The trends and risk factors to predict adverse outcomes in gestational diabetes mellitus: a 10-year experience from 2006 to 2015 in a single tertiary center

Predicting adverse perinatal outcomes among gestational diabetes complicated pregnancies using neural network algorithm

OBJECTIVE

The primary aim of this study is to utilize a neural network model to predict adverse neonatal outcomes in pregnancies complicated by gestational diabetes (GDM).

DESIGN

Our model, based on XGBoost, was implemented using Python 3.6 with the Keras framework built on TensorFlow by Google. We sourced data from medical records of GDM-diagnosed individuals who delivered at our tertiary medical center between 2012 and 2016. The model included simple pregnancy parameters, maternal age, body mass index (BMI), parity, gravity, results of oral glucose tests, treatment modality, and glycemic control. The composite neonatal adverse outcomes defined as one of the following: large or small for gestational age, shoulder dystocia, fetal umbilical pH less than 7.2, neonatal intensive care unit (NICU) admission, respiratory distress syndrome (RDS), hyperbilirubinemia, or polycythemia. For the machine training phase, 70% of the cohort was randomly chosen. Each sample in this set consisted of baseline parameters and the composite outcome. The remaining samples were then employed to assess the accuracy of our model.

RESULTS

The study encompassed a total of 452 participants. The composite adverse outcome occurred in 29% of cases. Our model exhibited prediction accuracies of 82% at the time of GDM diagnosis and 91% at delivery. The factors most contributing to the prediction model were maternal age, pre-pregnancy BMI, and the results of the single 3-h 100 g oral glucose tolerance test.

CONCLUSION

Our advanced neural network algorithm has significant potential in predicting adverse neonatal outcomes in GDM-diagnosed individuals.

Obesity Is Associated With Higher Risk of Adverse Maternal and Neonatal Outcomes Than Supervised Gestational Diabetes

BACKGROUND

Unlike gestational diabetic mellitus (GDM), which is strictly managed by most patients and physicians, obesity does not have proper management guidelines, and the importance of its management during pregnancy is often ignored. The aim of this study was to compare maternal and neonatal outcomes according to obesity and GDM, alone or in combination.

METHODS

This was a retrospective cohort study of 3,078 consecutive pregnant women who experienced prenatal care and delivery of a live singleton neonate between January 2016 and December 2020 at our institution. Study participants were categorized into 4 mutually exclusive groups, as follows: group 1, no GDM without obesity; group 2, GDM without obesity; group 3, no GDM with obesity; and group 4, GDM with obesity.

RESULTS

Compared to group 2, group 3 had higher rates of pre-eclampsia, cesarean section including emergent cesarean section rate. Also, neonates in group 3 were heavier and had lower glucose levels compared to those in group 2. Of note, there was no significant difference in maternal or neonatal outcomes except the rate of large-for-gestational-age (LGA) between group 1 and group 2. Among the GDM groups, group 4 had higher risks for pre-eclampsia, cesarean section, and LGA infant status than group 2.

CONCLUSION

Our data showed that obese women without GDM face higher risk of adverse pregnancy outcomes than women with supervised GDM and non-obese women. We also confirmed that adverse pregnancy outcomes associated with GDM were mainly attributable to obesity among women receiving GDM education.

Influence of Pre-Pregnancy Underweight Body Mass Index on Fetal Abdominal Circumference, Estimated Weight, and Pregnancy Outcomes in Gestational Diabetes Mellitus

This study aimed to determine the influence of pre-pregnancy body mass index on pregnancy outcomes in gestational diabetes mellitus (GDM), comparing underweight patients with GDM with normal weight patients with GDM. Maternal baseline characteristics, ultrasonographic results, and pregnancy and neonatal outcomes were reviewed in 946 women with GDM with singleton pregnancies. Underweight patients with GDM showed a benign course in most aspects during pregnancy, except for developing a higher risk of giving birth to small for gestational age neonates. Underweight women with GDM required less insulin treatment, had a higher rate of vaginal delivery, and had a lower rate of cesarean delivery. In addition, their neonates were more likely to have fetal abdominal circumference and estimated fetal weight below the 10th percentile both at the time of GDM diagnosis and before delivery. Notably, their risk for preeclampsia and macrosomia were lower. Collectively, our data suggest that underweight women with GDM may require a different approach in terms of diagnosis and management throughout their pregnancy.

