including women delivering term, singleton newborns, with first trimester height, weight and gestation dated by ultrasound and a last body weight measured within 4 weeks of birth. AGA newborns were those not classified as small for gestational age or large for gestational age by either INTERGROWTH-21st or Gestation Related Optimal Weight standards. The influence of maternal stature on GWG in delivering an AGA newborn was analysed, with GWG compared with existing National Academy of Medicine (NAM) recommendations.

Results

4340 women delivered AGA newborns. Mean maternal height (SD) was 151.5 cm (5.13), with 58.5% of women considered too short by INTERGROWTH-21st standards. Only one in four women (26.5%, 1150/4340) had GWG within NAM recommendations. Women of shorter stature had a significantly lower mean GWG compared with taller women in underweight and normal BMI categories (p<0.001 for both BMI categories). Mean GWG of overweight and obese women did not differ by height (p=1.0 and p=0.85, respectively) and fell within the lower range of NAM recommendations.

Conclusion

These results suggest that short maternal stature can be an important predictor of GWG and should be considered with prepregnancy BMI. Limited-resource settings and special populations need robust GWG recommendations that reflect height and BMI.

Estimated impact of introduction of new diagnostic criteria for gestational diabetes mellitus

BACKGROUND

Implementation of new diagnostic criteria for gestational diabetes mellitus (GDM) are still a subject of debate, mostly due to concerns regarding the effects on the number of women diagnosed with GDM and the risk profile of the women newly diagnosed.

AIM

To estimate the impact of the World Health Organization (WHO) 2013 criteria compared with the WHO 1999 criteria on the incidence of gestational diabetes mellitus as well as to determine the diagnostic accuracy for detecting adverse pregnancy outcomes.

METHODS

We retrospectively analyzed a single center Dutch cohort of 3338 women undergoing a 75 g oral glucose tolerance test where the WHO 1999 criteria to diagnose GDM were clinically applied. Women were categorized into four groups: non-GDM by both criteria, GDM by WHO 1999 only (excluded from GDM), GDM by WHO 2013 only (newly diagnosed) and GDM by both criteria. We compared maternal characteristics, pregnancy outcomes and likelihood ratios for adverse pregnancy outcomes.

RESULTS

Retrospectively applying the WHO 2013 criteria increased the cohort incidence by 13.1%, from 19.3% to 32.4%. Discordant diagnoses occurred in 21.3%; 4.1% would no longer be labelled as GDM, and 17.2% were newly diagnosed. Compared to the non-GDM group, women newly diagnosed were older, had higher rates of obesity, higher diastolic blood pressure and higher rates of caesarean deliveries. Their infants were more often delivered preterm, large-for-gestational-age and were at higher risk of a 5 min Apgar score < 7. Women excluded from GDM were older and had similar pregnancy outcomes compared to the non-GDM group, except for higher rates of shoulder dystocia (4.3% vs 1.3%, P = 0.015). Positive likelihood ratios for adverse outcomes in all groups were generally low, ranging from 0.54 to 2.95.

CONCLUSION

Applying the WHO 2013 criteria would result in a substantial increase in GDM diagnoses. Newly diagnosed women are at increased risk for pregnancy adverse outcomes. This risk, however, seems to be lower than those identified by the WHO 1999 criteria. This could potentially influence the treatment effect that can be achieved in this group. Evidence on treatment effects in newly diagnosed women is urgently needed.

Increasing prevalence of gestational diabetes mellitus when implementing the IADPSG criteria: A systematic review and meta-analysis

AIMS

Quantify the proportional increase in gestational diabetes (GDM) prevalence when implementing the new International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria compared to prior GDM criteria, and to assess risk factors that might affect the change in prevalence.

METHODS

A systematic review and meta-analysis was performed of cohort and cross-sectional studies between January 1, 2010 to December 31, 2018 among pregnant women with GDM using IADPSG criteria compared to, and stratified by, old GDM criteria. Web of science, PubMed, EMBASE, Cochrane, Open Grey and Grey literature reports were included. The relative risk for each study was calculated. Subgroup analyses were performed by maternal age, body mass index, study design, country of publication, screening method, sampling method and data stratified according to diagnostic criteria.

RESULTS

Thirty-one cohort and cross-sectional studies with 136 705 women were included. Implementing the IADPSG criteria was associated with a 75% (RR 1.75, 95% CI 1.53-2.01) increase in number of women with GDM with evidence of heterogeneity.

CONCLUSIONS

The IADPSG criteria increase the prevalence of GDM, but allow movement towards more homogeneity. More studies are needed of the benefits, harms, psychological effects and health costs of implementing the IADPSG criteria.