LncRNA-SNX17 Promotes HTR-8/SVneo Proliferation and Invasion Through miR-517a/IGF-1 in the Placenta of Diabetic Macrosomia

Gestational diabetes mellitus (GDM) has become a worldwide problem in recent years. Macrosomia, a primary consequence of GDM, has short-term and life-long consequences in the offspring of mothers with GDM. Our previous study showed that miR-517a was dysregulated in placenta and plasma of fetal growth restriction through inhibiting invasion of trophoblast and might be closely related with the regulation of birth weight by the placenta. To further investigate the mechanism of miR-517a, we conducted genome-wide microarray profile of lncRNAs. lncRNA-SNX17 was found to be significantly upregulated in the placenta of diabetic macrosomia by qRT-PCR, and the expression of miR-517a and IGF-1 were measured by qRT-PCR and Western blot. Interestingly, significant inverse correlations of the miR-517a with both lncRNA-SNX17 and IGF-1 expression were revealed in the placenta of diabetic macrosomia. Bioinformatic prediction also revealed that both lncRNA-SNX17 and IGF-1 possessed binding sites for miR-517a, which were then confirmed by luciferase report assay. LncRNA-SNX17 overexpression reduced the expression of miR-517a and increased the IGF-1 expression in HTR-8/SVneo human trophoblast cell line and thus enhanced the proliferation of HTR-8/SVneo. The enhancement of HTR-8/SVneo proliferation by lncRNA-SXN17 could be nullified by co-transfection of miR-517a mimics. The data suggested that lncRNA-SNX17 might promote the trophoblast proliferation through miR-517a/IGF-1 pathway and might play a role in the placentation of diabetic macrosomia.

Gestational Diabetes Mellitus: Diagnostic Approaches and Maternal-Offspring Complications

Gestational diabetes mellitus (GDM) is the most common complication during pregnancy and is defined as any degree of glucose intolerance with onset or first recognition during pregnancy. GDM is associated with adverse pregnancy outcomes and long-term offspring and maternal complications. For GDM screening and diagnosis, a two-step approach (1-hour 50 g glucose challenge test followed by 3-hour 100 g oral glucose tolerance test) has been widely used. After the Hyperglycemia and Adverse Pregnancy Outcome study implemented a 75 g oral glucose tolerance test in all pregnant women, a one-step approach was recommended as an option for the diagnosis of GDM after 2010. The one-step approach has more than doubled the incidence of GDM, but its clinical benefit in reducing adverse pregnancy outcomes remains controversial. Long-term complications of mothers with GDM include type 2 diabetes mellitus and cardiovascular disease, and complications of their offspring include childhood obesity and glucose intolerance. The diagnostic criteria of GDM should properly classify women at risk for adverse pregnancy outcomes and long-term complications. The present review summarizes the strengths and weaknesses of the one-step and two-step approaches for the diagnosis of GDM based on recent randomized controlled trials and observational studies. We also describe the long-term maternal and offspring complications of GDM.

Levels of inter-alpha-trypsin inhibitor heavy chain H4 urinary polypeptide in gestational diabetes mellitus

Gestational diabetes mellitus (GDM) can cause a variety of adverse maternal and fetal complications. The purpose of this study was to screen and identify the urinary polypeptides related to the severity of GDM and to analyze the correlation between urinary peptide levels and neonatal metabolic indices. A total of 31 normal pregnant women (N group) and 74 patients with GDM (GDM group) were randomly selected between February 2018 and August 2019. Patients with GDM were divided into two groups according to their fasting plasma glucose (FPG) levels. The urine samples were enriched using weak cation-exchange magnetic beads (MB-WCX), and eight different urine polypeptides were screened and analyzed. The peptide spectra were obtained using matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS). The urinary peptide signatures of the two groups were compared using the BioExplorer software. The difference analysis of the eight urinary polypeptides between the normal pregnant (N) group and GDM group showed that two polypeptides with mass-to- charge ratios (m/z) of 2175.7 and 2318.8, respectively, were significantly different between the two groups (P < 0.01). The m/z 2175.7 polypeptide was analyzed by liquid chromatography-tandem mass spectrometry (LC-MS), and the corresponding name of the molecule was inter-alpha-trypsin inhibitor heavy chain H4 (ITIH4). The changes in ITIH4 levels correlated with those in the neonatal metabolic indices. By establishing the Fisher discriminant function equation for the GDM group, the difference in sample distribution and mean value of the two groups could be observed directly.Abbreviations: GDM: gestational diabetes mellitus; FPG: fasting plasma glucose; MB-WCX: weak cation exchange magnetic beads; MALDI-TOF MS: matrix-assisted laser desorption ionization time-of-flight mass spectrometry; m/z: mass charge ratio; LC-MS: liquid chromatography-tandem mass spectrometry; glycosylated hemoglobin (HbA1c); PPG: postprandial plasma glucose; ITIH4: inter-alpha-trypsin inhibitor heavy chain H4; IR: insulin resistance; NFPG: neonatal fasting plasma glucose; NH: neonatal height; NW: neonatal weight; BMI: body mass index; RPL: recurrent pregnancy loss; OGTT: oral glucose tolerance test; ADA: American Diabetes Association; LIS: Laboratory Information System.

Rethinking third trimester ultrasound measurements and risk of adverse neonatal outcomes in pregnancies complicated by hyperglycaemia: A retrospective study

BACKGROUND

Antenatal ultrasound is used frequently in pregnancies complicated by hyperglycaemia; however, it is unclear which measurements have the greatest association with adverse neonatal outcomes.

AIM

To assess the association between third trimester ultrasound parameters with adverse neonatal outcomes in pregnancies complicated by hyperglycaemia.

METHOD

All pregnant women with gestational or type 2 diabetes who birthed in a regional hospital over 12 months were included. A composite adverse neonatal outcome was defined by one or more: admission to special care nursery, acidosis, hypoglycaemia, jaundice, shoulder dystocia, respiratory distress syndrome or 5-minute Apgar score < 5. Logistic regression was used to determine odds ratios (OR) for an adverse neonatal outcome, according to pre-specified cut points in both lower and upper percentiles of abdominal circumference (AC) and estimated fetal weight (EFW).

RESULTS

Of 275 births an adverse outcome occurred in 122 (44%). Unadjusted OR (95% CI) for AC ≤30^th was 3.2 (1.1-8.8) and >95^th percentile was 3.1 (1.5-6.0) compared with the reference group of 31-70^th percentile. Unadjusted OR for EFW ≤30^th was 1.5 (0.7-3.1) and >95^th percentile was 3.0 (1.4-6.3). After adjusting for maternal age, body mass index, diabetes type, ethnicity, gravidity, mode of delivery and gestation at birth the OR (95% CI) were as follows: AC ≤30^th percentile, 3.7 (1.1-12.4); AC >95^th , 2.2 (1.1-4.8); EFW ≤30^th , 2.6 (1.1-6.1); EFW >95^th , 2.5 (1.1-6.1).

CONCLUSION

An AC and EFW up to the 30^th percentile may pose just as great a risk to the fetus as an AC or EFW >95^th percentile in pregnancies complicated by hyperglycaemia.

Predictability of Macrosomic Birth based on Maternal Factors and Fetal Aneuploidy Screening Biochemical Markers in Hyperglycemic Mothers