Gestational Diabetes Mellitus in Southeast Asia: A Scoping Review

A rapid increase in the prevalence of gestational diabetes mellitus (GDM) has been associated with various factors such as urbanization, lifestyle changes, adverse hyperglycemic intrauterine environment, and the resulting epigenetic changes. Despite this, the burden of GDM has not been well-assessed in Southeast Asia. We comprehensively reviewed published Southeast Asian studies to identify the current research trend in GDM in this region. Joanna Briggs Institute’s methodology was used to guide the scoping review. The synthesis of literature findings demonstrates almost comparable clinical evidence in terms of risk factors and complications, challenges presented in diagnosing GDM, and its disease management, given the similarities of the underlying population characteristics in Southeast Asia. Evidence suggests that a large proportion of GDM risk in women may be preventable by lifestyle modifications. However, the GDM burden across countries is expected to rise, given the heterogeneity in screening approaches and diagnostic criteria, mainly influenced by economic status. There is an urgent need for concerted efforts by government and nongovernmental sectors to implement national programs to prevent, manage, and monitor the disease.

Cohort profile: molecular signature in pregnancy (MSP): longitudinal high-frequency sampling to characterise cross-omic trajectories in pregnancy in a resource-constrained setting

PURPOSE

A successful pregnancy relies on the interplay of various biological systems. Deviations from the norm within a system or intersystemic interactions may result in pregnancy-associated complications and adverse pregnancy outcomes. Systems biology approaches provide an avenue of unbiased, in-depth phenotyping in health and disease. The molecular signature in pregnancy (MSP) cohort was established to characterise longitudinal, cross-omic trajectories in pregnant women from a resource constrained setting. Downstream analysis will focus on characterising physiological perturbations in uneventful pregnancies, pregnancy-associated complications and adverse outcomes.

PARTICIPANTS

First trimester pregnant women of Karen or Burman ethnicity were followed prospectively throughout pregnancy, at delivery and until 3 months post partum. Serial high-frequency sampling to assess whole blood transcriptomics and microbiome composition of the gut, vagina and oral cavity, in conjunction with assessment of gene expression and microbial colonisation of gestational tissue, was done for all cohort participants.

FINDINGS TO DATE

381 women with live born singletons averaged 16 (IQR 15-18) antenatal visits (13 094 biological samples were collected). At 5% (19/381) the preterm birth rate was low. Other adverse events such as maternal febrile illness 7.1% (27/381), gestational diabetes 13.1% (50/381), maternal anaemia 16.3% (62/381), maternal underweight 19.2% (73/381) and a neonate born small for gestational age 20.2% (77/381) were more often observed than preterm birth.

FUTURE PLANS

Results from the MSP cohort will enable in-depth characterisation of cross-omic molecular trajectories in pregnancies from a population in a resource-constrained setting. Moreover, pregnancy-associated complications and unfavourable pregnancy outcomes will be investigated at the same granular level, with a particular focus on population relevant needs such as effect of tropical infections on pregnancy. More detailed knowledge on multiomic perturbations will ideally result in the development of diagnostic tools and ultimately lead to targeted interventions that may disproportionally benefit pregnant women from this resource-limited population.

TRIAL REGISTRATION NUMBER

NCT02797327.

Data Collection Tools for Maternal and Child Health in Humanitarian Emergencies: An Updated Systematic Review

The worst rates of preventable mortality and morbidity among women and children occur in humanitarian settings. Reliable, easy-to-use, standardized, and efficient tools for data collection are needed to enable different organizations to plan and act in the most effective way. In 2015, the World Health Organization (WHO) commissioned a review of tools for data collection on the health of women and children in humanitarian emergencies. An update of this review was conducted to investigate whether the recommendations made were taken forward and to identify newly developed tools. Fifty-three studies and 5 new tools were identified. Only 1 study used 1 of the tools identified in our search. Little has been done in terms of the previous recommendations. Authors may not be aware of the availability of such tools and of the importance of documenting their data using the same methods as other researchers. Currently used tools may not be suitable for use in humanitarian settings or may not include the domains of the authors' interests. The development of standardized instruments should be done with all key workers in the area and could be coordinated by the WHO.

The burden of diabetes and use of diabetes care in humanitarian crises in low-income and middle-income countries

Human suffering as a result of natural disasters or conflict includes death and disability from non-communicable diseases, including diabetes, which have largely been neglected in humanitarian crises. The objectives of this Series paper were to examine the evidence on the burden of diabetes, use of health services, and access to care for people with diabetes among populations affected by humanitarian crises in low-income and middle-income countries, and to identify research gaps for future studies. We reviewed the scientific literature on this topic published between 1992 and 2018. The results emphasise that the burden of diabetes in humanitarian settings is not being captured, clinical guidance is insufficient, and diabetes is not being adequately addressed. Crisis-affected populations with diabetes face enormous constraints accessing care, mainly because of high medical costs. Further research is needed to characterise the epidemiology of diabetes in humanitarian settings and to develop simplified, cost-effective models of care to improve the delivery of diabetes care during humanitarian crises.

Nutrition in transition: historical cohort analysis summarising trends in under- and over-nutrition among pregnant women in a marginalised population along the Thailand-Myanmar border from 1986 to 2016

The objective of the present study is to summarise trends in under- and over-nutrition in pregnant women on the Thailand-Myanmar border. Refugees contributed data from 1986 to 2016 and migrants from 1999 to 2016 for weight at first antenatal consultation. BMI and gestational weight gain (GWG) data were available during 2004-2016 when height was routinely measured. Risk factors for low and high BMI were analysed for &lt;18·5 kg/m2 or ≥23 kg/m2, respectively. A total of 48 062 pregnancies over 30 years were available for weight analysis and 14 646 pregnancies over 13 years (2004-2016) had BMI measured in first trimester (&lt;14 weeks' gestational age). Mean weight at first antenatal consultation in any trimester increased over the 30-year period by 2·0 to 5·2 kg for all women. First trimester BMI has been increasing on average by 0·5 kg/m2 for refugees and 0·6 kg/m2 for migrants, every 5 years. The proportion of women with low BMI in the first trimester decreased from 16·7 to 12·7 % for refugees and 23·1 to 20·2 % for migrants, whereas high BMI increased markedly from 16·9 to 33·2 % for refugees and 12·3 to 28·4 % for migrants. Multivariate analysis demonstrated low BMI as positively associated with being Burman, Muslim, primigravid, having malaria during pregnancy and smoking, and negatively associated with refugee as opposed to migrant status. High BMI was positively associated with being Muslim and literate, and negatively associated with age, primigravida, malaria, anaemia and smoking. Mean GWG was 10·0 (sd 3·4), 9·5 (sd 3·6) and 8·3 (sd 4·3) kg, for low, normal and high WHO BMI categories for Asians, respectively.

Maternal Hepatitis B Infection Burden, Comorbidity and Pregnancy Outcome in a Low-Income Population on the Myanmar-Thailand Border: A Retrospective Cohort Study

Objectives

Hepatitis B virus (HBV) was believed to have minimal impact on pregnancy outcomes apart from the risk of perinatal transmission. In more recent years, there have been reports of adverse associations, most consistently preterm birth (PTB), but this is in the context of high rates of caesarean section. The aim of this study was to explore the association of HBV on pregnancy outcomes in marginalized, low-income populations on the Myanmar-Thailand border.

Methods

HBsAg positive (+) point of care rapid detection tests results were confirmed by immunoassays. Women with a confirmed HBsAg status, HIV- and syphilis-negative at first antenatal care screening, singleton fetus and known pregnancy outcome (Aug-2012 to Dec-2016) were included. Logistic regression analysis was used to evaluate associations between HBV group (controls HBsAg negative, HBsAg+/HBeAg-, or HBsAg+/HBeAg+) and pregnancy outcome and comorbidity.

Results

Most women were tested, 15,046/15,114 (99.6%) for HBV. The inclusion criteria were not met for 4,089/15,046 (27.2%) women due mainly to unavailability of pregnancy outcome and nonconfirmation of HBsAg+. In evaluable women 687/11,025 (6.2%) were HBsAg+, with 476/11,025 (4.3%) HBsAg+/HBeAg- and 211/11,025 (1.9%) were HBsAg+/HBeAg+. The caesarean section rate was low at 522/8,963 (5.8%). No significant associations were observed between pregnancy comorbidities or adverse pregnancy outcomes and HBV status.

Conclusions

The results highlight the disease burden of HBV in women on the Myanmar-Thailand border and support original reports of a lack of significant associations with HBsAg+ irrespective of HBeAg status, for comorbidity, and pregnancy outcomes in deliveries supervised by skilled birth attendants.

A prospective cohort for the investigation of alteration in temporal transcriptional and microbiome trajectories preceding preterm birth: a study protocol

INTRODUCTION

Preterm birth (PTB) results from heterogeneous influences and is a major contributor to neonatal mortality and morbidity that continues to have adverse effects on infants beyond the neonatal period. This protocol describes the procedures to determine molecular signatures predictive of PTB through high-frequency sampling during pregnancy, at delivery and the postpartum period.