Background: Macrosomic birth weight has been implicated as a significant risk factor for developing various adult metabolic diseases such as diabetes mellitus and coronary heart diseases; it has also been associated with higher incidences of complicated births. This study aimed to examine the predictability of macrosomic births in hyperglycemic pregnant women using maternal clinical characteristics and serum biomarkers of aneuploidy screening performed in the first half of pregnancy. Methods: A retrospective observational study was performed on a cohort of 1,668 pregnant women who 1) had positive outcomes after undergoing 50-g oral glucose challenge test (OGCT) at two university-based hospitals and 2) underwent any one of the following maternal biomarker screening tests for fetal aneuploidy: triple test, quadruple test, and integrated test. Logistic regression-based models for predicting macrosomic births using maternal characteristics and serum biomarkers were developed and evaluated for prediction power. A nomogram, which is a graphical display of the best predictable model, was then generated. Results: The study cohort included 157 macrosomic birth cases defined as birth weight ≥3,820 g, which was equivalent to the top 10 percentile of the modeling cohort. Three primary models solely based on serum biomarkers achieved area under curves (AUCs) of 0.55-0.62. Expanded models, including maternal demographic and clinical factors, demonstrated an improved performance by 25% (AUCs, 0.69-0.73). Conclusion: Our prediction models will help to identify pregnancies with an elevated risk of macrosomic births in hyperglycemic mothers using maternal clinical factors and serum markers from routine antenatal screening tests. Prediction of macrosomic birth at mid-pregnancy may allow customized antenatal care to reduce the risk of macrosomic births.

Manifest diabetes after gestational diabetes: a double-cohort, long-term follow-up in a Danish population

PURPOSE

The aim was to follow-up two cohorts of women with GDM to investigate the incidence and time of diagnosis of manifest diabetes mellitus (DM) postpartum and identify the risk factors for diabetes in our population.

METHODS

A follow-up study on two independent cohorts having oral glucose tolerance test (OGTT) in 1991/1992 and 2011-2016: Cohort 1 consisted of 406 women including 54 with GDM and 352 with a non-GDM OGTT-test and cohort 2 had 433 women diagnosed with GDM. The first cohort had nearly 25 years of follow-up and gave information on magnitude, conversion rate and type of diabetes manifestation. The second cohort was started recently to evaluate whether newer diagnostic criteria and baseline information on the old cohort are still valid for prediction of diabetes risk.

RESULTS

The risk of manifest diabetes in cohort 1 at the end of follow-up was six times higher in women with previous GDM compared with non-GDM (RR = 6; 95% CI 4-11). We observed a 70% diabetes rate 25 years after pregnancy. Only family history of diabetes in cohort 2 was associated with conversion to manifest diabetes (p = 0.002), also after adjustment for age, BMI, non-Danish origin and smoking during pregnancy (p < 0.001) CONCLUSION: The incidence of diabetes after GDM is higher than that previously reported in Scandinavian populations and the rate of manifest diabetes rises steeply 15 years after pregnancy and after 40 years of age. The women of cohort 2 with recent GDM are at risk of DM at a higher rate. On this background our results are useful in identifying the time where GDM women may benefit from the effective implementation of evidence-based treatment to postpone and advert manifest DM.

Factors associated with poor-to-moderate quality of life among pregnant women with gestational diabetes mellitus: a cross-sectional study in Malaysia

PURPOSE

This study aimed to identify factors associated with poor-to-moderate quality of life (QOL) among women with gestational diabetes mellitus (GDM) in two tertiary hospitals in Malaysia.

METHODS

A cross-sectional study was conducted among 526 pregnant women with GDM in two tertiary hospitals in Malaysia. Diabetes-related QOL was assessed using the Asian Diabetes Quality of Life Scale (AsianDQoL). Socio-demographic characteristics, glucose monitoring treatments for GDM, past obstetric history, concurrent medical problems and a family history of diseases were captured from patient records. A multiple logistic regression was used for analysis.

RESULTS

A total of 526 respondents with GDM entered the analysis. The median age of the respondents was 32 (interquartile range = 7) while 82.3% were Malay women. More than half of the respondents (69.5%) received an oral hypoglycaemic agent (OHA), and/or diet modification in controlling their GDM. The study reported that 23.2% of the respondents had poor-to-moderate QOL. Those with a family history of depression and/or anxiety (adjusted Odds ratio [AOR] 6.934, 95% confidence interval [CI] 2.280-21.081), and a family history of GDM (AOR 1.814, 95% CI 1.185-2.778) were at higher odds of suffering from poor-to-moderate QOL compared to those without a family history. Similarly, those who received insulin, with or without OHA, and/or are on diet modification (AOR 1.955, 95% CI 1.243-3.074) were at higher odds of suffering from poor-to-moderate QOL compared to those receiving OHA and/or diet modification.