METHODS AND ANALYSIS

Four hundred first trimester pregnant women from either Myanmar or Thailand of either Karen or Burman ethnicity, with a viable, singleton pregnancy will be enrolled in this non-interventional, prospective pregnancy birth cohort study and will be followed through to the postpartum period. Fortnightly finger prick capillary blood sampling will allow the monitoring of genome-wide transcript abundance in whole blood. Collection of stool samples and vaginal swabs each trimester, at delivery and postpartum will allow monitoring of intestinal and vaginal microbial composition. In a nested case-control analysis, perturbations of transcript abundance in capillary blood as well as longitudinal changes of the gut, vaginal and oral microbiome will be compared between mothers giving birth to preterm and matched cases giving birth to term neonates. Placenta tissue of preterm and term neonates will be used to determine bacterial colonisation as well as for the establishment of coding and non-coding RNA profiles. In addition, RNA profiles of circulating, non-coding RNA in cord blood serum will be compared with those of maternal peripheral blood serum at time of delivery.

ETHICS AND DISSEMINATION

This research protocol that aims to detect perturbations in molecular trajectories preceding adverse pregnancy outcomes was approved by the ethics committee of the Faculty of Tropical Medicine, Mahidol University in Bangkok, Thailand (Ethics Reference: TMEC 15-062), the Oxford Tropical Research Ethics Committee (Ethics Reference: OxTREC: 33-15) and the local Tak Province Community Ethics Advisory Board. The results of this cooperative project will be disseminated in multiple publications staggered over time in international peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

NCT02797327; Pre-results.

Impact of adopting the 2013 World Health Organization criteria for diagnosis of gestational diabetes in a multi-ethnic Asian cohort: a prospective study

BACKGROUND

We assessed the impact of adopting the 2013 World Health Organization (WHO) diagnostic criteria on the rates of gestational diabetes (GDM), pregnancy outcomes and identification of women at future risk of type 2 diabetes.

METHODS

During a period when the 1999 WHO GDM criteria were in effect, pregnant women were universally screened using a one-step 75 g 2-h oral glucose tolerance test at 26-28 weeks' gestation. Women were retrospectively reclassified according to the 2013 criteria, but without the 1-h glycaemia measurement. Pregnancy outcomes and glucose tolerance at 4-5 years post-delivery were compared for women with GDM classified by the 1999 criteria alone, GDM by the 2013 criteria alone, GDM by both criteria and without GDM by both sets of criteria.

RESULTS

Of 1092 women, 204 (18.7%) and 142 (13.0%) were diagnosed with GDM by the 1999 and 2013 WHO criteria, respectively, with 27 (2.5%) reclassified to GDM and 89 (8.2%) reclassified to non-GDM when shifting from the 1999 to 2013 criteria. Compared to women without GDM by both criteria, cases reclassified to GDM by the 2013 criteria had an increased risk of neonatal jaundice requiring phototherapy (relative risk (RR) = 2.78, 95% confidence interval (CI) 1.32, 5.86); despite receiving treatment for GDM, cases reclassified to non-GDM by the 2013 criteria had higher risks of prematurity (RR = 2.17, 95% CI 1.12, 4.24), neonatal hypoglycaemia (RR = 3.42, 95% CI 1.04, 11.29), jaundice requiring phototherapy (RR = 1.71, 95% CI 1.04, 2.82), and a higher rate of abnormal glucose tolerance at 4-5 years post-delivery (RR = 3.39, 95% CI 2.30, 5.00).

CONCLUSIONS

Adoption of the 2013 WHO criteria, without the 1-h glycaemia measurement, reduced the GDM rate. Lowering the fasting glucose threshold identified women who might benefit from treatment, but raising the 2-h threshold may fail to identify women at increased risk of adverse pregnancy and future metabolic outcomes.

TRIAL REGISTRATION

NCT01174875 . Registered 1 July 2010 (retrospectively registered).

Comparison of different criteria for diagnosis of gestational diabetes mellitus

INTRODUCTION

The International Association of Diabetes in Pregnancy Study Group (IADPSG) criteria for gestational diabetes mellitus (GDM) has been adopted by most associations across the world including the American Diabetes Association and World Health Organization (WHO). We conducted a study comparing the IADPSG and previous WHO criteria and their effects on neonatal birth weight.

METHODS

The study was carried out in Obstetrics and Gynaecology Department of a tertiary care institute in South India in collaboration with Endocrinology Department. Thousand two hundred and thirty-one antenatal cases with at least one risk factor for GDM and gestational age of more than 24 weeks were included in the study. Both criteria were compared on the basis of 75 g oral glucose tolerance test results.