CONCLUSION

Nearly one-quarter of Malaysian women with GDM have poor-to-moderate QOL. GDM women with a family history of depression and/or anxiety, family history of GDM, and those who received insulin, with or without OHA, and/or are on diet modification were associated with poor-to-moderate QOL.

TRIAL REGISTRATION

NMRR-17-2264-37814.

Worrying in the wings? Negative emotional birth memories in mothers and fathers show similar associations with perinatal mood disturbance and delivery mode

Negative birth experiences can lead to symptoms of post-traumatic stress disorder in new mothers but have received much less attention in new fathers. A sample of 314 first-time expectant couples rated their symptoms of anxiety and depression in the third trimester and at 4-month post birth (227 vaginal delivery, 87 caesarean section), when they also completed the emotional memories subscale of the BirthMARQ (Foley et al. BMC Pregnancy Childbirth, 14, 211, 2014). We first examined mode of delivery (vaginal birth versus caesarean section) as a predictor of mothers' and fathers' BirthMARQ scores. Next, we used actor-partner interdependence model (APIM) to investigate intra- and interpersonal associations between birth experiences and maternal/paternal latent factors for antenatal and postnatal depression/anxiety. Reports of negative birth experiences were more common for mothers than fathers and for parents of babies born by caesarean section than by vaginal delivery. Within-couple agreement was moderately strong and, for both parents at both time-points, individual differences in negative birth memories were associated with symptoms of depression and anxiety. Negative birth memories also played a mediating role in the association between birth via caesarean section and reduced postnatal maternal wellbeing. Given the striking similarities between mothers and fathers in links between birth experiences and wellbeing, our findings highlight the need for partner-inclusive intervention strategies.

Neonatal outcomes and its association among gestational diabetes mellitus with and without depression, anxiety and stress symptoms in Malaysia: A cross-sectional study

OBJECTIVE

Prevalence of depression, anxiety and stress symptoms in gestational diabetes mellitus ranges from 10.2% to 39.9% based on previous studies in Malaysia. Presence of depression, anxiety or stress in pregnancy may increase the risk of neonatal morbidity and mortality. The aim of this study was to determine the prevalence of neonatal outcomes and its association among mothers with gestational diabetes mellitus with and without the presence of depression, anxiety and stress symptoms in Malaysia.

DESIGN

This was a cross-sectional study.

SETTING

Tertiary hospitals in Malaysia.

PARTICIPANTS

Mothers with gestational diabetes mellitus (n = 418) who deliver their neonates at two major tertiary hospitals in Malaysia.

MEASUREMENTS

Neonatal outcomes, such as low birth weight, preterm birth, macrosomia, metabolic and electrolyte disorders, neonatal respiratory distress and congenital anomalies were determined.

FINDINGS

Prevalence of low birth weight in neonates born to mothers with gestational diabetes mellitus was 14.6%, followed by metabolic and electrolyte disorders 10.5%, preterm birth 9.1%, macrosomia 4.8%, neonatal respiratory distress 5.8% and congenital anomalies (2.4%). Among the adverse neonatal outcomes, neonatal respiratory distress was significantly associated with the presence of depression symptoms in mothers with gestational diabetes mellitus using univariate analysis (p = 0.010). After controlling for confounding factors, predictors for neonatal respiratory distress at delivery were the presence of depression symptoms in mothers with gestational diabetes mellitus (Adjusted OR = 3.87, 95% CI = 1.32-11.35), living without a husband (Adjusted OR = 9.74, 95% CI = 2.04-46.51), preterm delivery (Adjusted OR = 7.20, 95% CI = 2.23-23.30), caesarean section (Adjusted OR = 3.33, 95% CI = 1.09-10.15), being nulliparous and primiparous (Adjusted OR = 3.62, 95% CI = 1.17-11.17) and having family history of diabetes (Adjusted OR = 3.20, 95% CI = 1.11-9.21).

KEY CONCLUSIONS

The findings of this study demonstrate the positive association of neonatal respiratory distress with the presence of depression symptoms in mothers with gestational diabetes mellitus.

IMPLICATIONS FOR PRACTICE

It is therefore important to identify depression symptoms after a diagnosis of gestational diabetes mellitus in pregnant mothers is made to enable early referral and interventions.