RESULTS

The prevalence of GDM using IADPSG and previous WHO criteria were 12.6% and 12.4%, respectively. The prevalence of GDM was 9.9% when both criteria had to be satisfied. Both GDM criteria groups did not differ in neonatal birth weight and macrosomia rate. However, there was a significant increase in lower segment cesarean section in IADPSG criteria group. Elevated fasting plasma glucose alone picked up only one GDM in the previous WHO criteria group.

CONCLUSIONS

A single 2 h plasma glucose is both easy to perform and economical. A revised WHO criterion using a 2 h threshold of ≥140 mg % can be adopted as a one-step screening and diagnostic procedure for GDM in our country.

Diabetes among refugee populations: what newly arriving refugees can learn from resettled Cambodians

A growing body of literature suggests that cardiometabolic disease generally and type 2 diabetes specifically are problems among refugee groups. This paper reviews rates of cardiometabolic disease and type 2 diabetes among refugees and highlights their unique risk factors including history of malnutrition, psychiatric disorders, psychiatric medications, lifestyle changes toward urbanization and industrialization, social isolation, and a poor profile on the social determinants of health. Promising interventions are presented for preventing and treating diabetes in these groups. Such interventions emphasize well-coordinated medical and mental health care delivered by cross-cultural and multidisciplinary teams including community health workers that are well integrated into the community. Finally, recommendations for service, policy, and research are made. The authors draw on local data and clinical experience of our collective work with Cambodian American refugees whose 30-year trajectory illustrates the consequences of ignoring diabetes and its risk factors in more recent, and soon to be arriving, refugee cohorts.

Estimating Gestational Age in Late Presenters to Antenatal Care in a Resource-Limited Setting on the Thai-Myanmar Border

Estimating gestational age in resource-limited settings is prone to considerable inaccuracy because crown-rump length measured by ultrasound before 14 weeks gestation, the recommended method for estimating gestational age, is often unavailable. Judgements regarding provision of appropriate obstetric and neonatal care are dependent on accurate estimation of gestational age. We determined the accuracy of the Dubowitz Gestational Age Assessment, a population-specific symphysis-fundal height formula, and ultrasound biometry performed between 16 and 40 weeks gestation in estimating gestational age using pre-existing data from antenatal clinics of the Shoklo Malaria Research Unit on the Thai-Myanmar border, where malaria is endemic. Two cohorts of women who gave birth to live singletons were analysed: 1) 250 women who attended antenatal care between July 2001 and May 2006 and had both ultrasound crown-rump length (reference) and a Dubowitz Gestational Age Assessment; 2) 975 women attending antenatal care between April 2007 and October 2010 who had ultrasound crown-rump length, symphysis-fundal measurements, and an additional study ultrasound (biparietal diameter and head circumference) randomly scheduled between 16 and 40 weeks gestation. Mean difference in estimated newborn gestational age between methods and 95% limits of agreement (LOA) were determined from linear mixed-effects models. The Dubowitz method and the symphysis-fundal height formula performed well in term newborns, but overestimated gestational age of preterms by 2.57 weeks (95% LOA: 0.49, 4.65) and 3.94 weeks (95% LOA: 2.50, 5.38), respectively. Biparietal diameter overestimated gestational age by 0.83 weeks (95% LOA: -0.93, 2.58). Head circumference underestimated gestational age by 0.39 weeks (95% LOA: -2.60, 1.82), especially if measured after 24 weeks gestation. The results of this study can be used to quantify biases associated with alternative methods for estimating gestational age in the absence of ultrasound crown-rump length to inform critical clinical judgements in this population, and as a point of reference elsewhere.

Angiotensin converting enzyme gene polymorphism studies: A case-control study

Mild gestational hyperglycemia (MGH) is a very common complication of pregnancy that is characterized by intolerance to glucose. The association of angiotensin-converting enzyme (ACE) insertion/deletion (I/D) polymorphism to MGH has been previously reported. In this study, we evaluated the association between ACE polymorphism and the risk of MGH in a Saudi population. We conducted a case-control study in a population of 100 MGH patients and 100 control subjects. ACE gene polymorphism was analyzed by the novel approach of tetraprimer amplification refractory mutation system (ARMS)-polymerase chain reaction (PCR). The frequency of ACE polymorphism was not associated with either alleles or genotypes in MGH patients. Glucose concentration was found to be significantly associated with the MGH group. Our study suggests that ACE genotypes were not associated with ACE polymorphism in a Saudi population.